The fear we all harbour when we are old enough to understand our own mortality is an open secret. It is the suddenness with which disease can strike us down, and the terrible ways it ravages the body. Cancer has its own dread, along with multiple sclerosis, senile dementia, and motor neurone disease too. But none is feared by our society more than plague – a contagion that spreads rapidly, causes shocking pain, and generates widespread fear in the community.
In 1346, the bodies of Mongol warriors who had died of plague were thrown over the walls of the besieged Crimean city of Kaffa (now Theodosia). After a lengthy siege, during which the Mongol army suffered many casualties, Zhanibek Khan, the military commander, decided to toss the infected corpses over the city walls to infect the inhabitants. It is highly probable this action was responsible for the arrival of the Black Death in Europe. Over the course of just six years, this disease would go on to kill around 75 million people worldwide.
This plague was the first of a cycle of microbial epidemics which continued well into the 18th century. There have been major pandemics since of course. One of the deadliest was the so-called Spanish flu, first identified in March 1918 among US troops. Unusually virulent, it spread to become a worldwide pandemic on all continents, eventually infecting about one-third of the world’s population and killing at least 50 million. In the last century alone just five diseases – smallpox, Aids, Sars, influenza and Ebola – have killed over 500 million people.
Another epidemic is certain. It could be born anywhere infected animals are in contact with humans. It might be a variant of hundreds of known microbial threats. Or it might be entirely new. If it is an airborne virus it could conceivably spread to every major urban centre in the world – killing millions of people within weeks, disrupting health care services, destroying the livelihoods of millions of survivors, causing a huge shock to global financial systems, and leaving a life-long trail of signature disabilities in its wake.
Yet plague hardly ever appears on official lists of the threats facing humans. A species-destroying asteroid, all-out nuclear war, runaway global heating, the malicious use of nanotechnology by a terrorist organisation, or poorly encoded machine intelligence, perhaps. But a pandemic? We barely give it a second thought.
This is extraordinary given that we know it will happen. And in terms of intensity and scale, a global pandemic ranks as one of the threats most likely to wipe out humanity.
As the number of epidemics increases each year, numerous causal factors come into play. The rate of urban growth in places like Africa and South America, for example, produces ideal conditions for any outbreak to spread like wildfire. Clearcutting forests in countries like Malaysia, Liberia and Guinea, destroys natural habitats and brings people into closer contact with animals, bats and rodents that carry dangerous pathogens, while the impacts of a warming climate on deforestation attracts more disease-carrying mosquitos.
Air travel has also made us increasingly nomadic, creating opportunities for the rapid transcontinental spread of around 400 new infectious diseases that have been identified in the past 75 years. Since 1971, scientists have discovered at least 25 new pathogens for which we currently have no vaccine and no treatment.
Ironically, unlike many risks that could result in our extinction, we have experience dealing with epidemics. Each year the direct costs of research, disease control, immunization and emergency response, along with the many indirect costs associated with the disruption to travel, transport of goods, tourism, financial markets and other areas of economic activity, cost governments around $100 billion. Yet for all that experience we have no way to know which microbe will produce the next major outbreak, what form that epidemic might take, where it will come from, and how it will be transmitted. We are flying blind.
It need not be so. The risk of a global pandemic is amplified by our evident unwillingness and inability to focus on upstream prevention. This disposition is compounded by a deep-seated complacency on the part of politicians and public health officials – a complacency aggravated by a pharmaceutical industry attuned to profits rather than the elimination of disease.
There are five strategies which, if followed scrupulously, would prepare us for the plague far better than any approach we have in place today. These are strategies that we can and should be adopting right now:
- Focusing on Prevention
It was proven decades ago, by people like W Edwards Deming – a pioneer in the field of Total Quality Management whose principles were incorporated into the Japanese theory of kaizen – that improving upstream processes could prevent considerable downstream costs and inefficiencies, which are caused by flaws in a process that is otherwise operating in accordance with its design specifications. If intentions do not match actual outputs, the only way of achieving the desired results is to change the inputs or redesign the process.
Logic suggests that if prevention is the most cost-effective process intervention point, the same preventive principles can be applied to the systemic management of disease – the goal being to contain any outbreak before it becomes a global pandemic. The most short-sighted, costly, and inefficient strategy, would be to wait for the next epidemic to occur before taking action. Believe it or not that is the current practice.
