The COVID-19 pandemic, in the words of Tedros Adhanom Ghebreyesus, the director general of the World Health Organization (WHO), “is a once-in-a-century health crisis.” Indeed, the last public health emergency to wreak such havoc was the great influenza pandemic that began in 1918, which sickened about a third of the world’s population and killed at least 50 million people. But because global conditions are becoming increasingly hospitable to viral spread, the current pandemic is unlikely to be the last one the world faces this century. It may not even be the worst.
The novel coronavirus hit a world that was singularly unprepared for it. Lacking the capacity to stop the spread of the virus through targeted measures—namely, testing and tracing—countries were left with few options but to shut down their economies and order people to stay at home. Those policies worked well enough to slow the growth of cases by late spring. But over the summer and into the fall, governments faced pressure to relax those restrictions, and cases rose. On November 4, more than 685,000 new cases worldwide were reported in a single day—then an all-time high. By that point, more than 48 million people had been infected with COVID-19, and more than 1.2 million had died.
The economic and societal effects of the pandemic will linger for decades. Worldwide productivity is expected to have contracted by five percent in 2020. The United States alone has suffered an estimated $16 trillion cost from lost productivity, premature deaths, and sickness. More than one billion children around the world have had their schooling interrupted. The World Bank has warned that some 150 million additional people will enter the ranks of extreme poverty as a result of the pandemic.
This staggering toll reveals the severe inadequacy of the global systems in place to protect against pandemics. Today’s public health architecture was built for outbreaks and epidemics, but pandemics require a different approach. In outbreaks and epidemics, the spread of disease is geographically limited, so the unaffected countries can, in theory at least, help the affected ones. In a pandemic, however, nearly everyone is hit at once, which means that there is far greater demand on the limited resources of the WHO, the World Bank, and other international organizations. This means that countries have to rely on themselves to stop the spread.
The United States and other countries are rightly focused on recovering from the current crisis, but they need to look past it and focus on preparing for the next one, too. That requires a fundamental change in the way that countries think about global health security. They have to give the WHO and other international institutions the resources and mandate they need to identify emerging threats and incentivize countries to develop the capacities to contain them. And they have to strike agreements to share data and conduct joint trials, so as to enable a truly global response to a pandemic. Otherwise, the world’s response will once again prove to be too little, too late.
CONDITIONS FOR CONTAGION
The emergence of COVID-19 should not have been surprising. Respiratory viruses, including the novel coronavirus behind this pandemic, are often well suited to widespread transmission. Because each infected person can pass the virus to several others, it spreads exponentially until control measures are put in place. Respiratory viruses also tend to have short periods between exposure and contagiousness, which leaves only a narrow window of time to intervene. To make matters worse, they often cause symptoms that look like those of other, more common diseases—and sometimes cause no symptoms at all—creating difficulties in identifying who is infected and who isn’t.
Then there is the matter of mortality. Respiratory viruses have a demonstrated potential to cause serious illness and death in a high percentage of cases. The coronavirus that caused the SARS epidemic in 2003 is estimated to have killed ten percent of the people who caught the disease, and the one that has caused outbreaks of MERS since 2012 has killed about 35 percent. Both are respiratory viruses.
Once a pathogen like this emerges and starts spreading locally, if it is not contained quickly, it can easily spread globally. Although there is no single definition of “pandemic,” epidemiologists generally use the word to describe an outbreak of infectious disease that has spread across multiple parts of the globe. Such spread is much easier today, in an era of international travel, mass displacement, migration, and urbanization, all of which allow pathogens to reach new susceptible populations. And the prevalence of chronic diseases, including obesity, makes people more prone to develop serious cases once they are infected.
The novel coronavirus hit a world that was singularly unprepared.
The H1N1 influenza took only two months from when it was first detected, in April 2009, to circulate around the world—and just a year to kill somewhere between 150,000 and 575,000 people. That pandemic turned out to be just the first in a series of infectious disease emergencies. After H1N1 came the emergence of the deadly coronavirus that causes MERS; the two biggest Ebola epidemics on record, first in West Africa and then in the Democratic Republic of the Congo; and the global spread of the once obscure Zika virus. There will be more. Even when accounting for better surveillance, the number of new emerging infectious diseases has increased steadily since 1940. Most of these new pathogens originated in wildlife and jumped to humans—a phenomenon called “spillover,” which is driven by globalization and humans’ increasing encroachment on nature.
