Here’s how to tackle the next killer disease
The G7 summit begins today in Germany with global health, antimicrobial resistance and Ebola high up the agenda. This statement from Wellcome Trust Director Dr Jeremy Farrar outlines what he thinks needs to be done if we are to effectively tackle future infectious disease outbreaks.
When the World Health Organization began in 1948, antibiotics were a recent advance and HIV had yet to be identified. It played a pivotal role in the eradication of smallpox, the near-eradication of polio, and huge improvements in child survival.
Today, the WHO continues to set standards that improve healthcare around the world. But it is not fulfilling another vital function: leading rapid and robust responses to epidemic infectious diseases. In the last 15 years, outbreaks of Sars, swine flu, avian flu and the Mers coronavirus (Mers-CoV) have exposed how our increasingly urbanised and globalised societies struggle to contain threats from infection. Ebola is the most recent, and perhaps starkest, example.
Defending against infectious diseases is a wicked problem. It is in the nature of germs that spill over from animals, or evolve greater virulence, or drug resistance, that they pose great uncertainty. But while we cannot know which disease will threaten next, we know a lot about which ones pose the greatest danger and how to prepare. We know what needs to happen to bolster the WHO's capacity to lead a swift and effective response when outbreaks arise. It was encouraging that Angela Merkel wrote in The Times this week that reform of the WHO would be on the agenda of the G7 summit which opens tomorrow.
The first step to better preparedness is better surveillance. When an outbreak begins, local and international health authorities need to know about it quickly, so that it can be contained. Ebola took root in west Africa because it was already spreading intensely before the alarm was raised. Defences that would have worked early in the epidemic arrived too late. An effective surveillance system for endemic and epidemic infections in a low-income country could cost as relatively little as $12 million. Every nation needs one.
Once an outbreak is detected, the world then needs to respond. Yet the WHO lacks the ability to mount a co-ordinated and rapid global response. It needs access to a trained, standing reserve of doctors and public health, epidemiology and logistics experts, who can be deployed quickly to help national health services to cope. Such a corps of 'white coats' could be assembled for around $200 million a year.
We also need better research into how to tackle diseases that pose the greatest threat. We cannot predict which infection will strike when but we do have a list of prime suspects: a group of mainly viral diseases that have the potential to spread between people, even if they don't yet do so. Ebola, once restricted to small localised outbreaks, is one. Others include Mers-CoV, which has now worryingly spread from the Middle East to South Korea, Lassa fever in Africa, Nipah in Bangladesh, Chikungunya in the Caribbean and Latin America and new strains of avian flu in Asia.
We can do much to understand the social and cultural contexts, such as burial practices, which might trigger epidemics. What's more, we often know enough about their biology to develop drugs and vaccines. This was true of ebola, yet we lacked insight into the cultural sensitivities and potential drugs and vaccines were not ready to begin trials when the outbreak began. Though research moved admirably quickly in the circumstances, a critical year was lost – along perhaps with many lives.
We must not make the same mistakes again. That means making sure that candidate drugs and vaccines against the threats we know about are tested in animal models and in safety trials with human volunteers between epidemics. Protocols for final patient trials must also be agreed in advance and co-ordinated by the WHO so they can begin immediately as soon as there is an outbreak.
Central to all of these efforts is effective global co-ordination. The body that can do that with greatest legitimacy and international buy-in is still the WHO, but its present structure and funding is not fit for that purpose. Most urgently, it needs a semi-independent epidemic response unit. This should have ring-fenced funding, authority, responsibility and accountability under its own director reporting to the WHO's director-general. It must not be bound by the organisation’s convoluted regional and national bureaucracies.
Combined with better surveillance and response capabilities, understanding of the social context and a stronger scientific pipeline for drugs and vaccines, this reform would transform resilience against threatening diseases. It would give the WHO the renewed mandate and resources it needs to meet the challenges the world faces, and help save countless lives.