Event 201: Late in the summer of 2019, a virus makes the leap from pigs in South America to the farmers who come into close and regular contact with them. It begins as a slow burn in Brazil; by October, it is gaining momentum and becomes known to the world.

The virus is called CAPS, a coronavirus, like SARS and MERS, that has never been seen before. It causes pneumonia and acute respiratory distress — in the most severe cases, liquid fills the lungs until breathing becomes labored or impossible.

A further mutation allows the virus to jump from person to person. From densely packed urban areas, the virus spreads, hanging in the very air we breathe. From its epicenter in Brazil, it spreads across the world.

A Pandemic Response Board is formed, made up of business leaders, public health experts, and representatives from the Centers for Disease Control. The Board is intended to coordinate the public and private plans for stopping — and surviving — the pandemic.

In their 18-month struggle against CAPS, 65 million people will die.

The World Health Organization responds, on average, to 200 epidemic events a year: the CAPS virus is “Event 201.”

CAPS isn't a real virus (yet), and this is not the world we live in — but it is, perhaps, the world next door. A few farsighted experts and executives are determined to be ready, in case the neighbors drop by to say hello.

Testing Global Pandemic Preparedness With Event 201

Beneath the chandeliers and sconces of the Pierre Hotel, against a painted palazzo backdrop of fake fountains and statuary with the pallor of death, they gather, representatives from a vast array of private and public entities.

Everyone here has a connection, whether scientific, political, or economic, to infectious disease. They are here for Event 201, a kind of wargame for disease run by the Johns Hopkins Center for Health Security, and fifteen are selected to be members of the notional "Pandemic Response Board." Event 201 is a chance to test global pandemic preparedness, but uniquely, this simulation focuses on the response by the private sector.

Eric Toner, Project Director for Event 201, briefing leaders of business, governments, and public health. The pandemic exercise is hosted by the Johns Hopkins Center for Health Security with the World Economic Forum and the Bill & Melinda Gates Foundation. Credit: Nick Klein / Center for Health Security

With no current global pandemic plan in place, these simulations are crucial for teasing out insights, formulating future plans, and hopefully attracting some attention — and maybe even some political or financial capital — toward preparing for a major pandemic.

On the hierarchy of bad things, pandemics are among the worst. If diseases spread around the world, like the 1918 flu, they qualify as pandemics, one of the few events that could threaten all humanity. The World Health Organization (WHO) responds, on average, to 200 epidemic events a year: the CAPS virus is "Event 201."

With no current global pandemic plan in place, simulations like Event 201 are crucial for teasing out insights toward preparing for a major pandemic.

The players in the simulation must tackle big problems: how do we allocate limited medical and financial resources? How do we balance the risks and benefits of trade and travel? And how do we battle misinformation and disinformation, from innocent mistakes to conspiracy theories to propaganda?

We don't have the answers yet. But what is clear is that pandemics will greatly impact the private sector, and any global pandemic plan will require the private sector's expertise, resources, and support. The goal is to develop a plan that we can begin setting up now.

Leveraging Private Action in Nigeria

Director General of the Nigeria Centre for Disease Control (NCDC) Chikwe Ihekweazu knows firsthand the importance of public-private partnership. Originally slated to be a member of the simulated Pandemic Response Board, Ihekweazu could not make the trip to New York. To excuse his absence, he reported that he had come down with a case of CAPS (he has, thankfully, fully recovered from his brush with fake death).

Ihekweazu's home in Nigeria is host to the (unfortunately very real) Lassa virus, which causes viral hemorrhagic fever. When Lassa periodically raises its head, managing the outbreak requires samples to be studied in labs. These labs may be far from where the outbreak occurred, and every moment lost while waiting for lab results can mean more suffering and death.

How do we allocate limited medical and financial resources? How do we balance the risks and benefits of trade and travel? And how do we battle misinformation and disinformation, from innocent mistakes to conspiracy theories to propaganda?

To ensure swift and efficient transportation of samples, the NCDC contracts a courier company, the Nigeria-based Trans-Nationwide Express (TRANEX). TRANEX's expertise and infrastructure makes using them both more efficient and cost-effective than having the government try to develop their own system, Ihekweazu says. And this public-private partnership worked well in 2018-2019, when the country battled a dramatic — and still unexplained — spike in Lassa fever cases.

George Fu Gao, the Director-General, Chinese Center for Disease Control and Prevention, at Event 201. Credit: Nick Klein / Center for Health Security

The fear was that Lassa had mutated into a new form; tests to determine if that was true could have taken a painfully long time if samples had to be sent to labs in Europe or the U.S. But Nigeria had the foresight to set up a top-of-the line genomics lab, the African Center of Excellence for Genomics of Infectious Disease (ACEGID). Because ACEGID is located in Nigeria, and TRANEX could quickly deliver Lassa samples, the lab was able to analyze the genetic information of the virus in near real-time. This information helped the NCDC to identify which strains of Lassa fever were causing the infections, and where in the country those strains were active. With their culprits identified, the NCDC could confirm they were not dealing with a new, mutated virus.

The logistics of transportation, while complicated and amorphous, are not as effervescent as one of the most challenging issues a global pandemic plan will face. The spread of misinformation and disinformation can spark panic and violence. Bad news going viral could be almost as dangerous as the virus itself — if not more so.

Faced with a deluge of misinformation and conspiracies, the Nigeria Centre for Disease Control partnered with Facebook for analytical tools and help targeting their messages to outbreak zones.