The emergence of new, worrisome pathogens is to be expected; whether they cause a global pandemic depends on how the world responds. As the epidemiologist Larry Brilliant once put it, “Outbreaks are inevitable; epidemics are optional.” Even as global conditions empower pathogens, countries and international organizations can take measures to stop outbreaks from becoming epidemics and epidemics from becoming pandemics. But doing so successfully will require changing the way they approach the basic task.
PANDEMIC GOVERNANCE
The International Health Regulations, or IHR, are a set of guidelines first adopted by the WHO in 1969 and strengthened after the 2003 SARS epidemic. A legally binding agreement, the IHR require governments to develop the capacity to respond to outbreaks that have the potential to spread widely, and it gives the director general of the WHO the power to declare a “public health emergency of international concern.” Arguably, the IHR’s greatest strength lies in their requirements for early detection. The regulations establish the expectation that countries will develop the public health capacities necessary to identify and report potential global emergencies. If national governments can quickly detect and notify the WHO of major outbreaks, the logic goes, then the rest of the world has a chance to prevent them from growing.
Yet many countries have failed to fulfill their obligations under the IHR. By 2012, less than a quarter of all WHO members had reported full compliance. Two years later, that fraction had increased only slightly, to just over a third. As was made clear during the West African Ebola epidemic that began in 2013, the lack of progress is deadly. Delays in detecting an outbreak in Guinea allowed the disease to spread to Liberia, Nigeria, and Sierra Leone, eventually sickening close to 30,000 people and killing more than 11,000. Only after foreign governments and international organizations sent in personnel to help was the epidemic eventually contained.
In the wake of that episode, several independent commissions concluded that it was not enough for countries to grade themselves on their compliance with the IHR; rigorous external review was needed. In response, the WHO developed a voluntary process for outside evaluation. To date, more than 100 countries have opened themselves up for inspection, although there are some notable exceptions: China, India, and Russia, along with much of western Europe and all of Latin America. And although this process represents an improvement over self-assessment, few countries, even wealthy ones, have taken steps to address the gaps that have been identified.
The WHO’s implementation of its own regulations has also come under scrutiny, particularly its process for determining whether to declare a global public health emergency. During the Ebola epidemic in West Africa, the organization waited until August 2014 to make that declaration, more than four months after the virus had spread internationally and more than eight months after the epidemic likely began. After another outbreak of the disease began in Congo in August 2018, it waited 11 months to do the same, even as the number of deaths exceeded 1,000. When Tedros finally declared the epidemic a global emergency, he stressed that countries should not respond by implementing travel or trade restrictions, reflecting concerns about the political consequences of making such a designation.
The next pandemic will require a fundamental change in the way that countries think about global health security.
The WHO’s judgment was called into question again once COVID-19 started spreading in the Chinese city of Wuhan in December 2019. At meetings on January 22 and 23, the organization declined to declare an emergency, contending that there were insufficient data from China, before reversing course a week later. A week’s delay may not have mattered much in terms of the virus’s spread, but it suggested something troubling: that the WHO was letting Beijing influence what was supposed to be an independent, science-driven process.
The IHR are also limited by their lack of teeth. The regulations grant the WHO the power to recommend which travel and trade restrictions are necessary and which aren’t, but governments often go their own way. As the H1N1 pandemic swept across the United States and Mexico, the WHO issued strong warnings against the use of travel or trade restrictions, contending that they would do little to slow a virus that was already spreading widely across the globe. Nonetheless, China and Russia quarantined planes from North America and banned U.S. pork imports, which likely exacerbated the social and economic toll of the pandemic. Similarly, during the West African Ebola epidemic, more than a third of countries went beyond what the WHO recommended, instituting measures that did nothing to prevent Ebola from coming out of West Africa but did make it harder for doctors and supplies to get in.
