Dr. Wilmot James: from fighting apartheid to preparing for the next pandemic

Dr. Wilmot James has spent much of his life fighting threats to his country. As a young man, the chief threat was apartheid rule. But after the newly democratic South Africa was born and Dr. James became a parliamentarian and then a Senior Research Scholar at the Institute for Social and Economic Research and Policy at Columbia University, those threats included the Zika virus, Ebola, HIV and AIDS, and most recently COVID-19.

All this research and policy work has positioned Dr. James as an internationally recognized leader in pandemic preparedness and biosecurity, with a special focus on fast and effective early warning systems. “The faster you detect a threat, the faster you can respond to it, and the more lives you can save,” he said.

Exemplars News spoke with Dr. James, who now serves as Senior Advisor to Brown University’s Pandemic Center about his ongoing research on early warning systems, about the International Conference on Public Health in Africa (CPHIA) taking place this week and fostering the next generation of pandemic decision makers.

How did you become interested in pandemic preparedness and early warning systems?

Dr. James: I trained as an academic, a sociologist, and an African historian. I also chaired a government commission for South Africa on refugee protection and immigration and was a member of an electoral reform task team. Then I spent nine years as a member of parliament in South Africa, responsible for education, trade and industry, science and technology, and health.

During my parliamentary period, we had to deal with the 2014 West Africa Ebola and Zika outbreaks, and I started to become involved with pandemic preparedness and response as a legislator.

The basic issue is that a lack of preparedness and response capacity means that people will die. Pandemics always bring surprises and, therefore, there is no such thing as perfect preparedness. But, when we do not use experts, science, and systems to stop or mitigate the spread of novel pathogens, our failure is not technical but moral. Human lives are at stake. These deaths can be prevented.

As a parliamentarian, I committed myself to mobilizing our experts, technology, and science to stop these preventable deaths. I am particularly focused on improving early warning systems because, if you have effective early warning systems, you can act quickly enough to save lives by preventing an outbreak from taking hold.

There seems to be varying definitions for early warning systems. How do you define the term?

Dr. James: Early warning systems include both the tools we need to detect emerging pathogens and the means for experts, countries, and organizations to respond swiftly to identified threats. You could argue that the term should really be early warning and response systems.

Effective early warning systems rely on multiple streams of surveillance information. These streams of information can be broadly separated into two categories: indicator-based and event-based surveillance.

Indicator-based surveillance traditionally relies on patient diagnosis and laboratory testing in hospitals or clinics and requires patients to present to a physician or a hospital. In general, these streams of information detect potential threats more slowly, often after they have potentially spread through the community. COVID-19, for example, was first reported by a doctor who saw a cluster of symptoms in his patients that seemed very unusual to him, and he reported that. But by then, it was too late. It had already been spreading widely in the community.

Meanwhile, with event-based surveillance, information is compiled from multiple, unstructured data sources collected at any time and does not rely on patients turning up ill at a health clinic. These systems can tap for data resources such as front-line community health workers spotting something unusual and reporting it. It can even be a rumor or something that pops up through social media that gets reported. It also includes environmental observations that pose vulnerabilities such as flooding that might spark a cholera epidemic. Some countries have active testing, where teams of experts visit communities and actively test for a pathogen. The challenge with this mode of surveillance is that it can be difficult to spot a real threat-signal amongst all the noise that is generated.

Sometimes, even when a pathogen is detected, reporting that pathogen to trigger a public health response often comes too late, if it comes at all. We saw this play out with many countries’ early responses to the COVID-19 pandemic when established public health interventions such as social distancing, widespread testing, and quarantine measures were not implemented until well after the virus had achieved community spread. These measures may seem costly and extreme at first glance, but, as we have seen with COVID-19, the upfront costs of these interventions are greatly outweighed by the human, social, and economic losses caused by a pandemic.

Disease surveillance and early warning systems are getting a lot of attention in the global health community right now. Can you share with us some of the new investments and research projects in this space?

Dr. James: Yes, to give you some really big examples, WHO launched its Early Warning, Alert and Response System (EWARS) which is designed to improve disease outbreak detection in emergency settings, such as in countries in conflict or following a natural disaster. It is a simple and cost-effective way to rapidly set up a disease surveillance system.

The newly established Pandemic Fund at the World Bank recently awarded its first set of proposals, with an emphasis on strengthening disease surveillance, laboratory systems, and health workforce. Thus far, 37 countries in six regions have received US$338 million in grants in this initial set of awards.

The Global Fund is investing in a number of lower- and middle-income countries to strengthen early warning systems and pandemic preparedness.

Earlier this year, Wellcome Trust announced funding of 24 research teams in 12 countries around the world to develop innovative digital tools to model the relationship between climate change and infectious disease transmission in order to improve early detection.

Also, earlier this year, the Africa CDC launched its continent-wide event-based surveillance network.

