The Plague Cycle
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The world’s governments also need to work together to eradicate some of the worst infectious threats, including polio, measles, and malaria. Such efforts are some of the highest-return investments we can make. The eradication of smallpox, beyond saving somewhere over 40 million lives worldwide since the 1970s,11 also avoided $2 billion a year in vaccination and hospital expenditures in the US alone—an impressive return for a global program that only cost around $300 million, and for a disease that had already been almost completely eliminated as a domestic health threat in the US before the global eradication program began.12 The US recoups its investment in the global smallpox eradication effort once every twenty-six days.13
When it comes to protecting some of our most valuable tools in the fight against infection, much depends on a new set of global agreements around drug quality and antibiotic use. Take antibiotic use in animals: the economic case for truly global action is urgent and overwhelming. That’s not least because the benefits of antibiotic use in agriculture have proved limited: antibiotics substitute for improved farm sanitation in a way that is, at best, marginally effective. Economic analysis suggests that the slightly slower growth of pigs taken off antibiotics might raise farm-gate meat prices by perhaps 1 percent.14 Meanwhile, the harmful impact of livestock-related resistance is both considerable and global.
An international agreement on antibiotic use in animals could, as a first phase, mandate the rapid reduction of the use of antimicrobials also used in humans, followed by phase-out of all antibiotic use for growth promotion, with support for farmers in poorer countries to encourage heightened use of sanitary techniques and other alternatives. Perhaps there could be similar agreements aimed at phasing out multi-use needles, or tightening requirements for human antibiotic use.
The world’s governments should also come together to fund research toward new vaccines, antimicrobials, and vector control. A particular problem with respect to drug development is that a market that focuses on current diseases of the rich denies the world cures to diseases that mostly affect the poor. Case in point: we have multiple cures for erectile dysfunction but lack a single malaria vaccine.15
The total global market for all vaccines is about two-thirds of the market for the single cholesterol-reducing drug Lipitor.16 The antibiotics market, though also vital to health, is similarly unrewarding. This is a matter of rich-world self-interest: if we want to reduce the risk of a global breakout by a disease customarily found in a developing country, the best response is proactive research and development, and that’s going to take global cooperation.
One response to the research problem was developed in 2009 by the Gavi Alliance—a consortium of donors that support vaccine purchases for the world’s poorest countries. The alliance wanted to spur the creation of a vaccine to fight pneumococcal strains in developing countries—a bacteria that causes pneumonia, meningitis, and sepsis. Pneumococcal diseases killed 1.6 million people each year in poorer countries, accounting for one out of every four child deaths.17 Instead of funding research and development, the Alliance simply guaranteed that they’d spend $1.5 billion to buy the vaccine at $7 per dose if drug companies manufactured it.
Drug companies rose to the challenge. Only two years later, GlaxoSmithKline and Pfizer had rolled out suitable products, and a number of developing country drug manufacturers were close behind.
Besides increasing research funding, we should be rushing out similar commitments for new antibiotics or vaccines for diseases like malaria. The new Center for Epidemic Preparedness Innovations, backed by donors including the governments of Norway and Japan, is supporting research, development, regulatory trials, and stockpiling of vaccines for potential outbreak diseases including Lassa fever, Nipah, MERS, and Ebola (it’s also supporting work on a Covid-19 vaccine).18
Other approaches include manipulating mosquito DNA so that mosquitoes are incapable of carrying malaria, and using “gene drive” technology to ensure that nearly all offspring develop the desired traits. Drastically reducing the global population of mosquitoes—or, at least, reducing them to a nuisance rather than the world’s most deadly animal—would be a massive boon.
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Controlling the risk of new infectious outbreaks and pandemics is first and foremost about getting public health systems to work. Take Ebola: for it to spread, the bodily fluids of an infected person need direct contact with an open wound or the mucous membranes of another. We’ve seen that despite its lethality, it’s an unlikely candidate to spark a global pandemic when the natural response through the ages—staying away from people who look sick—is such a powerful preventative.
It is a sign of the weakness of health systems in parts of West Africa that Ebola spread at all in 2014. In that year, Nigeria saw nine laboratory-confirmed cases of the disease, and patients were rapidly isolated. Health authorities followed up with nearly nine hundred patient contacts and kept the contacts under observation for twenty-one days. The disease was stopped in its tracks.19 Nigeria has an income per capita that is one-tenth the level in the US—showing that even poor developing countries can control the condition.
The same is broadly true of all infectious diseases: if you can find and isolate patients and sterilize contact, the chain of infection should be broken. It is in everyone’s interest that every country can provide at least the bare minimum of health coverage and epidemic preparedness to support that response for less contagious conditions such as Ebola.