When COVID-19 first appeared, the WHO did not recommend travel restrictions, a decision that has been the subject of much controversy since. But the WHO was trying to keep in mind a larger consideration: that the prospect of such restrictions can make countries unwilling to report major outbreaks. When countries respond to reports of new disease outbreaks by penalizing those that first report them, it undermines the IHR’s greatest strength: early detection. The later the rest of the world learns of an outbreak, the harder it is to respond. Ideally, countries that honor their obligations to report outbreaks early should be rewarded with help and priority access to resources—not penalized. Yet the IHR offer no such incentives.
The shortcomings brought to light by COVID-19 have led to renewed calls for strengthening the IHR. Tedros himself has called the pandemic “an acid test” for the regulations, and in August 2020, he announced that an independent committee would review them. Upgrading the IHR would not be easy: the last major overhaul came after a decade of debate and was completed only in response to the shock of SARS. Especially in the wake of the Trump administration’s decision to withdraw the United States from the WHO, countries may decide it’s not worth trying to negotiate stronger regulations.
GETTING GOVERNMENTS TO ACT
Ultimately, it’s up to sovereign states to prepare for pandemics. The problem, however, is that efforts to motivate action have largely failed. COVID-19 may have caught political leaders by surprise, but health experts had been sounding the alarm for decades, making it clear that a serious pandemic was a matter not of if but of when. Perhaps the highest-profile of these warnings came in a September 2019 report. The Global Preparedness Monitoring Board, an independent panel convened by the WHO and the World Bank, called a fast-moving, highly lethal pandemic a “very real threat” and urged countries to prepare.
Despite such premonitions, governments dragged their feet in reacting to COVID-19. Many restricted travel from China or otherwise closed their borders, but it was too late: the virus had already leaped across continents. Governments waited weeks and weeks to institute lockdowns at home—a delay that gave the virus crucial time to flourish. Part of the problem may have been the WHO’s reluctance to call COVID-19 a “pandemic.” It was only on March 11 that the organization first used that word to describe the disease. By then, more than 100,000 cases and more than 4,000 deaths had been reported. The label carries no legal significance, so the delay in using “pandemic” to describe the spread of a virus to more than half of the world’s countries was puzzling.
Tedros justified the WHO’s hesitation by making the dubious argument that the word “pandemic” could “cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death.” In refusing to use the word for months, the WHO missed a chance to educate the public that the term “pandemic” indicates a disease’s geographic spread, not its severity. It also missed a chance to motivate governments to take preemptive action. In all likelihood, some of them failed to institute lockdowns in part because they did not understand the virus’s transmission potential.
As countries began to grasp the gravity of the unfolding pandemic, they found themselves hindered by inadequate health-care systems. Efforts to “flatten the curve,” such as shutdowns, have been aimed largely at preventing hospitals from becoming overwhelmed by a surge of patients. In the United States, images of overrun intensive care units in Italy spurred politicians into action. The realization that there wasn’t enough personal protective equipment for health-care workers only added to the concern.
Countries were right to fear that their health-care facilities wouldn’t be able to cope with COVID-19. The 2019 Global Health Security Index—published jointly by the Johns Hopkins Center for Health Security (where I work), the Nuclear Threat Initiative, and the Economist Intelligence Unit—looked at 195 countries and assessed their readiness for an epidemic across six categories. The average score for their health-care systems was 26 out of 100, the lowest average among all the categories. Even rich countries lost the most points in this category.
Yet even though hospitals and clinics play a central role in mitigating or amplifying the toll of public health emergencies, governments have given them short shrift. The WHO, for its part, has issued a list of “core capacities” needed to combat infectious disease outbreaks, but that list excludes the tools needed to deal with serious respiratory illnesses. It doesn’t include the capacity to keep critical government functions working in the face of widespread illness and absenteeism, for example. Nor does it include the capacity to rapidly acquire medicines and protective equipment when other countries are trying to do the same. COVID-19 has revealed both the fragility of global supply chains and the unequal distribution of medical supplies around the world. Low-income countries, in particular, have suffered a severe shortage of masks, respirators, gloves, gowns, and much else.
