Solving Big Problems in Microbiology: An Interview with Dr. James Wilson

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Dr. James Wilson, Associate Professor at University of Nevada, Reno.

 

Today, people travel globally, and food and other supplies are shipped farther than ever before. As a result, microbes, diseases and other biological threats reach a greater number of people. These emerging global changes create a need for increased health security, including new ways to combat microbes that are becoming resistant to antibiotics.

Dr. James Wilson, director of the Nevada Medical Intelligence Center and associate research professor at the University of Nevada, Reno’s School of Community Health Sciences, is a leading expert on health security and recently helped form the Global Health Security Alliance. Wilson has 25 years of operational experience in the field, including creating several global warning systems for infectious diseases and providing warning for the 2009 H1N1 flu pandemic.

In this question-and-answer session, Wilson discusses his current work and describes the role of public health entities in improving global health security intelligence.

What are two or three things that are most exciting to you at the moment with regard to the research in your field of expertise?

The most exciting thing I’ve seen in a long time is the creation of the Global Health Security Alliance group. We did that in Berlin just two weeks ago. That group is really an elite group. I’ve never seen a group of professionals, in 25 years, that’s been put together like this one before, and we’re very excited about that. The formation of that group is a major development in health security.

The world that I live in is not really trying to develop the latest, greatest mathematical algorithm to predict disease. There are a lot of people doing that, and I’m not really a mathematician. My role in this is to try to figure out how to network with people to use that information effectively and overcome a lot of institutional and political inertia to avoid dealing with the problem. If you unpack that, you’ll see our world history is full of examples where we tend to ignore things until they are a mess and incredibly difficult to manage — everything from wildfires to climate change to the collapse of our ecosystem to Ebola. If you look at all these issues that you read about in the media, it’s over and over again the story of “coulda, woulda, shoulda.” How do we overcome that?

I do design warning systems, but I think one of our greatest failures is to constantly emphasize the technology and not really think about how we’re going to create a sustainable, engaged community that’s able to act on this information in a way that promotes resilience. That’s really what it’s about. When you read about what I’m doing, there’s emphasis on disease forecasting, and we did bring that, but one of the challenges is what the heck to do with the information.

If I give you a prediction that something is going to happen, do you do anything with that prediction? And what happens next? It’s a real challenge to try to get human beings engaged, especially when everyone is distracted by daily events and headlines. If you look at the media, it appears that the sky is falling. With some of that, there’s validity, and I’m deeply worried about our collapsing ecosystem. I don’t think we’re in a good position at all, but when it comes to diseases, how do you get people to engage?

What are some of the answers you’ve landed on regarding how we can get people more engaged in these big problems?

I think it’s a question of figuring out who needs to be engaged and determining the reasons they would want to engage versus what the inhibitory factors are. What are the behavioral factors in institutions versus individuals that would prevent them from engaging? It’s that process of understanding how people interact with these systems that’s really key. When you unpack all that, you start to understand why we’re having so much trouble solving the opioid epidemic or the antimicrobial resistance epidemic. To me, this is really a case of not so much the technology as it is what to do with the technology — and that’s really what most of my work is focused on.

I do a lot of work trying to balance the narrative. I have an operational role as well. I’m not just a researcher; I’m an applied researcher, and I have a very big operational role, which is to engage with commercial industry and with governments to try to help them understand the other side of the narrative. When we talk about worst-case scenarios, we always take it to the worst case instead of saying, “The reality often falls well short of the apocalyptic scenario. What is the range of potential outcomes?”

A lot of the work I do is calming people down, honestly, and showing them the reasons why they should calm down. If we overdo it with people — if we go too far with the hyperbole we see in the media, and even in some of the government communications — we back them into a corner. And when you back people into a corner with too much hype, the recipients tend to get panicky and fearful, and you basically see paralysis. They’re overwhelmed with complexity, and it becomes very hard to carry forward a productive conversation. I’ve gotten burned many, many times, so I’m speaking from the position of stepping on some land mines.

Is there a different way you approach institutions versus individuals when trying to avoid hyperbole while still getting people involved?

Yes, there are many different ways. It’s an exercise in complexity when you’re communicating with stakeholders. I think there’s a movement in the leadership world regarding how to train leaders that I’ve kind of glommed on to. Former Chairman of the Joint Chiefs of Staff General Martin E. Dempsey just published a book that I think speaks to this: Radical Inclusion. It’s really the issue of making sure you lead by empowering others, and empowering entire groups of people, even if they have dissenting opinions, to just say, “OK, we’re all in this together. We’re going to sink or float depending on how we do this together.” It’s challenging. When you’re dealing with people who are scared, you really have a tough challenge to make sure that people aren’t so fearful of what’s being discussed that they can’t engage intellectually or leave the emotions at the door and have a logical conversation.

Here in Nevada, my role is to be a facilitator. We’re addressing the antimicrobial stewardship issue because Nevada unfortunately is a state that struggles with antimicrobial resistance, like many other states, so it’s a real challenge, and the emotions are high. People are very fearful of this topic because antimicrobial resistance is a scary thing.

You’ve researched the responses to epidemics over the course of more than a century. What are your main findings about what has changed and what hasn’t?

It’s my opinion that people at the turn of the century were more resilient, in some ways, than we are. If you develop a health care system over time to defeat and prevent multiple causes of high morbidity and mortality, the social expectations for that standard of care rise with those improvements. We tend to become complacent and almost tend to be very brittle as a result. We don’t tolerate the reintroduction of a high-morbidity disease, so the fear factor and the ability to stoke fear go up tremendously. At the turn of the century, people were used to seeing their loved ones die from mortal disease. They were desensitized and used to seeing that. It’s that acceptance of death, if you will, that is actually a form of strength and resilience in and of itself.

