Download Brahmbhatt and Jonas

International Cooperative
Responses to Pandemic Threats:
A Critical Analysis
Milan Brahmbhatt
Senior Fellow
World Resources Institute
Olga Jonas
Economic Adviser
World Bank
One of us lives in a large block of apartments. At least a couple of times a
year, the fire alarm in the building rings in the middle of the night and within
minutes the local fire brigade arrives. There has never been a serious fire in the
building. Nevertheless, residents do not complain that the absence of a serious
fire merits cutting spending on the fire brigade. Yet, as a world we appear to be
willing to spend very little on prevention and control of a larger threat to human
welfare than fires: infectious disease outbreaks and pandemics. The worldwide
probability of death by fire in 2013 was about 3.5 per 100,000 people.1 According
to a World Bank estimate, the global probability of death due to a severe global
influenza pandemic is about three times as large, one in 10,000.2 Even so, as
we discuss in Section 1, the recent Ebola crisis has demonstrated that the world
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Milan Brahmbhatt is Senior Fellow at the World Resources Institute and a member of the project team
for the New Climate Economy Initiative of the Global Commission on the Economy and Climate, where
he leads the work of the Country Transitions workstream. Before joining the New Climate Economy,
Milan worked at the World Bank as Senior Adviser to the Vice President of the Poverty Reduction and
Economic Management Network, dealing with a wide range of macroeconomic and structural policy issues, including the economics of climate change, sustainable growth, and infectious diseases.
Olga Jonas is an Economic Adviser at the World Bank. She has coordinated responses to avian flu and
other pandemics since 2006. Her prior duties include advising on replenishments of the World Bank’s
fund for the poorest countries, leading economic work of the global task force on small states, and coordinating responses to the extractive industries review and the 2004 Indian Ocean tsunami. She also led
macroeconomic operations in francophone African countries for over a decade. She joined the World
Bank in 1983 after working at the Bank for International Settlements and the OECD. She holds degrees
from Williams College and Princeton University. Copyright © 2015 by the Brown Journal of World Affairs
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Milan Brahmbhatt and Olga Jonas
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appears to be far less well prepared for the threat of infectious disease outbreaks
and pandemics than it is for fires. In 2013, the entire influenza budget of the
World Health Organization (WHO) was $7.7 million, less than a third of what
New York City alone devotes to public health emergencies.3
In this paper, we argue that the world appears to be seriously underinvesting
in international cooperation for the prevention and control of pandemics—for
reasons that range from outdated models of the pandemic threat to challenges
in the provision of global public goods, in tackling catastrophic risks, and in the
political economy of public choice. Nevertheless, these challenges can be met.
The economic returns on investments to prevent and better control pandemics
are extremely large. The last 15 years provide valuable lessons from both successes and setbacks, suggesting four principles for a plan of action to revitalize
international cooperative responses to pandemic threats.
Section 2 of this piece argues that insufficient attention to pandemic
threats may be partly due to an outmoded notion that scientific progress alone
will make infectious diseases an increasingly unimportant health problem. The
reality, however, is that there is unlikely to be any final victory in the perennial
struggle between humans and harmful microbes. The evolutionary process of
natural selection makes it inevitable that new microbial threats will continue to
emerge, requiring constant vigilance and the maintenance of strong human and
animal public health systems as a front line of defense. Section 3 explores the
economics of pandemics, arguing that international cooperation to prevent and
control pandemics is an investment with very high expected economic returns.
Section 4 discusses why the world appears reluctant to seize this high-return
investment, only doing so in sporadic and fragmented ways. Among the challenges to international cooperation are incentive problems in supplying global
public goods, behavioral inhibitions in grappling with catastrophic risks, and the
political economy of public choice. Section 5 briefly traces the fraught history of
international efforts to combat infectious disease outbreaks and pandemics—the
“Road to Ebola” as it were. So far in the 2000s we have seen successes—a significant strengthening of WHO’s International Health Regulations (IHR) and
a major international effort to tackle the pandemic threat from avian influenza
starting in 2005—as well as setbacks—a dispiriting loss of momentum at the
end of the decade and the Ebola crisis itself. The article concludes by suggesting
four principles for a plan of action to revitalize international cooperation for
prevention and control of infectious disease outbreaks and pandemics.