As in the optimization of emergency services, where multiple organisations and skills are required to work together harmoniously, applying a systemic approach to prevention is the best way of minimizing the potential impacts of any future pandemic. Improvements to the design of upstream processes (possibly reinventing them totally) will optimize the system of global disease management, enabling rapid and informed action aimed at containing the spread of epidemics.
- Shifting Investments
Most investments start to flow once an epidemic has taken hold. This is far too late given that a pandemic could easily cost the global economy several trillion dollars by the time we have it under control.
Most epidemics could be stopped in their tracks if we applied the right preventive and response measures at the right time. Obviously, things such as hygienic self-care habits, for example, rigorous sanitation and disinfection practices, early detection of disease through surveillance, strict immunization regimes, and rapid response tactics to treat the sick, prevent the spread, and maintain routine health services, all play their part.
By shifting the bulk of our investments from response to prevention – including adequate support for multinational teams working on the development of new vaccines that can be produced and distributed rapidly, and those working out how to diagnose illness quickly and treat it immediately – we can substantially reduce the likelihood of epidemics and lessen their impacts.
- Knowledge Sharing
Optimizing the management of epidemics by directing resources to prevention requires a range of different organisations and individuals, some purely politically-motivated, to put aside their differences and minor jealousies, so as to find ways of sharing information and working seamlessly together. All the basics of process improvement are needed: effective teamwork, accurate analysis of current dynamics, a willingness to prototype novel ideas, and establishing information feedback loops so as to expand our understanding of what works and why.
But the most important factors are (i) citizen engagement, and (ii) the sharing of profound knowledge vis-a-vis social global networks. In this day and age, the role citizens can play, including those already suffering from disease, is given additional cachet through digital technologies. Citizen networks have the capacity to track performance and monitor local events, in ways that add enormously to our strategic intelligence, allowing scientists along with field operatives to act quickly and with greater precision than might otherwise be the case.
Given the huge range of organisations usually involved – from researchers in laboratories, to parliamentarians, corporate bosses and international agencies, knowledge sharing only becomes possible when trust is both implicit and pervasive, boundaries are permeable, and individual disciplines are transcended. Compartments or conventions where people are allowed to work in isolation from each other, or pull rank, simply obstruct the kinds of collaboration needed.
- Truth Telling
Dishonesty and propaganda have become art forms in political life. They are practiced constantly and unremittingly. As a consequence, our distrust of authority, in almost any form, has become a common theme in contemporary life. Rumours, conspiracy theories, political interests, and a tendency to apportion blame, can all combine to create panic in the minds of the community. Unfortunately, once panic has transpired it is almost impossible to stop.
This makes life extremely problematic for those in the front line of disease management, where establishing and maintaining trust through honest and open communication is paramount.
In times of extreme anxiety and unrest communications must be crystal clear – particularly at the local level where fears can be so easily detonated. Contradictions and ambiguities must be avoided, while instructions must be simple to understand and to enact.
In the context of disease, the undisguised truth, rather than opinions or speculation, is a powerful channel for managing the situation, rather than letting it run out of control. It is remarkable how communities are able to deal with the most terrifying facts, but are so easily rattled by half-truths, suspicions, and incomplete information.
- Building Resilience
If truth telling is an essential ingredient in managing epidemics, so is building resilience. Technically speaking, resilience refers to the proficiency of a system to retain its capacity to function optimally when under stress. Resilient health care systems form the basis upon which prevention, preparedness, security and rapid response can be forged.
But this requires public health systems to work in tandem with the private sector, funding organisations, communities, activists, victims and international agencies. All to often, the building of resilience is weighed down by needlessly bureaucratic complications and constraints. For example, we are often see politicians putting parochial interests before the public good. That is simply an example of negligent and cowardly leadership and hampers effective coordination.
The source of resilience in this context is twofold: rapid, coordinated, action based upon scientific evidence and profound knowledge, rather than on political or financial interests; and a level of inbuilt redundancy to ensure vital systems do not collapse because of one or more process failures.
So where does all of this leave us? It is quite simple. If we can become attuned to dealing with unpalatable realities, overcome our natural fears by coming to terms with the fact that sooner or later we will need to respond to the next major plague, and find new ways of cooperating as a society to secure global public health, the five strategies outlined above could save millions of lives and even curtail the likelihood of a global pandemic.
As Dr Jonathan Quick, Chair of the Global Health Council, pointed out in a recent article: We know how to stop the next epidemic. This is no excuse for unpreparedness. If we are to save ourselves and our children, we must act decisively. The threat is real. The pathway is known. The time for action is now.