How to prevent the next pandemic

‘I have been reporting as a science journalist for years that the world is at increasing risk of pandemics like this; that this was predicted; that we know what we need to do to prepare and we simply haven’t done it; and that more and worse pandemics are coming so we need to do that, now’

Immune response
No supranational authority: Dr Tedros Adhanom Ghebreyesus of the WHO (©Xinhua / Alamy Stock Photo)

You don’t need some scary global government to manage global threats like pandemic disease—just better treaties. Preferably before the next, and possibly worse, pandemic that follows Covid-19.

On the second-last day of 2019, the world’s disease watchers picked up an online, local bulletin from the health department in the Chinese city of Wuhan, reporting a novel kind of pneumonia. Novel pneumonia is bad news: respiratory infections can spread out of control, and a new one might mean a pandemic. The World Health Organization asked Beijing about it.

On January 3 Beijing answered that there were indeed 44 cases, and some were severe—but there was “no evidence of significant human-to-human transmission”. That meant whatever the new infection was, it was unlikely to become an international problem.

The WHO published that—but it also activated its emergency response teams, just in case. The story, however, remained unchanged until January 20 when, with case numbers rising across China and beyond, Beijing admitted the virus did spread person to person.

In fact, its doctors knew that in December. They also knew the infection was a coronavirus, a family of viruses the WHO had already fingered as a potential global threat. China did not tell the WHO that until January 9. And the WHO was completely dependent on what China chose to tell it: it had no right, despite representing the global community that was at risk, to come in and look.

I spent two months this year writing a “crash” book about Covid-19 (Covid-19: The Pandemic that Never Should Have Happened, and How to Stop the Next One, published by Bridge Street Press in June). It was mostly based on what I have been reporting as a science journalist for years: that the world is at increasing risk of pandemics like this; that this was predicted; that we know what we need to do to prepare and we simply haven’t done it; and that more and worse pandemics are coming so we need to do that, now.

But I also asked epidemiologists whether it would have helped to have known a few weeks earlier that there was a new, contagious, respiratory coronavirus in China. The bottom line was that, while we probably would not have completely stopped Covid from going global, we might have slowed it down in more places while there were fewer cases, limited the impact and made it more manageable. And we would have all been working together on response from the start.

That story sums up what went wrong with this pandemic, and what remains wrong—potentially catastrophically wrong—with our ability to manage global disease emergencies. Sovereign power in health, as in most things, lies with nation states, even though the risk is global.

If a potentially pandemic outbreak occurs in an impoverished country ill-equipped to track or contain it, or a powerful one with a secretive bureaucracy averse to panicking its people, it’s up to that country whether it tells the world, or allows foreign assistance. We all have to hope it does the right thing, even though local interests and capabilities can be very different from global ones. There is no global governance that can override whatever local decision health authorities make.

But when disease strikes, countries may not even act in their own interests. China suffered badly from the delay in admitting the new coronavirus was contagious. Without that, no public infection control measures could be taken in Wuhan, so by January 20 there were so many cases in the city that the only choice was to lock down its 60 million people.

Cities elsewhere in China stopped transport and gatherings, and traced and isolated cases and contacts, fast enough to avoid similar lockdowns. Still, the economic impact was dire, and official Chinese media quietly admitted the early cover-up was a bad idea.

Why does this happen, and how do we stop it happening again? There are more potentially pandemic viruses out there, and some are far deadlier to more people than Covid-19. There are many lessons to learn before the next pandemic, but the biggest priority must be to ensure that all countries detect and report worrying outbreaks quickly, honestly, and publicly—and that when they do, rapid global responses kick in.

In fact, in March G20 leaders promised to “substantially increase” their pandemic preparedness spending, and to “establish a global initiative on pandemic preparedness and response” at a meeting of health and finance ministers to be held “in coming months”.

As I write, no such meeting has yet been scheduled. But I am optimistic. We already impose global governance—effectively, collective controls—on other risky things. As long as the world stays focused on the threat—and suitably shaken by the ability of a disease as relatively benign as Covid-19 to damage economies—this should be possible.

First, it is important to recognise that keeping outbreaks quiet is not unique to China. This is a very old problem. We are psychologically primed to react strongly to news of infectious disease, and all governments fear panic and instability.

The International Health Regulations (IHR), the global treaty governing diseases that could have impacts across borders, started in the 1800s as an effort to make countries warn shipping of cholera outbreaks in ports. There was so much resistance to this, the negotiations took decades.

