Last fall, Harvard University’s Outbreak Week—a University-wide program on epidemic and pandemic preparedness in the 21st century—generated provocative discussions about how the world must better prepare for the next inevitable microbial threat, whether expanding drug resistance, a new strain of influenza, or another infection like AIDS, Ebola, Zika, or SARS. Designing and guiding the event were two experts at the Harvard Global Health Institute (HGHI): Shana Yansen, program manager for global health security at the time, and senior fellow Olga Jonas, a former economic advisor at the World Bank. They shared their insights recently with Madeline Drexler, editor of Harvard Public Health.
Q: It’s been a century since the great 1918 flu. What do we still get wrong about pandemics?
A: Jonas: We think that these are discrete episodes of different infections, with all the peculiarities of different strains of microbes, and that these episodes come as a surprise. That view masks the fundamental permanence of the threat—and the fact that we need a permanent system in place to deal with it. In other words, we need vigilance between outbreaks. In The Plague, Camus made the same point: that people forget and then are always surprised. With the scientific progress that we have made and our understanding of how human activity aggravates the threat, disease outbreaks shouldn’t be surprises.
Yansen: If the threat of pandemics is perceived as a permanent risk, it also changes the types of solutions that are put on the table. For example, you can systemize investment on an annual basis, rather than make the spending episodic, which is what it is now.
Q: Why does institutional vigilance lapse?
A: Jonas: One problem is that the leadership of our institutions, such as the World Health Organization (WHO) or local health departments, are not rewarded for vigilance between outbreaks. Vigilance doesn’t get noticed. What you see, instead, is that it’s the people who are prominent in an emergency response who often move on to higher-status positions in global health.
Yansen: Another reason is that leaders sometimes believe that somebody else will bail them out. Not every government around the world may feel the same responsibility for epidemic and pandemic preparedness. If they think that some other entity may come to the rescue, why spend X percentage of their already-stretched budget on this issue, when they have mothers and children dying every day, or other health priorities that need immediate attention?
Q: Isn’t that a valid argument?
A: Yansen: I think it’s flawed, for two reasons. One, there is a legal contract—the International Health Regulations, or IHR, which was updated in 2005. One hundred and ninety-six countries agreed to this legal instrument, including all members of the WHO. According to the IHR, countries are obligated to prevent, detect, and respond to public health emergencies, including disease outbreaks. The second reason is that nations can benefit by investing in core public health services—it’s what we call “positive externalities.” When you invest in laboratories, surveillance systems, and human resources, the benefits spill over into other areas of disease prevention. For example, if you’re improving surveillance and detection, you also get better at detecting—and likely managing—endemic febrile diseases.
Jonas: Weakness of core public health functions is at the crux of the problem. We know that 75 percent of pandemic-potential pathogens are zoonotic. That means countries need surveillance for both human and livestock health, as well as for environmental risks. But these functions have been marginalized; no developing countries today have the capacity to comply with IHR. External aid organizations have neglected this, too, which is really inexcusable. The World Bank, for example, has rarely financed public health systems.
Q: Why not?
A: Jonas: We’ve heard that a low visibility of results is to blame. Put another way, there are fewer photo opportunities in prevention than in responses and treatment. Ministries of health demand new clinics and hospitals, vehicles, health worker training, and travel to global health meetings and events. But such demands are seldom what a country needs most. That’s a problem of governance: Few people care much about the health of the population as a whole.
Q: How much money would it take to help countries with weak economies prepare for the next inevitable pandemic?
A: Jonas: Robust core systems in 140 developing countries would require $3.4 billion a year, which is less than 1 percent of the $373 billion of public spending on health in developing countries. Health ministers should lead on this—to save lives, save money, and help economic development. It’s good for investment, especially in tourism, which is so sensitive to perceptions of disease risk.
Yansen: The strongest argument for strengthening public health infrastructure is economic. It could be likened to the building of highways. When we built interstate highways, initially it was for transportation and national security. But ultimately, it led to so many other unanticipated economic benefits—like increased productivity, lowered cost of goods, and improved access to jobs and education. Likewise, investing in core public health infrastructure can translate into improved health outcomes, increased productivity, and fewer, less expensive public health emergencies to contain.
Q: Olga, you were at the World Bank for 33 years, and you coordinated that organization’s operational response to avian and pandemic flu threats, among other looming crises. What do you know now about pandemic preparedness that you didn’t know when you started out?
A: Jonas: To be more scared. On a more practical level, we need to sharply distinguish between public goods—of which core public health systems are a prime example—and the supportive roles of governments and their partners in access to quality health care. Closing the gaps in public health—ensuring that it is perceived and funded as a public good—will be the best investment in the coming decades.
Photos: Kent Dayton
