Someone With Money Needs to Step Up to Save ProMED
The world’s best disease-alert service is both broke and on strike — over a mere $1 million. When ProMED is silent, the world is less safe.
On August 3, a disturbing email went out to the 20,000 subscribers to ProMED, the disease-alert service. More than half the service’s moderators announced that they would go on strike because the International Society for Infectious Diseases, its overseer, had announced two weeks earlier — without informing the moderators who are the service’s backbone — that it would start charging for subscriptions, would limit subscribers’ ability to search past posts (a crucial part of seeing how each outbreak spreads) and would again delay paying the modest stipends that moderators earn.
To my mind, this is a crisis. ProMED is the best early warning system for epidemics the world has, for reasons I’ll explain. It set off the first alarm bells about SARS in 2003, about MERS in 2012 and about Covid-19 in 2019.
ProMED in financial trouble and/or out of action is bad news for anyone worried about epidemics — which, frankly, should be all of us.
Science-oriented outlets quickly picked up the story. STAT News covered the strike as soon as it was declared, saying ProMED “appears to be in peril.” Science followed suit the next day. Wired weighed in on August 7, Nature did on August 10. The Financial Times was on it even before the strike, writing on July 23 that the service was “in danger of financial collapse” because it had raised only $20,000 in donations to cover its $1 million budget. (Back in January, The Lancet effusively sang ProMED’s praises, then waited to the last paragraphs to bemoan that “its propects for the future are uncertain.”)
Are the infectious disease writers at The New York Times, The Washington Post and The Wall Street Journal asleep at the wheel? Don’t they recognize a story?
ProMED has three crucial elements that make it essential. It’s fast — dozens of tips come in from all over the world and it normally collates and distributes a list of them twice a day seven days a week. It relies on expert human experience, not algorithms, to sift out what’s important. And, most of all, it’s independent. ProMED is not beholden to a government or a public health agency, but to the wits and consciences of its moderators.
It was founded in 1994 by the Federation of American Scientists as the Program for Monitoring Emerging Diseases, an experiment to see if the then-newfangled internet could be used to spot outbreaks by tracking local news reports from remote places. Starting as a 40-member listserv, it has grown into a network of dozens of volunteers all over the world — working or retired epidemiologists, clinicians, veterinarians, parasitologists, plant disease biologists and members of other specialties. They file tips and local articles to moderators who add explanatory information and footnotes linking them to similar previous reports. Sometimes the tips are submitted anonymously because the contributors’ governments want the news suppressed. ProMED covers human, animal and plant diseases, which is necessary because many pathogens leap from animals to humans, plant diseases sometimes produce toxic poisons and widespread death in subsistence crops or herds leads to famine.
One would like to think the World Health Organization would be the master clearinghouse for all alerts. It has GOARN, the Global Outreach Alert and Response Network, and EIOS, the Epidemic Intelligence from Open Sources, a computer program that gathers thousands of news reports from around the world, translates them and uses algorithms to pick the important ones. And, of course, it has the International Health Regulations, which obligate all member countries to report outbreaks within their borders.
But the WHO systems don’t impress. In 25 years of covering epidemics, I can’t think of a single one I learned of first from them. This is an issue I follow closely because lives depend on it. I predicted early on that Covid would go pandemic, I think I was the first reporter outside of Brazil to raise alarms about Zika, and arguably also the first to warn that monkeypox would infect thousands of Americans. In disease response, speed matters. The faster the word gets out, the sooner a competent and motivated health agency can head off disaster — and the more lives are spared. For example, if global health authorities had jumped on the 2014 West African Ebola outbreak while it was still in the sparsely populated interior and before it reached the crowded capitals of Liberia, Sierra Leone and Guinea, only a few hundred people might have died, rather than 11,000.
In the case of Covid, bureaucracy kept the WHO from moving faster. Its EIOS system did get early notice of pneumonia deaths connected to a seafood market in Wuhan. But it has a chain of command: a WHO officer in China who hears something must report it to the regional office in Manila, which may or may not pass it on to Geneva. Response times in Geneva, during my time covering the agency, slowed down considerably after 5 PM. In years past, I was regularly told “Oh, the expert you want has gone to dinner and can’t be disturbed. Please call back tomorrow.” (The agency has become much better than it once was on that score.) But the WHO’s biggest limitation is that it’s a UN agency. Like a London men’s club, it is owned by its members, and management must defer even to the most temperamental ones. When it gets a report of an outbreak, it must ask the member country — China, for example — for information. If China decides not to answer — or even to lie — there is no effective penalty. The WHO can complain to the media, but that’s dicey because the member country may threaten to stop paying dues — as the Trump administration did in 2020.
