By TL Andrews
In the past 35 years, the world has been afflicted by more than 32 new diseases that had never previously been reported in humans, such as hepatitis C, avian influenza and Zika. This has meant that global health systems have been caught off guard again and again.
“We generally wait for epidemics to occur and then we respond—we generally do too little too late,” says Duane Gubler, professor of tropical medicine at Duke NUS Medical School, Singapore.
Yet with over 20,000 fatalities recorded from Ebola alone, it has become clear that we need a new strategy. And given the potential that 3 billion annual airplane passengers have to turn epidemics into pandemics, the international community, and specifically rich nations, needs to make sure that any proposed solution takes into account the global impact an inadequate local health care system can have.
According to leading epidemiologists, becoming more proactive in fighting new diseases will require changes in two key areas: the way we approach public health in developing countries and the way we create and distribute vaccines.
William Muraskin, professor of urban studies at Queens College, argues that health systems in poor countries need to be seen “as the first line of defense against new diseases.” This is due to the way in which these diseases are arising.
Unbeknownst to most of us, there are thousands of viruses in tropical regions that ordinarily would stay there, living in primates. However, human encroachment on forests in places like Brazil is increasing people's exposure to these viruses, often in very poor regions where the standard of public health is low and residents’ immune defenses are weak.
“Poor people in poor health, who are malnourished, are exposed to diseases which then can adjust to humans,” Muraskin says.
If the diseases had been introduced to healthier populations, there might not have been a problem. Improving the standard of health among vulnerable groups should therefore be the starting point of policy discussions aimed at overcoming the serious deficiencies that have accrued over the decades in these regions.
First, much of the infrastructure designed to combat infectious diseases is dilapidated and neglected. The main reason behind this is complacency. By the second half of the 20th century, the world had eradicated smallpox and was well on its way to doing the same with polio. It seemed like infectious diseases were a thing of the past.
In fact, in 1970 the surgeon-general of the United States announced it was "time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."
Gubler explains that by the 1990s, the world had “allowed our infrastructure to deteriorate, especially against vector borne diseases. We stopped developing new insecticides and vaccine development continued but at a slower pace.” Consequently, the World Health Organization reports that infectious diseases like dengue fever, HIV/AIDS and malaria currently account for 48 percent of all premature deaths.
As defenses against these diseases got weaker, the conditions in which they spread got worse. In 1950, around 746 million people lived in cities; by 2014, that number had reached 3.9 billion—creating the perfect conditions for viruses to rapidly infect many victims.
According to Gubler, the viruses adapted very quickly to these new conditions. Dengue fever, for instance, was a forest pathogen that spread to villages, but today it no longer needs proximity to forests to survive. Once viruses get to cities, they are poised to wreak havoc on a globalized world.
Addressing this situation must begin—but certainly not end—with increased spending on public health in developing countries. Rich countries should provide funds, but local budgets must also be adjusted.
The World Bank reports that poor countries like Venezuela and the Philippines spent around 1 percent of their gross domestic product on health between 2011 and 2015. In Brazil the figure is a little higher at 4.7 percent, but is still small compared to many EU countries, which spend over 10 percent.
The World Health's Commission on Macroeconomics and Health (CMH) recommends the world's low and middle-income countries should dramatically scale up health spending to a minimum of $35 per capita. The CMH believes it is possible for low and middle-income countries to increase budgetary outlays for health by 2 percent compared with 2001 levels. Expenditure is an expression of priorities, and these certainly need to change if the world is to withstand new outbreaks.
Battling Reemerging Diseases
What's more, the state of health care among even the richest countries is ultimately leading to the reemergence, in underserved regions of these nations, of diseases thought to be eradicated. There has been a resurgence of monkey pox in the United States and dengue in Brazil, to name just two.
“Most of the world's neglected diseases are occurring among the poor in G-20 countries,” says Peter Hotez, dean of the National School of Tropical Medicine at Baylor College. “If we could get the 20 wealthiest economies to commit to their own neglected and vulnerable populations we could eliminate more than half the world's neglected diseases.”