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1. EBOLA EXPOSES MAJOR WEAKNESSES IN THE GLOBAL RESPONSE TO INFECTIOUS
DISEASE OUTBREAKS
Ebola virus disease is a harmful, often fatal illness in humans caused by the Ebola
virus, which is transmitted to humans from wild animals and which spreads
in the human population through human-to-human transmission.4 The recent
Ebola outbreak began in rural Guinea in early December 2013 but remained
under the radar for nearly
four months. Although Even in February 2015, there was a $1 billion
doctors in the area noticed funding gap between donor contributions
clusters of deaths with unusual symptoms and sent and the “Needs and Requirements” for the
reports to the Ministry Ebola response requested by UN agencies.
of Health, the outbreaks
remained unexplained. No action was taken to control the contagion, which
continued to spread and ultimately reached the capital and neighboring countries. At this early stage, the Ebola crisis exposed one of the major flaws in the
current global framework for tackling infectious diseases: the weakness or even
absence of public health systems in many developing countries.
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The NGO Médécins Sans Frontières (MSF) sent samples to France, where
the disease was identified as Ebola on 22 March 2014. Although MSF launched
an emergency response at this point, followed by warnings that the situation
was worsening, there was a further lapse in the response from the rest of the
international community. The critical work of isolation, treatment, and contact
tracing was left almost entirely to NGOs, necessarily limited in their capacity,
until August. Small teams from WHO and the U.S. Centers for Disease Control
and Prevention (CDC) helped monitor the emerging crisis, but it was only in
early August that significant funding, skilled health professionals, medicines, and
other resources started to be mobilized. On 8 August, WHO declared a formal
Public Health Emergency of International Concern (PHEIC) under the IHR.
International assistance, however, remained ad hoc, fragmented, and unevenly coordinated. It was only in October 2014 that substantial international
assistance, including troops, arrived on the ground. In the meantime, thousands
had been infected each week, causing treatment centers to overflow. The approach
of passing the hat for the disease control program only after the epidemic was
underway further slowed and weakened the response. Even in February 2015,
there was still a $1 billion funding gap between donor contributions and the
“Needs and Requirements” for the Ebola response requested by UN agencies.5
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Delays between the onset of the epidemic and the implementation of
measures to control the disease proved costly. When contagions grow exponentially, the costs of controlling them rise in tandem. The cost of extinguishing
a few smoldering sparks is much less than fighting a blazing fire. Whereas the
epidemic could have been controlled for less than $200 million in April 2014,
according to a UN estimate, by the fall, the estimate of control costs had risen
to $4 billion—a rapid 1,900 percent rise in just six months. These are resources
that could otherwise have been devoted to valuable development programs that
improve living conditions in poor countries.6
The global response to the Ebola crisis brought to light many weaknesses
in international cooperative efforts to combat infectious disease outbreaks and
pandemics. How did we arrive at this point?
2. THE PERMANENT ARMS RACE BETWEEN HUMANS AND MICROBES
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Humans have always lived and will probably always live in a permanent arms
race with harmful microbes, despite the growth of scientific knowledge and the
development of powerful antibiotics and vaccines. The term microbe refers to
bacteria, viruses, protozoa, and other microorganisms. Although most microbes
either aid or cause no great harm to humans, a limited number are pathogens,
meaning they induce infectious disease patterns in their hosts to spread and
further their own reproduction. Evolution ensures a constantly shifting balance of power between microbes and humans. Human populations develop
immunity to a given pathogen over time; however, genetic mutations and other
biological processes generate lethal new pathogens against which humans have
little immunity. Pandemics have swept through human populations throughout
history, killing millions and often changing the course of political and economic
development.7
Since the middle of the nineteenth century, humans have achieved unprecedented advances in their war with pathogens. Three developments have been of
particular importance: the spread of public health systems to promote measures
such as better sanitation, cleaner water, and stronger disease surveillance and
control; the development of vaccines to control the spread of viruses; and the use
of antibiotics to combat bacterial pathogens. Over the course of the twentieth
century, these advances had an enormous impact in reducing the incidence of
infectious diseases, raising hope that a complete victory over infectious diseases
was at hand. By the late 1960s, the U.S. Surgeon General considered the time
ripe to “close the book on infectious diseases.”8
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Yet, a complete victory over microbes was not to be realized. A warning
sign was the influenza pandemic of 1918–19 that caused 50 to 100 million
deaths worldwide even with the great scientific advances of the nineteenth and
early twentieth centuries. Remarkably, this “forgotten pandemic” seems to have
had little impact on thinking about infectious diseases threats over subsequent
decades.9 Nevertheless, by the end of the twentieth century there was growing
evidence of the microbial threat’s durability and resilience.