For more than 20 years, Canada had an excellent alert service, the Global Public Health Intelligence Network or GPHIN (GEE-fin). It was once a major contributor to the WHO system — but it went dark just before Covid began. It was founded in the 1990s after an outbreak of pneumonic plague in India triggered a staff panic at Toronto’s airport, where many travelers from India landed. It hired a dozen multi-lingual epidemiologists as analysts. In 2009, it was praised for its early detection of H1N1 swine flu in Mexico, and it was quick to spot the West Africa Ebola outbreak. But, as a series in Toronto’s Globe and Mail reported: “over the years, with no major threats materializing, the government grew weary of GPHIN.” Its budget was cut, its analysts were shifted to new jobs. In 2018, they were forbidden to send out alerts without senior management approval. Notices that once appeared in 15 minutes suddenly took days, rendering GPHIN worthless. Its last alert, about a mystery outbreak in Uganda, was issued in May 2019, about six months before Covid erupted.
Even China itself has an alert service that should have reported Covid. VPUE, the Viral Pneumonia of Unknown Etiology network, was set up after SARS and is run by China’s CDC. Hospital doctors are supposed to report any serious cases of viral pneumonia they cannot explain. However, many were unaware of VPUE’s existence. In Wuhan, according to Michael Worobey, an evolutionary biologist at the University of Arizona who has investigated the pandemic’s earliest days, the first report of a mysterious pneumonia came on December 29 from Dr. Xia Wenguang, vice president of the Hubei Provincial Hospital of Integrated Chinese and Western Medicine. The Wuhan Municipal Health Commission issued an alert the next day. But it immediately came under pressure from the mayor’s office, which closed and hosed down the market on January 1 and sent police officers to intimidate doctors who were raising alarms on social media, telling them to shut up or face criminal charges. (Mayor Zhou Xianwang, an ambitious local politician, had a big party congress scheduled for mid-January and a January 19 potluck dinner for 40,000 families he hoped would put him in the Guinness World Records book.) Nothing was posted on VPUE until January 3, by which time the coverup was steaming forward.
The CDC has many ways to track alerts, but it too is hampered by politics. In the days after Christmas 2015, while tens of thousands of American women of child-bearing age were on or planning vacations in the Caribbean, central America or Brazil, the agency dithered for two weeks before issuing an alert saying pregnant women might want to reconsider going because a mosquito bite might kill their babies or render them microcephalic. The agency first wanted to inform all the affected countries that it was about to drop a bomb on their winter tourism income.
A small, spunky disease-alert site, Flutrackers.com, has existed since 2006. It is often quick to post reports of outbreaks and it tracks worrying genetic changes in viruses. It claims to have alerted the world to Covid 24 minutes before ProMED did. “Everyone knows it was us,” Sharon Sanders, the site’s editor in chief wrote on August 4, linking to a report it posted of a Hong Kong TV station’s pickup of a China state TV report of suspected SARS cases in Wuhan. Flutrackers also claims to have been first to spot the 2009 swine flu, the 2013 outbreak of H7N9 avian flu in China and the 2014 Ebola outbreak. But the site is haphazardly organized and hosts discussions about everything from mask-wearing to “pandemic gardening,” so it isn’t taken as seriously as it might be by experts or journalists.
ProMED screens reports carefully and suggests where they might be wrong or alarmist, but it doesn’t hesitate to move fast. Mostly, it reacts by issuing requests for more information about worrying rumors that are not easily explained away. Sometimes these turn out to be false alarms. A “mystery pneumonia” that killed six people in a rural Argentine hospital last year turned out to be Legionnaire’s disease. I remember a wedding in West Africa after which guest after guest dropped dead; it turned out to be not a new virus but a lethal batch of homemade alcohol that was slowly destroying their livers. A similar spate of deaths after a celebration in South Asia turned out to be caused by a cooking vessel used to make rice. It had been made from a pesticide drum.
