The world failed to learn from 30 years of novel diseases. We must be better prepared for the next pandemic.
The globalized world of the new millennium has become highly vulnerable to epidemics of infectious diseases. It is a vulnerability that has been underscored by several recent pandemics, including Covid-19. Driven by global demographic and societal trends, these events have become more frequent, larger, and – depending on the pathogen – more deadly.
Unfortunately, the ‘out of sight, out of mind’ mentality often results in lessons being forgotten during interepidemic periods. Epidemics will continue to wreak havoc on human and economic health unless we develop more effective and sustainable early warning surveillance, prevention and control programs.
Our rising vulnerability to epidemics
In the past 30 years there have been six infectious disease pandemics: dengue, 1970-2020; HIV-AIDS, 1981-2020; Chikungunya, 2004-2014; Zika, 2007-2016; H1N1 influenza, 2009; and now Covid-19. Several major regional epidemics have had the potential to become pandemics: pneumonic plague, in 1994; West Nile encephalitis, 1994-2004; H1N5 avian influenza, 1997-2005; Nipah encephalitis, 1998-2000; SARS, 2002-2003; and Ebola, 2014. These regional epidemics are animal pathogens and, except for Ebola, are transmitted to humans via the respiratory route or by mosquitoes. Many other viruses pose similar threats.
Infectious disease epidemics obviously affect public health, but they also pose major threats to our economic security in a globalized world with a transnational economic system that depends on modern transport for food, medicines and other commodities. In short, we are more vulnerable than ever to infectious disease epidemics.
The emergence and rapid geographic spread of pathogens has been facilitated by several global trends, including population growth, human migration, unprecedented urban growth, modern transportation, changes in animal husbandry practices, and environmental and lifestyle changes. Ecotourism, the encroachment of humans on animal habitat, and complacency about the threat posed by infectious diseases have also contributed. These conditions are unlikely to change in the near future, so we must learn from past epidemics in order to prepare for future threats.
Five lessons from past epidemics
- Unprecedented urban growth has created crowded cities of 5-20 million people living in inadequate housing with limited or no sewage, water or waste management. These are ideal conditions for transmission of infectious diseases.
- There are often prolonged intervals between epidemics during which the ‘out of sight, out of mind’ mentality kicks in. Funding for surveillance and response plans is deprioritized.
- Changes of political administrations during long interepidemic intervals result in personnel turnover. Decision-making positions are filled by staff who do not take the threat seriously or do not appreciate the need to maintain readiness.
- Emergency response plans are developed and written by public health officials, but implementation requires political decisions. Most policymakers do not like to initiate emergency response plans until it is certain that there is a true public health emergency, by which time it is usually too late to effectively contain the disease.
- Because of media and public pressure, we have evolved into a crisis-oriented society that responds to emergencies ‘too little, too late’. The old adage that ‘an ounce of prevention is worth a pound of cure’ has long been forgotten.
Reversing the trend
Successful reversal of the trend of epidemic infectious diseases will require a coordinated partnership involving many segments of society, including the public, local, state/provincial, national, international and animal health agencies; urban planners, environmental groups, the air travel and shipping industries; food production and animal husbandry industries; the media, and national and international corporations. All have an important role in reversing the problem they helped create, yet few are involved in current prevention programs: responsibility sits solely with health agencies, which suffer from fragmented and inadequate funding and coordination.
Successfully reversing the trend requires action in several areas.
1. Adequate coordinated global funding
A global fund should be established to help resource-poor countries develop the infrastructure needed for effective early-warning surveillance, prevention and control programs. This fund would be a new independent organization, directed by a panel of experts and supported by first-world governments, international health and funding agencies, foundations and international business corporations. The advisory panel would determine funding priorities and coordinate activities.
2. Effective national laboratory-based surveillance
Surveillance, prevention and control programs must be developed and maintained by most – or all – countries.
3. Community involvement
This is critical: outreach programs must be intensive, transparent, factual and based on the best science available. Panic and fear in the media and among the public at large should not be allowed to drive policy decisions.
4. Intersectoral partnerships
Given the driving forces of epidemics/pandemics, the response must include intersectoral partnerships. Countries, regions, states/provinces and communities are often very different culturally, demographically, ecologically and economically, and hence require unique policy approaches and interventions.
5. Automatic triggers
Epidemic/pandemic response plans must include automatic triggers for implementing responses by local, national and international public health officials. Regular drills by key agencies can help maintain readiness.
Countries must fully fund and maintain their public health infrastructure and health programs. They should not rely on international sourcing and funding agencies.
Work to develop new and innovative tools for surveillance, prevention and control of infectious diseases, including vaccines, drugs, diagnostic tests and vector control, should be funded at a high level. This should be coordinated by the global advisory panel.
Keeping the problem in view
The vulnerability of today’s interconnected global economy makes it imperative that we don’t allow the out of sight, out of mind mentality to undermine early warning surveillance programs for infectious diseases. Detecting and containing emerging pathogens before they spread globally is critical. We need to learn the lessons of the past 30 years to be better prepared for, or ideally to prevent, the next pandemic – wherever, and whenever, the threat emerges.
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— Duane J Gubler is emeritus professor and founding director of the program in emerging infectious diseases at the Duke University-National University of Singapore Medical School