The Next Pandemic: Natural, Bioterrorism, or (YIKES!) Worse?

We recently heard anew that the next pandemic isn’t an ‘if’, it’s a ‘when.’ Then there’s the question: Will that next pandemic will be intentional or not?

For instance, picture this:

Some real-life version of a Bond villain releases a synthetically produced smallpox pathogen, perhaps on a cruise ship carrying passengers from dozens of countries. Because it takes a couple of weeks for symptoms to appear, those passengers will have traveled back home and, bang, given that smallpox has a mortality rate of about 30%, there you have it, the start of a new pandemic capable of stopping the world in its tracks.

So, that’s bad. Very bad. BUT, here’s the good news: that scenario was from a preparedness exercise undertaken a decade ago, and there’s a new version of that exercise that is about to be repeated in India at a confab of public health big brains. So, that means for every Bond villain there are multiple public health Bonds… or so we hope.

We learned about that upcoming conference in India from one of the big brains who’ll be there, Brad Goble, a Canadian with a military background who travels the world consulting on preparedness, and who is due for congratulations: Brad was recently named an Associate Fellow with Chatham House, the influential London think tank founded after WWI, officially named the Royal Institute of International Affairs.

Brad’s focus is on NATO and on public-private partnerships, especially stockpiling vaccines to combat outbreaks, whether natural, bioterrorism or military. He described that work: “Stockpiling takes into sort of three different circumstances: One, is for crisis — so things like pandemics. We obviously learned a lot from COVID-19, and we still continue to look at that interaction between industry and governments, where government is trying to incentivize industry to build and manufacture the best vaccines, antivirals, and diagnostics. The second component is conflict, so looking at war. Of course, Ukraine becomes an initial a focal point. Then, third, comes disasters, like fires and floods.  The strategic stockpiling initiative is really that engagement between government and industry to make sure that we’re best prepared in any of those scenarios.”

Later, he added, ominously, “We need to take the lessons learned from the current crisis in Ukraine and make sure that we’re hyper-prepared for what may come next because we’re certainly not sure that this is the end of the game.  We know that Russia continues to be a threat to its neighbors.”

Sadly, Brad and his colleagues aren’t just worrying about tanks and troops, but worse: “From a NATO context, what we’re looking at in Ukraine and what may come next is chemical and biological attacks — so it’s the C and the B of CBRN. [That’s Chemical, Biological, Radiological and Nuclear – the big four of security planning.]  There’s a lot of focus on chemical nerve agents.”

Sigh. It’s bad enough to worry about natural outbreaks or some crazed terrorist, but adding government resources to the crazy? Brad added, “A big focal point for NATO is to be able to ensure that they’ve got the right concoction for the right attack. There’s a lot of work on that in terms of vaccines — being able to ensure that they’ve got the right manufacturing, the right contracts in the right industries. As for manufacturing, one of the one of the things that has been a significant focus is the fact that the majority, maybe over 90%, of the advanced pharmaceutical ingredients that go into creating vaccines is manufactured and sourced out of China. So that puts us at a significant vulnerability.”

So, big picture, how worried should we be? Or, maybe we should ask, Is there any good news?

“When you look at what NATO is going through right now,” Brad responded, “with the back and forth – the US, is it in is it out? – it has really stimulated NATO to step up in Europe. That change in dynamic has really made a significant impact on investments, especially civilian-military cooperation. NATO is hyper-focused on how Europe structures itself. As you probably know, there are 32 NATO member countries and 27 of those NATO countries are in Europe. So Europe is a highly charged environment, making sure not only its investments but it’s governance structure gives it the ability to drive its own resources.” [For those of us who could not name all 32 members of NATO, there’s a list at the end of this article.)

What then, we wondered, do you see as the role of the U.S. going forward?

Brad: “There have been a lot of concerns around the way that the CDC been stripped down. It was the preeminent institution around disease surveillance and control. I don’t want to make any proclamations, me being a Canadian up here looking down at your institutions, but globally speaking, the U.S. is not involved in the way that it was during the pandemic and even pre-pandemic. When the crisis happened, the U.S. took a leading role in the world and was able to essentially contain a pandemic that hadn’t happened for 100 years. The question you’re asking now is, If the next one came tomorrow, would the U.S. be in a position to do the same thing? I’m not sure. However, personally I don’t think that this is something that is going to continue. The U.S. can find its footing again as leaders in the global environment. Meanwhile, as the U.S. is pulling back, the rest of NATO recognizes it really needs to be able to stand on its own two feet in a way that it possibly hasn’t been pushed in the past. From that standpoint, I see it as a positive.”

So, assuming the United States returns to a leadership role, and with Europe increasing its commitments, we have some good news to cling to.  Meanwhile, what about the role of the WHO?