“The authorities’ key concern, before they know how big the problem may be, is to downplay things to maintain stability and prevent economic consequences,” says Jean-Pascal Zanders, an expert on the treaty banning biological weapons—which for obvious reasons is concerned with mysterious disease outbreaks. Fear of instability has only worsened, he thinks, as internet trading makes markets more volatile.

But the internet is also making it harder to hide outbreaks: in 2003, alerts from city health departments weren’t posted on the internet, and China was much slower to admit to an outbreak of a related coronavirus, SARS. That was only stopped from going pandemic by a massive international containment campaign led by the WHO—aided by the virus’s inability, unlike Covid-19, to spread before it caused symptoms.

That was China. But in 2014, when the largest-ever Ebola epidemic hit West Africa, Guinea refused to report real case numbers for fear of discouraging foreign investment. That helped delay the international response and almost let the epidemic spin out of control.

In the 1990s, British authorities, fearing public panic—and damage to the beef industry—downplayed the possible risks to people from bovine spongiform encephalopathy, or Mad Cow Disease. By 1996, when it was clear infected tissue could cause horrendous disease in people and controls were tightened, 15-30,000 had been infected. Only dumb luck—the causative agent worked more slowly in humans than cattle—prevented disaster.

So, the problem is that a country’s perceived interests might not always be the same as the global interest in containing an infectious threat. Some agency must be able to override local concerns in the global interest. In theory that is the WHO.

But its own member states have refused to give it that power. In 2007, after SARS, the revised and strengthened IHR gave the WHO at least the power to ask member states about outbreaks, even if it had heard about them from sources other than that member state itself. It also allowed the WHO to publicise outbreaks—if news of them had emerged anyway. The fact that those were major concessions shows how tightly member states kept control.

But sometimes states are wrong. In April, US president Donald Trump said the US would leave the WHO because it had “failed to adequately obtain, vet and share information in a timely and transparent fashion,” and especially that it “parroted” the claim of no human-to-human transmission despite “clear evidence to the contrary”. This, he claimed, showed the WHO was controlled by China.

But before China admitted it, the WHO had no reliable information the virus spread human-to-human. It could only praise China’s openness with other information and hope it would improve—which eventually it did. The US was among the countries that opposed giving the WHO the power to obtain information independently of the countrys official channels.

There is a clear way forward. The IHR requires countries to declare any outbreaks with possible international implications. China did that—but there was no way for the WHO to check its facts. There is no supranational authority that can enforce international law.

But nations can join to verify it. Under the 1995 Nuclear Non-proliferation Treaty, countries declare their nuclear material and production facilities, and the International Atomic Energy Agency verifies that the declaration is true. It caught Iran cheating, twice, and imposed an inspections agreement that stopped Iran making bomb material until Trump left the agreement in 2018.

Under the 1997 Chemical Weapons Convention, ccountries declare their chemicals and potential weapons production capabilities, and treaty inspectors verify whether the declaration is true. Any country can demand a challenge inspection of a country it suspects is cheating, and in theory treaty members agree to inspection, anywhere, anytime.

Joshua Gans of the University of Toronto—who like me produced a “crash” Covid book during lockdown—also called for limits on national sovereignty to prevent pandemics. He cites the 1944 Bretton Woods agreement, under which countries ceded some financial sovereignty in the interests of global stability, as providing “hope that a future global pandemic response institution might be possible”.

Let’s say the IHR required countries to declare, not only novel outbreaks, but infectious diseases generally, and the WHO verified the declarations—as well as any suggestions from other countries that something undeclared was happening. When China declared a new pneumonia in early January, the WHO might have said thank you—we’ll be there tomorrow to talk to your doctors and scientists. Technical experts communicate well, and the real threat might have become clear more quickly.

Such a system might also help countries do better at spotting outbreaks in the first place. Global “hotspots” where new viruses are most likely to jump from animals to humans tend to be in the tropics, where there are more kinds of wildlife and accompanying viruses, environmental destruction brings them into contact with more people and surveillance is poor.

“Surveillance is key,” says David Heymann, now at the London think tank Chatham House, who led the WHO response to SARS. The IHR requires rich countries to help poor ones improve their disease surveillance, but he says little has been done. If the IHR was verifiable, inspectors could check that a country reporting no new diseases really had the systems in place to know if that was really true—as the polio eradication campaign does now when countries declare they have no polio. If not, they could help build those systems.

None of this is impossible. An existing treaty can be sharpened, using tested verification tools, to make sure disease surveillance is done, and declared, in the global interest. We could have used that with Covid-19. We need it now to spot and—we must all hope—head off the next pandemic.