The TED Interview
A future without pandemics? with Mark Smolinski
October 20, 2022
[00:00:00] Steven Johnson:
Welcome to the TED Interview. I'm your host, Steven Johnson. A few weeks ago, President Biden triggered a small controversy during an off-the-cuff interview on 60 Minutes by remarking that the COVID pandemic was over. But one thing that might have got lost in the soundbite was Biden stressing that the fight against Covid continues.
Our guest this week, Mark Smolinski, has been a major participant in that fight, but he's also devoted much of his career to an even more ambitious goal: not just ending the current pandemic, but ending pandemics altogether. That may seem overly optimistic at a time when more than a thousand people are still dying all around the world each day in our third year of the Covid crisis.
But Mark is so committed to this long-term vision that he founded the organization Ending Pandemics, where he leads a team of innovators working to improve early disease detection and rapid response in the hotspots for emerging diseases. Before that, Mark served as the Chief Medical Officer and Director of Global Health at the Skoll Global Threats Fund, where he developed the Ending Pandemics in Our Lifetime initiative in 2012, he was also one of the creators of the influential disease tracking program, Google Flu Trends.
He's worked in the office of the US Surgeon General and at the CDC. He was also one of the scientific advisors to the unnervingly prophetic 2011 film Contagion, which managed to anticipate with remarkable accuracy many of the elements of the Covid Pandemic that emerged a decade later. One of the true visionaries from the field of public health explains how we can rid the world of pandemic disease.
That's next on the TED interview.
[00:02:06] Steven Johnson:
Mark Smolinski, welcome to the TED Interview.
[00:02:08] Mark Smolinski:
Well, thank you for having me. Delighted to be here.
[00:02:12] Steven Johnson:
You've been thinking about and working on preventing pandemics and other health threats for just about three decades now. So we're thrilled to have you on the show to talk about, you know, where we are with the current crisis and, and how we can prevent future pandemics down the road.
But I, I wanted to start the conversation by asking you really about, about the kind of origins of your career back in the, in the early nineties when you played a, a key role in identifying a new strain of hantavirus. Um, I, I, I, I'd love to hear more about that experience ‘cause I think there's something about tracking down and identifying these emergent threats. It's, you know, it's just so fascinating. It's kind of a detective story on some level. Um, how did you find yourself on that case?
[00:03:00] Mark Smolinski:
Well, it's interesting that you say it's a detective story because “threat detective” has been the handle, uh, that I've had on my email since that time, uh, when we didn't have the luxury of the internet and so forth in an outbreak that, uh, I was still a resident in training. Uh, there was a report of young people, literally in their twenties and thirties previously healthy, developing this acute flu-like illness, but literally dying, uh, within a couple of days from complete respiratory failure. And so it was a, a mystery that literally as most, uh, outbreaks first get detected was only because some physicians in New Mexico were discussing this in the doctor's lounge about you know, these young people who had passed away so quickly.
And lo and behold, I was at the Arizona Health Department and we had our first cases in Arizona, and it turned out the first initial cases were all in the four corners region of the United States. Um, but it was an incredible new virus in a sense, because hantavirus had been known as a pathogen predominantly in Asia, but it had always had hemorrhagic fever and renal disease.
And I'll never forget the blackboard, uh, that we had in the health department. And we just made a list of every potential thing we thought this could be, and hantavirus wasn't even on the list because it had never been known to cause respiratory failure. And certainly something, uh, that quick and that severe.
[00:04:49] Steven Johnson:
It's kind of an incredible coincidence on some level that you just happen to be there. I mean, that was a very unusual event in terms of United States health, right? I mean, there, there aren't that many—
[00:05:00] Mark Smolinski:
[00:05:00] Steven Johnson:
—you know, completely new rogue strains of a virus that, that appear, and you just happen to be there.
[00:05:04] Mark Smolinski:
And what's interesting is now you hear a lot of talk about what they call “One Health”, which is really recognizing that humans, the animals in our ecosystems are all related, especially when it comes to infectious disease. But even back then, in 1993, it was the perfect example of One Health because when we had gone up onto the Four Corners region to look at the initial cases, um, we had kept hearing from, you know, locals on the reservation about piñon nuts. And, you know, we're thinking, “Could they have been contaminated?”
