On World Health Day, Are We Ready for the Next Outbreak?
When the Ebola virus broke out in three desperately poor West African nations in 2014, the global health community was woefully unprepared to mount an aggressive response. The case count rose, first in remote rural areas of Guinea, Liberia and Sierra Leone, then in densely packed urban slums in Monrovia and Freetown.
For the first time in modern history, the Ebola virus reached cities with daily flight service to major global hubs in Africa and Europe. Left unchecked, the Centers for Disease Control and Prevention estimated the virus would have infected as many as 1.4 million people in the span of just a few months.
But the Ebola virus did not go unchecked, thanks in part to herculean efforts made by the CDC. Over the course of more than a year, 1,450 CDC staffers — virologists, epidemiologists and other virus hunters — deployed to the three African nations. With the help of billions of dollars allocated by Congress and the Obama administration, those staffers traced contacts, tested samples, cared for patients, and helped build the health infrastructure that finally brought Ebola to heel.
Later, some of that money helped CDC launch an early assault on the Zika virus, which began spreading north Central America and the Caribbean into the United States just as the Ebola virus was on the wane.
The supplemental spending bill Congress passed to fight Ebola included $582 million to help countries on the front lines of emerging health threats create teams of disease detectives, laboratories and rapid response units to surveil and track outbreaks of the next killer pathogen.
Now, that money is running out and Congress has no plans to replace it. That oversight will put global health security — and with it, American national security — at risk, just as the conditions necessary to create a global pandemic come into alignment.
Without additional funding, the CDC will be forced to cut its global health security funding. In a letter to health officials around the world, the director of the CDC’s Center for Global Health warned that the agency will have to stop funding epidemic-prevention efforts in 39 of the 49 countries where it now operates.
In the course of reporting a book about the Ebola outbreak in West Africa, I was told by public health officials to think of the global public health system as a chain. The weakest link, whether in Liberia or China, exposes every other link, no matter how strong, to the growing risk that the next epidemic might become the next pandemic.
We live in a globalized world, in which anyone is just a flight or two away from a megalopolis like Beijing or New York. At the same time, the growing global middle class, whether in China or India or Africa, increasingly has the financial means to travel internationally. Thomas Eric Duncan, the first person to die of the Ebola virus inside the United States, traveled by plane from Liberia to Europe, then through Washington to Dallas.
As human society expands, settlements encroach ever closer on tropical or subtropical jungles, where the next disease might lurk. Climate change has expanded the range of tropical and subtropical environments, and even the range of the insects that might spread disease.
“We don’t know what the next pathogen will be. We don’t know where it will come from, we don’t know when it will hit. But we are 100 percent certain that it will come,” said Tom Frieden, who spent eight years running the CDC under the Obama administration and who now heads Resolve to Save Lives, a global public health nonprofit.
What worries public health professionals most is not a virus like Ebola or Zika. Though Ebola is highly lethal, it is difficult to transmit between people. Though Zika is easily transmissible, through the common mosquito, it presents real health risks to only a very small slice of the population.
Instead, what worries those public health experts is a disease that combines those worst traits: something that is deadly like Ebola and easily transmissible like Zika. That something is probably going to be a strain of the influenza virus.
This year’s flu season has been dominated by two strains: The H3N2 strain, which is more resistant to vaccines than other strains, and the H1N1 strain, the culprit behind the 2009 swine flu outbreak. Those two strains are bad, but they kill fewer than one in 1,000 people who contract them.
The H7N9 strain of influenza, on the other hand, is far more dangerous. Since it was first reported in China in 2013, H7N9 has broken out five times; 39 percent of those confirmed to have contracted it have died, roughly comparable to the percentage of those infected with Ebola who died in West Africa. And the number of confirmed cases has risen with each subsequent outbreak.
The good news is H7N9 is not easily transmissible between humans. The bad news is that health experts use a caveat when discussing it: H7N9 is not easily transmissible yet.
Viruses are simple organisms, made up of a few strands of RNA that can and do easily mutate when they replicate. Every mutation is a roll of the dice: If the right combination comes up, if the right mutation occurs, a virus that was once difficult to contract might become more readily transmissible. A virus can replicate millions or billions of times inside a single host, meaning millions or billions of chances for the right combination to strike.
“We’re really only a few nucleotide pairs away from a potential catastrophe,” Frieden said.
Worryingly, China is among the nations CDC has said it would have to cut from its infectious disease surveillance and prevention program.
While the Chinese Center for Disease Control and Prevention has improved itself in recent years, with substantial help from American technical assistance, it is nowhere near as capable as the CDC in Atlanta, the gold standard of public health organizations.
Foreign aid is an easy and tempting boogeyman for fiscal hawks to target. But spending millions of dollars on global health security today could prevent or stem that next pandemic, saving billions of dollars and millions of lives — both foreign and American — tomorrow.
“Public Health is Purchasable,” wrote Hermann Biggs, when he ran the New York Department of Health in the early 20th century. “Within natural limitations, any community can determine its own death rate.”
We ignore Biggs at our own peril.