Behind the Lectern: Jennifer Nuzzo

You helped found the Pandemic Center at Brown two years ago, having come from the Johns Hopkins Center for Health Security. How is Brown’s culture helping to advance the Center’s goals? 

Brown is a truly special place. I've always known that it's famous for having a spirit of interdisciplinary collaboration, but since coming to Brown, it's really true. It's in the DNA of this university and certainly in the DNA of the School of Public Health. People from different disciplines work together as a matter of practice and they roll up their sleeves to tackle hard problems.

That was really attractive to me because, as someone who's worked in pandemic preparedness, it was clear after COVID that we needed to start fresh, that so many of our challenges weren't necessarily medical or public health, or really even scientific. They were social and behavioral, economic, political.

It was quite clear when I visited Brown, I felt like I was stepping onto a rocket ship. Everybody was just so excited. The School of Public Health is trying to build for the future, not build for what existed a hundred years ago. With the speed of growth and the School’s upward trajectory, it just felt like really special circumstances to be able to help rethink public health for the next 100 years.

The Pandemic Center is still very new, but tell us about some areas where it is already having impact.

We are really growing a network of academics engaged in rigorous research, and doing it in partnership with governments, to make sure that the research that we're doing is addressing the biggest problems that governments face. Through our work, we've really amassed a nice network of academics around the world working on these issues.

In collaborating together, I think we're building global research capacity. Just by the fact that we are engaging in this research, we've made the state of preparedness better because now there are these standing groups, in multiple countries, that are ready to partner with their governments and to help them.

I'm particularly proud of work we have been doing with the Global Health Exemplars program to partner with research teams in a number of low- and middle-income countries with the goals of trying to understand what works and trying to surface lessons that would otherwise not be captured.

We've looked at questions like, How were low- and middle-income countries able to keep their health systems running despite having the stresses of COVID on them? What are great practices for spotting infectious disease outbreaks early and can we use them better? A lot of interesting new surveillance strategies have been developed since COVID-19, and it's our mission to try to harvest what the best of those are so that we can share them with others so that they may adopt them.

The pandemic really underscored the importance of, not just having evidence, but sharing that evidence with the public and with policymakers. How is the Pandemic Center reaching out beyond academia?

Working with policy makers is, I think, a moral imperative for anyone who engages in research. Research is supposed to make our lives better, and it can't do that if it just lives in a journal that only a few specialized people read. We feel it's very important to engage outside of the walls of the university, so we work with policy makers and decision makers at all levels of government to advise them, to bring the evidence that we generate to them to make sure that, when they're making decisions, they have the evidence to support them in that decision making. It often isn’t easy for academics to do that unless they've had experience, but fortunately, the faculty of the Pandemic Center have had long experience working with policymakers. 

We also spend a lot of time talking to the media and the public because it's critical that they have access to the right information. And in this world, it's increasingly hard to find the right information, so we take very seriously our roles as trusted, independent sources of data and facts.

I think COVID made a lot of universities rethink how they interact with those outside of their walls. Academics were called to speak in the public sector at a scale that hadn't really existed before. I'm really glad to see so many academics roll up their sleeves and try to become public voices and public scholars throughout the pandemic.

The traditional academic model isn't really set up to encourage that, but that absolutely needs to change. We need to spend as much time making sure the product of our research gets translated into actual policies and practices as we do generating that evidence in the first place. If we don't, then what is the impact of our work going to be? What is the impact of our groundbreaking research going to be if just a few people read it in a journal? We need to make sure that that information is available to all who need it. Otherwise, all of the research that goes on within the walls of universities isn't going to improve lives in the way that it could.

Brown has been wonderfully supportive of this idea that we should be spending time doing the translational piece, as we like to call it in academia—basically talking to people, making sure the product of our research gets translated into policies and practices that work for people and save lives.

What was it like working in pandemic preparedness when you first started out, long before COVID-19?

When I got into this field 20 plus years ago, it was mostly about trying to bring people's attention to pandemics. On average we have about three pandemics a century. We were, at that point, overdue for another pandemic, so it was mostly about consciousness raising. About how pandemics are destabilizing and can touch all of society and therefore aren't just things that doctors and nurses need to think about, but senior level officials in government need to think about.