And this is like some huge acute, you know, fulminate pneumonia, uh, from, you know, a toxin or something in the environment. But I had just moved to Arizona after living in Michigan my entire life, and it was in November of, uh, 1992, and I couldn't believe that I moved to the desert, and all it did was rain. Rain, rain, rain, rain, rain.
And I thought, Well, okay, maybe they have this like rainy season in the desert. Well, it turned out that was a huge El Niño event, and it was the most rain they've had in decades in that region. And the result was the piñon nut was the food for the deer mice in that particular area of the world. So the population just exploded due to this availability of food source.
And so all of these rodents were living in the cabins and in the, you know, places where people only went like over Memorial Day weekend to open them up on the lake, and so forth, and swept up all this rodent dried urine feces and inhaled that. And that was how hantavirus, which was carried through these deer mice as part of something they live with, it apparently doesn't cause any illness in the mice themselves, but it was that amount of virus being shed in the urine and feces, uh, that was the cause of the outbreak.
[00:07:05] Steven Johnson:
Yeah, that's exactly the kind of detective work that, that I just think is so extraordinary. What ended up happening in, in terms of the hantavirus outbreak?
[00:07:13] Mark Smolinski:
So the initial outbreak had, a case mortality rate of about 75%, uh, which as more cases were identified, dropped about 50%. Was still was a very—
[00:07:26] Steven Johnson:
[00:07:26] Mark Smolinski:
—A lethal disease, but we didn't really have, hou know, the human-to-human transmission that you see with COVID, and you know, quite quickly when we figured out what it was and what the cause was, the preventive measures were very simple.
You know, you mix some bleach in a 10% solution with water and you, you know, put a mask on and you spray down your cabin and leave all the windows open until all of that liquid dries. You can clean it and there was no, you know, risk further on and, and we were able to stop the outbreak.
[00:07:58] Steven Johnson:
We've already had more coverage of rodent feces on this episode than we have in any of the other episodes so far. So it's, it's, we're already into the good stuff. I, I like this lot, but just a couple of stops along the way in your career that I want to touch on, um, before we get to the present, um, one of which is a, a fascinating and very influential project you were involved with in, in a crucial way, um, which was Google Flu Trends.
You know, one of the first cases where we were trying to use kind of public big data to look for patterns of, of, of disease using the internet, using search. Um, how did that come about? What was that, what was that project like?
[00:08:38] Mark Smolinski:
Yeah, so that was a great, uh, opportunity. I came out, uh, to help them start Google.org. And you know, one of the first things was what could they do that was unique, uh, to really contribute to disease surveillance? And so this is when I learned a lot, uh, from the engineers. They're like, “Don't tell us how you wanna solve the problem. Just tell us what the problem is and we'll figure out how to do it.”
And so the idea was could you look at what people were searching on Google, assuming that you would probably go to the internet when you're first sick and try to see, you know, where's the clinic or what are the symptoms and so forth, and could that help us understand where influenza was heading? Then we decided to go with a disease that had a unique pattern or footprint.
So influenza in the United States, you know, we have the flu season and then we have the non-flu season, and then we have the flu season again, and so there’s a really nice curve that goes up and down, and they needed something like that because their solution was, you know, I would've thought, “Well, let's pick the terms that we think people are looking at for flu or fever.”
And they're, they're like, “No, we can run all of the data coming through Google, aggregated and anonymized, and look to see what matches the curve, what, what terms are people searching that follows that same pattern of flu.” And that's how Google Flu Trends came to be. And they added up the terms that match that curve until I think we came to 45 terms or somewhere around there.
And those terms, which we've never shared because when I would present this at public health meetings, I would always get pushback like, “Well, you need to let us know what the terms are,” and I’m like, “The tool works. Do you want the tool to work, or do you really need to know what the terms are?” Because here's how it was built, and people understood.
Yeah, so the idea was to get advance warning, and well, you know, we were very interested in the parts of the world where we knew diseases were emerging, but you know, you had to have, obviously a significant amount of people using Google in that particular area of the world to really be able to pick up a signal.