And there are many other initiatives, including the Health Security Partnership to Strengthen Disease Surveillance and Epidemic Intelligence in Africa, founded by a partnership between the WHO Hub for Pandemic and Epidemic Intelligence, the Africa CDC, the Robert Koch Institute and the Global Partnership Against the Spread of Weapons and Materials of Mass Destruction. It is an 18-month-long pilot project to strengthen event-based surveillance systems in six African countries: Tunisia, Morocco, Mali, Gambia, South Africa, and Namibia. That partnership will also strengthen biosecurity as research on dangerous pathogens continues in those countries.

This week, Exemplars in Global Health and the Pandemic Center at Brown University School of Public Health will also announce a new research project on early warning systems at the Conference on Public Health in Africa (CPHIA). We call our project Advance Warning and Response Exemplars (AWARE) and believe it will add value to all of these other global and continent-wide efforts.

Tell us about AWARE and what knowledge gaps the initiative will address.

Dr. James: AWARE will look at the issue of pandemic surveillance through two different lenses. The first lens will build on past Exemplars in Global Health research on COVID-19 response by studying positive outliers – in this instance – for implementing robust early warning systems for climate-sensitive infectious diseases. We are looking at innovations that emerged in a number of countries that can serve as best practices when it comes to successful early detection and response.

The second and very exciting lens we will use in this research is to examine the linkages between climate and infectious diseases and identify best practices in using climate data to forecast disease outbreaks. We hope this can contribute to establishing climate-sensitive tools to forecast disease outbreaks.

We have selected four countries as case studies for this research: Brazil, Kenya, South Africa, and Vietnam. We selected these countries for their geographic diversity and because we determined that these countries have been implementing innovative practices. In particular, they are beginning to use climate data to assess disease risks. They have also introduced innovations in their event-based surveillance systems, including the use of epidemic intelligence from open sources, wastewater surveillance, laboratory systems innovations, and improvements in diagnostic capabilities.

Can you tell us a bit about using climate data in monitoring health outbreaks?

Dr. James: Usually, climate data is used for agriculture. But countries are starting to also use it for health, that's an innovation.

Using climate data to look at disease risks might include looking at weekly rainfall patterns to predict the distribution of disease-carrying vectors like mosquitoes to better prepare communities and the health system for potential disease outbreaks.

For example, if you can more accurately predict the path of a typhoon and, therefore, the possibility of massive floods, you are better able to implement interventions to deal with the treatment of cholera. You can prime your public health interventions far more clearly and precisely if you are able to have an early warning system that can utilize climate and environmental data.

We’ll be discussing this at our side event at the CPHIA and I think it's going to be fascinating. We’ll feature a variety of speakers to discuss: what exactly are climate signals when it comes to detecting possible outbreak threats? What are the factors and indicators that are used for early detection?

What does success look like for AWARE?

Dr. James: AWARE’s goal is to identify innovations, particularly in low- and middle-income countries where we may least expect it. We want to document those exemplary practices through our research and turn them into best practices that can be used in other contexts, so we are better prepared before the next pandemic. We don't know exactly when the next pandemic will occur and which pathogen will cause it, but we know there's an increasing cycle of emerging pathogens that will bring harm. For this reason, AWARE is a forward-looking effort.

You co-teach a course at Brown University called Pandemic Game Changers, which is intended to train the next generation of decision makers to prevent, prepare for and respond more effectively to health emergencies. What game changers related to health emergency preparedness and response have you identified that might be of interest to public health decision makers?

Dr. James: An example of a game changer is Taiwan's integrated national surveillance system where all the information coming through the system is sent to a centralized location where it is analyzed, digested, and used to target interventions. Based on that, the government can make informed decisions about where to put resources. Taiwan is a country that fared comparatively well during COVID-19 and this system likely contributed to that.

Another example is South Korea and its effective testing response to the COVID-19 pandemic. Coming out of its experience with the Middle East Respiratory Syndrome coronavirus in 2015, South Korea was able to conduct large-scale testing to detect diseases and target support and resources, including the use of an integrated information, communication and technology-based system that links data systems across sectors.

One of the most important things that we must take care of is to make sure that there is sustainable financing in the long term to support these innovations and exemplary practices.

How can we convince leaders to support this work?

Dr. James: Well, the first thing to communicate is that preventing a pandemic is the best way to save lives. The second is that, along the way, you create jobs and opportunities in an expanding health care sector. Even in poor countries, there's an incipient bioeconomy emerging. We can create an ecosystem whereby new technologies and systems can emerge in places other than the developed world.

Most importantly, we have to convince decision makers to do three things in this post-pandemic world. We have to train the new generation of global pandemic decision makers across multiple sectors. We need to do this everywhere and encourage collaboration between universities across the globe. We have to bolster and strengthen our surveillance and response systems, which is what we're doing with the AWARE project. And, lastly, we have to decentralize vaccine manufacturing.

Those three things are what I call the hymn sheet of pandemic prevention. We all need to be singing from that same hymn sheet.

This interview has been edited for clarity and length.

Editor’s Note: The AWARE project event at CPHIA will take place on Thursday, 30 November 2023 at 7:00AM CAT in Mulungushi International Center, Room 3, Old Wing.