It was about 8:30 pm on December 30, and Marjorie Pollack, a physician and epidemiologist, was working in her home office in Cobble Hill, Brooklyn.
Her email pinged. In her inbox was a note from a frequent and reliable contributor to ProMED, an email list of disease alerts for which Pollack serves as deputy editor. The contributor, who speaks and reads Chinese, wanted her to know about a new post that was getting some attention on Weibo, a within-China social media network. The post said that a few hours earlier, the Wuhan Municipal Health Committee had issued “an urgent notice on the treatment of pneumonia of unknown cause.”
It was the sort of note that ProMED gets every day. The low-tech list and site relies on a worldwide network of readers who funnel notices and tips—social media chatter, health department announcements, stories from small media outlets—to its roughly 50 very part-time employees. Almost all of them are medical or public health or research professionals in real life, and they share an ethos of strict standards of evidence, never publishing anything for which they cannot find confirmation through at least one other source.
So Pollack swung into action. She alerted the rest of the network. Within a few hours, they found the confirmation their standards call for, a story on a Chinese business news site that confirmed the existence of the Wuhan authorities’ notice and included more details. They wrote up a post, vetted it through ProMED’s structure of copy editors and moderators, and hit the button to publish it at one minute before midnight on December 30.
All the time, even hammering on her keyboard, Pollack could not shake a back-of-the-neck chill: “I said to myself, until proven otherwise, this is SARS revisited.”
She was right: The Wuhan health department’s notice was the first warning of Covid-19, which, like SARS in 2003, is caused by a novel coronavirus. And she was in a position to know—because ProMED also published the first bulletin, in February 2003, that alerted the world outside of China to the existence of the SARS epidemic. It also published the first notice of MERS, another transnational coronavirus epidemic, when it arose in Saudi Arabia in September 2012, and of numerous additional outbreaks of Zika, Nipah, Ebola, and other terrifying diseases.
Consistently, this human-curated, barely funded, open-access list—avidly followed in the realm of public health and almost unknown outside it—has been an alarm bell for the world.
ProMED (it stands for “Program for Monitoring Emerging Diseases”) began in 1994, the personal project of John Payne Woodall, an entomologist and virologist who died in 2016. Its cofounders were Stephen Morse, a professor of epidemiology at Columbia University’s Mailman School of Public Health, and Barbara Hatch Rosenberg, a biological weapons expert and former professor of microbiology at SUNY Purchase.
Woodall, universally known as Jack, had an unconventional career. He was born in China to a British family who arrived as missionaries, stayed to run important schools, and were interned in a Japanese prisoner camp from 1941 to 1945. (He once told an interviewer that he dated his interest in insects to the bugs he saw while wandering around the camp's weedy grounds.) He worked on several continents for almost every organization that was important in the post–World War II push to improve global public health, from the Centers for Disease Control and Prevention to the World Health Organization to the Rockefeller Foundation.
Maybe because of that much-traveled background, he believed passionately in the usefulness of everyday people’s reports of events—what the WHO now calls “epidemic intelligence from open sources”—to augment the official data gathered by governments and nongovernmental entities. He also believed in the power of the internet to get that information to people without governments interfering. He founded ProMED at about the same moment that internet use was opening up to everyone, and the site and its email format retain an endearingly clunky text-forward design.
At its founding, ProMED had 40 supporters and readers. In 1999, it came under the aegis and hosting support of the nonprofit International Society for Infectious Diseases, based in Massachusetts. It now has about 83,000 email subscribers, along with modest followings on Facebook and Twitter. Its pyramidal structure of correspondents, copy editors, moderators, and editors stretches across 34 countries. It is never offline.
“Traditional public health is very good at some things,” says physician Larry Madoff, who is ProMED’s editor in chief and, in his day job, medical director for the Bureau of Infectious Disease and Laboratory Sciences at the Massachusetts Department of Public Health. “It is very good at collecting case reports and individual lab data, and aggregating them and doing case investigations. But it has holes: It is not particularly good at quickly identifying events.”
