Feature THE PROBLEM WITH PANDEMIC PLANNING Two decades of war-game scenarios foresaw leaky travel bans, a scramble for vaccines and disputes between state and federal leaders. But none predicted Donald Trump. By Amy Maxmen and Jeff Tollefson ILLUSTRATION BY ANA KOVA ANA BY ILLUSTRATION ike all pandemics, it started out small. Morhard was not the only one sounding 150,000 deaths, the country has proved itself A novel coronavirus emerged in Brazil, the alarm. Event 201 was one of dozens of to be one of the most dysfunctional. Morhard jumping from bats to pigs to farmers simulations and evaluations over the past and other biosecurity specialists are asking before making its way to a big city two decades that have highlighted the risks what went wrong — why did dozens of simu- with an international airport. From of a pandemic and identified gaps in the lations, evaluations and white papers fail to there, infected travellers carried it to ability of governments and organizations predict or defend against the colossal mis- the United States, Portugal and China. around the world to respond. steps taken in the world’s wealthiest nation? Within 18 months, the coronavirus had The exercises anticipated several failures By contrast, some countries that hadn’t ranked Lspread around the world, 65 million people were that have played out in the management nearly so high in evaluations, such as Vietnam, dead and the global economy was in free fall. of COVID-19, including leaky travel bans, executed swift, cohesive responses. This fictitious scenario, dubbed Event 201, medical-equipment shortages, massive dis- The scenarios still hold lessons for how to played out in a New York City conference cen- organization, misinformation and a scramble curb this pandemic, and for how to respond tre before a panel of academics, government for vaccines. But the scenarios didn’t antici- better next time. Deadly pandemics are inev- officials and business leaders last October. pate some of the problems that have plagued itable, says Tom Frieden, a former director of Those in attendance were shaken — which is the pandemic response, such as a shortfall of the US Centers for Disease Control and Preven- what Ryan Morhard wanted. A biosecurity diagnostic tests, and world leaders who reject tion (CDC). “What’s not inevitable is that we specialist at the World Economic Forum in the advice of public-health specialists. will continue to be so underprepared.” Geneva, Switzerland, Morhard worried that Most strikingly, biosecurity researchers world leaders weren’t taking the threat of didn’t predict that the United States would be More than a game a pandemic seriously enough. He wanted among the hardest-hit countries. On the con- Pandemic simulations first started gaining to force them to confront the potentially trary, last year, leaders in the field ranked the popularity in the 2000s. Biosecurity and immense human and economic toll of a global United States top in the Global Health Security public-health specialists took their cue from outbreak. “We called it Event 201 because we’re Index, which graded 195 countries in terms war-game exercises used by the military, in an seeing up to 200 epidemic events per year, and of how well prepared they were to fight out- effort to stress-test health systems, see what we knew that, eventually, one would cause a breaks, on the basis of more than 100 factors. could go wrong and scare policymakers into pandemic,” Morhard says. President Donald Trump even held up a copy fixing the problems. In these round-table The timing, and the choice of a coronavirus, of the report during a White House briefing on events, academics, business leaders and proved prescient. Just two months later, China 27 February, declaring: “We’re rated number government officials made real-time decisions reported a mysterious pneumonia outbreak in one.” As he spoke, SARS-CoV-2 was already to deal with an expanding crisis, laid out in the city of Wuhan — the start of the COVID-19 spreading undetected across the country. television-news-style reports. pandemic that has so far killed around Now, as COVID-19 cases in the United Two early simulations involved biological 650,000 people. States surpass 4 million, with more than attacks, in which other countries unleashed 26 | Nature | Vol 584 | 6 August 2020 ©2020 Spri nger Nature Li mited. All rights reserved. ©2020 Spri nger Nature Li mited. All rights reserved. smallpox in the United States. Operation 11,000 people — roughly half of those infected. Dark Winter, in 2001, and Atlantic Storm, in In response to the drumbeat of epidemics, 2005, were orchestrated by biosecurity think the United Nations commissioned a panel to tanks in the United States and attended by explore how the world could better prepare influential leaders, such as the former head for future threats. The resulting 2016 report of the World Health Organization (WHO), Gro IT’S BECOME CLEAR made several