For a high-level overview of the global fight against COVID-19 and how developments are likely to unfold, GLG VP and Team Lead of GLG’s Healthcare Content team Michael Weissman spoke with the Hon. Mark Dybul, MD, Co-Director of the Center for Global Health Practice and Impact at Georgetown University and former U.S. Global AIDS Coordinator, on March 25, 2020. The widely recognized global health expert and humanitarian is also Chair and Fellow with the Joep Lange Institute, a Netherlands-based nonprofit working to transform healthcare systems. Portions of the conversation, edited for space and clarity, follow.

Many countries are initiating or expanding lockdowns. At the same time, there’s a growing counterargument in the U.S. that the economic damage wrought by lockdowns may be too costly. What are your thoughts?

It’s a complicated question. In the UK, where lockdowns are expanding, there initially were no significant public restrictions. Since we know now that 80% to 90% of COVID-19 cases are asymptomatic or mildly symptomatic, they were basically allowing transmission to permit immunity to develop in the population and then trying to do what they could to protect people at higher risk. Then cases started jumping to up to 1,000 a day from under 500. That jump, with only some mild restrictions, made them fear they were going where China went and where the U.S. is headed. The Dutch did something similar and now are imposing much more restrictive rules.

What would be the economic cost of a totally out-of-control epidemic? We don’t know. Finding out would require many people from different sectors looking at costs, weighing them, and modeling them. There’s a lot of work to be done, but I think the UK is a good example of what happens if you don’t clamp down early.

Some areas that got hit hardest and earliest seem to be emerging from the worst of it. Is there anything the U.S. and Europe can learn from Wuhan, Singapore, and South Korea?

Perhaps, but it might be too late to apply the lessons. Once China responded, for example, it did so aggressively and had true lockdown – not what we’re calling lockdown. It separated families. If you had a fever, you got tested to see if it was influenza or a bacterial infection; if it wasn’t, you went into a ward with no generational mixing. After a week of seeing no new cases, it now has some, including in Wuhan. Most of the new cases, as best as we can tell, are the result of people being free to move around again and outsiders coming to Wuhan. That could be a very important signal of what happens after lockdown and what you do afterward.

South Korea’s experience may help. A couple of years ago, it had a problem with another coronavirus – the Middle East Respiratory Syndrome, or MERS – and it didn’t do well. A lot of people died, and the health system didn’t respond much. But it learned from that and put new systems in place. As soon as China reported cases, South Korea tracked everyone entering from China and screened all travelers coming into the country. It then tracked people in the country by case and made the information public. Without revealing names, South Korea said it had identified an infected person who went to such-and-such specific places. That way, the public would know those potential danger spots and understand the risks. Then it aggressively tested, an area where it is far ahead of the U.S.

Singapore tested even more aggressively. It has checkpoints on the street to check people’s temperature and do swabs. It learned, as the South Koreans learned from their MERS experience, to have a system ready to respond, and it responded aggressively. Singapore is now down to less than 100 cases a day from about 1,000 cases a day not too long ago. Its system is working. But the U.S. can’t copy South Korea or Singapore because it’s too late. We’re now more on the path that Italy took.

Should we be thinking now about a second wave?

Yes. As background, it’s good to note what happened in the flu pandemic of 1918, which had three main waves. The first, in the spring of 1918, was related to World War I troop movements. About three-quarters of the French troops and half the British troops had the flu, but it wasn’t overly deadly. It then followed troops to North Africa and parts of the Southern Hemisphere, likely mutating genetically. Then, starting in August in Northern Hemisphere countries, it came back with a vengeance and caused huge numbers of death. The third wave occurred in late December and in January 1919, causing fewer infections. But the last two waves together cost around 50 million lives, which, given the world population back then, was a massive number.

Today, we don’t need troop movements to spread a disease; we have travel and tourism. Once travel becomes less restricted, a second wave could easily occur. The big concern is how the virus is mutating. There already are more than 1,000 strains, so if it mutates more and becomes deadlier or even more infectious, a second wave could be very deadly.

