IF YOU are looking for certainty in these uncertain times, here is something to chew on. âThere will be another pandemic,â says , a global health epidemiologist at George Mason University in Fairfax, Virginia. Of what, starting where and when, and how dangerous it will be, we donât know. But we had better be ready, because it could happen at any time and could be worse than this one. âWe canât let our guard down,â she says.
Dealing with global outbreaks is theoretically quite straightforward, says Kenneth Timmis, a microbiologist at the Technical University of Braunschweig in Germany. âPandemics are always combated by the same basic strategy: surveillance, interruption of infection chains and the ramping up of prevention and treatment capacity.â That holds true even though the nature, evolution, timing and source of new pathogens is uncertain, he says. âYou donât know what youâre preparing for, so you have to be generic,â says Timmis. âThere are certain things you have to do and these will be universal for every country and every pandemic. We therefore only need one pandemic preparedness.â
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And the world has one, in the shape of a global agreement called (rather prosaically for something so dramatic) the (IHR).
All 194 members of the World Health Organization (WHO) have signed up to them. They are a guide to both preparedness and emergency response, and, according to Jacobsen, are largely fit for purpose. âWe need some sort of international agreement about how weâre going to work together to prevent the next pandemic, but we donât need to start from the beginning, we have a good solid starting point with the IHR,â says Jacobsen. To cut a very long story short, all the world has to do to be ready for next time is to implement those regulations. Unfortunately, that is easier said than done.
The IHR trace their origin to the cholera epidemics that roiled Europe in the 19th century and inspired the first global health treaty, the . Following the founding of the WHO in 1948, it adapted this into the International Sanitary Regulations, which in were superseded by the . The aim was to prevent the spread of six diseases: cholera, plague, typhus, relapsing fever, smallpox and yellow fever.
In 1995, the WHO began revising the IHR to reflect the changing global health landscape, including the eradication of smallpox, the growth of international travel and trade, and the threat of emerging diseases such as Ebola. A decade later, the member states signed off the new IHR and they entered into force in June 2007. Their overall goal is âto prevent, protect against, control and provide a public health response to the international spread of disease (in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade)â.
The regulations are available in six languages and run to some 80 pages. They address everything from monitoring infection risk at a countryâs points of entry to best practice for looking after peopleâs personal health data during a crisis. They also set out how long it should take for countries to assess and respond to reports of new threats.
âIt made a difference whether countries had pandemic experts at the heart of governmentâ
That includes declaring and then dealing with â apologies for the jargon overload â public health emergencies of international concern (PHEIC), including pandemics. (They even helpfully provide for nations to determine whether their emergency meets this threshold.) Since 2007, there have been six such emergencies: the 2009 H1N1 swine flu; polio eradication setbacks in 2014; the Ebola epidemics of 2014 and 2018; Zika virus in 2016; and now covid-19.
With covid-19, the WHO declared a PHEIC on 30 January, by which time there were confirmed cases in 20 countries, including China, Thailand, Japan, France, Australia, Germany, India and the US. The UK and Italy both .
The announcement automatically triggered procedures laid out in the IHR: convening an emergency WHO committee and coming up with recommendations for action. One of those was that all member states should urgently review their preparedness plans and, crucially, get ready to identify, isolate and care for people with the illness, and hence shut down transmission (see âContaining a pandemic, step by stepâ).
The WHO kept on banging the drum. A few weeks later, a report on the situation in China said that all countries â even those with zero cases â should âimmediately enhance surveillance for COVID-19 as rapid detection is crucial to containing spreadâ.
The message didnât get through to everyone. On 11 March, the WHO officially declared a pandemic. At that point, Italy, Spain, France and Germany â the hardest-hit countries in Europe at the time, with exponential growth of cases and more than 900 deaths between them â were only offering tests to people with symptoms, even though it was becoming clear that cases could be asymptomatic but still contagious. Iran, the worst-hit country in Asia after China, had no testing policy at all.