Brad: “As you know, for the US to be safe and secure the rest of the world needs to be safe and secure, because we know diseases know no borders. I work with the WHO and they’ve got some brave folks. They’re struggling a little bit because there’s only so many resources to go around, but I’m again confident that the rest of the world is really doubling down on that collaboration. I think there is increased focus in our international institutions to ensure that we close the gaps and continue to keep us safe. Over the last couple of weeks the WHO held a very large international exercise where it was looking at Disease X:  it was basically saying, let’s assume that there’s another pandemic of some of some sort. They brought together different institutions from around the world to say, if this next disease happens, what could we do? They were able to advance knowledge of how they would deal with the next pandemic. Even though the WHO has reduced resources because of the issue with the U.S. pulling out, they’re still not stopping trying to be the best they can.”

Given that Brad is someone who gets to go behind the curtain and see how countries truly are working together, we asked him where, if anywhere, people are overestimating or underestimating the global dangers. We close with his uplifting response:

“Looking at either the current conflicts or the threat assessments of what’s coming next, I’m confident that the senior officials in the organizations, whether it’s NATO and defense departments around the world, or from the broader public health perspective, I’m confident that we have the right institutions, and that the right people in those institutions are paying attention to what may be coming next. Obviously, there’s a lot of disruption, but I think global institutions are strong and continuing to strengthen. From my standpoint, I’m confident that there are no gaps. I’m optimistic that we are in very good hands.”

(START SIDEBAR)

We’ve gotten to interview Brad twice previously, and you can read more about his counter-terrorism work in “Something Wicked This Way Comes” at

Something Wicked This Way Comes And Where You Fit Into The Defense

Here is the brief bio from that article.

BRAD GOBLE and

The day the world got smaller

Goble is Canadian, a graduate of the Canadian version of West Point, the Royal Military College, and served fifteen years in the military. He described how he came to be involved in the fight against the CBRN threats (Chemical, Biological, Radiological, Nuclear):

“I backed in. The General I had worked for was retiring and I was ready for a new career. So I’d gone back and gotten an MBA from Queens University, and I became one of the people working to create the Canadian version of the CDC. This was right before 9/11. After that happened, the world got smaller, and we became more focused on new and emerging threats. Not long after 9/11, Tommy Thompson, then Secretary of HHS, came to Canada to meet with our Minister of Health, and out of those meetings came the Global Health Security Initiative – bringing together the ministers of health from the G-7 countries, Mexico, the WHO and the European Commission.  I was one of the people assigned to figure out how the international community prioritized investments against threats.”

“After 9/11, we were paying more attention to what the bad actors were doing,” Goble explained, “working to assess the new threats and to coordinate the work of defense departments and health organizations.” Included in that work was the development of plans to deal with terrorist attacks, which Brad summed up this way: “We couldn’t assume rational behavior – we have to assume crazy.”

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STATS OF THE MONTH

We The People’s Data?

By Bill Davenhall, Geomedicine Analyst

Time to get serious about governmentally-collected data ownership. — Is it their data or “we the people’s” data? 

Government data (especially health-relevant data) has, in my lifetime, always been the currency of health service innovation in the United States — perhaps as important as gasoline is for the economy.  Without it, innovations will be stifled, priorities set a skewed. However, these signs are popping up every day: “Not Available”, “Can’t Find This Page,” and “File Removed.” They are becoming frequent “visitors” at my computer screen. Measuring failure and success in healthcare, let alone trying to assure Federal expenditures are accountable, has become the “muddy data flats” at my desk.  I have witnessed over my many years of using a great many Federally-provided datasets useful to health and human services how healthcare organizations often have been driven into action, and/or get the “tail pined on their donkey” when “we the people” could get our hands on the raw data. Now, will we increasingly be unable to able to answer with confidence the question “what does the data say?”

To illustrate the seriousness of this “data withdrawal”, The Data Foundation, (launched in 2023) attempted to identify the 100 most critical data ecosystems in the US within these major sectors – Financial Services, Education and Workforce,  Climate and Environmental,  Agriculture & Nutrition, and Public Health. The Foundation believes we are at an critical inflection point when it comes to our governmental data trove and the ability to expect professionally-collected and published data useful (and I might add, critical)  to the many organizations that require this important fuel. I would suggest that you read the Data Foundations 2026 Advocacy and Policy Agenda Report and decide for yourself if you think it’s worth supporting or at least following their work. Without a reliable stream of high-quality data will all our finely tuned ecosystems producing of health relevant data streams will generate anything which can help us response better and faster? What will the AI agents be “reading” if the data centers are filled with muddy data or any of the data you need? So, what can you do about this dramatic removal of critical data sets today?