The resurgent microbial threat is evident on several fronts. One of the
most troubling is the emergence of multiple drug resistant (MDR) bacteria
as a result of natural selection, including those that cause cholera, gonorrhea,
malaria, and tuberculosis (TB). The growing threat is also seen in the emergence of new infectious diseases and virulent new strains of existing diseases
at the pace of about one per year. Numerous examples include Lassa Fever in
the 1960s, Ebola in the 1970s, the delayed detection and diagnosis of AIDS
in the 1980s, and many highly pathogenic bird and animal influenza viruses
in the 1990s and 2000s. These viruses have the capacity to mutate into forms
capable of easy transmission among humans, potentially causing a devastating
influenza pandemic. 10 Other recently emerged viruses with pandemic potential
include Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle
East Respiratory Syndrome (MERS) in 2012.
Importantly, around 75 percent of these newly emerging pathogens are
of animal origin: so-called zoonoses, or infectious diseases found in animals
that can be transmitted to humans under natural conditions.11 The emergence
of zoonoses appears to have accelerated as the push of human settlement into
tropical regions brought people into contact with previously isolated animalborne pathogens, such as AIDS and Ebola. Zoonoses have also grown in importance as the stock of domesticated animals has grown with global economic
development, thereby creating more opportunities for animal pathogens to be
transmitted to humans. The denser and more rapid global transport networks
of recent times further hasten the international spread of infectious diseases.
Basic veterinary and human public health systems—the first line of defense
against infectious diseases—remain weak in many developing countries, and
have even collapsed entirely in some failed states. Eight out of 10 countries do
not comply with WHO’s IHR because they lack the capacity to perform the
core veterinary and human public health functions of detecting, diagnosing,
and controlling contagions.12
The resilient, multifaceted, and permanent nature of the microbial threat
has important implications for public health policies. Instead of viewing each
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emerging infectious disease as a separate threat that requires its own frantic
emergency response, we argue below that it would make significantly more
sense to build a common core of permanent capabilities at both the national
and global levels that can be applied against a wide range of microbial threats.
3. THE ECONOMICS OF INFECTIOUS DISEASE AND PANDEMICS
Given that infectious diseases are a permanent threat to human health, what
level of the world’s scarce resources should we allocate to preventing and controlling infectious disease outbreaks and pandemics? The answer depends on the
economic costs of these diseases. These costs in turn depend to a large extent
on the specific epidemiological characteristics of a given disease, as well as on its
broader social context and on the effectiveness of various public health measures
to control outbreaks.
The economic costs of pandemics are of two kinds. First are the direct and
indirect costs of illness. The direct costs of illness are the resources used to treat or
cope with the disease, including costs of hospitalization and medication. Indirect
costs of illness comprise the present and future costs to society from morbidity,
disability, and premature death, in particular the loss of output caused by the
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reduced productivity or death of workers. Second are the costs of contagion
avoidance. These include the economic disruptions that often result when the
public acts spontaneously to avoid becoming infected—for example, by avoiding
crowded areas, travel, or workplaces. These actions can cause serious disruptions
to supply and demand in key
The costs of contagion avoidance can sectors such as tourism, retail
trade, transport, and entersometimes comprise the bulk of the tainment. Avoidance costs
costs of an infectious disease outbreak. also include those incurred
by social-distancing measures
enforced by governments—that is, public health measures such as the temporary
shutdown of nonessential government activities, school and market closures,
quarantines, travel suspensions, and trade embargoes.
