He Helped Eradicate Smallpox – Listen to His Concerns About Monkeypox

Larry Brilliant

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Mark Masselli: Our guest is a renowned epidemiologist and innovator who serves as
the chair of the advisory board of Ending Pandemics, non - profit
working to fight outbreaks faster around the world. His expertise is a
result of his success in helping the World Health Organization
eradicates smallpox in the 1970s, the only disease the human race has
eliminated.

Margaret Flinter: Dr. Larry Brilliant has a very appropriate last name. He is often
referred to as brilliant and by many other comp limentary adjectives.
He’s been recognized by Time Magazine as one of the 100 Most
Influential People. He’s led public companies and startups. He is an
author, received four honorary doctorates and currently serves on a
number of foundation boards of di rectors.

Mark Masselli: Dr. Brilliant, welcome to Conversations on Health Care.

Dr. Larry Brilliant: Thank you so much for inviting me. I am very happy to be with you.

Mark Masselli: You know it’s Immunization Awareness Month and we have a lot to
go over on that topic. You have praised the WHO for declaring
monkeypox a global health emergency and you believe rin g
vaccination approach is needed as New York State, San Francisco,
where you’re nearby, have declared it as an emergency situation. I’m
wondering if you could unpack that for our listeners and give us the
details of how a ring vaccination strategy could work.

Dr. Larry Brilliant: I think my praise was tempered. My exact comment was better late
than never, which might be WHO’s nickname, better lat e than never.
We should have taken action when there were 100 cases or 1,000
cases. Today, there are over 20,000 cases. We now sadly have three
deaths to report , two in Spain, one an immunocompromised person,
we don’t know the state of the second one, o ne in Brazil. During this
period, there have also been five deaths from monkeypox in the two
endemic regions in Africa. That alone should make us say that this is
an emergency, a disease of international concern.

What I’m most worried about, however, i s that these two spots of
endemicity, one in Congo, one in West Africa, the two different clades
of the virus, what I’m most concerned about is that those two areas of
endemicity could balloon up to 100 or 1,000, and in every large city
we might have endem ic monkeypox. Let me explain why that is.

First of all, smallpox is not a disease of smalls and monkeypox is not a
disease of monkeys. There are hundreds, if not thousands, of
different orthopo xviruses, many of them like cowpox infect dozens of
differen t species and the virus, which is called monkeypox, is probably
dominantly a rodent infection. We don’t really know what its original
host animal is, but it is certainly capable of infecting hamsters, prairie

Larry Brilliant

dogs, giant Gambian, house rodents and regular urban rats. If we
have so many cases of human monkeypox virus and we allow it to
allow unchecked, that’s like giving Steph Curry unlimited shots on
gold, and he will make most of them. What I worry about is that
number of replications will lead to so ma ny mutations that the virus
may take on much worse clinical characteristics might become
endemic in our urban sewers and urban rodent population, squirrel
population, and as it bounces back and forth, spilling over and spilling
back, we don’t know what thi s virus will do.

I have a small group of friends that I am part of the Smallpox Warriors,
we call ourselves. Unfortunately, it’s a dwindling group but there is a
lot of concern, could this virus over time, with enough shots on goal,
mutate into something that resembles smallpox, heaven forbid, and
that’s where the ring vaccination comes from, Mark. The original
vaccine against smallpox is extremely effective against monkeypox.
I’ve seen numbers of 85% or 90%. In the case of that v accine against
smallpox, it was close to 95% to 100%. It’s a very effective vaccine.
Because it was so effective, because the world feared smallpox so
much in the immediate period before it was eradicated, smallpox
th
killed half a billion people, 300 milli on to 500 million in the 20
century alone. One out of three people who contracted it died from it
and the way that we were able to eradicate it was by following a
unique strategy conceived by Bill Foege who then was working on the
smallpox program, beca me the head of CDC, and that was to find
every case of smallpox in the world at the same time, and to draw a
ring of immunity around each case, and that ring was not just
geographic, it was sociometric, investing the index case by doing
forward and backwar d tracing, words that we’ve come to learn about
from COVID, but in reality they have a much deeper meaning than the
simple way of thinking about just contact tracing.