For starters – 1. Make up an inventory of the governmentally published data sets that you can’t afford to lose – those that involve your  everyday planning, managing or evaluations of your work, service delivery,  or program impact. 2. Know what specific data you can’t afford to be without, even for one month. I know there is plenty of data that you “can’t afford to be without” because I have add to worry about data currency when assisting people navigate decision-making for more than four decades and counting. This activity will either increase your workload or minimize it! Expect increasing issues in the amount and quality of the data streams coming out of government agencies and generating data relevant to your health and human service organizations.

Finally, will the health data datapalozza’s of yesteryear be ancient history in public health?  Will the agencies that you depend on to provide you the timely data you need be there when you need it?  What’s you plan if it’s not?  Check out SHADAC (State Health Access Data Assistance Center at the University of Minnesota) who have written extensively about challenges to timely and reliable health data access, particularly how disruptions affect state agencies’ and their partners ability to obtain the “right data at the right time” for policy, surveillance, and public health decision-making. Interesting reading.

No time to waste here  – don’t run out of data your most critical “fuel” – check out the data removals and web page withdrawals here and go forth –and good luck!

As always, I appreciate your 2^nd opinions.

Lessons in Better Vax Programs with Epidemiologist Sara Brown

As background for our interview for this month, let’s talk about creativity. After two decades of innovation work with dozens of organizations, here’s the most important bit of wisdom I gleaned:  Experiments never fail.

Of course, most things you try do not work out the way you hoped. BUT, the willingness and ability to try something different, to embrace the new despite long odds, that’s THE key skill of the innovator; thus, every experiment is a victory in the battle with complacency and mediocrity.

Speaking of trying something new…

You know who’s a tireless experimenter? Mother Nature. And that includes viruses. They’re relentlessly mutating and that’s why vaccination programs must, too.

WHAT GETS MEASURED GETS DONE… AND SOMETIMES UNDONE

Figuring out what really works

What got me thinking about experimentation in vax programs was talking with Sara Brown, the energetic epidemiologist at STChealth. (More on her and the life of an epidemiologist in a minute.)  Sara is involved in several ongoing research studies and I visited with her after reading read one of them, an analysis of the usefulness of reminder cards on vaccination rates.

The study was done in partnership with the immunization team at the Louisiana Department of Health and they monitored the results of sending out reminder cards. This project targeted one particularly vulnerable population, those 65-70 years of age, and it covered two time periods, with big samples — over 90K postcards mailed out. How did it go? Here are a couple of quotes from the published results of the study (JPHMP, May/June ’26):

“There were no greater odds of receiving the flu vaccine during the week after the reminder-recalls were mailed compared to the week prior.”

“Compared to prior seasons when no reminder-recall was conducted, no substantial difference in percent vaccinations was noted.”

You see why this got me thinking of “experiments never fail.” In this case: yes, the postcards failed, but the experiment did not.

CONCLUSION: YOU CAN’T BRING THE MOUNTAIN

How did Sara take the results of the reminder card study? She said, “The results are consistent with other studies, so maybe what we’ve done in the past is no longer applicable to where we are now right. The conversation around vaccines is different now. We need to meet the people where we’re at. You can’t bring the mountain. We have to find what is working, and this is showing that maybe postcards aren’t working. It’s a lot of money to do postcards — each postcard is about $0.50 to send out and we’re talking about tens of thousands of them. We can reinvest that money in another strategy that does work.”

So, are the results, in fact, good news? First, Sara put the finding in context. Figuring out what does and doesn’t work is one of her specialties. It turns out that her first job after getting a master’s in public health at USC was working in program evaluation at Cedars-Sinai in Los Angeles, and it was there she learned a big lesson …

“I started in program evaluation. One of the big issues for public health was the DARE program in elementary schools. Drug awareness/resistance education is this big thing and they spend so much money, and they’ve been spending it for all this time. But the research shows that it doesn’t really work in preventing teenagers from inevitably doing what teenagers do. When you take that data and take the feelings out, it doesn’t prevent drug use. You feel that it should work, right? You want it to work. People involved in these programs put their time and energy and money and then… wow, it didn’t work. But, what does work? Maybe we can be better so we can help more people.”  

(For anyone disappointed to hear the results of the drug program, Sara did add this: “However, we found that it does help with relationships with police officers.“)

So how should we look at disappointing research results? Take the time to acknowledge the feelings of “it should have worked” and then embrace the energy that comes with concluding this: “We just learned something important and we just freed up some resources – what can we try now?”

(START SIDEBAR)

“YOU’RE SUCH AN EPI”

We always like to get to know something about the people we interview, and in this case it was a chance to learn from Sara about how spending your days thinking about epidemics might affect you as a person. Here are some highlights from the conversation…

DALE: If I worked in epidemiology, I think I’d spend all my timeworrying. Are you a professional worrier?