“Programs like ours are better at very rapid alerts of events,” he continues. “We report in very close to real time. And we tend to be immune to attempts to suppress information or failure to report information.”
That ability to route around data gaps and censorship was vividly displayed in the first SARS alert ProMED carried on February 10, 2003. The post was a note from a physician named Stephen Cunnion, living in Maryland and working as an international health consultant, who was relaying an email from a former neighbor on a Hawaiian naval base. It asked: “Have you heard of an epidemic in Guangzhou? An acquaintance of mine from a teachers’ chat room lives there and reports that the hospitals have been closed and people are dying.”
This was, of course, a rumor. So in accordance with ProMED’s standards, that post included a confirmatory source, a bulletin from the government of Hong Kong cautioning territory residents about pneumonia on the mainland but telling them not to be “unduly concerned.” Also in accordance with standards, the combined post was headed “Request for Information.”
At the time, no information had leaked to the West of an epidemic of pneumonia that had been raging in Guangdong for months; the only indication of trouble had been some chatter picked up by a Health Canada data-mining program. The ProMED post was the first public notice of illnesses and deaths. Less than a day later, Guangdong’s Department of Health released the first official statement on an outbreak that would go on to sicken 8,098 people and kill 774 of them around the world.
That 2003 ProMED post didn’t only alert the world to a public health peril. It also changed forever the way that global public health is conducted. At the time of SARS, the rules governing the WHO, known as the International Health Regulations or IHRs, specified that governments were required to report outbreaks of only four diseases: yellow fever, cholera, plague, and now-vanquished smallpox. (Therefore, technically, the government of China was not required to make a formal report of SARS.) The post-SARS IHRs broke reporting free from that strict list. More importantly, they empowered the WHO to intervene in a suspicious outbreak even if the report of the outbreak comes not from a government but from a nongovernmental information source—one such as ProMED.
That enhanced influence made ProMED a publication that a small international cadre of doctors and disease watchers are eager both to read and to support with information. On the night after the first Covid-19 post, Peter Daszak, a disease ecologist and president of the EcoHealth Alliance, interrupted Pollack’s New Year’s Eve dinner to relay details his Mandarin-speaking staff members had picked up from China. Early lab work done in Wuhan showed the novel coronavirus behind Covid-19 had 80 percent homology—similarity due to shared ancestry—with the 2003 coronavirus that caused SARS.
Daszak wanted the ProMED volunteers to know, he says, because “they are a gold standard for information.” He went on: “People say, ‘We have the internet, why do we need this?’ But what ProMED gives you is the value of expert moderation. They do not publish hearsay. We all know that, if you see something on ProMED, it is likely to be real.”
“If ProMED did not exist, we would have to invent it immediately,” says Matthew Watson, a biosecurity expert and senior analyst at the Johns Hopkins Center for Health Security. “They nailed every coronavirus emergence. Their ability to pinpoint off-normal but not-yet-diagnosed disease reports is so powerful.”
But while it is valuable, it is not lucrative. AI health startups are attracting vast venture capital (a commercial AI program flagged the Wuhan pneumonia cases one day after Pollack’s source), while ProMED’s old-fashioned human curation runs on a shoestring. Its many moderators receive stipends totaling what Madoff estimates to be “a few thousand dollars,” gathered through periodic fundraising calls. The group gets support from several philanthropies and governments, and has collaborative agreements with academic research programs such as Harvard’s HealthMap. But everyone involved with the effort is donating many hours of uncompensated time.
“It’s a challenge to get funded when your overhead consists of nominal pay and communication charges,” Pollack says. “We could use all the help we can get.”
And then Pollack excused herself. She was about to finish ProMED’s 96th update on Covid-19 since that first post 81 days earlier. The updates have grown to thousands of words, containing a curation of case counts from every country reporting them, medical journal articles, public health system notices, news reports, and the analytical notes that moderators append to every post before publishing. (She confessed she has already crashed their server several times.)
Pollack’s note in this most recent update was unnerving. She wrote: “I feel like we are on a runaway train.”