We are still in the throes of the worst respiratory disease pandemic since the “Spanish” flu of 1918─and it’s far from over yet. Given the pain and misery, we will surely absorb all that COVID-19 can teach us about preventing another pandemic. Or will we?
There are daily debates about why we have failed to stop COVID-19 from killing well over four million people (by August 2021) and causing serious illness in many more. We can look for gaps in each of the well-known elements of the disaster management cycle: prevent, prepare, detect, respond, and recover. Within this cycle, the functions that need to work include: assess the risk of pathogen spill-over from animal to human populations; employ early detection, speedy notification, and rapid response mechanisms; develop R&D blueprints for new technologies; build staff capacity and skills and share data openly; and do this within an agreed system of global governance.
All these are vital elements of what should be done. Whether they will actually be done depends on the motives and incentives of all those who have a stake in the outcome. My own work has focused on this second point─the reasons why anyone would be willing to do what is necessary. The question needs to be asked because fully-formed pandemic preparedness plans have been lying fallow for years in government offices around the world. If prevention is indeed better than cure, as the time-honoured proverb has it, why have they not been implemented? Why, in general, are we so reluctant to invest in staying healthy? I call this problem The Great Health Dilemma, and offer some explanations and possible solutions in a recent OUP book with that title.
The solution to this age-old dilemma begins with a timeless truth: good health comes at a price. It follows that prevention is more likely to be favoured when an imminent, high-risk, high-impact hazard can be averted at relatively low cost. To understand if and when prevention is worth the effort, we must look at each of three key components of any threat: hazard, risk, and timing.
The more severe the hazard, the bigger the threat. A novel, rapidly spreading infectious disease, which is often serious or fatal, is likely to stimulate a response. Besides the number of people who become ill and die, the fear factor is magnified if a hazard is new, changing, uncertain, and uncontrollable. The International Health Regulations (IHR 2005) are geared to managing infections of this kind, including a powerful way of mobilizing resources by declaring a Public Health Emergency of International Concern (PHEIC). PHEICs were issued for swine flu in 2009, Ebola in 2014, Zika in 2015 and COVID-19 in 2020, attracting worldwide attention. Contrast this with major endemic diseases like tuberculosis, malaria, dementias, diabetes, cancers, and heart disease that routinely kill millions of people each year, but which will never benefit from a PHEIC. COVID-19 has underlined the value of IHR 2005 and the PHEIC. But it also exposed many defects that need to be repaired, including a low level of compliance by governments on reporting new events that could become international emergencies, a matter that is still contentious for COVID-19.
Pandemic influenza, Ebola, Zika, and COVID-19 have all been scary. But if the risk of recurrence is thought to be low, we are unlikely to take steps to prevent it. One way round this is to treat disease outbreaks, not as separate, unpredictable events, but as a collective threat. Between 2011 and 2018, WHO tracked 1483 epidemics in 72 countries, including Ebola, Severe Acute Respiratory Syndrome (SARS), and pandemic influenza. The total number of events recorded was predictable, averaging 185 per year within a narrow range of 154 to 213. This predictability suggests pooling the risks and sharing the costs of managing multiple hazards, a technique used by the insurance industry. In practice this means, for example, developing early detection and response systems, not for a single bacterium or virus but for a wide variety of pathogens. Or building “platform technologies,” like those based on DNA and RNA tools, which are generic precursors for the rapid development of diagnostics and vaccines against an array of pathogens.
A high-risk, severe hazard is a greater threat if it is likely to happen sooner rather than later. The reason is that the future is generally not worth as much as the present. So, to portray COVID-19 as a once-a-century event, as some influential commentators have done, underscores the severity of the current pandemic but discourages timely action to prevent another. The challenge is to create systems for preparedness that value the future, today. One approach is to invest in multi-purpose health systems, including a network of laboratories that produce results daily, but have built-in surge capacity. This is better than creating a stand-alone emergency service that would be scrambled during a pandemic.
Memories of pandemics fade; history is discounted, just like the future. Now is the time then, while motivation is still high, to implement the measures that can prevent devastation by another pathogen, whatever the next Disease X may be. In this respect, the 2014-16 West African Ebola epidemic still holds a warning: billions of dollars promised for the immediate emergency response were largely delivered, but pledges to fund the post-epidemic recovery were not. And very little money was allocated to R&D that would have long-term benefits for the prevention and control of Ebola and similar diseases.
Former US Secretary of Health and Human Services, Michael Leavitt, remarked in 2007 that “Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate.” We are not likely to eradicate both types of error, but we can certainly mitigate them by learning lessons from Ebola, influenza, SARS, Zika, and COVID-19, which collectively add to our understanding of when and why prevention is better than cure.