And most diseases don't have necessarily the seasonality that we were able to create this tool for. And so, you know, we've now, uh, moved beyond even the idea of just looking at automated things to directly engaging communities to say, “If we could find signals in a community ‘cause people are on the computer and searching for things, why aren't we just asking people on a regular basis, like every Monday when you get this ping, ‘Hey, how were you feeling last week? Were you sick or were you healthy?’”
And you know, starting to look at signals in space and time directly coming from communities, and the huge advantage there is we didn't know anything about the people who were searching on Google because it was all aggregated and anonymized in order to be able to build such a signal.
Well, now that people are volunteering to be in their community as part of, uh, disease surveillance, then immediately, you can have prevention or messaging going out, including, like, where to get vaccinated and other things that are really relevant to stopping, you know, the, the spread or even preventing spread to new communities.
And that's really where we've now moved on beyond this, you know, what we would call digital disease detection, uh, system like Google Flu Trends to now what we call participatory surveillance, where people are really part of the solution themselves.
[00:12:21] Steven Johnson:
I did want to make one other kind of stop in your, in your career history, which is your, your work on the film Contagion, uh, the harrowing, uh, Steven Soderbergh film about a pandemic that I think Larry Brilliant also was a part of as well.
And, you know, that film is very celebrated, rightly celebrated for, you know, this extremely, um, realistic portrayal of a pandemic. Um, and in many ways prescient, uh, portrayal of a pandemic. Uh, I'm curious about the process, uh, for dreaming up that scenario. How did you all kind of decide what the kind of general outline of that particular outbreak was gonna be?
[00:12:58] Mark Smolinski:
I had been living in Cambodia for Google, um, because we were spending a lot of time helping with bird flu in the region. So I ended up living there and at that time, Larry had left to go over to start the Skoll Global Threats Fund. And he had made them promise when he left Google that he could take me with him.
And so, I said, “Okay, yeah, Larry, I'll come and join you.” And so the first day I showed up in the office, he hands me the script and he said, “Okay, our first job is to make sure that this movie, that Participant Media is going to make is scientifically sound and we can stand behind everything that's in this movie.” I thought, “Oh, that's gonna be great.”
So it was already written. Scott Burns, brilliant writer. Um, I took the script home. In fact, I still have it because it's all watermarked for Larry. So he would be responsible if, like, that ever leaked at the time. And I wrote on the back ‘cause I still have it to this day. I said, “Where are all the dead animals?” Um, because I was like, this is an incredible, incredible, uh, you know, pandemic that, you know, really accounts for the realities of the threats we worry about.
I mean, they're zoonoses, you know, they're gonna jump from animals to humans. And that's been the majority of the cases and most of the cases of the, you know, recent, uh, epidemics and pandemics. And so that was, I just don't remember. It was my first impression, which now as I think about it, in telling you the story of hantavirus really was a dumb reaction to write on there because there were no dead mice from hantavirus. Just dead people.
[00:14:43] Steven Johnson:
To turn now to COVID, one question I, I, I'd love to ask you is right before the outbreak, uh, you know, how ready did you think we were? I mean, if I had, if I'd been talking to you in, in October 2019, say. And I'd said, “Okay, you know, there's gonna be an outbreak of a, of a novel coronavirus in, in China with an initial fatality rate higher than, than flu and, you know, a, a strong knack for asymptomatic spread,” um, what would you have said our preparedness for that was gonna be like? What would you have imagined the, the outcome to be, you know, sometime in, in 2019?
[00:15:29] Mark Smolinski:
Well, I would've told you we weren't ready just from watching something a few years earlier when we had a few healthcare workers coming back from the Ebola crisis in West Africa, and diagnoses even being missed from a related case, you know, that showed up at a tertiary hospital that these are our pipelines of readiness and you know, what preparedness plans have been written for. But watching, you know, sort of the mishandling in many cases of something that, you know, was not a pandemic threat by any means… But if this, if these were the same institutions and systems that our preparedness plans are really built upon, I was worried.
[00:16:26] Steven Johnson:
Were you surprised at the wave of kind of anti-science or anti-public health sentiments that, that emerged in the, in the COVID crisis, or was that something that you anticipated coming as well?