Unfortunately, we don't have to do much consciousness raising anymore because we've all just lived through a pandemic. So what we're trying to do now is to point to really tractable, practical solutions.

Now that we have lived through a major pandemic, how have the field’s challenges changed?

Of course everybody is tired of COVID; we've all lived it and we really feel done with it. So the challenge now is about getting people to want to roll up their sleeves and invest in long-term sustainable solutions that will make us, ultimately, much more resilient and safer from these threats.

But we've seen this waxing and waning of interest on these issues throughout the time I've been working on them. We call it a cycle of panic and neglect. We're probably approaching the neglect cycle, but we're working very hard to push the needle and move interest up the hill to get to where we need to be. 

How are we better off now, in terms of pandemic preparedness, compared to 4 years ago?

I'm absolutely encouraged by some of the developments that have happened during COVID-19. First, the enormous scientific success that was the development of multiple safe and effective vaccines within year one of the pandemic. That is really worth acknowledging. I don't like to call it a miracle because that negates the decades of research that went into the development of those vaccines, but it certainly speaks to what can be done with sufficient political attention and financing in the midst of a crisis.

There have been other important scientific developments during the pandemic. One of my favorites is the fact that we can now test ourselves at home. That really is just ushering in, I think, a whole new era of personal empowerment over our own health, giving us the ability to make decisions for our own safety and the safety of our loved ones. I would like to see more development on that front.

Data, I think, has also played a really pivotal role in responding to COVID-19.  I was involved in some efforts to collect and analyze some of the early data sets and I think it speaks to the power of academia to bring all of its analytical prowess to bear, to put forth information that people can use to navigate their lives as safely as possible.

But what we've learned in this pandemic is that just having a technology isn't the full solution. We have to make sure that technology is introduced along with a strategy. Our team has developed a playbook for how we can, in future emergencies, more quickly have the testing that we need and have it in the hands of people who need it faster than what we saw during COVID-19, and faster than during the MPOX emergency that happened right after it.

So it’s not just having the tests or the vaccines or the data, but actually being able to make use of these tools in the real world to improve health outcomes.

Yes. It's really important that we look, not just at what technologies exist and how we can develop them faster, but also at whether government is set up to make the right decisions and to vet these technologies as quickly as they need to to make sure they have the highest impact that they can.

It was quite impressive that within a year we developed multiple safe and effective vaccines, but we unfortunately lost more lives after the development of those safe and effective vaccines. And that is because too many people failed to avail themselves of the benefits that those vaccines offered. And I think that really underscored the importance of working to make sure that we have systems for distributing those technologies to the people who need them and systems for stimulating demand for those life saving technologies.

It may seem hard to imagine that people would refuse a life saving technology, but that certainly happened with COVID. We needed to make sure that we had systems in place to address people's concerns about the safety and the benefits of the vaccines and how they could get it for themselves and their loved ones. That all takes work. System building is absolutely as much of the work of preparing for pandemics as the research and development and the technology piece. And unfortunately, it's those social and behavioral pieces that often don't get enough attention, or that are left to the end. But as we saw during COVID, they'll absolutely determine whether or not those technologies actually achieve their promise. 

What people are really hungering for now is to be able to engage, to be able to say, here is what my pandemic experience was, and here is what I would like to happen next time. We now have the bandwidth to be able to go out there and do some values exercises to try to understand what the pandemic response meant to people and whether it was aligned with their realities and their values, and whether it was operationally feasible for them.  

In an emergency when things happen with no notice, you don't have a lot of time to go out and talk to people and ask them what they want to have happen. But, when you have to act in an emergency that quickly, what it means is that you're going to leave behind a whole lot of people whose experiences and life circumstances don't match the average case that most pandemic plans were developed for.

So now we need to hear: How well did the plans work? How well did the response work? What could we do differently? What we're learning in our work is that communities tried many more different approaches than the headlines portrayed. You hear that people either wanted to shut things down or they didn't care. They either wanted to stay in their home forever or they didn't care. They either cared about the pandemic or not. 

