60 cents a year for every person on the planet would make us safer against pandemic threats

As the world continues to learn difficult lessons from the Ebola crisis and the failures that occurred during the response, a landmark report published today spells out what must be done to increase our resilience to such outbreaks in future.

Wellcome Trust Director Dr Jeremy Farrar examines the main recommendations from the Global Health Risk Framework Commission, and the steps that should be taken to increase the world's resilience against epidemic and pandemic threats.

Few global events can inflict death, ill-health, economic disruption and social upheaval with the reliability of infectious disease.

The 1918 flu pandemic killed more than 50 million people, and HIV/Aids has claimed 35 million lives and counting. Even smaller outbreaks with much lower death tolls, such as SARS in 2003 and Ebola in 2014–15, can destabilise nations and destroy prosperity. The latest modelling estimates the likely cost of pandemics this century at more than $6 trillion, or $60 billion a year.

It will never be possible to eliminate these risks completely: it is the nature of evolution that new infectious agents will emerge, and that old ones will evade our efforts to control them. Yet in a world where military spending touches $2 trillion a year, we have systematically under-invested in preventing, preparing for and containing dangerous outbreaks of infectious disease. The evidence is plain from inadequate responses to the defining outbreaks of the past 15 years – SARS, swine flu, the MERS coronavirus, and most recently, Ebola.

As the failures and lessons of the Ebola epidemic are assessed by the international community, it is becoming increasingly clear how this under-investment should best be addressed. The costs of greater health security, too, need be nothing like as steep as is commonly imagined.

This week, the Global Health Risk Framework (GHRF) commission, convened by the US National Academy of Medicine, concluded that extra global spending of just $4.5 billion each year – about 60 cents for every person on the planet — would build substantially greater resilience against epidemic and pandemic threats. That is less than the world's cellphone users spend each year on new ringtones.

A growing consensus

The GHRF report, together with Dame Barbara Stocking's review of the Ebola crisis for the World Health Organization, and an independent report led by the London School of Hygiene and Tropical Medicine, Harvard University and The Lancet, also underpins a growing consensus on how extra resources should best be spent, and on the accompanying structures needed to deliver a resilient world health system. The conclusions can be grouped into three sets of measures that would together create greater health security for all.

The first cornerstone of global defence is strong regional and national capacity to monitor, detect and respond to emerging and endemic infectious diseases. In too many countries, especially those with low incomes and weak states, this essential infrastructure is missing – as it was in the three West African countries where Ebola struck. As the GHRF recommends, we need standards for core capacity, and financing mechanisms in place so this can be delivered.

All countries must contribute to this investment, of around $3.4 billion a year, but the rich nations that will bear higher costs should not think of these simply as altruistic aid. It is also in their naked self-interest. As the spread of SARS to Canada showed, pathogens do not much care about national borders – global defences against pandemics are as strong as their weakest links. In the worst case, over-investment in this health infrastructure will deliver great improvements in the fight against endemic killers such as malaria, tuberculosis and HIV, with limited benefits for pandemic defence. In the best, it could head off an emerging threat before it goes global.

The second essential step is reform of the WHO, to give it the institutional capacity and resources to lead preparedness for and response to infectious disease emergencies. The WHO, commendably, has already begun this process, establishing a programme to oversee this vital function and a contingency fund to pay for it. The GHRF rightly recommends extending this approach, to create a permanent Center for Health Emergency Preparedness and Response that would lead and co-ordinate defences and action against pandemic threats. This should have sustainable funding – which will mean increased WHO subscriptions, especially from richer member states — and a strong independent board.

Accelerating research and development

Finally, we need urgently to upgrade the tools at our disposal for preventing and treating emerging infections. This will involve substantial investment in drugs, vaccines and diagnostics, as well as in strategies for understanding and engaging with affected communities, where market incentives alone will not drive research and development. We cannot afford a repeat of the situation with Ebola – candidate vaccines existed when the outbreak was confirmed, but had not completed the necessary safety testing to begin effectiveness trials immediately and contribute to containing the epidemic.

To catalyse this, the WHO should establish an independent expert panel charged with accelerating this vital R&D. It would help prioritise the most urgent needs and identify the most scientifically promising candidates, oversee the development and sharing of protocols for trials, and ensure supply and equitable access, all with the unique authority and legitimacy of the WHO.

The resulting framework would help to guide investments by national governments, industry and philanthropy – the WHO should not make spending decisions, but is uniquely well placed to play a critical co-ordinating and convening role. This panel could also link up parallel efforts designed to support R&D in more specialised fields such as drug-resistant infections and vaccines, which will be discussed in Davos next week. The GHRF recommends global investment of at least $1bn a year, for at least 15 years.

Humanity cannot prevent the emergence of infectious threats like Ebola, but if we make eminently affordable investments, and some very achievable institutional reforms, we can certainly limit the damage to life, health and prosperity that they can inflict.