Wuhan took about eight weeks to go from initial lockdown to the easing of restrictions. We’ve seen roughly similar timelines in South Korea and Singapore. Do you expect something similar in the U.S.?

Since we don’t yet know whether COVID-19 is a seasonal virus – although we’ve begun intensive lab studies to find out – it’s impossible to predict when the spread may slow. That depends on whether the disease is truly seasonal and whether the measures now being taken are enough. In 1918, there were series of strict restrictions that would come on and off as conditions improved and worsened, and that inconsistency may have contributed to the disease waves as well.

Do you think that the current piecemeal approach – state-by-state efforts in the U.S. and country-by-country responses in Western Europe – has been effective? Would a federal or European-wide approach be better?

Piecemeal approaches can work if people aren’t moving and if you understand where new infections are occurring. But that’s not the case in our country or in the rest of the world. We really have no idea how many infections we have, and they’ve been reported all over the country. Unless we have a federal response that is linked to state and local responses getting deep into the community – you can’t beat a pandemic without engaging the community – it’s going to be almost impossible to contain.

Large manufacturing companies have announced using their capabilities for public health purposes. Is that a good first step? Should large companies do more?

What they’ve done is great. And they’ve moved from just making an announcement, which could be merely a public relations stunt if you wanted to be cynical, to doing things that are within their competencies. Ford is partnering with others to produce ventilators, masks, and other important pieces of equipment, for example. The production of ventilators is hugely important. LVMH is doing what it can, which is producing hand sanitizer – we need a lot of it because it kills the virus. What would really be useful is a systematic approach to all this, where we say, “Here is what we project and this is what we need, so please produce X, Y or Z.” And we haven’t done that yet.

What do you see as a timeline for a vaccine? We hear 12 to 18 months.

That’s accurate. And coming from Tony Fauci, my mentor, it’s also very aggressive because a vaccine must be proven safe. The worst possible scenario would be to rush through a vaccine that leaves people worse off than the disease or kills a lot of them.

After you prove a vaccine is safe, you must prove it’s effective, which is complicated. Ebola, for example, disappeared before the vaccine could be tested, which had to wait until Ebola reemerged in Congo recently. This wave of COVID-19 may abate before a vaccine is available to test. Finally, producing a vaccine in mass quantities is difficult and complicated.

What Tony Fauci and others have been driving at is that we need more effective vaccines because viruses mutate so quickly. So now, in addition to taking the traditional approach to vaccines – which is what we do for influenza – we’re trying different and new types of vaccines that would work against any coronavirus variant, not just the variant of a particular year. Researchers are moving aggressively and skipping animal models and things normally done to cut the usual 5-to-7-year timelines down to 12 to 18 months. There’s no foot-dragging or red tape by anybody, but a vaccine almost certainly is not imminent.

In all this, what worries you most?

There could be two types of next waves to COVID-19. The first would come from the movement of people within our country between areas that are confined and unconfined. The other, if the disease is seasonal, is that a wave could come back in the fall and next year. What worries me most is that the virus may percolate over the summer in the Southern Hemisphere and, if it’s not truly seasonal, in the Northern Hemisphere, resulting in enough genetic change so that if and when it comes back in the fall, it is even more virulent, aggressive, and deadly.

If it comes back that way, we should have in place the tools necessary for case identification, which means having tens of millions of test kits available, contract tracing, and a systematic response. We can do that, but it means having a national task force coordinated on federal, state, and local levels – including deep into the community – that is also linked globally. This is a global infection. If we don’t pay attention to the world’s health, we are at high risk ourselves.

Hopefully, this is a seasonal disease and, after this season, we see cases dropping. But if we don’t prepare for a possible return, we could see something worse.

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About Mark Dybul

Mark Dybul is a professor in the Department of Medicine at the Medical Center and the Co-Director of the Center for Global Health Practice and Impact at Georgetown University. He was also U.S. Global AIDS Coordinator from 2006 until the beginning of the Obama administration.

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This article is adapted from GLG’s March 25, 2020, teleconference “COVID-19 Global Response.” If you would like access to this teleconference or would like to speak with Mark Dybul, or any of our more than 700,000 experts, contact us.

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