This year marks the 100-year anniversary of the Spanish influenza pandemic, in which an estimated 40–100 million people died worldwide, up to five times as many as were killed during the First World War. Outbreaks of infectious disease, whether from newly identified pathogens such as the Middle Eastern Respiratory Syndrome (MERS) virus or sporadically reoccurring diseases such as Ebola, continue to cause major national, regional and global crises. The annualised cost of a major flu pandemic has been estimated at USD 560 billion.

Today we are still unable to predict accurately where or when outbreaks will occur. Yet, overall, the frequency, spread and severity are likely to increase, often linked to processes of globalisation: with intensified travel and trade, disease can rapidly spread from one country to another, as when yellow fever spread from Angola to China in 2016. A growing global economy is also linked to increasing meat consumption and broader environmental degradation, meaning that humans, livestock and wildlife will reside in closer proximity, increasing the risk of pathogens transmitted between animals and humans. The deadly H5N1 avian flu outbreak in 2005 was spread, in part, through poultry markets. In addition, urbanisation can increase the speed with which diseases are transmitted from human to human and raise new challenges for outbreak control, as we saw when Ebola reached several West African capital cities simultaneously during the 2014 outbreak. Furthermore, pathogens can evolve rapidly. This means that viruses can become deadlier, and bacteria may no longer respond to the existing arsenal of antibiotic medicines. Finally, climate change continues to unearth surprising new risks that we do not yet fully understand. For example, in 2016, melting permafrost in Siberia allowed frozen anthrax spores in the soil to reactivate, killing a boy, infecting two dozen other people, and prompting the government to cull thousands of reindeer as a control measure.

UNEVEN IMPACT ACROSS COUNTRIES

Outbreaks are often labelled a global security issue. Given the widespread panic, economic disruption and political consequences that often result, this is understandable. Indeed, the richest countries are not immune, as recent outbreaks of MERS in South Korea and Zika in the United States have demonstrated.

Public health poster from Spanish flu era. "Prevent Disease. Careless Spitting, Coughing, Sneezing, Spread Influenza and Tuberculosis

But, as with many aspects of globalisation, the implications and impacts are uneven across countries. Outbreaks are also a development and social justice issue, though less often framed as such. The highest human price is often paid in developing countries and by the most vulnerable populations, especially in contexts where health systems are weak, access to resources limited, and economic security fragile. The 2014 Ebola outbreak in Liberia, Sierra Leone and Guinea led to the closing of schools, healthcare facilities and businesses, and hence to less food consumption, income and employment, combined with broader economic consequences that outlasted the epidemic itself. Economic losses from Zika were projected at up to USD 18 billion, 80% due to the drop in international visitors to tourism-dependent developing economies in the Caribbean. Outbreaks also affect vulnerable civilians in armed conflict. In late 2017, cholera broke historical records by infecting one million people in Yemen, enabled by non-functioning water and health systems and blocked aid efforts. The disease is easy to prevent and treat in peacetime.

Addressing outbreaks today

When it comes to medicine and public health, science and technology have advanced tremendously since 1918. For example, we can track how viruses mutate through genomic sequencing technology, we have safe and effective vaccines to prevent a host of infections, and epidemiological modelling can predict the spread of disease and suggest the measures that will most effectively contain it. However, we still lack diagnostic devices, drugs and vaccines for many known pathogens, and are even less prepared for pathogens that have yet to be identified. Measures to facilitate the development of new technologies during outbreaks – such as agreements for sharing data, pathogen samples, and research results – remain weak. The rise of new technologies, such as genomic sequencing, simultaneously facilitates the rapid spread of information and undermines carefully crafted international rules to balance the sharing of virus samples and resulting benefits. Even when technologies do exist, we do not have global arrangements to ensure they will be affordable and available in the countries and to the people who need them. Even when technologies do exist, we do not have global arrangements to ensure they will be affordable and available in the countries and to the people who need them.

When it comes to governance, there has also been significant progress, often driven by specific crises. In 2005, in the aftermath of the Severe Acute Respiratory Syndrome (SARS) outbreak, the international law governing disease outbreaks was strengthened to enable faster detection of outbreaks, encourage building of national capacities, and grant authority to the World Health Organization (WHO) to declare international emergencies. After coming under heavy criticism for a tepid initial response to the 2014 Ebola crisis, significant attention was paid to reforming WHO to rebuild its in-house expertise and operational capacity on outbreaks. Ebola also prompted renewed efforts to assess and build national outbreak management capacities in rich and poor countries alike, to prioritise and globally coordinate R&D efforts, and to increase the availability of rapid financing for emergency response.

However, the tendency to implement patchwork reforms after each major outbreak has produced a fragmented global landscape. Plenty of gaps remain. For example, financing for WHO and capacity-building in weaker countries remains fragile, difficult to track, and largely inadequate. Despite a proliferation of (often much-needed) initiatives, no entity is in charge of ensuring that they add up to a functional whole. Without a sensitive barometer of global capacity to handle outbreaks, we simply do not know how prepared we are. And since outbreaks are a security, development, and social justice issue extending beyond the health sector alone, it remains unclear who is responsible for the state of the world’s preparedness. One hundred years after the Spanish influenza, a global pandemic remains a very real possibility for which we have many technological tools, but inadequate global governance.