On 16 March, WHO director general Tedros Adhanom Ghebreyesus warned that the world was still not doing enough, especially in relation to testing, isolation and contact tracing, which he said were the âbackboneâ of the response. âWe have a simple message to every country: ,â he said.
Some countries followed this advice. had already set up a widespread testing regime, including thermal imaging cameras at airports. People confirmed as having covid-19 were required by law to go into isolation. Everyone they had come into contact with was intensively â and sometimes intrusively â traced and tested. These measures quickly contained the outbreak and no lockdown was necessary. In early May, the country even began easing its social distancing measures, though it in response to a spate of new cases. As of , South Korea had had just 11,814 confirmed cases and 273 deaths.
Other countries didnât follow the advice and failed to contain the outbreak. The UK began a but abandoned it soon after for reasons that, , still havenât been adequately explained. At the time of writing, the country is beginning to ease restrictions but has ,000 deaths among those who tested positive for covid-19.
It may be that countries that experienced previous pandemics took this threat more seriously, sooner, and have better contained outbreaks as a result. In the past decade, Saudi Arabia, South Korea and the United Arab Emirates all had to contend with outbreaks of the MERS coronavirus, for instance, and all three nations quickly imposed stringent restrictions for covid-19.
Another factor that seems to have made a big difference in countriesâ responses, says Timmis, is whether they had pandemic experts at the heart of government. âWithout such expertise, responses to catastrophes will generally be slow, ad hoc and inadequate,â he says. The US response, for example, has been widely criticised and the country now has the most covid-19 deaths in the world. A recent editorial in the medical journal The Lancet argued that much of this faltering response was due to political decisions that are ââ the US Centers for Disease Control and Prevention.
Fail to prepareâŚ
Yet many popular hypotheses about why some countries are doing well and others badly arenât supported by the evidence, says at the University of Oxford, who co-runs a research project called the . âThereâs a lot of randomness,â he says. âThe reason for that is we saw a lot of herd behaviour, governments copying other governments under conditions of huge uncertainty.â
According to Nirmal Kandel of the WHO, the UK and South Korea started out with almost identical, very high, levels of preparedness, especially in testing capacity (both scored 100 per cent on that measure in a ). Clearly, preparation and response arenât the same thing, a vital lesson for the next pandemic.
Other countries were simply ill-prepared. Once the pandemic was officially declared, Kandel and his colleagues assessed every WHO member stateâs level of readiness, based on its most recent submissions to an . They evaluated four categories of preparedness â capacity to prevent, detect, respond and enable (which essentially means having the financial and human resources) â and also created an overall metric called Operational Readiness Capacity. Of 196 signatories to the IHR, the team found that for the pandemic and just 38 were at the highest level of readiness. Fourteen nations lacked any data at all, including some advanced economies such as Greece. The lowest levels of preparedness were in low-income and lower-middle-income countries. But even in the European region (which includes some central Asian nations) only 18 of 49 were at the highest level.
Most advanced economies scored highly, yet many also had significant weaknesses. Australia and New Zealand, for example, were rated as poor on the ability to detect diseases that can be transmitted to humans from animals; the UK fell short in detecting and responding to infectious diseases at points of entry such as airports, a glaring weakness for a major international transport hub. The US had inadequate human resources to implement the IHR. Developing economies, meanwhile, often had multiple weaknesses.
âSome countries have stronger capacities than others,â says Kandel. âHowever, many are underprepared. All countries should invest in building greater preparedness. Investments urgently need to be scaled up.â
Of course, preparedness is only half the battle. As the divergent experiences of South Korea and the UK amply demonstrate, best-laid plans can go to waste. Whatâs more, even though advance preparation has to be generic, the response must be tailored to how infectious and deadly a pathogen is. âDifferent diseases will require different detailed responses,â says Timmis. âBut the specifics only become apparent once youâre in the middle of the pandemic.â
Given these significant challenges, and multiple shortcomings, what can be done? According to Kandel, in the five years leading up to the covid-19 pandemic, real progress was being made towards fully implementing the IHR. So maybe it is simply a matter of time before the job is completed, and then we must make sure the capacity stays in place.