ON THE LOOKOUT
COVID-19 has also uncovered the inadequacies of existing efforts to conduct surveillance for pandemic threats. Early on, it was clear that there was no single official source for tracking the spread of the disease in real time, which sent public health researchers scrambling to fill the void. The COVID-19 dashboard set up by my school, Johns Hopkins University, emerged as one of the first places to publish reliable, up-to-date case numbers from around the world. But the very fact that a university website, rather than the WHO, became the go-to source for information about the pandemic’s spread exposed the gaping holes in international surveillance. There are no clear expectations that governments should share data about potential pandemics, nor is there a standardized way for them to do so.
A key flaw of surveillance efforts is that they rely on voluntary reports from governments. As COVID-19 took off in Wuhan, the Chinese government delayed sharing information about the number of cases and the ease of transmission, a decision that limited the rest of the world’s understanding of the new pathogen. Relying on individual governments to report data in a timely, complete fashion has not worked out well, and nongovernmental sources are often more reliable: after all, it was the Seattle Flu Study, a project funded by Bill Gates, that first detected community transmission of the novel coronavirus in the United States. Such initiatives should be encouraged. Health-care facilities, for example, should band together to create a global network that shares hospitalization data.
As challenging as COVID-19 has been, there are even worse scenarios out there.
Governments should also pledge to share samples of emerging pathogens. Although Chinese researchers shared early genetic sequencing data from patients infected with the novel coronavirus, they held back samples of the virus. Their reluctance was problematic because scientists need more than genetic specimens to develop vaccines, medicines, and diagnostic tests; they need actual samples of the virus. It would be useful, then, for the world to expand on the method it has employed since 2011 to share samples of avian influenza, a WHO framework known as “pandemic influenza preparedness.” Indeed, global pandemics require global responses. With COVID-19, larger, more international trials of medicines and vaccines have fared far better than smaller, unilateral ones. For example, the Solidarity trial, an approximately 12,000-patient study of COVID-19 treatments organized by the WHO, has yielded useful data about which therapeutics work and which don’t.
One of the biggest challenges to pandemic preparedness, of course, is funding. Historically, much more money has been spent on responding to epidemics and other emergencies than preparing for them. Making matters worse, the economic toll of the current pandemic will squeeze budgets, as was the case following the recession that began in 2008. That’s why there is an urgent need for new financing mechanisms to fill the gaps in countries’ core capacities. One option would be to create a global health security challenge fund, through which donors would agree to match low-income countries’ spending on preparedness. Another idea is for the World Bank to encourage the world’s poorest countries to use its grants and loans to pay for pandemic preparedness; historically, countries have spent World Bank money on other priorities, only to turn to the bank for emergency funds once an outbreak occurs.
THE OTHER THREAT
As challenging as COVID-19 has been, there are even worse scenarios out there. The very same scientific advances necessary to develop new therapies and vaccines also raise the possibility of an accidental or deliberate release of a deadly novel pathogen—natural or laboratory-engineered. The harm from such an event could eclipse anything ever seen. A new pathogen could prove more severe than known diseases and resistant to traditional methods of diagnosis and treatment. Moreover, if it were thought to have been released deliberately, then countries’ security and intelligence agencies would no doubt spring into action. They would be unlikely to act transparently and share information about the nature of the pathogen. That, in turn, could make it harder for countries to assess their risk and develop evidence-based response plans.
An exercise at the Munich Security Conference in February 2020 showed just how unprepared the world is for such a scenario. A key finding was that dealing with natural diseases is hard enough, but dealing with a deliberate one requires capabilities beyond those found in public health agencies. And there is a distinct lack of clarity about who would be in charge were such a scenario to occur. Although the WHO’s mandate includes leading the global response to pandemics of natural origin, it is the UN secretary-general who is empowered to investigate state-sponsored biological attacks. It is far from clear which organization would be responsible for looking into an event that was neither natural nor carried out by a state. Countries need to figure out the division of labor now rather than trying to work it out on the fly during an emergency.
It’s impossible to put a number on the probability of an accidental or deliberate release of a new pathogen, but given the enormous consequences, it certainly merits more attention. Working with the private sector and philanthropies, governments should establish norms and safety measures to safeguard biological research and make plans for how to respond if those efforts fail. The goal should be to discourage ill-intentioned governments or people from unleashing a disaster. Of course, as COVID-19 has shown, disasters do not require malevolence. A lack of preparation is enough.
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