SARA: I would say this: yes, you start off as a worrier. But then you have to be the calm one. You have to pull back and think, Is this a significant increase? Is this a pattern? Is this a blip? I would say epidemiologists are the warning bell: ‘Hey we’re noticing this and these are things we can do to prevent them.’ The news media really focuses on like the negatives and the sensationalism, but as an epidemiologist, you know how these diseases spread and you know when they go into the areas that have these high prevention effort and high vaccination rates, they stop. And that’s when we can see the benefit of all our efforts.

DALE: So, big picture, not a professional worrier, but the warning bell. What does that look like in everyday life/work?

SARA: [laughing] You’re thenagger of the group. Most people sit there and worry about viruses and think, there’s nothing we can do. But, with public health, there is a lot we can do. I know I can be really annoying with some of my nagging — like before my parents go on a plane, I tell them to wear a mask. When I go in concentrated areas, I will have amask with me and I’m one of like 30 people in the airport wearing a mask. And I always have hand sanitizer with me. When we have like a team meeting, I bring out hand sanitizer and offer it. One of my colleagues always says, ‘You’re such an EPI.’

DALE: Speaking of nagging, is there one thing that most people believe about disease that you wish they wouldn’t?

SARA: When you get your master’s in public health, you learn about perceived threat versus perceived benefit – how risky is this to me versus what I have to suffer. So, when it comes to a virus, people don’t think it’ll affect them. They think, I’ve been fine before, or, This has never happened to me and it won’t ever happen to me.  Everyone has a level of survivorship bias. You see it all the time:  ‘Well, I’ve never gotten the flu shot and I’ve been fine.’ One thinks it will never affect them until it does, and then it’s too late. My grandparents talk about how they had the measles and they made it through just fine. But we don’t talk about all the kids that have died from measles in the past because they don’t make it to adulthood to talk about it.

DALE: That’s dark. But you’ve reminded me of what I experience every year when I’m going to get a flu shot and invite my wife who invariably says, ‘I never get the flu.’

SARA:  I think we all suffer from it at different levels of survivor bias. The biggest misconception about disease spread is thinking it’s not going to happen to you — unless you’re an epidemiologist and then you do think that everything could happen to you.

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STATS OF THE MONTH

To Be (Immunized) or Not To Be (Immunization)…That Is The Question

By Bill Davenhall, Geomedicine Analyst

That title recalls the famous Shakespeare quote from Hamlet. Why do I ask it, and why ask now?

Well, perhaps it’s about perspectives on using data to solve non-mathematical problems along with the desire to see things clearly without limits and filters. It was looking at non-medical immunization exemptions rates in the US since 2014 that caused me to pause.

The graph below reveals what startled me – the speed of the change since 2014 in the observed rate of parents seeking exceptions for non-medical reasons for their children entering elementary school. The graph below, courtesy of USAFacts, suggests either a blip or a trend — what do you think? To me it’s a dramatic increase in a statistic that otherwise has been a rather steady state for over a decade – but this graph infused with more recent data (2025 school year) suggests that that this rate of growth will likely continue to rise if we also experience the continued polarization of immunizations/vaccine “theory”. Perhaps this suggests a focus on the outliers or extremes in the data instead of the value of seeking an average? Maybe the perspective about the usefulness of the average really matters versus the need to tightly focus on the extremes. Which perspective do you value the most?

Serious public health analysis is suggesting the change is the result of the passage of state legislation making non-medical exemptions easier to request and immunization easier to decline. Public health analysis now estimates that about 185,000 children received  an immunization exemption in 2025 (which in the estimated universe of 3.4 births for the same year). That number does not seem that concerning… or does it? That depends a great deal on whether if you think you are seeing a data blip or a longer lasting trend.  Climbing exemption may be suggesting that what we are experiencing is simply a symptom of a confused public — due to aggressive political advocacy and not due to the faulty practices of the scientific method.

So, a change in one’s perspective often helps analyze any data; or, better yet, helps in trying to explain the data to the public. The perspective of flying to the moon seems useful this month, offering us an example of how changing your view gives you a chance and the opportunity to dramatically alter your perspective on things, including immunization of children.

Christina Koch, Astronaut and Mission Specialist on Artimus II gave some good hints about changing perspectives this week when she spoke extensively about the overview effect (a cognitive/emotional shift many astronauts experience). So instead of Shakespeare, try this explanation of Christina’s ideas about perspective about her new view: “The overview effect is when you’re looking through the cupola and you see Earth as it exists with the whole universe in the background. You see the thin blue line of the atmosphere…What you realize is every single person that you know is sustained and inside of that blue line.”

As always, I appreciate your 2^nd opinions,