We were able to immunize all those people who might next get
smallpox until there were no more susceptible hosts around, and
that’s how we eradicated smallpox. We could do the same thing with
monkeypox now. If we wait much longer, it will be too late. Once it’s
endemic in rodents all over the world, I’d not like to believe that we
would b equeath our children and our grandchildren a world like that ,
Mark.

Margaret Flinter: Dr. Brilliant, I think you just gave our listeners a lot to think about
there and I wonder if I can ask you, what’s your assessment of how
ready and capable we are throug hout the country, either states
operating independently or as part of a coordinated strategy with CDC
to implement this ring approach? I’ll put that in the context in our
own state of Connecticut, certainly one of the smaller states but as of
today, I thi nk, Mark, 15 or 20 community clinics of which we have six
of them, have vaccine on hand to be used in the appropriate

Larry Brilliant

situations, and certainly very much tied to Public Health Department,
really, identifying the positive cases and making sure that they do
contact tracing, and that those vaccines are pretty readily available in
facilities and organizations that people are likely to be able to access.
Do you think that’s part of the state health departments already
having watched this ring approach? What do you see happening
across the country in the US right now?

Dr. Larry Brilliant: I don’t think we are very well - prepared. I don’t think that CDC has
mounted as energetic a response as I would like to see. Scott Gottlieb
by the former head of the FDA has a n op - ed in today’s New York
Times, I believe, saying that if we don’t act quickly this would become
the most abysmal public health failure in memory. There is a lot of
other competitions for that throne, so that would be something.

You know, I think that part of the reticence , and I attended a couple
of WHO advisory meetings on monkeypox, part of the reticence is
that we have an approved vaccine that works against smallpox and
monkeypox that works both before you’re exposed and after. I
likened it back to that something we called P EP, post - exposure
prophylaxis. If you’re using it as a post - exposure prophylaxis, the
question you might ask, should it be regulated as a vaccine or should
it be regulated as a therapeutic, and I would like to come back to tha t
because a big difference in the amount of vaccine we have available
to us if we regulate it as a treatment, as a p ost - expo prophylaxis, but
the… I think I said prophylaxis, I meant therapeutic.

So, if we think of this as something we are vaccinating pe ople and the
risk is low, like the vaccines that we use for childhood immunization,
then the bar has got to be very high and no side effects of any real
consequence, rare side effects, if at all. If you’re using this as
something in the middle of an epide mic or a pandemic that’s going to
save lives immediately, then the bar is a little bit lower. The vaccines
that we have that are specific for monkeypox, they are mostly without
many side effects. The old smallpox vaccine, which we’re calling dry
vax that we used to use by distributing it almost like freeze - dried
coffee in little vials, and then reconstituting it in the field, and then
using a bifurcated needle and a couple of … I’ll show you my arm
here, and a couple of int radermal pokes with a bifurcated needle, that
vaccine has to me a very low number of side effects, but it is true that
that would be an unacceptably high number of side effects, were it
not that this was an emergency, and those are the things that WHO
has been wrestling with and because I’m concerned about this long -
term possibility of monkeypox becoming endemic in the animal
populations all over the world, I would be in favor of using more
vaccine more quickly, and we just don’t have enough of it right now to
vaccinate everybody.

Larry Brilliant

I think in fairness to WHO and CDC, those are the things that they’ve
been wrestling with. I think I would’ve taken a much more aggressive
position but I may be in the minority, because I’ve seen so much
death from smallpox.

Ma rk Masselli: You give low grades to WHO, Gottlieb criticizes C ongress maybe
around the CDC and implicitly, the CDC. Just trying to think back over
the last couple of decades, we’ve had SARS and swine flu and MERS,
COVID - 19 , now monkeypox. Maybe Marburg i s on the horizon there,
who knows. What’s your global sense of this early warning system, is
it just building on these two organizations? Obviously, the Europeans
and others do it. What’s the larger strategy, because we were talking
and been interviewin g people during the COVID - 19, something else is
coming, something else is coming, be ready. Everyone should be
forewarned. Don’t be casual about what’s around the corner. What’s
our state of readiness in your mind?