[00:16:39] Mark Smolinski:
Uh, no, we're certainly in a, a different era. I mean, when I think back in hantavirus, you know, where we were faxing information from, you know, the New Mexico Health Department to Arizona and to the other two states that were involved in that, to now, you know, a 24-hour news cycle, let alone social media cycles, and so certainly misinformation has been a public health challenge on many different fronts.
You know, certainly for vaccinations and the safety of vaccinations prior to COVID, uh, has, you know, raised those issues that that's the reality of the world we're living in. And something that, uh, unfortunately, is what we have to deal with when it comes to this crisis. But you know, what I saw from my perspective, which was unfortunate, is that politics took a very front seat in the US response to Covid. So, you know, there are things that we were prepared for, but you know, you have to have the political will to treat this emergency as it is a public health emergency, and time matters.
You know, all, everything you do early, from detection to response is just exponential of savings of lives, uh, the earlier you work. So yes, I mean, it's hard here because we made a lot of missteps, and then I think the door just opened the floodgates to easily criticizing science, and anybody, you know, uh, who was fair game in, in sort of the whole arena of players that it takes to respond to a threat. So it's very, very unfortunate, but I don't think that that is common across the globe. Um, but certainly here in the United States, uh, we saw a real attack on science.
[00:18:34] Steven Johnson:
Yeah. On the global side of things, is there a country out there that you think is, has done a particularly admirable job, um, that we can learn from their success?
[00:18:45] Mark Smolinski:
Well, I certainly have to say Cambodia since I lived there and, you know, really helped them advance their early detection over several years. And they have done incredibly well because they created a national hotline, uh, which was a system that we helped think through by bringing technologists from that country together with their ministries of health and their ministry of agriculture to say, “Hey, you know, what could we be doing to find outbreaks faster and respond to them quicker in Cambodia?”
And the Minister of Health was one who challenged whatever the solution was, it literally had to be available to every citizen in the country. And so the National Hotline was born, which is a free service because all of the telecom companies collaborate and make it free, uh, no matter what your device is or who your provider is, and it had been operating for six years prior to COVID, and it was getting 600 phone calls a day, and 20 to 30 per month for a true animal health or public health, uh, event that needed a, a response.
And the immediate response and the feedbacks from the community on seeing this hotline and how action resulted, um, became more popular. So during COVID, they were getting 18,000 phone calls a day, and it became the primary means of communication of what to do and what resource was available to the entire general public. So it's been an amazing tool and because the hotline was so prevalent and everybody knew about it, that to do true contact tracing, which we completely failed to do here in the United States, but Cambodia was still successful in really tracking the contacts of every case. They were able to use the hotline, so if a contact di—was in quarantine or isolation and needed to be checked on every day, they could just do the reporting that they were okay, um, through the hotline.
And then they only needed to send a healthcare worker for people who were reporting with symptoms. And they were able to manage a huge contact tracing system where, you know, 90% of it or greater was completely automated because they used this hotline for that function and that's how they were able to keep up.
And they've been really doing quite well. And, um, it's been great to see. As have many of the countries in Southeast Asia who experienced SARS 1, uh, you know, back in 2003 and had that experience of what it takes to really get communities involved in universal mask wearing and avoiding, you know, large gatherings and so forth force.
[00:21:47] Steven Johnson:
Bringing up the Cambodia project is a, is a great segue because I, I wanna talk about the future and, and you've written a very powerful essay recently on, on preventing, uh, future pandemics. Your organization is called Ending Pandemics. Not, you know, not about ending this pandemic, but ending pandemics altogether.
Um, and you talk in, in, in this new essay about participatory surveillance like the Cambodia hotline and, and other examples we've talked about. Is there, uh, if you could kind of wave a magic wand and create a system in the United States, uh, along those lines, you know what, what would that be?
[00:22:25] Mark Smolinski:
Well, we did create one in the United States for flu after Google Flu Trends, uh, you know, was a success in seeing what we could see from data online.
