“COVID-19 has demonstrated the vital importance of good leadership and containment coordination.”
From the Introduction
by Andrew S. Natsios
Pandemics have changed the course of history. They can cause widespread illness and death, disrupt the world’s commerce, collapse economies, cause political crises, and drive countries to withdraw into themselves. Pandemics cause more suffering and kill more people than nearly any other category of crisis—more than war, more than famine, and more than economic collapse. The 1918 pandemic was the single deadliest event in the recorded history of mankind: life expectancy dropped by 12 years. Pandemics have debilitating long-term physical and mental health consequences for those who survive them that can last a generation, even if those consequences are invisible to the untrained eye.
Pandemics cause mass panic and can quickly loosen, and even dissolve, the fragile bonds that make civilization possible. The 1918 great influenza pandemic killed between 50 and 100 million people within six months (5 percent of the world’s population at the upper end of the estimates). In 1918 at the height of the pandemic, Victor Vaughan, dean of the Michigan Medical School and one of the most influential and respected medical scientists in the United States in the first third of the 20th century, sitting in the Surgeon General’s Office of the US Army, wrote, “If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear . . . from the face of the earth within a matter of a few more weeks.” Victor Vaughan was not prone to exaggeration or panic; by nature he was restrained, calm, and collected. He wrote these words as he watched the death rates soar around the world and as he received reports of people ill with influenza starving to death in their own homes because grocery stores were fearful of delivering food. In many American cities, the streets were empty as people locked themselves in their homes to avoid contact with the outside world being ravaged by the disease. Factories shut down for want of workers. Stores closed from the lack of customers. Schools lay empty. Earlier pandemics were even worse.
The bubonic plague epidemic of the medieval period, commonly known as the Black Death, killed, by some estimates, 22 percent of the world’s population and depopulated Europe. Ole Benedictow argues that the earlier European mortality estimates of 30 percent should be doubled to 60 percent based on more recent research on medieval demographic data. It took around 150 to 200 years for Europe to recover from the population losses. The labor shortages caused by the loss of 60 percent of the population had a profound effect on the economy and may have led to new inventions to increase productivity and make up for the severely depleted workforce.
Local endemic yellow fever forced the French to abandon their attempt to build the Panama Canal. Later, US president Theodore Roosevelt took over the project, having solved the disease problem through the efforts of Colonel William Crawford Gorgas, who took lessons from Walter Reed and the Yellow Fever Commission in Cuba. Dr. Gorgas undertook malaria and yellow fever control by aggressive control of the mosquitoes that carried the diseases, effectively ending one of the impediments to the construction of the canal. The death rate on canal construction during the French effort was 176 out of 1,000 but fell dramatically to 6 out of 1,000 after Colonel Gorgas’s eradication campaign.
The influenza pandemic profoundly affected the unfolding of history during and after World War I. The devastation of the influenza pandemic contributed to German defeat in World War I as the last German offensive in the war was stopped in its tracks by the rapid spread of influenza among the German troops. It also devastated the US, British, and French armies. Some estimates suggest half of American war casualties were due to influenza.
Science has made enormous strides since the devastating influenza pandemic of 1918. We are better prepared now than we were then in many, but not all, respects. The germ theory of disease is now universally accepted among scientists and policymakers worldwide as scientific truth, which was not the case before or even early in the 20th century. Vaccines have been developed for many diseases—but not all of them. Even when a vaccine is developed, however, pharmaceutical companies may decide not to produce and sell it if there is low market demand. This prevents the distribution and use of effective vaccines for diseases in which there are relatively few patients. For diseases with adequate demand and profit potential, an enormous and highly efficient private-sector pharmaceutical industrial infrastructure has developed globally for vaccine/drug development and production. A public infrastructure has developed in the United States to fund and carry out medical research on infectious disease at the CDC, the NIH, and universities and institutes. Over the past two decades, the US government has funded the construction of several large vaccine manufacturing plants capable of producing a massive number of doses of vaccine in a short period of time that the pharmaceutical industry is not capable of making. Unfortunately, it takes at least 18 months for a new vaccine to be prepared, tested, manufactured, and distributed. Certainly, the organizational capabilities of the modern state to respond to disease are much greater than they were a century ago, but even they have limitations. Other advanced industrialized countries have made similar progress.
Despite all this progress, nations remain unprepared for a pandemic. Globalization—which has brought so much prosperity to so many people—may actually accelerate the spread of a highly communicable lethal disease before we can apply the power of science and technology quickly enough to stop mass casualties. According to data from the CDC, during the 2009 flu pandemic, 1.9 billion people contracted the flu within six months. The only reason it did not become a catastrophe is because the genetic sequencing of the virus’s RNA did not mutate to become highly lethal as it did in 1918. This resulted in a 2009 death rate that was remarkably low, a condition that may have been an anomaly. We may not be so fortunate during the next flu pandemic.