Dr. Larry Brilliant: First of all, I give very high grades to WHO for doing what it’s
supposed to do as a regulatory agency, as an agency that sets
standards, despite having the world’s worst organizational structure,
not the fault of the current administration of WHO, but the idea that
WHO h as to rule by consensus of 100 countries meeting once a year
has a regional structure, with all the power and monies in the regions,
but the responsibility is at the center. Both of these agencies, WHO
and CDC are a bit long in the tooth from their origin al structures.

You know I’ve written a lot about entering an age of pandemics. My
colleagues and I in foreign affaires couple of years ago wrote an
article about COVID, we called it the Forever Virus. Those sound like
very pessimistic titles for article s, but they are actually quite
optimistic because if you identify those problems, then you can do
something about it, Mark and Margaret, and if you don’t identify
them and you don’t name them for what they are, COVID is a forever
virus. We are in an age o f pandemic. That doesn’t mean that we
should hide or live in fear. I think there is something like 1,400
recognized zoonotic viruses that can infect human beings, maybe it’s
more than that now, it doesn’t mean we live in fear of the
environment that we’r e in. It means we understand what we need to
do to identify those pathogens that are in animals that will jump or
can jump to humans, that do create illness or death and we prioritize
that part of our health system. It’s not the cancer control part of a
health system or the stroke part of a health system, but this part of
our health system and it needs to be permanent.

In the middle of a huge forest like we have in California right now is
not the time to start thinking about what the paint on the fire engine
should look like or how many people should be sitting in the fire
department, it has to be there all the time. That’s what Benjamin

Larry Brilliant

Franklin taught us, the fire department has got to be there all the time
and we are in the midst of a fire of new pa ndemic potential diseases,
more so than ever. I think a sweet interlude between the Spanish flu
of 1918 and COVID, we had two other small pandemics, each with a
million deaths, which is small in the pandemic world, but that doesn’t
mean it’s going to be a nother 100 years before we have another
catastrophic pandemic, and why is that?

Well, because human population is going all over the globe, because
we’re cutting down rain forests, because we have created climate
change that have made animals from the so uth move to the north
and spread their viruses and mingle their viruses with other like
species. It’s because the human - animal interface has been broken
and when you live in the same eco - system as animals, you’ll share
viruses with them, and we’re seeing with monkeypox a virus that can
spread over, spill over from animal to an animal to a human, and then
spill back, as we saw in 2003 with an epidemic of monkeypox in
Minnesota that began in Texas with the importation of exotic animals,
and led to a small bu t important epidemic of monkeypox in prairie
dogs which were being kept as pets and humans got it from prairie
dogs. We’ve seen it with mink in Denmark that mink farmers were
able to give COVID to the mink, and then mink give it to humans, so
much so that we had to wipe out that industry. I think that we
sacrificed, which means killed, 17,000 – 20,000 mink.

So, we are living in that world in part, in large part because of
modernity. Modernity means we have rapid transportation, a virus
that jumps from an animal to a human. A bird flu epidemic that
begins in Laos or Cambodia among chickens, among ducks that is
transferred and humans contract that disease. That disease can be
around the world in hours. So we need to rethink what we’re doing.

There is a good conversation going on in the world about a pandemic
treaty that would elevate the requirements on how to deal with
pandemics to the level of a treaty organization. There have been very
good conversations of lots of scientists putting a ring arou nd the
world of high - performance sequencing labs that help with the early
detection or early specification of virus. I’m optimistic that there is
enough interest beyond just WHO and CDC, but certainly including
them, if you had GAVI and if you add the FAO , and you look at CORDS.
I can give you an alphabet soup of acronyms, of really good
organizations that are working very hard, but we need Congress to
take this seriously. There has been a bill that was stalled for $18
billion to go to pandemic preparedn ess. Now, the Biden
administration, which we all want to have succeed wants to take
away these duties from CDC and bring it into an office. That’s what’s
Gottlieb’s article is hinting at and taking the assistant - secretary for
convention Esper and turn th at into an agency like CDC. We need to

Larry Brilliant

have a national conversation about how important these
communicable diseases are that are primarily but not exclusively
jumping from animals.