The reality is that people are much more complex than that, and they have much more nuanced circumstances. And a lot of people did some really interesting things in order to protect themselves and their communities during the pandemic. It's really important that we harvest those lessons and to try to surface more options for communities to consider next time.

Another tool that was under utilized during the pandemic is communications. How do you look at what went wrong?

Public health really needs to take a hard look at how we communicate. Risk communication is often approached from a deficit model, meaning you just package the facts at a level that your recipient can understand and give that to them and that's sufficient. That approach is a bit divorced from our pandemic experience.

We need to understand how to truly communicate with people, how to address their concerns. It's about making sure that what we are communicating is actually what people need to know. There was a big disconnect during the pandemic where a lot of the messages were just simply too simple to answer the questions. So we need to overhaul the public health communication approach so that we make sure that we are delivering to people the life saving information that they actually need and that they can use that information to act to protect themselves.

The information crisis, I'll call it, is an area where I would like to see Brown play the leadership role. Brown's Information Futures Lab has really been pivotal in helping to define the problem and also really shining a light on the information ecosystem and how myths and disinformation can move throughout it.

Another key area of interest for the Pandemic Center is climate change. How do pandemics and climate change overlap?

The changing climate makes us more likely to have pandemics in the future. It also stresses the exact same systems that we need in order to respond to pandemics. When we see hospitals being overwhelmed when there are storms, and surveillance systems stressed, and all the ways climate causes disruption, and knowing that could happen at the same time as a pandemic, and knowing that the ways to improve resilience for pandemics and climate change are actually quite similar, I think we really need to simultaneously be thinking about how to mitigate the health impacts of climate change and the health impacts of pandemics.  

What would a pandemic-proof future look like?

My mental model for thinking about a pandemic-proof future is to think about fires. Most of us don't wander around in our daily lives worrying about the threat of fire. That is because we have built into the buildings we occupy, and the cities that we live and work and play in, protections against fire that make us less vulnerable to them in the first place, and that alert us early when problems do arise so that we can seek safety and protect ourselves as quickly as possible. When a threat arises, it causes as little lasting and pervasive damage as possible.

So the first hope is that we could stop pandemics in their tracks. There's always hope that if we spot outbreaks early enough, there'll be resources on the ground to stop it. We need to have systems in place everywhere to make sure that, first of all, people know what's happening, then know how to protect themselves and have access to the tools they need to protect themselves. 

It is always the goal of pandemic preparedness to improve our capacities for detecting future outbreaks early and responding quickly to contain them at their source so that they don't grow to become epidemics and pandemics. That is absolutely a goal. But we can't only work towards that. We also have to work towards the possibility that we might fail on that front. If there is another pandemic—meaning some pathogen has spread globally—we need to be ready to deal with it within our communities in such a way that it won't result in loss of life.

Tell us about the Pandemic Game Changers.

It’s really important to make sure that the next generation of public health leaders, who will be in the decision making seats for the next pandemic, are equipped to make decisions. That's really core to our mission.

Often in public health, we are a bit of a retrospective field. We gather data and we wait until there's a signal in the data that tells us something clearly is a problem before we act. With future pandemic threats, we really need to act early, sometimes before we have all of the data available. And that requires different ways of thinking about problems and solving problems. It requires diverse leaders who can think ahead to spot problems down the road that haven't even happened yet. It also requires different skills in bringing together teams so that they produce work that actually changes outcomes.

Our Pandemic Game Changers initiative is going to do just that. It's going to try to train people to be anticipatory of scenarios that could happen and emerge, not just the data that are in front of them. So we're developing curriculum and reaching people who are interested in pandemic leadership, and recruiting and training a diverse class of pandemic leaders who can speak to the experiences of all communities, including some of the communities that have been hardest hit and that haven't been in the pandemic leadership circles we've seen to date.

Are young people sick of pandemics?