The costs of contagion avoidance can sometimes comprise the bulk of the
costs of an infectious disease outbreak. The 2003 SARS outbreak, for example,
was estimated to have caused GDP losses of 0.5 to 1 percent in China, Taiwan,
Hong Kong, and Singapore, the most affected economies. These losses were far
too large to be explained by the costs of illness and death associated with the
8,096 cases of infection and 776 deaths caused by SARS. Instead, they primarily
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reflected the widely reported economic disruptions caused by the spontaneous
avoidance actions of the public.13
One World Bank study estimated the cost of a severe influenza pandemic,
modeled on infection and mortality patterns of the 1918 flu pandemic, at 4.8
percent of world output.14 Given the gross world output of $87 trillion in 2013
in purchasing power parity terms, this would represent a GDP loss of some $4.2
trillion.15 There have been four influenza pandemics over the past century: the
1918–19 pandemic mentioned above and three less serious pandemics in 1958,
1968, and 2009. We assume for illustrative purposes that a serious infectious
disease pandemic occurs on average once in a hundred years (i.e. a 1 percent
probability of occurring in any given year) with an economic impact similar
to the World Bank estimate for a serious flu pandemic.16 Then the annualized
expected cost of a serious pandemic—or equivalently, the benefit from averting
such a pandemic—is $42 billion per year. This is about 12 times the annual
investment of $3.4 billion needed to strengthen veterinary and human public
health systems in developing countries to the standards defined by the World
Organization for Animal Health (OIE) and WHO, according to World Bank
estimates.17 Such an investment would be worth undertaking even if serious
pandemics occur only once every 200 years and if the investment succeeded in
preventing only one out of five pandemics. Current investment rates in these
systems are far below desired levels, only about $350 million per year.
Lawrence Summers, former U.S. Treasury secretary and chair of the Lancet
Commission on Investing in Health, recently highlighted the risk of a serious
flu pandemic, noting that “Optimists think that the risk is 1 percent a year.
Pessimists think that the risk is 2 percent a year. Pandemic flu, if it came today,
would likely be worse than [it was in] 1918 because of the greater communicability around the world.” Given the odds and the costs of a serious pandemic,
Summers described investing in pandemic preparedness as “probably the single
most important area for productive investment on behalf of mankind.”18
Figure 1 (on the next page) provides a stylized view of how the costs of
controlling a zoonotic outbreak escalate over its various stages. Arresting the
exponential growth in costs early—by means of investment in veterinary and
human public health systems—is evidently a more economically sound decision
than delaying a response.19
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4. CHALLENGES
THREATS
FOR
INTERNATIONAL COOPERATIVE RESPONSES
TO
PANDEMIC
While prevention and control of infectious disease outbreaks and pandemics represents an investment with very high returns for global well-being, there are also
significant challenges that need to be tackled to achieve this desirable outcome.
Pandemic prevention and control is a global public good because it is
nonexcludable—prevention and control efforts by one country benefit not only
that country, but also all others—and nonrival—enjoyment of the benefits of
pandemic prevention and control by one country does not reduce the benefit
available to other countries.20 Like any public good, pandemic prevention faces
the so-called free-rider problem: there exists the temptation to enjoy its benefits
while letting other countries pay for it. These problems can however be overcome when international cooperative efforts are designed in ways that provide
adequate incentives for countries to participate. We review both successes and
setbacks in international health cooperation in the next section.
Another challenge is that pandemics belong to the class of catastrophic
risks. These are risks that have a small and uncertain probability of occurring,
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but hold potentially disastrous outcomes. There is significant evidence that humans, including policymakers, have a hard time rationally prioritizing actions
when dealing with these kinds of problems, resulting in too little long-term
investment in the prevention of catastrophic risks.21 Instead, one sees a typical
pattern in which infectious disease outbreaks lead to brief spurts in funding for
emergency responses to the immediate problem—but this funding rapidly tails
off rather than providing what is truly needed, a stable, long-term stream of
resources to build a permanent capacity for infectious disease prevention and
control, particularly in developing countries.22 Such an approach would not
only be more effective in controlling outbreaks promptly—it would also be less
expensive than the current approach in helping avoid the dramatic escalation of
costs that typically occurs when an outbreak has spiraled out of control.