We learned in 2020 that the challenge is considerably greater with a disease that can spread so easily from people who are showing few if any symptoms. That said, we’ve known most of the effective responses to a contagious pandemic for a hundred years or more by now. US cities and states responded to the 1918 flu by issuing public service announcements about risk and by increasing hospital surge capacity; closures, quarantines, and social distancing measures; disease surveillance; and vaccine research and distribution.20 The problem both in 1918 and 102 years after wasn’t that we didn’t know what to do, it was that many countries didn’t do it well.
In the early stages of the Covid-19 response, many countries, including the US, failed to properly communicate: leaders underplayed the risk the virus presented as well as the response that would be required; they led through bad example when it came to enforcing social distancing and wearing masks; and they touted treatments that had no scientific basis. Hospitals struggled to deal with the patient load and reported a lack of isolation units, ventilators, and supplies of basic protective equipment including masks. Social distancing measures were introduced too late in many regions and removed too soon in others; and it took far too long to ramp up capacity to test, trace contacts, and isolate the infected.
Meanwhile, other countries achieved early victories against the disease. South Korea, scarred by a poor performance battling the Middle East respiratory syndrome outbreak in 2015, had considerably bolstered its capacity to respond. By early March 2020, it had tested more people for Covid-19 than the US, the UK, France, Italy, and Japan combined. It also imposed strict isolation of sick people in hospitals and dorms—away from families or group houses. In mid-March, the US and South Korea each had about ninety Covid-19 fatalities. During the month of April, South Korea lost eighty-five more people to the disease while the US lost sixty-two thousand.21
Still, worldwide, attempts to limit the coronavirus’s spread by reducing contact were unprecedented in scale—a far broader shutdown than achieved by Italian cities confronting the plague seven centuries ago, and more widespread and longer-lasting than the school shutdowns, prohibitions on public gatherings, and quarantines put in place by US cities during the 1918 influenza pandemic.22
We’ve seen that because of their (appropriately) impressive scale, these efforts carried immense cost. That cost could have been reduced, and, more important, lives could have been saved, if countries had been better prepared. For future outbreaks, governments should expand their stockpiles of masks, basic medical equipme
nt, and drugs. And given that countries that tested many of their citizens early have seen fewer cases and less disruption, every nation should be creating the infrastructure and gathering the equipment to roll out testing, tracing, and isolation.
From their experiences with Covid-19 governments should also learn what level of isolation is sustainable and for how long. During the 1918 flu pandemic, distancing measures helped slow spread, but they didn’t have a significant effect on overall death rates.23 In part, that may be because they were abandoned too soon. Realistically, there is no one-size-fits-all solution to what is a sustainable level of shutdown and social distancing—and that suggests the need for individual planning by governments worldwide.
One thing that determines how long and how much people can remain distanced is how long they can afford to do so. For some lucky, largely better off employees, working from home is straightforward. For others, work necessitates going somewhere else. Many of the biggest coronavirus hot spots in the US were large workplaces, including meat packing plants, aircraft carriers, and nursing homes. Providing financial support to ensure those who don’t need to go to work don’t have to, and providing protective equipment and training to the rest, is a tool both to reduce the economic impact of infection and to save lives. The programs started in 2020 in countries including Brazil, the UK, and the US to extend unemployment benefits, provide universal income support, or pay employers to retain workers were all steps in that direction. Thinking through financial mechanisms to equitably cushion the cost of lockdowns is a vital part of pandemic preparation.
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Another lesson we learned again from Covid-19 is how much we need improved planetary cooperation to confront pandemics. Ever since we’ve had a global disease pool, we’ve needed global responses to deal with it. Slowly, too slowly, we’ve built some of that capacity. In fact, some of the earliest cooperative international agreements involved pandemic response: in the 1830s, there was a treaty on quarantine in the Mediterranean, for example. The International Cholera Control Commission met in Istanbul in 1866 to impose a quarantine against ships coming from India, much to the disgust of free-trading British ministers.24 And in 1898, an international conference on the spread of Yunnan plague was held in Venice. Once again, the government of India was chided for its lack of action on the disease and quarantines were imposed on Indian exports.25
More recently, under the auspices of the World Health Organization, there’s been global cooperation to track and combat infection. And the response to outbreaks including swine flu and bird flu has shown that the web of international treaties, however threadbare, can still achieve results. The International Health Regulations obligate countries to notify the World Health Organization within twenty-four hours of any event that may constitute a “public health emergency of international concern”—and with the 2009 swine flu outbreak that was broadly what happened.
At the same time, the regulations call for improved detection and reporting capacity of health events.26 But in 2013, out of 193 member countries, the WHO judged that only 80 countries were displaying the core capacities required for hazard alert and response. The World Health Organization itself has limited capacity. Member countries flatlined the institution’s core budget beginning in the 1980s. From 1993 onward, the policy has been one of zero nominal growth—with no accounting for inflation. Today, its budget is worth about 30 cents per person per year worldwide.