That’s the biggest thing we’re seeing — the price that comes with improvements in health care is actually an intolerance of any [perturbation] of our baseline. That’s a challenge. The complacency also factors into the whole anti-vaccination debate. When you take these diseases away, people say, “Well, why are we vaccinating?” It’s a real challenge to explain that we can’t stop vaccinating because the indicator that the disease isn’t here means the vaccination was successful. It’s that discourse that becomes really challenging.

Another problem I’ve noticed is that public health is political health. The problem with public health writ large is that these institutions, and particularly the operational institutions, are often subservient to whatever political leadership is in power. And when you mix politics with health care, you often have suboptimal results. We know that. Public health is so politicized now that, in many ways, it’s almost been rendered ineffective. The trend that we’re seeing is a return of infectious disease as an important health care issue. There was a time when people thought we were overcoming disease, in the ‘60s and ‘70s — that we were getting ahead of it because of all our new vaccines and antibiotics — but that was a honeymoon. The honeymoon is over.

A lot of our countermeasures are stopgap countermeasures, because these pathogens evolve, and they evolve past our countermeasures. The system is not a static system. It’s very dynamic, and everything is a balance. What we’re seeing is a return of bacterial infections, but now they’re drug-resistant — so this represents a shift in the balance. There are a lot of challenges here about how we address the new world. We also have a major problem with abuse due to the advent of the countermeasures and the availability of all these medications. The drugs are now a source of trouble. The drug-resistant bacteria were caused by the overuse of antibiotics, in part, and now we’re getting into trouble.

How could the public health sector do a better job of creating that balance between the superior health care system we have now, in the 21st century, with the proper caution and awareness that these problems won’t go away?

I think we made the mistake of putting all of this on public health. Public health, to me, is a facilitator of the solution. It’s a key player at the table, but the challenge with public health is it’s poorly funded. It’s overtasked. It doesn’t have enough resources. It’s really a challenge expecting public health to stay ahead of a problem that it’s not really funded to engage in. It’s an issue of trying to say, “OK, is that the appropriate expectation?”

We need to start absorbing a lot of the health care responsibility into our health care infrastructure. Take basic vaccinations, for example. It used to be a public health function — you’d go to the public health clinic to get that done. Over time, we ended up including that in our routine business on the front line of medicine. If I’m a pediatrician, for example, I give vaccines to kids in my clinic. They don’t have to go to the public health clinic for that. That’s a very simple example.

On the topic of biological weapon deployment, is there anything you notice that media coverage or the general public tends to get wrong? For example, does it over- or underestimate the risk that it will happen to the American population?

I think there is tremendous uncertainty, so it’s easy to claim people are over- or underestimating something. The question is what has history shown us about these events so far? History has shown us that it’s actually quite difficult to collapse a human society due to any infectious disease, regardless of how it got there. There are very isolated examples of communities that were already dying — because they had depleted their local resources or were already vulnerable, thoroughly isolated and in small numbers, immunologically naive — where the community was tipped over the edge. But in terms of a broad nation, where you have disparate genetic backgrounds and large numbers of people heavily networked, it’s really, really unlikely to cause the collapse of a society using a biological agent. History has shown that humans are incredibly resilient. They really are, even if they receive a high-strike hit like that. In my research, I asked how long it took for a community to recover from a biological attack, and communities recover pretty fast. But yes, these events are acutely disruptive, socially and economically.

What is your role in helping to prevent something like a biological attack from having a large-scale effect?

The first problem is that the world does not have an effective warning system for these problems. Everybody keeps making an assumption that the World Health Organization is in charge — that it does this, that it’s flawless. The reality is that we don’t do after actions on warning failures. We slaughtered the intelligence community over the 9/11 attacks. The irony is that more people have died from some of our recent health security issues, such as Ebola, Zika and swine flu, than the number of people who died in the World Trade Center collapse, yet we have not had an open congressional review of the failures related to those events. To me, that’s a telling signal. We do not have a reliable warning system, and using a technology like Google as a warning system is not good enough. We need to have people who are involved in that warning system.

We need dedicated human beings with a sustainable framework who are properly funded to do this work for a living. I’m dubious that a government should own it, because as soon as politics take charge of something like that, you get political influence on how the information should be released, so it’s a devil of a problem. You have to have an unbiased warning system. There can’t be influence from political leadership when you’re trying to issue a hurricane warning, for instance. The same should be true about a public health threat. Unfortunately, our warning systems here are heavily politically influenced, and we see all kinds of issues with notifying the public about what’s going on. That’s really a huge part of my work: working toward a vision of fixing the problem so that we create resilience for the entire world.

With the Global Health Security Alliance, we’re trying to unpack the issues so that people understand what this is all about. That’s the first step: understanding the issues. A lot of people working in global health and health security make huge assumptions that we have this fantastic system of warning when we don’t. We’re not approaching the problem correctly and using best practices from the natural disaster community. We need to educate people on that shortcoming, and then we need to hold educational sessions and [write papers] that highlight and explain the nature of this issue and how we’re going to solve it. It’s a massive challenge, but it’s a worthy one. We’re going to try to figure out how to create a better warning system for the world when it comes to health security threats. This is a 21st-century challenge.

I’ve put out publications giving people hints of what the warning system would look like. The stage we’re at in the process is first defining the nature of the problem. Then, over time, in the context of discussing that, we say, “OK, here is what that solution looks like.”

Could Dr. Wilson check this word? We weren’t sure what exactly this was, or if it was correct.

 

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