As previously noted, policymakers may also be influenced by outmoded
mid-twentieth-century notions of different infectious diseases as distinct problems divorced from a consistent pattern; these diseases are also seen as becoming
less important due to scientific progress. A more accurate perspective would
view these outbreaks as manifestations of a broad class of permanent and serious microbial threats to human health. Lastly, there is the unfortunate reality
that policies are generally chosen not on the basis of purely rational cost-benefit
analysis, but more frequently on the basis of private and public interest group
pressures, lobbying, and other political processes that may favor ad hoc, shortterm responses rather than stable, long-term solutions. Politicians and civil
servants may, for example, find enticing opportunities for advancement in a
highly visible emergency response to an outbreak. Successful but less visible
prevention of outbreaks might not bring such rewards.
5. PATTERNS OF INTERNATIONAL POLICY RESPONSES
OUTBREAKS AND PANDEMICS
TO
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INFECTIOUS DISEASE
Countries have grappled with the problem of how to build international cooperative action against infectious disease outbreaks and pandemics for more than
150 years. The last 15 years in particular have shown a combination of both
promising advances and disheartening setbacks in this cooperative effort—both
of which yield valuable lessons for the future.
Important milestones in international health cooperation included a series
of International Sanitary Conferences between 1851 and 1938 and the founding
of OIE in 1924 and WHO in 1948 as the primary international organizations
for animal and human health respectively. WHO’s International Sanitary Regula-
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tions in 1951 provided a single set of rules for responding to six specific infectious
diseases. Importantly—unlike earlier treaties that required countries to opt in
to the agreement—the Regulations adopted an opt-out rule that automatically
binds all WHO members. This important institutional innovation helps to offset
the free-rider problem, discussed in the previous section, by creating moral and
behavioral pressures in favor of cooperation between countries.23
The SARS outbreak in 2003 appears to have played an important role
in reawakening global awareness of the pandemic threat.24 It was followed by
considerable strengthening of the IHR in 2005. There was also a major international cooperative response to the threat of a human influenza pandemic that
arose from H5N1 avian flu, beginning in 2005. Yet, by the end of the decade
this positive momentum had weakened, accompanied by a loss of focus that set
the stage for the problematic Ebola response.
The revised IHR expanded coverage from six specific diseases to any
“public health emergency of international concern.”25 They also provided an
innovative set of guidelines to help countries decide when to notify WHO of a
public health event, formalized information links between WHO and member
countries, and allowed WHO to take account of a wide range of information
from NGOs, the media, and other sources. Perhaps most importantly, the IHR
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required member countries to undertake a formal evaluation of their public
health capacities by 2009 and to develop an operational plan to bring these
capacities up to required standards. The public health capacities designated for
evaluation included surveillance, reporting, notification, verification, response,
and collaboration.26
Valuable as they were, the revised IHR had several flaws. First, there was no
formal provision for aid to help weaker developing countries upgrade their public
health systems to the specified levels. The amount of aid was left to the discretion of individual donors and has generally been well below the levels needed to
fulfill the new IHR’s mandate.
The mission of WHO has become The 2009 U.S. Global Health
extraordinarily diffuse. The IHR are now Initiative, for example, did not
mention implementation of
but one of a great number of objectives. the IHR as a target for U.S.
assistance.27 Second, and perhaps just as important, there was no provision for the enforcement of obligations
undertaken by countries. Third, as critics have observed, the mission of WHO
has become extraordinarily diffuse. The IHR are now but one of a great number
of objectives that include universal health coverage, noncommunicable diseases,
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the Millennium Development Goals, and addressing the social, economic, and
environmental determinants of health as a means of reducing health inequities,
among others. Funding for work to mitigate infectious disease threats in WHO’s
budget has been cut. The result has been a loss of focus on and prioritization of
infectious diseases and global health security.28
Viewed analytically, international collective action on health should provide
two different types of functionality: core functions and supportive functions.