And then after making the movie Contagion, um, there was a campaign that went along with the movie, and part of the campaign was challenging communities: what are you gonna do to prepare for the next pandemic? And I had always wanted to, like, take Google Flu Trends and say, “Why don't we create something like Flu Near You where ask people to tell us their symptoms?”
And the idea was, well, if, you know, gave us a chance to figure out: what does it really take to get the public to report? Is it reliable? You know, uh, how long will they do it? And, you know, can you find this signal? And it was a huge success.
And in fact, what's interesting, you're in Brazil, uh, one of the first people who contacted us after Flu Near You was clearly making a lot of headway, the Ministry of Health said, “Hey, we're gonna be hosting the World Cup. Um, could you build a system like Flu Near You and have people coming from around the world, like, monitor whether they're healthy or sick while they're at the World Cup?”
And we thought it was an incredible idea. We hadn't even thought about doing it for a mass gathering. And so everything that we've supported, including Flu Near You in other countries around the world, it's all open source. Uh, the code is available to anybody. Um, but we've always partnered governments with technologists within their own country.
And today they're using participatory surveillance in Brazil, uh, to monitor all kinds of diseases. And it was very helpful when Zika, uh, was there and they had already had a system in place. Again, I think it, it compliments the, the message for Cambodia where we have great opportunities to do better disease detection in all communities, and that's the way we're gonna move from, you know, even as exciting as it is to be finding outbreaks faster by engaging the community.
If we start thinking differently about how we're monitoring the animal health, the environmental health, and other issues, we could start getting to predicting and preventing, uh, these outbreaks without any human disease. And that's when it gets really exciting.
[00:24:39] Steven Johnson:
Another question about the, the human side. What's your take on kind of smart thermometer-like technologies where you, you get kind of just data coming in from people with, with just, you know, temperature readings? Um, there was a little bit of that at the beginning of COVID. Is that also in our future?
[00:24:56] Mark Smolinski:
Absolutely. So I remember being in Cambodia and I had, um, my Fitbit on. And, I wasn't really feeling well, and I looked down and I could see like my heart rate was like 105, and you know, usually, it's like 75, 80, and I was like, “Oh man, I must have a fever.” But that, you know, to me was like, “Wow, you know, that was my signal that something wasn't right.”
I've said this for a while. I think I still believe it, although now it's so easy to have added value from other things, but fever surveillance alone might be the single most important thing that we could track. I mean, if we knew true fever, I mean, you know, people would literally need to be monitoring, uh, you know, their temperature because, you know, people think they have a fever and they don't, or vice versa. So like, you know, we really do need to think about the opportunities that if we could do true fever surveillance, and you're looking at that in time and space, that could be one of the earliest signals that some communicable event is happening.
And in fact, in medical school, the cases we were concerned about the most were the fevers of unknown origin. When you had a febrile case in the clinic or in the hospital, and you could not determine the origin, that's the most frustrating thing because it could be the next HIV or the next hantavirus or the next COVID.
[00:26:27] Steven Johnson:
And the new generation of smartwatches are now starting to have temperature sensors on them.
[00:26:32] Mark Smolinski:
[00:26:33] Steven Johnson:
So you'd just be, you know, collecting, you know, you just, if you have even, you know, 10 million people across the country who are wearing a, a temperature sensing smartwatch and reporting that data anonymously, but geographically, you know, pinpointed that, that’s a lot of data.
[00:26:48] Mark Smolinski:
It's a lot of data. And that's where public-private partnerships could really play a role is, you know, some of these automated thermometers and so forth, you know, are in the private sector. So, you know, in the same way when the Google engineers built Google Flu Trends and anonymized and, and anonymize and aggregate all that data, so that signal could be useful to public health, but you know, the downside is we can never track back, you know, any individual and so forth.
So as people are volunteering, are part of their community surveillance system, you know, the more data that either they're willing to share on their own or that we get anonymized data from these private sector partners who have, you know, the real value in, in getting a, a bigger picture, uh, that's when we're really gonna change the, the community, uh, signals that come out.