Even though they've had this virus upend their lives and sometimes at critical moments of their lives—I think about high school proms missed and high school graduation ceremonies missed and years of college online—students are not tired of the pandemic. Students are showing up with a deep interest in the topic and they want to roll up their sleeves and make sure it never happens again. So they're really, really interested. They understand that an important driver of pandemic severity is our underlying vulnerabilities, our inequalities within societies, and they want to tackle that. They want to tackle that in the nexus of climate change. They're just ready to work and to make the world better and it's honestly incredibly inspiring.

I derive a lot of energy from being around young people whose default answer to everything is Why not? It just makes us really rethink whether or not something is truly impossible and to make it possible.

Tell us about the Global Health Security Index, which began before you got to Brown and before COVID.

The Global Health Security Index started in 2019. I work on it with colleagues at the Nuclear Threat Initiative and Economist Impact trying to inventory the capacities of 195 countries to be ready for a pandemic. We look at things like their public health capacities, whether they have surveillance systems in place, whether they have a workforce in place, we look at their health care capacities, whether they have enough doctors and nurses for their population, and then we also look at what their underlying economic, environmental, and social risks are. These are things that might make them not able to use the capacities that exist in their public health or health care system. We also look at their commitment to financing preparedness, as well as their commitment to international norms. And we get a snapshot of where countries are, where their strengths are, and where the gaps are. 

We hope that they use that information to see where they need extra work. And we have evidence of countries doing that. My favorite example is New Zealand. It looked at its scores and saw that it had some holes and they got to work at plugging those holes and when COVID happened they continued to work on it. What has been     widely hailed as a successful country-level response to COVID-19 I think speaks to their continuous commitment to improving, and to using data to drive those improvements. 

They actually publicly credited the Index as being very helpful to them so it’s really heartening to see that they did so well and that they used the tool in the exact manner we hoped they would.

How do you account for the U.S. being relatively well prepared, but faring very poorly during the pandemic?

There are a lot of headlines about the fact that the countries that were highest ranked in the index and deemed the best prepared countries, like the United States, did not necessarily fare the best during COVID.

That observation made people wonder, well, Does preparedness matter? If these better prepared countries are doing so poorly, does it matter? Can we even prepare for a pandemic in the first place?  I'm here to tell you, fortunately, that preparedness absolutely does matter.

A tool like the Index benchmarks the capacities that countries have, including their abilities to diagnose people with a completely novel infection, and to be able to determine if somebody dies, whether it was due to that novel infection. Not all countries have those same abilities, so it's really, really hard to just look at a country’s official case or death reports and then say who did better than who. You have to do some work in order to adjust for big differences in surveillance capacities that countries have, as well as big differences in underlying vulnerabilities that countries have. 

Some countries have an older population, so they're just going to be more vulnerable to something like COVID-19 that disproportionately affects the elderly. When you do that, when you address those differences and do a more fair comparison, what we see is that better prepared countries absolutely did better.

That said, there are countries like the United States that stand out as really stunning outliers, and there are probably a lot of reasons for that. A lot of them are still unknown. But I think one important thing to remember is that what we're measuring in the index are capacities.

To put it in a fire safety context, we may be measuring if countries have fire alarms or signs telling people how to exit a building, that's what a capacity is. But, unfortunately, we're not able to measure whether or not, say, a political leader tells its public to ignore the fire alarms and stay inside the building.

So we can't really measure how countries use the tools that they have, and unfortunately there seems to be evidence that that's what happened to the United States; that we underutilized the resources and the pre-pandemic advantages that we had. We really didn't bring all of our resources to bear.

One stark problem the U.S. has that was magnified by the pandemic is racial and ethnic health disparities. 

The fact that there were disparities during COVID, deep disparities, is not news to anyone in public health. This is the story of public health, particularly the story of infectious diseases.  

In the early days of pandemic preparedness, we developed plans, and then maybe we had an appendix for people whose situation wasn't exactly the average case. And I'm here to tell you that that model is completely wrong. We have to flip that model on its head. We are not going to be able to protect people and save lives in future emergencies unless we center our plans around reducing our inherent vulnerabilities and achieving a more equitable response.

So we have to put equity and social vulnerabilities at the center of our pandemic response and move from there. 

What does that mean concretely? 