Sometimes, though, ProMED nails it.
In 2003, the media paid little attention to what ultimately became SARS until the WHO put out a global alert on March 12. But ProMED had started asking questions on February 10 about rumors that southern China cities were battling a mysterious pneumonia. The initial request for more information had come from a subscriber, Dr. Stephen O. Cunnion, a retired U.S. Navy outbreak specialist. Dr. Cunnion had a friend with a friend who belonged to a teachers’ chat room in Guangdong. The teachers were nervously discussing reports of pneumonia deaths and hospitals filling up. The discussion even included an odd and very specific detail: vinegar was vanishing from supermarket shelves and the smell of boiling vinegar was everywhere. A rumor had arisen that the fumes kept the mystery pneumonia at bay. The outbreak had actually started weeks earlier, but the mayors of the affected cities and then the central administration in Beijing were orchestrating an intensive coverup.
Something similar happened with Covid almost 20 years later. On December 30, 2019, Dr. Marjorie Pollack, ProMED’s deputy editor, got an email from a colleague who kept up with Weibo, the Chinese social media app. It reported rumors of a mysterious viral pneumonia in Wuhan and added a document from the Wuhan municipal health commission saying case clusters were linked to a seafood market. Dr. Pollack kept digging until she found a Chinese business website confirming the commission’s report and put out an alert one minute before midnight. I remember reading it the next day. The WHO’s process took longer. On the 31st it picked up a media report based on the health commission’s warning, but then it had to query China for information and wait. China didn’t reply with confirmation until January 3.
The idea that such a valuable service can’t function because of a fight over a mere $1 million is tragic — and stupid. The National Oceanic and Atmospheric Administration, which predicts hurricanes, has a budget of about $5 billion. Hurricanes are bad, but not one, not even the Great Galveston Storm of 1900, has ever come close to killing as many people as any pandemic — or even a bad flu season — does.
Many issues must be be worked out — control of the money being the most obvious one. There is apparently bad blood between the International Society and its ProMED subsidiary. In 2021, ISID’s managers forced out Dr. Lawrence Madoff, a professor at the University of Massachusetts Chan medical school, who had been ProMED’s editor for nearly 20 years and was effective at raising money through donations and grants. According to Science, ProMED moderators earn only $7,000 a year for their contributions, even though many spend several hours each day on the work. For those getting Western salaries or pensions, that may be just a stipend in return for efforts that began as volunteer service, but moderators in poorer countries depend on the money, one British moderator said. However, even if all 45 moderators make that much, that’s only $315,000. What accounts for the other $700,000 that ISID claims the service costs? Helen Branswell of STAT News reported that ISID’s tax forms show it took in $4.3 million in donations in 2020 and 2021 at the height of the Covid epidemic. As Ms. Sanders of Flutrackers asked in an August 5 thread: “What happened to, literally, millions of dollars?”
Whatever the International Society for Infectious Disease does — other than sponsor ProMED — does not seem as vital. Its website suggests it offers small grants to foreign students, holds an annual meeting and publishes an obscure journal. Its American counterpart, the Infectious Diseases Society of America, is well-known for setting clinical guidelines for its members treating Covid, AIDS, sepsis and other ills.
Someone with money needs to step in. Even if killer epidemics occur only once every few years, what ProMED does is too important to let it suffer blackouts or brownouts. We don’t give the National Weather Service weekends off, or let the batteries on our military early-warning satellites run down. Perhaps it’s time for ISID and ProMED to part ways. A subscription model for ProMED is not unthinkable, but it would need a sliding scale of rates so it’s affordable even in Cameroon and Cambodia — which are more likely to be on the front lines of the next pandemic than Manhattan or London are. Perhaps a sliding scale of salaries can be worked out — volunteerism can’t be relied on forever. But, whatever happens, whoever puts up the money, the expert observers and moderators who keep ProMED going must keep their independence. Their experienced judgements and their wariness of politicized coverups is what protects us all.
Much of the background information in this article is from a chapter on disease surveillance in my book, “The Wisdom of Plagues, Lessons from 25 Years of Covering Pandemics.” It is due out from Simon & Schuster on January 9.
An earlier version of this article gave the wrong date for the first coverage of the ProMED strike by STAT News. Its article was posted on August 3, the day the strike was announced, not on August 8.