And the more we can get the private sector within these hotspot areas of the world to understand the role, you know, like the telecom companies did quite quickly in Cambodia when they realized, you know, the bandwidth that was needed to be helping with this hotline over their overall, you know, uh, company model, they were very happy to contribute that to public health. And in many cases, we hear from the private sector, they just don't understand the role that they can play. And most of 'em are very happy when they understand there's something very specific that they can do and, and are more than willing to help.
[00:28:14] Steven Johnson:
We have been talking mostly about, you know, naturally occurring viruses. How much time do you spend worrying about and how much time should we spend worrying about engineered threats? Um, you know, do, do you think that a future pandemic could be started via some kind of by a weapon or, or kind of a, a viral terrorist attack of some sort?
[00:28:38] Mark Smolinski:
Uh, I certainly think it’s possible that, you know, those kinds of events, uh, we may see in the future. You know, everything that we've seen in the recent past, obviously people have considered, “Could it be bioterrorism?” And, and that's something that you always need to think about. Um, because in all cases, and certainly the work that we've done around the world, um, we look at the whole spectrum of what's possible from what we call BioWare, to bio-terror, to Mother Nature. Anything’s possible at the beginning, and if you don't have all of those radars going, you could be missing something that's really important in the prevention and control. So, you know, we've gotta think about, uh, all three scenarios whenever there's a new outbreak.
But when you think of probably why someone may do an agent of terror, to really evoke terror. But if they released it to eliminate humanity, then it kind of defeats the purpose, even for their own, uh, population that they may be trying to preserve.
[00:29:47] Steven Johnson:
So let's try and wax optimistic here just for a second ‘cause we've spent a lot of time talking about threats. Um, do you think there is actually a future scenario where humanity itself can look back and say, “We, we ended the threat of, of pandemic disease, um, through a combination of the things that we've been talking about in this conversation”?
[00:30:08] Mark Smolinski:
Yeah, absolutely. Um, it's hard not to talk about threats and you know, go down what might seem pessimistic, but I've always been optimistic.
It's the reason, you know, I'm in the field and you really take the challenges that we've come to see as, you know, true challenges that can be overcome. And we're incredibly optimistic in the partners that we've worked with across the globe that have really, you know, shown us that it's, you know, not impossible to do anything when you have the political will and the public will combine to really not be afraid to innovate and to try something new. That's where the promise that we see is happening. And so countries are breaking down those silos. They're bringing those sectors together. They're trying innovations and surveillance. They're finding outbreaks faster.
We've made incredible progress in the last decade. That, you know, from taking months, uh, to find outbreaks just in the early nineties, to finding outbreaks now within days in most every area of the world. And so the more we take this technology that exists and apply it, uh, to public health in the same way we apply it to the business sector, the financial sector, and really take, um, this public good that we all need to be part of, if we want to prevent pandemics…
And if we don't do it, it will be our own fault because the technology, the science, and like I said, the willpower, I think both politically and publicly are there, and we can't, you know, hit the snooze, uh, on the alarm that went off for COVID. Uh, let's take this opportunity and run with it because, uh, the future is ours to really. And one without pandemics in it is fine by me.
[00:32:12] Steven Johnson:
Well, Mark Smolinski. You know, I think one of the challenges about public health work is when people are healthy, um, they tend to not recognize the importance of people who are working in defense of the public health.
Um, one of the things that happens in a pandemic as we suddenly realize the value of all that work. Uh, and so we really appreciate everything you've done over the years and the work you're gonna continue doing keeping us all safe. Thanks for, thanks for being on the podcast.
[00:32:37] Mark Smolinski:
Well, thank you for having me. It was a real pleasure.
[00:32:41] Steven Johnson:
That's it for the show today. The TED interview is part of the TED Audio Collective. This episode was produced by our managing producer, Wilson Sayre, and mixed by Erica Huang. Sammy Case and Jimmy Gutierrez are our story editors. Fact-checking by Aparna Nathan. Farrah Desgranges is our project manager, and Dan O'Donnell is our executive producer.
Special thanks to Constanza Gallardo, Michelle Quint, Anna Phelan. I'm your host, Steven Johnson. For more info on my other projects, including my latest book, Extra Life, you can follow me on Twitter at @stevenbjohnson or sign up for my Substack newsletter: Adjacent Possible.