Core functions comprise the provision of global public goods related to health,
which individual countries cannot provide for themselves. Compliance with the
IHR is the quintessential example of a core function. In contrast, supportive
functions are not global public goods and should, in principle, be undertaken by
national governments. However, some poorer developing country governments
may be unable to build such functions by themselves, and thus they are then
supported internationally for humanitarian or altruistic reasons. An example of
a supportive function would be aid for anti-smoking programs in developing
countries. The bulk of development aid for health is for supportive functions.29
It has been persuasively argued that these two functions could be better
achieved with a cleaner division of labor, with WHO focusing wholly on core
global public good functions such as the IHR, while other development partners—such as development banks, aid agencies, charitable foundations, and
NGOs—take the lead on supportive functions. These partners would also help
ensure that WHO and OIE are adequately funded to deliver on core global
public good mission.30
As noted at the start of this section, another key development after 2005
was a major international collaborative effort to tackle the pandemic threat
from H5N1 avian influenza: the Global Program for Avian Influenza Control
and Human Pandemic Preparedness and Control (GPAI). Political leadership
by the United States and the European Union helped mobilize $4 billion for
this effort from more than 30 donor countries, combined with effective cooperation between the UN, WHO, the World Bank, the Food and Agriculture
Organization of the UN, and OIE. Most of the funding went to strengthening
veterinary and human public health systems in developing countries, with the
purpose of better preventing and controlling infectious diseases in general, rather
than the avian flu alone. Five ministerial conferences between 2006 and 2010
raised funds, bolstered international political commitment, and enabled the
exchange of experiences among countries. Technical assessments of the quality of
animal and human public health systems were undertaken in many developing
countries, including in Guinea, Liberia, and Sierra Leone, the three countries
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that would later be most affected by the Ebola crisis. These assessments were
followed by the drafting of Integrated National Action Plans for investments
to bring public health systems up to minimum standards. There was growing
appreciation of the need for “One Health” approaches that closely coordinate
human and animal public health systems.31
Unfortunately, these Action Plans were by and large never funded or
implemented. As many developing countries came to grips with the immediate
problem of controlling avian flu, funding from donors rapidly tailed off after
2008. This trend occurred even as the H5N1 flu virus continued to circulate
and other new and dangerous flu viruses, as well as other pathogens, continued
to emerge. With reduced public attention and so-called “pandemic fatigue” in
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the media, the political incentives for policymakers to continue working on pandemic threats quickly dissipated (Figure 2).32 From 2008 on, the global financial
crisis effectively monopolized the attention of top policymakers in any case.
It was at this time that the 2009 H1N1 flu pandemic provided the first
test of the revised IHR. By all accounts, the system worked as intended. Early
warnings by affected countries such as Mexico enabled WHO to promptly
announce a Public Health Emergency of International Concern and allowed
other countries to launch their own responses. Coordinated action between
Mexico, the United States, and Canada in particular allowed for early control
of the virus. Yet, in the climate of pandemic fatigue, even this generally successful response led to a backlash against WHO, with unfounded criticisms
that it had declared a “fake” pandemic.33 This backlash is likely to have further
discouraged international organizations and donors from supporting work on
pandemic preparedness and public health systems.34
CONCLUSION: WHERE DO WE GO FROM HERE?
As the world slowly emerges from the long aftermath of the global financial
crisis, it is time for leaders to once more take on the pandemic threat, drawing
on both the positive and negative lessons of the last 15 years. A plan of action
based on the following four principles can significantly enhance global health
and economic security for this and future generations.
First, there needs to be a clear understanding that infectious disease outbreaks are not one-off events that are best tackled only after they occur, with
hurriedly improvised emergency efforts. Rather, infectious disease outbreaks are
a permanent feature of the world that warrant a robust and systematic defense.
New or more resistant strains of infectious diseases will continue to emerge as
natural selection does its work and as pathogens mutate and evolve. We therefore
need permanent institutions, instruments, and policies backed by stable and
sustained funding to tackle infectious disease and pandemic threats in a unified
way. The economic rationale for such a strong and permanent effort is clear.
The costs of infectious disease outbreaks and pandemics are extremely high, as
are the economic returns on investments to prevent and control such events.