recommendations, including Harlem Brundtland, and Madeleine Albright, THAT ALL THE THINGS investment in vaccines, therapeutics and the secretary of state under former president diagnostics for emerging infectious diseases Bill Clinton (see ‘Games without frontiers’). WE WORKED ON WERE — and a need for “all relevant responders” to During the course of Dark Winter and take part in infectious-disease simulations (see Atlantic Storm, participants found that power NOT COMMENSURATE TO go.nature.com/2pc4bst). struggles between federal and state leaders In January 2017, the World Bank and the Bill bogged down a health response as the epi- WHAT WE NEED.” & Melinda Gates Foundation in Seattle, Wash- demic doubled and quadrupled. Hospitals ington, backed a pandemic simulation at the were unable to handle the influx of people internationally. Not long after the 2003 out- World Economic Forum in Davos, Switzerland requiring care, and national vaccine stockpiles break of severe acute respiratory syndrome — a gathering of global leaders in business, pol- ran dry. Tom Inglesby, director of the Center (SARS) spread to more than two dozen coun- itics and academia. The exercise highlighted for Health Security at Johns Hopkins Univer- tries, and killed 721 people in mainland China, a need for better coordination between com- sity in Baltimore, Maryland, which helped Hong Kong and Taiwan, the 194 member states panies, governments and non-profit organiza- to lead both of the exercises, says that along of the WHO agreed to bolster the world’s tions when it came to managing global supply with the fresh memory of terrorist and anthrax defences against health threats through a set chains for medical equipment, diagnostic attacks in 2001, these events encouraged the of rules called the International Health Regula- tests, treatments and vaccines. The scenario US Congress to act. Not long after the Dark tions. These included commitments by coun- coincided with the launch of an Oslo-based Winter exercise, the US government commit- tries to invest in pandemic preparedness, and foundation to develop and distribute vaccines ted to developing a national supply of small- to report outbreaks to the WHO so that other for emerging infections, called the Coalition pox vaccines. And in 2006, Congress passed nations could be alert. The regulations were put for Epidemic Preparedness Innovations (CEPI). the Pandemic and All Hazards Preparedness to the test in 2009, when an H1N1 influenza virus It has received funding from the Gates Foun- Act, to improve the nation’s public-health and is estimated to have killed more than 100,000 dation, the UK biomedical charity Wellcome medical response capabilities in the event people, and again in 2013, with the spread of and countries including Japan and Germany. of an emergency. This included funding for Middle East respiratory syndrome (MERS). At the same time, Morhard and his colleagues research on emerging infections. Then came the world’s largest outbreak of the set about building a network that would coor- Anxiety about pandemics was also rising Ebola virus, in 2014–16, which killed around dinate logistics and regulations globally, such Nature | Vol 584 | 6 August 2020 | 27 ©2020 Spri nger Nature Li mited. All rights reserved. ©2020 Spri nger Nature Li mited. All rights reserved. Feature as those associated with the use of potential Health Security Index, and in a complementary new treatments, if an epidemic caught hold. effort overseen by the WHO, called the Joint “We were working on that when this pandemic GAMES External Evaluation. When it came to detect- hit,” Morhard says. “But it’s become clear that ing new pathogens, this ranking commended all the things we worked on were not commen- WITHOUT the United States for its laboratory networks surate to what we need.” and “an extensive commercial market” for FRONTIERS diagnostic tests. False security As the coronavirus pandemic gained speed As these global efforts were under way, Simulations and real-world events have this year, it became clear that the United States Inglesby felt that his own country wasn’t helped to influence pandemic-preparedness needed more than exceptional lab capacity devoting enough attention to preparing for policy over the years. and legions of epidemiologists to contain the a pandemic. The fact that the United States spread of the virus. saw relatively few deaths from MERS and Ebola 2001: A simulation of a smallpox bioterror might have given policymakers a false sense of attack, called Dark Winter, precedes a series The reckoning security, he says. of US anthrax attacks by several months. By late January, Inglesby was anxious. The In May 2018, with leaders in the White coronavirus outbreak was escalating at a House and Congress who had never dealt 2003: Severe acute respiratory syndrome frightening pace in China and spreading to with a major epidemic, Inglesby and his col- (SARS) is reported in Asia.