That wonât do, says Jacobsen. The IHR should still form the basis of the worldâs pandemic preparedness plan, she says, but they need to be as soon as possible in every country regardless of wealth. That means high-income countries need to help low-income countries get up to speed â not as an act of charity but for reasons of self-interest. âItâs really an investment in their own health security. When it comes to infectious diseases, an infection anywhere can quickly spread,â she says. IHR will also need updating in the light of covid-19. âItâs not a perfect document and we expect that after this pandemic, revisions will be made,â says Jacobsen. âWe will learn from this what we need to do for the next pandemic.â
As Harvey Fineberg, president of the Institute of Medicine in Washington DC, wrote in his preface to the WHOâs review of the H1N1 flu outbreak in 2009: âpandemics can be fearsome teachersâ.
Ready for anything
Nations should also start building an extra layer of preparedness, says Jacobsen, by implementing a little-known global agreement called the , which all UN member states signed up to in 2015. âSendai is primarily about building resiliency to manage the kinds of events associated with climate change, but it also mentions pandemics,â she says. âThe idea is all-hazards preparedness: if countries are prepared to handle one kind of disaster theyâre also more prepared to handle others.â
âWe need to acknowledge that the health of humans, wildlife and ecosystems are connectedâ
Another widely held view is that pandemic planning needs to be built on a framework called , which acknowledges that the health of humans, wildlife and ecosystems are intimately interconnected. This was developed by the , partly in recognition that as human populations grow, more people live in contact with domestic and wild animals and the chance of pathogens crossing between species rises.
A key part of the One Health approach is keeping an eye on potentially dangerous animal viruses. âWe can assume that the most probable source of a new pandemic will be an animal virus, probably a coronavirus, whose natural host is a wild animal, possibly a bat,â says Timmis. This is another area where the world needs to up its game (See âWhere could the next pandemic come from?â).
Much has been made of the need to build up capacity for more rapid development and production of vaccines and treatments in the face of an outbreak. We have made strides in this area: in 2016, the international Coalition for Epidemic Preparedness Innovations was created precisely for these reasons and it is helping to develop many of the vaccines now in the works. Improving technology is certainly a critical part of preparation, but it isnât what matters for prevention.
âWe donât want to rely on new technology,â says Jacobsen. âOne of the challenges we have now is people saying, âWell, we will definitely have some fill-in-the-blank technology that will end this in a couple of weeks or a couple of monthsâ. At this point, we canât even guarantee that weâll have a vaccine, so assuming that technology will save us is not something we should rely on.â
The good news is that we do have a recipe to avert disaster, built on knowledge and technologies that already exist. However, whether global preparedness will be prioritised in time for the next pandemic is a matter of political choice. President Donald Trump recently threatened to withdraw the US from the WHO and pull funding. What that would mean for the existing regulations and pandemic preparedness is unclear, but many fear it could undermine efforts to provide a coherent international response.
Regardless, it will cost money to boost preparedness, but as Timmis points out, nowhere near as much as it will cost â is costing â to deal with an actual pandemic. He argues that governments have a duty to their citizens to prepare for pandemics.
Governments may baulk at the idea of investing in resources that, by definition, are surplus to immediate requirements, says Timmis, but they spend vast sums on military capability that they hope to never have to use and should view pandemic preparedness in the same way. âIt is simply one of several essential insurance premiums to which the state must commit,â he says.
Right now, pandemic preparedness may seem like the most pressing and obvious priority, but, warns Jacobsen, memories are short. âI think that by the end of this calendar year, it may be hard to get countries to invest in preparedness,â she says. âPanic-then-forget is how we operate. Weâre already seeing the beginning of the âforgetâ phase as we rush to reopen economies and shift our resources to economic recovery and away from prevention, detection and treatment.â
Back in 2011, the WHO concluded that the H1N1 flu pandemic could have been a lot worse. âWe were lucky this time,â wrote Fineberg. Maybe when we look back at covid-19 we will conclude we were lucky this time, too. But third time lucky? Donât bet on it.