Second, there needs to be a clear-eyed appreciation of the challenges facing
international cooperation over containing pandemic threats, including classic
incentive problems in supplying global public goods, low pandemic threat
awareness, behavioral difficulties in tackling catastrophic risks, and the political
economy of public choice. To tackle these problems, it will be helpful to make
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a clear policy distinction between the core and supportive functions of international health cooperation. The core function is to supply global public goods,
the most important of which are global health security and implementation of
the IHR. The supportive function is to help developing countries pursue health
goals that primarily benefit the residents of these countries themselves. While
both functions need adequate and stable support, there is a strong case for a
clear organizational division of labor, with international health bodies such as
WHO narrowing and intensifying their focus on leadership in order to deliver
core functions. Partners such as development banks, aid agencies, charitable
foundations, and NGOs can aid WHO in its core mission, while also taking
the lead in the provision of supporting functions.
Third, given the zoonotic nature of most emerging infectious disease threats,
a “One Health” approach that builds cooperation and coordination between
animal and human public health systems is essential. Robust veterinary systems
that meet OIE standards are needed to provide early warning, curb antibiotic
and other drug resistance in microbes, and control emerging animal diseases in
a cost-effective manner before they threaten humans.
Fourth, as the Ebola crisis vividly demonstrated, public health systems in
developing countries are the weakest link in global cooperation against pandemic threats. According to the World Bank, “investments in public health are
a notorious blind spot in health systems financing: interventions are often invisible to consumers of health care and, as such, fall to the bottom of the priority
list.”35 A sustained investment to significantly strengthen veterinary and human
public health systems in developing countries by 2030 should be at the top of
the international health and development cooperation agenda. Such an effort
will allow a much greater reduction in threats to global health and economic
well-being than is possible with current capacities and will yield extraordinarily
high returns for both developing and developed countries. WA
NOTES
1. GBD 2013 Mortality and Causes of Death Collaborators, “Global, regional, and national age–sex
specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis
for the Global Burden of Disease Study 2013,” The Lancet 385, no. 9963 (2015): 117–71.
2. Olga Jonas, “Let’s Talk Development: Danger of a Pandemic,” World Bank Blog, May 9, 2013.
3. Lawrence Summers, “The World Can’t Hide From Pandemics,” Washington Post, November 9, 2014.
4. “Ebola Virus Disease: Fact Sheet No. 103,” World Health Organization, updated April 2015.
5. UN Mission for Emergency Ebola Response, Internal Situation Report no. 103 (New York: United
Nations, February 12, 2015); UN Office of the Special Envoy on Ebola, Resources for Results III, February
25, 2015 (New York: United Nations, updated April 7, 2015), 5.
6. David Nabarro, “Ebola Virus Outbreak,” presentation to UN General Assembly, October 10, 2014;
For further information, see: “The Economic Impact of Ebola on Sub-Saharan Africa: Updated Estimates
the brown journal of world affairs
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International Cooperative Responses to Pandemic Threats
for 2015,” World Bank, January 20, 2015.
7. Dorothy H. Crawford, Deadly Companions: How Microbes Shaped Our History (New York: Oxford
University Press, 2007).
8. J.R. McNeil, Something New Under the Sun: An Environmental History of the Twentieth Century World
(New York: W.W. Norton, 2000).
9. Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918 (Cambridge, UK: Cambridge
University Press, 2003).
10. Crawford, Deadly Companions.
11. Lonnie J. King, Emerging and Re-emerging Zoonotic Diseases: Challenges and Opportunities (Paris:
World Organisation for Animal Health, May 2004); World Health Organization, World Organisation for
Animal Health, and the Food and Agriculture Organization of the United Nations, Report of the WHO/
FAO/OIE joint consultation on emerging zoonotic diseases in collaboration with the Health Council of the
Netherlands, May 3–5, 2004 (Geneva: World Health Organization, 2004).
12. Julie E. Fischer and Rebecca L. Katz, “Moving forward to 2014: Global IHR (2005) implementation,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 11, no. 2 (2013): 153.
13. Milan Brahmbhatt and Arindam Dutta, “On SARS Type Economic Effects during Infectious Disease Outbreaks” (World Bank Working Paper Series WPS 4466, 2008), 48; Olga Jonas, Pandemic Risk
(Washington, DC: World Bank World Development Report Background Paper, 2013), 10–11.