The progress we have made is not evenly distributed across the world. Perhaps three dozen advanced industrial states do have elements of an efficient response system in place, even with continuing systemic weaknesses. Middle-income countries have less robust systems but do have some capacity to respond to pandemics. It is lesser developed countries that would be most at risk. Historically, donor aid agencies have funded health programs in the developing world more than any other sector of development. As a result, developing countries have not funded their own health programs, and now that most donor governments are cutting back on aid, it will be health programs in developing countries that could be most at risk. Thus the progress that developing countries have made in creating health infrastructure may now be at risk because of unstable and unpredictable funding sources.
Over the past 50 years, 40 new diseases have appeared for which there is limited or no vaccine protection. These offer a warning that modern medical science and emergency operations have not mastered the threat of infectious diseases, epidemics, and pandemics. Diseases such as HIV and Zika are believed to have existed for many years but never reached epidemic levels until the past few decades.
Globalization has had one other unintended perverse consequence. It has created a highly efficient distribution mechanism for infectious disease—whether airborne or through direct contact—through the development of the modern international airport. Modeling done on the spread of disease has concluded that it is through the global system of international airports that a lethal and highly efficient pathogen—particularly one that spreads through the air with a longer incubation period—will infect the populations of urban areas connected to these airports. Unintentionally, we have created the most efficient and effective mechanism in world history to render the entire globe more vulnerable to a deadly microbe.
The economic, infrastructural, demographic, and technological warning signs are presenting themselves across the globe that another event of history-altering consequence may confront us over the next decade. Pandemic preparedness planning offers the best approach to put the systems in place now to protect the public and countries around the world when the crisis does come. This book brings together some of our leading authorities on pandemics and preparedness to review our state of knowledge and capture lessons we have learned from previous outbreaks to better inform our efforts to prepare for the future. We have placed heavy emphasis on public-private alliances for pandemic preparedness, as these have not been explored in enough depth previously.
. . .
From the Epilogue
by Christine Crudo Blackburn
At the time of this writing, COVID-19 is spreading across the world. All the chapters in this book, with the exception of chapter 7, were written before a suspicious cluster of pneumonia cases appeared in Wuhan. As this book goes to press, it is too soon to know what the final outcome will be, but the warnings many pandemic preparedness experts have been exposing for years appear to be unfolding before us. Public health professions have often discussed “the next 1918-type flu” with full knowledge that such an outbreak would be exponentially worse than the 1918 outbreak, due in large part to advances in technology and our highly globalized world. Advances in technology have given societies the tools to better track outbreaks throughout the world, but technological advances have also created the most effective method of disease spread (airplanes), incubators for disease emergence (land use change and urbanization), and a new threat of man-made catastrophes (downsides of synthetic biology). The vast majority of national leaders, public health officials, and scientists agree: the next pandemic is unavoidable. And today, it is here.
In 2011, Laurie Garrett published an opinion piece in which she stated, “There is no governing structure for a pandemic, and little more than vague political pressure to ensure limited access to life-sparing tools and medicines for more than half the world population.” While many in this book, including myself, would argue that improvements have been made since 2011, Garrett is correct in asserting that more must be done. Countries must strengthen coordination and capabilities internally, but the international community must also work to improve the global pandemic response plan. COVID-19 has demonstrated the vital importance of good leadership and containment coordination. Although the pandemic is ongoing, countries have widely varying case-fatality rates, which, at least in part, can be attributed to government response.
Margaret Chan, former director-general of the World Health Organization, once said, “Pandemic influenza is by nature an international issue; it requires an international solution.” This book has examined lessons from the 1918 pandemic, focused on factors that weaken pandemic preparedness, and outlined factors that make a pandemic more likely. Additionally, policy solutions have been offered to close the gaps and strengthen the international preparedness structure. While it might be too late to apply these lessons in COVID-19, we are fooling ourselves if we believe this is the last pandemic we will face. As the global climate changes, as the population increases, as animal habitats are destroyed, and as we maintain or increase physical and economic interconnectedness, the risk of pandemics will also increase. Understanding the lessons and implementing the solutions outlined in this book are an important step in pandemic preparedness. As full countries go on lockdown and hospitals around the world struggle to accommodate the sick and dying, the world must both respond and realize that in the aftermath lessons must be learned, not just observed. Once COVID-19 reaches its resolution, the world is not free from the threat of the next pandemic; the clock will still be ticking.
Dr. Christine Crudo Blackburn currently serves as the Deputy Director of the Pandemic and Biosecurity Program at the Scowcroft Institute of International Affairs in the Bush School of Government and Public Service at Texas A&M, conducting research on various aspects of pandemic disease policy and control. She teaches at the Bush School and at the Texas A&M School of Public Health.