NIH Directors: The World Needs a New Pandemic Playbook

Over the past two decades, scientists developed a pandemic preparedness playbook that has failed catastrophically. It grew out of the fears aroused by the global emergence of highly pathogenic avian influenza in 2003 and the swine flu pandemic of 2009. The U.S. National Institutes of Health (NIH)—which we now lead—made massive investments that failed to cope with the Covid pandemic. Worse, the playbook itself may have caused it.

The pandemic preparedness playbook is breathtaking, even utopian, in its ambition. It entails three basic steps. First, catalog every existing pathogen by sending scientists to every remote place (bat caves in China, and the like), take biological samples of wildlife there, and bring them back to labs, often located in city centers like Wuhan, China.

Second, evaluate the risk of each pathogen infecting humans by testing its ability to penetrate human cells—and sometimes even genetically modifying it to make this more likely. The latter practice is now called dangerous gain-of-function (dGOF) research. This may seem crazy to the uninitiated, but it is a critical step in the playbook. The idea is to estimate the likelihood that the infectious pathogen will mutate in a way that could conceivably threaten humans.

Third, having identified which few of the countless pathogens studied pose the greatest risk, develop vaccines and therapeutics before they leap into human populations. Crucially, this step involves awarding large contracts to pharmaceutical manufacturers to develop and stockpile the countermeasures.

Every step of this agenda is fraught with risk and danger.

The very act of sending scientists into remote places to collect pathogens risks a spillover of a pathogen that might never have occurred otherwise.

The laboratory work, even if not classified as dGOF, is risky. Even with precautions, there is always a risk that a lab will inadvertently leak a pathogen that poses a catastrophic threat. In fact, lab leaks are common, and biosafety oversight is not harmonized worldwide, meaning these pathogens are often manipulated in relatively low-security environments.

President Trump’s executive order placing dangerous gain-of-function work under strict regulatory control helps address the problem, but achieving its goals will require the entire scientific community worldwide to embrace its principles. All scientists must embrace a culture of careful consideration of the benefits and risks of every experiment—regardless of whether it is classified as dGOF.

From a historical and evolutionary standpoint, the playbook makes little sense and needs to change. The measures developed to counter the threat will never have their efficacy tested in humans before an outbreak occurs. Inevitably, the version of the pathogen that ultimately causes an outbreak will differ significantly from those collected to develop countermeasures.

Evolutionary processes are extremely hard to predict; indeed, the one thing we can say with confidence is that the pathogens with the capacity to cause outbreaks are unpredictable. We are left with well-prepared, expensive countermeasures that are unlikely to work.

The stockpiled countermeasures developed under the old pandemic playbook offer a false sense of security and empower those who would impose lockdowns, mandates, and other such strategies. The recent Covid pandemic is a case in point of how such an approach can dramatically fail, harm the population, and undermine confidence in public health.

Furthermore, the playbook creates vested interests with incentives to overreact to new threats. It creates a group of well-funded scientists who benefit from scaring the public beyond what the evidence warrants and at the same time falsely minimizing the risk of lab accidents. These scientists make a living doing research for the traditional pandemic preparedness playbook—an extreme conflict of interest.

The playbook also creates an industry of vaccine and drug manufacturers to whom the government awards vast sums of money to produce the pharmaceutical stockpile that, by design, has never been tested in human populations.

What, then, can be done in the face of the reality that another pandemic will eventually arise?

We must stop wasting money on the traditional playbook. We do not need to find and create new pathogens that could cause future outbreaks. Rather, we must improve our understanding of the pathogens that we know cause disease in humans now, without speculating about hypothetical risks. We should develop better prevention and treatment strategies for these existing pathogens.

We should learn from recent example: a metabolically healthy population, physically active and eating nutritious food, will cope far better in the face of a novel pathogen than a population facing a severe chronic-disease crisis.

Sweden, without lockdown or school closures, was the best in the world at protecting human life during the Covid pandemic. It had the lowest level of age-adjusted, all-cause excess deaths in the world between March 2020 and December 2024. Sweden succeeded in part because its people are relatively metabolically healthy. By contrast, the U.S. chronic-disease crisis all but guaranteed that Americans would have one of the highest mortality rates in the world.

Ultimately, public health agencies encouraging people to take whatever steps they can to improve their health will have a dramatic effect during the next pandemic. Whether simply by stopping smoking, controlling hypertension or diabetes, or getting up and walking more, anything that makes the population healthier will prepare us better for the next pandemic.

The best pandemic preparedness playbook for the United States is making America healthy again.

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