We play with fire if we skimp on public health
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Epidemics and pandemics are like earthquakes. Tragic, inevitable and unpredictable. It starts as a random event. A virus jumps species from a bird, bat, or other animal to “Patient Zero” – who passes it on to other human beings. More likely than not, over the course of this century we will face an influenza pandemic similar to the one in 1918 that killed 50m people.
President Barack Obama’s first chief of staff, Rahm Emanuel, said in the wake of the global economic meltdown that “you never let a serious crisis go to waste”. Crises are opportunities to learn. They point to measures that will prevent the collapse of institutions when they are under extreme pressure.
While the focus is understandably on responding to the Ebola crisis, it is equally important that it serves as a wake-up call with respect to inadequacies that threaten not just tragedy on an unprecedented scale but the basic security of the US and other wealthy nations. As with climate change, no part of the world can insulate itself from the consequences of epidemic and pandemic.
The report of the Global Health 2035 commission, which I co-chaired, points up three crucial lessons. First, collective action must be taken to build strong health systems in every corner of the globe. In west Africa, Ebola was a “stress test” on national health systems, and in Sierra Leone, Liberia and Guinea the systems could not cope. There were too few trained health professionals; there was also too little equipment and too few supplies, and too little capacity for public health surveillance and control.
Nigeria’s containment of the virus after the first case was diagnosed in July is instructive. Its success, hailed by the World Health Organisation as a piece of “world class epidemiological detective work”, is explained by its aggressive, co-ordinated surveillance and control response. It already had a polio surveillance system, with skilled outbreak specialists who were quickly put to work tackling Ebola. While much of Nigeria’s health system, such as primary care services, remains very weak, on Ebola the surveillance and control system worked. Every country needs this kind of system. Prevention is cheaper than cure and leads to better outcomes.
Building these systems takes time and money. Our research, conducted with an international team of economists and health experts, and published last year in the medical journal The Lancet, suggests that the price of this “systems strengthening” would be about $30bn a year for the next two decades. The good news is that we have the financing to pay for this through a combination of aid and domestic spending. The cost represents well under 1 per cent of the additional gross domestic product that will be available to low- and lower-middle-income countries due to increased GDP growth over the next 20 years.
The second lesson is that the lack of investment in public health is a global emergency. The WHO’s slow response to Ebola was not surprising, given its recent staff cuts. For that, we all share the blame. Since 1994, the WHO’s regular budget has declined steadily in real terms. Even before the Ebola crisis, it struggled to fund basic functions. The entire budget for influenza was just $7·7m in 2013 – less than a third of what New York City alone devotes to preparing for public health emergencies.
It takes just one infected airline passenger to introduce an infection into a country. We need the WHO more than ever. It alone has the mandate and legitimacy to serve as a health protection agency for all countries, rich and poor. Starving it of funds is reckless.
The third lesson concerns scientific innovation. When it comes to discovering and developing medicines, vaccines and diagnostic tests, we have been largely ignoring the infectious diseases that disproportionately kill the world’s poor. Consequently, we still have no medicines or vaccine for Ebola. All we can do is provide basic life support, such as fluids and blood pressure treatment. For prevention, we have to rely on old-fashioned measures such as quarantine.
Margaret Chan, the WHO’s director-general, has explained the reason for this neglect. Doctors were “empty-handed”, she said, because “a profit-driven industry does not invest in products for markets that cannot pay”. Ebola affects poor African nations, so drug companies see no profit in working on it. Nor is there an adequate incentive to invest in prevention. No society will allow companies to reap huge profits when disease is spreading rapidly.
Rich governments and donors need to step up. Investing several billion dollars a year, less than 0.01 per cent of global GDP, could be decisive in preventing tragedy on the scale of world war.
Some issues are even more important than recessions and elections. Ebola is a tragedy. Let us hope that it will also be a spur to taking the necessary steps to prevent the far greater one that is nearly inevitable on the current policy trajectory. The next Ebola is just around the corner.
The writer is Charles W Eliot university professor at Harvard and a former US Treasury secretary. Dr Gavin Yamey of the University of California contributed to this piece
Letters in response to this column:
Fight against Ebola needs big pharma on board / From Sir William Castell and Jeremy Farrar
Spending €1.4bn for the ‘Rosetta stone’ is a tragic misappropriation of resources / From J Antoni Rafalski