In the first months of 2020, pandemic panic has spread faster than the novel coronavirus itself. Rural communities in China have built illegal blockades for self-isolation. Singapore has prohibited all travel to and from China. The US Centers for Disease Control and Prevention (CDC) has issued the first quarantine in over fifty years, and the Chinese government is carrying out the largest quarantine in human history. Epidemiologists are predicting that more people will contract COVID-19 than originally estimated, and we still aren’t certain how quickly the virus spreads or mutates.
Only one thing seems clear: we wouldn’t be in this situation if we’d been better prepared. Former CDC director Tom Frieden and others have warned that neither the US nor the world is ready for a global pandemic. Alarm bells have been rung before, time and again, but the status quo remains in place. Why? Because investments in global health preparedness are motivated by myopic self-interest and a misplaced faith in the free market. Private interests are privileged over the public good.
Pandemic preparedness is the idea that global health practitioners can take steps to prevent, rapidly identify, and contain a dangerous new pathogen at its source. Rich nations like the US tend to focus their preparedness efforts, misguidedly, on biochemical agents relevant to national security. Every few years, select members of the US government participate in a bioterrorism simulation. The original, 2001’s “Dark Winter,” played out the rapid and devastating course of events following an aerosolized smallpox release on US soil.
Alongside such simulations and efforts to combat terrorism more broadly, the US has invested billions of dollars in biosecurity and biodefense over the last two decades. The federal government now stockpiles 300 million doses of smallpox vaccines, enough to vaccinate nearly ever person in the US. (The World Health Organization, by comparison, reserves only 35 million smallpox vaccines for discretionary deployment in case of emergency.) This militarization of public health ties expenditures to national security interests — neglecting all the ways that national and international health have more to do with the unpredictability of pathogens than that of the national security state.
Countries in the Global South, meanwhile, still rely on philanthropy for outbreak response — and the largesse often comes with strings attached. Following the 2014–16 Ebola contagion, the World Bank developed the Pandemic Emergency Financing Facility (PEF) to fund rapid outbreak response. Under the new funding mechanism, investors bought pandemic bonds at high annual interest rates that would then create pooled insurance payouts to fight certain pandemic diseases. “Higher risk” diseases like Ebola offered higher returns on investments.
Some touted the PEF as a creative way to engage the private sector, a case of “philanthrocapitalism” doing good. But in response to the current Ebola epidemic, the second-largest in history, the World Bank has deployed none of these funds — because the disease has failed to meet specific criteria, including killing enough people in enough places. Investors are nevertheless cashing in, even as the Democratic Republic of the Congo is left with scant resources and little autonomy as it continues to try to fight a deadly epidemic amid ongoing violent conflict.
The growing dependence on private, for-profit actors to deliver public services is not working. Nor are countries like the US a model: militaristic investments in biosecurity cannot bring about real pandemic preparedness.
A better system would include a few key elements.
First, preparedness involves prevention. In public health, unlike in the marketplace, the best possible returns are those that will never materialize. In other words, people won’t get sick. Prevention requires strong public sector health systems focused on primary care. Only universal health care can ensure that even the most marginalized can access care, and during disease epidemics, that no one will be left on the sidelines.
Second, preparedness involves rapidly identifying emerging diseases — and that takes public investments in education and research capacity. Identifying emerging diseases depends on the capacity of health professionals to recognize unusual symptoms, laboratories to detect novel pathogens, and epidemiologists to identify aberrations in reliable data. All of that means a stronger public sector.
Finally, preparedness involves disease containment. With collective funding, multilateral partnerships can build strong emergency response teams to carry out isolation strategies, distribute supplies, and promote public health education. Partnerships are needed not only to ensure global stockpiles of supplies but also the ability to scale up production of these global public goods. To do so equitably and efficiently, delivery strategies must be transparent and predetermined, with all affected stakeholders at the table. Developing countries can’t be placed in a subordinate role.
If we want to be prepared for the next big pandemic, we must focus on improving public goods and services, especially in the places where pathogens emerge first and health infrastructure is needed most.
The current global health regime, which rests on philanthrocapitalism and militarized investment, is failing. It’s time for a regime change.