Don’t forget, we’ve got antibiotic - resistan t organisms that have been
h eld [inaudible 00:18:35] for antibiotics and these antibiotics are not
working anymore, and there is very few new ones in the pipeline, but
this is not to scare people, this is just to say we can do anything we
want if there is public will, but there can’t be public will without public
trust, and there can’t be public trust without a conversation like this.

Margaret Flinter: Dr. Brilliant, I think what you’ve just said should be mandatory
listening or reading for people to understand this world that we’re
living in, how we’re responding to it and how we want to think about
the response going forward. We do have this sense as we go about
the work of health care and public health of community fatigue,
listening fatigue, if you will, to some of this, and in t he midst of all
that we now have as our next little hurdle on the landscape the
announcement by the Biden administration that next month, we
expect to have reformulated COVID booster shots available that are
expected to hold up better against the now domin ant Omicron sub -
variant BA . 5. I wonder what your view on this is. Is this a big step
forward? Is it possible to avoid a winter surge as people grapple with
the big issues, this next one seems right in front of us?

Dr. Larry Brilliant: As much a fan as I am of the miracle of the mRNA vaccines, they are
not the right vaccines to stop people from getting COVID or to stop
people from giving COVID. They don’t produce very much mucosal
immunity or I gA. We need intranasal vaccines for that. Because they
require such deep refrigeration, they don’t travel very well. It’s hard
to get to the two billion or three billion human beings to WHO classify
as being outside of the reach of public health systems around the
world. I’m cheered by hearing about work being done now to
prioritize these intranasal vaccines.

The mRNA vaccine new iterations that are coming out are
improvements at the margin but they are not dramatic
improvements. I’m not so sure that the new vaccines that will come
out in Se ptember or October, or whenever they are, by the FDA when
they are made available, I’m not so sure that they will be that
effective against BA . 4 and BA . 5. I hope they will be. From what I
understand, they are going to have two different antigens, one for the
original COVID and one for Omicron, but the Omicron that they
targeted against can’t possibly be BA . 5, because we haven’t had it
long enough. So, what I’ve heard at least is that it’s just going to be
the original Omicron. If that’s the case, I hope they are going to be
effective. I’d rather see a BA.5 - specific vaccine, but if you do that,
you’re going to play whack - a - mole, because of what’s going to

Larry Brilliant

happen with the next variant. Much better, I think, would be to work
on intranasal vaccines that pr event you from getting the whole family
of COVID, not just on vaccines that try to catch up with the next
variant.

That being said, I am going to stand in line to get it because it’s
certainly an improvement than an incremental one.

Mark Masselli: Dr. Brilliant, let me turn to the environment. The Senate over the
weekend announced, one would hope, an historic environment
between the Schumer and Manchin, and it would make about $400
billion - worth of investments towards combatting climate change and
you ’re senior counsel at Skoll Foundation, which has a very strong
focus on mobilizing climate action, what difference will this law, if it
passes the Senate and House, gain for the health of Americans and
how can it deliver on its promise?

Dr. Larry Brillian t: It’s huge. Mark, you probably feel as I do, if there is a category of
modern risks that are difficult to articulate, the climate change is
odorless, invisible, tasteless gas in the air and people can’t believe
that it’s changing the climate, and so lon g as we did nothing in the
United States, the rest of the world will still look to us. They are not
going to do things. India is not going to do things to stop climate.
China is going to do less, unless we play our role.

There are so many people aroun d the world who say the industrial
countries have created this mess, let them clean it up, and if we were
absent at the table, if we were not part of the Paris Agreement, if we
were not working on cutting carbon emissions, having targets that we
meet, that leadership would be gone and then I think what we do is
we all sit around and say this is inevitable, maybe it’ll happen in 50
years. For god’s sakes, just look around you, it’s happening today.
Look at the floods in Virginia, the historic floods in Vir ginia. Look at
the wildfires all over the West. Look at the great drought in the West.
Look at hurricanes last season, gathering much more steam because
of the super - heated water that creates these super - storms. We are in
the middle of climate change r ight now, we’re not early, we’re in the
middle of it right now, and this law, while it’s a small amount of
money compared to what we need, it is catalytic. I can’t overstate
how important that is, and how reeled and surprised I was to see it.