The WHO’s limited capacities were well demonstrated in its response to the West Africa Ebola epidemic. The organization announced the discovery of Ebola in Guinea on March 22, 2014. But in mid-April its spokesman was suggesting “this outbreak isn’t different from other outbreaks,” which had rapidly petered out. The organization shared a concern with Guinean officials that advertising the potential magnitude of the outbreak could lead to significant economic damage. But it went far too far in accommodating that concern.27 By the time the emergency was finally announced in early August, 932 people were already dead and there were 1,070 more cases of Ebola.28
At that point, if anything, the problem switched to overreaction. The Centers for Disease Control projected that up to 1.4 million could be infected in Liberia and Sierra Leone by January 2015. Global institutions and donor countries rushed late but headlong to respond. Thankfully ignoring nativist calls to quarantine the whole region, governments began mass airlifting of troops and supplies to set up hospitals.
As it turned out, most of those beds were never used. In reality, by January of 2015 there were 19,140 cases—about 1 percent of earlier forecasts.29 Those are still tragically high numbers for a desperately poor region already suffering an immense disease burden. And they could have been lower if the global response to the outbreak had been early and proportional rather than late and panicked.
The World Health Organization did better in its response to Covid-19. It started daily “situation reports” on Covid on January 21, 2020, when there were only 282 confirmed cases worldwide. By mid-February, the organization was sending Covid-19 laboratory testing kits to member countries, and personal protective equipment to developing countries with the greatest need. At the start of March, it had developed guidance for containment and suppression based on the findings of a joint WHO-China report on the virus and its epidemiology. The guidance was followed by South Korea and Hong Kong with considerable success. And in March the organization also launched a cross-country “mega-trial” of four potential treatments for Covid-19—big enough to rapidly and accurately demonstrate levels of efficacy.
WHO played an important role in advising against harmful responses, too. Director General Dr. Tedros Adhanom Ghebreyesus warned that all countries “must strike a fine balance between protecting health, minimizing economic and social disruption, and respecting human rights.” In the case of Covid-19, the organization advised against the application of travel or trade restrictions for more than short periods.30
Many countries didn’t fully live up to their commitments under the International Health Regulations. At the year’s start, China actively suppressed information on Covid-19 and arrested whistleblowers. It was slow to approve a WHO mission to study the disease. And while WHO advised against travel and trade restrictions, countries including the US ignored that guidance. But, if anything, that suggests the need to strengthen the organization.
The International Health Regulations put countries in charge of reporting outbreaks and deny the WHO independent authority to inspect incidents absent host country permission—a significant limit on the organization’s ability to monitor infectious threats. When the International Atomic Energy Agency wants to inspect nuclear reactors in a country, it doesn’t need to ask nicely and get an invitation first. The Nuclear Nonproliferation Treaty gives the organization authority to verify that the states that have signed on are living up to their obligations not to develop nuclear weapons, and the IAEA’s 2,560 staff members are available to carry out those inspections. The same should apply to the World Health Organization in a time of disease outbreaks. (Similarly, more authority and resources should flow to the Implementation Support Unit of the Biological Weapons Convention. The unit needs considerably more than its current four employees, as well as a tighter treaty authority, to conduct investigations around bioweapons production.)31
And rather than relying on the capacities of nongovernment groups like Doctors Without Borders and an overstretched WHO core staff to respond to outbreaks, the United Nations should create a body to do for infectious disease what blue-helmeted peacekeeping troops do for war. The WHO’s Health Emergencies Program, which leads response to pandemic outbreaks, is chronically underfunded and under capacity. The organization should have access to a roster of volunteers from participating countries who could be called up at short notice to respond to a disease outbreak within days or a few weeks; it should have the ability to call up logistical support from charter companies and (if necessary) the militaries of countries that have agreed to provide transport; fina
lly, it should have access to a significant global stockpile of basic medical supplies.
In April 2020, many of the world’s countries were brought together by the World Health Organization to pledge greater cooperation on coronavirus vaccine research and make a commitment to share research, treatment, and medicines globally.32 That should be the start of a broader effort to create the technological base to better respond to future pandemics. That would include global research in broad-spectrum antivirals and antibiotics that might help fight outbreaks, as well as techniques that allow for more rapid test and vaccine development.
In addition, the world as a whole needs the spare capacity in pharmaceutical manufacturing to quickly scale up vaccine production. Not least, that involves retooling factories in advance of knowing precisely which vaccines will prove effective. In the case of Covid-19, the Gates Foundation supplied some of the funding for this exercise, but the world shouldn’t have to rely on private philanthropy to guarantee public health: a dedicated fund under an international organization like the World Health Organization or the World Bank should be able to support rapid development and manufacture of pandemic-response technologies.