Ihekweazu saw the virulence of fake news during a 2017 monkeypox outbreak. The disease had not been seen in Nigeria in many years. When monkeypox (which resembles the deadly but eradicated smallpox) re-emerged in 2017, hysteria followed. Faced with a deluge of misinformation and conspiracies, the NCDC partnered with Facebook for analytical tools and help targeting their messages to outbreak zones.

Battling misinformation is a massive challenge for the NCDC, the menacing-looking monkeypox being a prime example. "A lot of my work at the time was focused on responding to the media impact rather than to the outbreak itself," Ihekweazu says.

Nigeria's answer to bad information is similar to the one the Pandemic Response Board came up with during the Event 201 simulation: a centralized source of information, in this case the NCDC. This central source would collect news and rumors and rapidly decide whether to combat bad info directly with their own facts or let conspiracies die a natural death. Communications can no longer be low priority, Ihekweazu says. Robust comms teams and coordinated responses will be important in future outbreaks, and even more so in pandemics.

Private actors play a big role in Nigeria, Ihekweazu says. Ensuring the best outbreak response means leveraging their resources and expertise in partnership with the NCDC's own.

"We will need them," Ihekweazu says. "Definitely, if we were to have a pandemic."

Preparing a Global Pandemic Plan

Unlike Lassa in Nigeria, Event 201's CAPS virus was not stymied. The fictional virus had escaped detection long enough to explode into an epidemic and then pandemic, and with no official global pandemic plan in place, had to be fought on the fly.

After the brutal final toll of the CAPS pandemic rolls on screen — each disheartening statistic thundering like the water-rippling steps of an approaching T-rex — the Center for Health Security and the players presented their ideas for increasing global pandemic preparedness. In their simulation, 65 million people died. The world's GDP plunged by 11% and governments were poleaxed.

Players at Event 201 discussing challenges and recommendations during the major pandemic exercise at The Pierre New York on October 18, 2019. The image is focused on Tim Evans speaking. Credit: Nick Klein / Center for Health Security

The Center for Health Security's recommended actions were generally supported by the board. Suggestions include getting businesses on board to recognize how damaging pandemics could be to the economy and coming up with contingency plans beforehand, and beginning to plan partnerships with governments now.

Building up stockpiles of medical supplies would help ensure against shortages, and a focus by governments and transportation companies on keeping goods flowing would ensure those supplies get where they are needed. Global financing for pandemics needs to be reassessed — in the simulation, there was simply not enough money as CAPS ran roughshod — and the mechanisms to fight fake news, conspiracies, and propaganda campaigns should start being developed now.

We don’t have the answers yet. But what is clear is that pandemics will greatly impact the private sector, and any global pandemic plan will require the private sector’s expertise, resources, and support.

Measures to counter fake news may be necessary, but they are also a double-edged sword. In the CAPS outbreak, governments moved from suppressing propaganda and misinformation to smothering their own citizens and political opposition. Some governments took the opportunity to tighten their grips, martial law blooming like anemones in the virus's wake.

But it is hard to get corporations to care about a hypothetical problem that is not directly impacting them. It is the "panic-neglect" cycle, where an outbreak spurs attention, will, and capital which fades away when peace is restored. During an outbreak, the NCDC finds ready and willing help; in peacetime, Ihekweazu says, it is difficult to drum up support.

Some businesses have brushed against disease already, which has made them more receptive to planning ahead. SARS escaped from Hong Kong on Lufthansa flights (among others). In response, the airline has created protocols for similar outbreaks.

"We are well aware of the fact we would be one of the first to be affected if a new virus, a new disease, were to show up," Martin Knuchel says. The head of crisis, emergency, and business continuity management for Lufthansa, Knuchel participated in Event 201 as a member of the Pandemic Response Board.

Lufthansa trains its crews now for just such an occurrence, Knuchel says. All of their aircraft are equipped with gloves, masks, and other basics of "barrier nursing," and crews are trained how to handle an infected passenger. For a larger spread like SARS or Ebola, Lufthansa will administer special directions to its crews, he says, including how to inform the arrival airport and to be prepared to receive the patient(s) on the ground.

Global financing for pandemics needs to be reassessed — in the simulation, there was simply not enough money as CAPS ran roughshod.

Public and private actors are also working together to fund vaccine research at the Coalition for Epidemic Preparedness Innovations (CEPI). CEPI has invested millions in developing new vaccines — including the second Ebola vaccine — and technologies that will make future development less expensive.

Vaccine development for emerging or rare diseases is time consuming and incredibly expensive, and pharmaceutical companies have little financial incentive to make them.

"We're missing something in the architecture," says Jane Halton, CEPI chairman and an Event 201 player. "It's about actually filling some of these gaps, to actually start developing some vaccines in respect of these viruses that nobody's got a vaccine against."

But how far are we from proper global pandemic preparedness?

The players' answers varied. Halton, whose home country of Australia lies perilously close to where a coronavirus like CAPS is likely to emerge from, is in a perpetual state of alert.

"I've spent a significant portion of the last however many years worrying about this," Halton says. "And I see nothing that makes me feel I shouldn't worry."

A natural optimist, Knuchel is hopeful; he believes that, when our backs are against the wall, humanity will rise to the global challenge.

Members of the Pandemic Response Board all agreed that running simulations like these — forcing people to think about, and confront, nightmare pandemics — is beneficial. But the messaging must leave the ballroom and gain traction in the boardroom.

With the Board's suggestions and their own private takeaways in their heads, Event 201 attendees move towards lunch, collecting adorable CAPS virus plushies from a table next to the buffet.

They have since spread all over the world.