14. Andrew Burns, Dominique van der Mensbrugghe, and Hans Timmer, “Evaluating the Economic
Consequences of Avian Influenza” (Washington, DC: World Bank, 2008).
15. “The World Factbook 2013–14,” Central Intelligence Agency, 2013.
16. We do know enough about the long-run historical frequency of influenza pandemics in the past to
form a strictly empirical estimate of their probability in future. However, for the purpose of estimating
the expected costs of infectious disease pandemics, the annual 1 percent probability we have assumed is
likely to be a conservative estimate, since it ignores the impact of more moderate influenza pandemics (of
which there were three in the past century), as well as the impact of pandemics caused by infectious diseases
other than influenza. As discussed later in the text, Larry Summers, Chair of the Lancet Commission on
Investing in Health, reports a 1 percent probability to be relatively optimistic.
17. World Bank, People, Pathogens and Our Planet, Volume 2: The Economics of One Health (Washington,
DC: World Bank, 2012).
18. Lawrence Summers, “Toward Universal Health Coverage for 2030” (comments at World Bank
Panel Discussion, Washington, DC, April 11, 2014).
19. World Bank, People, Pathogens and Our Planet.
20. Scott Barrett, Why Cooperate? The Incentive to Supply Global Public Goods (New York: Oxford
University Press, 2007).
21. The behavioral and analytical aspects of policy responses to catastrophic threats are discussed in:
Richard A. Posner, Catastrophe: Risk and Response (New York: Oxford University Press, 2004). For a rigorous analysis of catastrophic risk management, see: Robert Pindyck and Neng Wang, “The Economic and
Policy Consequences of Catastrophes,” American Economic Journal 5, no. 4 (November 2013): 306–39.
22. Milan Brahmbhatt, “The Role of Incentives in Global Pandemic Response” (paper presented at
Wilton Park Conference on Global Pandemic Response: Improving International Coordination, 2009).
23. Julia E. Fischer, Sarah Kornblet, and Rebecca Katz, The International Health Regulations (2005):
Surveillance and Response in an Era of Globalization (Washington, DC: The Stimson Center, June 2011),
5–7; Barrett, Why Cooperate?.
24. Brahmbhatt and Dutta, “On SARS Type Economic Effects,” 4–8.
25. World Health Organization, International Health Regulations 2005, 2nd ed. (Geneva: World Health
Organization, 2008); see also: Fischer, Kornblet, and Katz, The International Health Regulation, 9–14.
26. Ibid.
27. Fischer, Kornblet, and Katz, The International Health Regulations, 23–4.
28. “World Health Organisation: Too Big to Fail,” Economist, December 13, 2014; Charles Clift, What’s
the World Health Organization For? Final Report for the Centre on Global Health Security Working Group on
Health Governance (London: Chatham House, May 2014).
177
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29. Dean Jamison, Julio Frenk, and Felicia Knaul, “International Collective Action in Health: Objectives,
Functions and Rationale,”The Lancet 351 (1998): 514–17; The Lancet Commission on Investing in Health,
“Global Health 2035: A World Converging Within a Generation,” The Lancet 382 (2013): 1898–955.
30. Clift, What’s the World Health Organization For?, 8–13.
31. Olga Jonas and Lucas Warford, “Global Program for Avian Influenza Control and Human Pandemic
Preparedness and Response: Project Accomplishments” (discussion paper, World Bank, Washington, DC,
September 2014); Another somewhat later success was the Pandemic Influenza Preparedness Framework
Agreement of 2011, negotiated under WHO auspices to facilitate the sharing of virus samples with pandemic potential. See: World Health Organization, Landmark agreement improves global preparedness for
influenza pandemics (Geneva: World Health Organization, April 17, 2011).
32. Jonas, Pandemic Risk, 16–7.
33. Michael Smith, “H1N1 Experts Assail ‘Fake’ Pandemic Claim,” ABC News, January 26, 2010.
34. Fischer, Kornblet, and Katz, The International Health Regulations, 29–32.
35. Timothy Grant Evans, “Solidarity and Security in Global Heath: What Can We Learn from the
Ebola Crisis?,” Keynote Address to the Prince Mahidol Award Conference, Bangkok, January 2015.
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