One of the proposals put forward by a WHO Expert Working Group is to establish a global health research and development “observatory” under the auspices of the WHO. Its aim would be to collect information and prioritize a research and development pipeline. It should set up clear links to financing mechanisms to ensure that resources are allocated according to identified and agreed-upon priorities, needs, and gaps.
The WHO Expert Working Group also calls for specific and binding financial commitments from wealthy G-20 countries, such as commitments of 0.01 percent of GDP to global health research and development, and has suggested that 20 to 50 percent of such funding be administered through a pooled funding mechanism.
The U.S. also needs to make budgetary adjustments, even though it is the only nation that spends more than 0.01 percent of its GDP on health research. Relevant U.S. agencies, such as the National Institute of Health and the U.S. Agency for International Development, should be given the resources necessary to include late-stage medicine development in their annual budgets, so that new treatments can be licensed more quickly. Hotez recommends that up to 1 to 2 percent of the financial support currently committed for global health overseas assistance could be diverted to this cause. Potentially, these funds could be pooled with support from other donor countries, either in one centralized fund or through various pooled funds.
Investment in Research and Technology
Resource-rich countries also need to invest in poorer countries’ immediate needs, like early diagnostics technology. With diseases like the Zika virus, much needs to be done to create a screening method to diagnose people who are asymptomatic but can still infect others. This is increasingly urgent as evidence emerges that the disease may be transmitted through blood and sexual intercourse.
Research into infectious diseases needs to be more broad-based and robust. Even though the pathologies of new diseases are by definition unknown, the similarities between different infectious diseases make communication between researchers critical to fighting new aggressors. For instance, Kathy Stover of the National Institute of Infectious Diseases reports that the organization is presently supporting early-stage efforts to develop a Zika vaccine based on a virus that was also successfully used in an Ebola vaccine.
Mary Wilson, professor of Global Health and Population at Harvard, calls for even more connections among researches: “So many of the diseases we've seen that have been devastating to humans: MERS, SARS, AIDS, Zika originally have come from animals,” Wilson says. “We need to really work on establishing better connections between researchers of human and animal diseases.”
We also need to coordinate the creation of early-detection stations in the regions where the diseases are emerging. These need to be built as part of a general drive to revive surveillance infrastructure. Only then will bodies like the WHO be able to detect diseases fast enough to respond to them in time.
But even if waving a magic wand could fix infrastructural and spending problems, there are still massive concerns further upstream with the system for new vaccine development. The current system makes pharmaceutical companies reluctant to develop vaccines for patients in poor countries, where the return on the companies’ investment is low. A case in point is Ebola, Hotez explains.
The first testable vaccine candidates against the pathogen emerged in 2003, but that knowledge sat on shelves for over a decade until Ebola started to threaten American lives and the U.S. government put up $100 million for the development process. In 2014, GlaxoSmithKline managed to finish the process incredibly quickly.
What is needed is a global vaccine creation mechanism that has different incentives to pharmaceutical conglomerates and which has different means of finance.
This may require a “blurring” of the traditional boundaries and firewalls that exist between industry, universities, and governments. Ultimately, it may become necessary to use public funds to support private and not-for-profit entities, including multinational companies, biotechs, and product development partnerships. Such public funding for research and development carried out in the public interest will need to come with strong conditions that will guarantee affordability and access for patients.
Increasingly, it will become necessary to support public–private partnerships. A promising example is GAVI, or The Global Vaccine Alliance, which immunized 500 million children between 2000 and 2014. Another is the Sabin Vaccine Institute, run by Hotez, which makes vaccines neglected by industry. The group has started developing vaccine candidates against SARS and the West Nile virus.
The lesson to be learned from new diseases is that the world is far more connected than we thought. Animals have a great impact on human health, diseases that develop in rural areas can easily spread across the globe, and an outbreak in a developing country will impact developed nations, too. Multilateral coalitions of wealthy countries must therefore lead a response that is as mindful as possible of the interconnectedness of global health systems.
TL Andrews is a freelance journalist based in Berlin. He covers global politics and health for international media outlets, including the Guardian and the British Medical Journal.