Here's an example. When states finally started publishing COVID case hospitalization and death data broken down by race and ethnicity, it was really shocking. Stunning, horrifying to see the disparities and who was getting COVID, who was being hospitalized with it, and who was dying from it.

But it took a really long time to have those data translated into tailored responses. We did a study where we looked at who was getting tested for COVID, broken down by race/ethnicity and we found that the Latino population, which was one of the hardest hit, was being under tested as a community compared to other patient groups. 

So in the future we should know to use the resources that we have in the communities we expect to be hard hit and to make sure they have, as a matter of priority, access to life-saving tools, like tests, and access to safe places to isolate, paid leave so that they don't have to choose between feeding their family and staying home and protecting themselves and others, and making sure treatment is accessible as early as possible to avoid lose of life.

That kind of a response would require some pre-existing infrastructure within communities that could respond.

Pandemic means pan-demos, right? All of society. All of our populations. It's unreasonable to think that we could be prepared for a pandemic unless the community were part of that. Government can't do everything. And even if it tried to, it wouldn't have the important insights that community members and community groups do.

So it's really essential that we get communities to be part of our pandemic preparedness to make sure that the plans that we are proposing actually work for them and are aligned with their values. We need to engage people in the work of pandemic preparedness so that when it happens, it doesn't feel like it's something happening to them, but it's something that they helped create and build. 

There are many bad headlines about Americans being divided and the level of contention in our communities, but when you live in a town, you see something very different. You see people taking care of their loved ones, of elderly neighbors. There is so much untapped potential in our communities that could be brought to bear in a pandemic. To be a resource extender and to make sure that what we are proposing is actually working and embraced by communities. 

How has the pandemic changed our society?

I think the most obvious way that the pandemic has changed our society is that people now understand epidemiology and infectious diseases. One very real tangible outcome of that is the level of excitement and interest we are seeing, a surge of excitement and interest in students wanting to study infectious disease epidemiology and pandemic-related sciences.

I have been teaching for a number of years and the pandemic really brought a huge increase in the number of students who wanted to enroll in the courses I was teaching and get involved with our research projects. So you have a whole generation entering into the field, coming in with enthusiasm, ready to change it. I'm really hopeful that that will translate to lasting change in our society.  

I do a lot of work with international teams and the home office trends that the pandemic started actually greatly facilitated our ability to work with international partners. We communicate and coordinate and collaborate on our work much more than we were able to. It's possible those technologies would have been developed eventually, but I think the pandemic really expedited the uptake of those technologies, and now, we don't necessarily have to fly around the world and burn a lot of fossil fuels in order to collaborate. Getting together in person is still really important, but we can be much more strategic and selective about when we do that.

One unfortunate tangible change caused by the pandemic is that we've experienced historic setbacks in life expectancy here in the United States. All of the disparities that we saw in life expectancy before the pandemic were worsened by the pandemic. So that will have a long, profound arc on our society, as will the disruptions that the pandemic caused to children's learning. We have a generation of kids who lost out on their education and are struggling to catch up.

Absent some really ambitious revolution in trying to overcome that learning loss, we're going to see, potentially, the long-term impact on their growth, development, and economic potential.

I look forward to people no longer understanding what an epidemiologist is or does. May we all work hard enough to put ourselves out of a job.

That is not likely however, because you do expect another pandemic, correct?

There are going to be more pandemic threats in the future. That's a fact. We have very strong data that tell us that. But it doesn't have to upend our lives the way that COVID-19 did. We don't have to let these pandemic threats wash over us, absorb them, and then just take stock of the wreckage afterwards. We absolutely can get to work, today, and Brown is uniquely positioned to help lead, to make sure that our societies are resilient in the face of these threats.

We can make efforts now through targeted, practical research—data and evidence—working with policymakers, engaging with the public, working with students, training them for the future, to make sure that we have a stronger system that is pandemic proof. 

We have all seen it, lived it. We don't need to raise consciousness about it because we all have firsthand experience. But we have to decide, right now, if we are willing  to put into place the very feasible steps it will take to make sure that we take off the table infectious diseases’ ability to upend our lives and cause the deep, deep,  disparities and inequities that COVID-19 did.