By the way , there is a similar bill that Pat L e ahy, Senator Pat L e ahy of
your neck of the woods has proffered and asked specifically for
stopping and for creating agencies to work on pandemic
preparedness, and I hope that that bill gets the same attention,
because w e need that just as much.

Margaret Flinter: It was a bit of good news a fter a seemingly endless not so good news,
but I am going to ask you to look into your futurist ball maybe for a

Larry Brilliant

moment. You are known for the development of the Well, a virtual
comm unity that you started way back, in the ancient days of 1985
that’s been called the precursor of every online business from
Amazon to eBay. I’d like to look into your futurist crystal ball and say
what’s in the future for health care in terms of the metav erse. Is
there a purposefulness there that can be captured for the betterment
of people and health care?

Dr. Larry Brilliant: I haven’t thought very much about that. I do think there is some
things that you can do virtually as training programs that are
extraordinarily helpful but I actually wish that we wouldn’t spend so
much time thinking about the metaverse and we’d think much more
about the universe that we live in. There is so much more work to do,
Margaret, and the fundamentals are honesty and tran sparency, and
trust, and dare I say love that we’ve forgotten about. You can’t get
good at the metaverse if you’re not good at the universe, and I think
all of us, if we’re honest, the last couple of years have forced us to do
some soul - searching and we f ailed a lot.

My friend Bill Foege, who I spoke about earlier, my mentor, is working
on a program called How to Be a Great Ancestor. I think just thinking
about that, how do we become a great ancestor, whether you’re
dealing with bequeathing a health care system that’s functional and
working, and we don’t have anyone who’s not covered by health
insurance, or whether you’re thinking about how do we put in place
the stopgaps to prevent the worst excesses of climate change or
pandemics, or drought, or famine, which we are in the cusp of in so
many places around the world. I f we could focus on tha t and not the
metaverse, I’d be happier.

Mark Masselli: Let me shift gears a little. You know the Biden administration has
announced plans for legal psychedelic the rapies within two years and
you’ve been talking about this for years. Why do you think it’s taking
so long and what do you think about the prospects of its approval?

Dr. Larry Brilliant: I’d like to pay some homage to my friend, Dr. Richard Rockefeller wh o
passed away a couple of years ago. He was really the progenitor of a
lot of this research and he was also the chairman of the Rockefeller
Foundation and the chairman of Doctors without Borders, a
psychiatrist who gave so much to the world, and one of th e things he
did, helping to create MAPS and all these other organizations and
having the actual peer - reviewed prospective cohort studies done that
have allowed the FDA to approve some psychedelics for use in
individual clinical care , I think that’s a big s tep forward. I don’t know
where it will go.

I know I came out of the ‘60s when psychedelics had a very different
meaning and purpose, and were much more intertwined with our
youthful life, but I personally know a lot of people who have been

Larry Brilliant

treated in a psychiatric session with legal psychedelics and they report
tremendous results . I’ve heard that some people have been treated
for PTSD, coming out of the Iraq war in a single session and have
achieved great insight. So, it’s not my area of specialty. I ’m an
epidemiologist and I’m looking to the data that will come out of it, but
I guess I am a cheerleader for anything that can work with the … Jon
Stewart reminds me with our wounded veterans who gave everything
to fight in Iraq and Afghanistan and have c ome back wounded with
PTSD and in that sense, I am really optimistic and hopeful.

Margaret Flinter: Dr. Brilliant, we can see why past company stated there are few who
have had more impact on the world than you have. Thank you so
much for being with us. Thanks to our audience as well. You can
learn more about Conversations on Health Care or sign up for our
updates at www.chcradio.com . Dr. Brilliant, thank you so much for
being with us and sharing your thoughts to day.

Dr. Larry Brilliant: Thank you for inviting me and thanks so much for your patience and for the good work that you guys do. Thank you so much.

Mark Masselli: And you’re well inspiration. We’ll continue to follow your work, and again, thanks for ta king the time.

Dr. Larry Brilliant: Bye - bye.

Margaret Flinter: Bye - bye.

Mark Masselli: Ciao.

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