Covid-19 is no ‘black swan’ and this crisis shows pandemic prevention must be part of government policy the world over

Global health agencies have spent 25 years helping countries prepare for pandemics but recent operational lapses, including for Covid-19, are a reminder that nations must prioritise funds for emergency response plans

Duane J. Gubler

Published: 1:00am, 6 May 2020

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Pandemics are conventionally thought of as “black swan” events – totally unexpected and unpredictable. The Covid-19 pandemic challenges this notion.

This pandemic was neither unexpected nor unpredictable; many infectious disease experts, myself included, have repeatedly warned of epidemics of novel and known pathogens that have the potential to threaten both global public health and economic security. A black swan Covid-19 is not – more a grey swan, perhaps.

Over the past 25 years, the world has experienced four pandemics (1970-2020 dengue, 2004-2014 chikungunya, 2007-2016 Zika virus and 2009 H1N1 influenza) and six regional epidemics with pandemic potential (1994 pneumonic plague, 1997-2005 bird flu, 1998-1999 Nipah encephalitis, 1999-2004 West Nile encephalitis, 2002-2003 severe acute respiratory syndrome or Sars, and 2014 Ebola).

All were zoonoses that had jumped from their natural animal hosts to humans; four from bats, three from other mammals and three from birds.

It is uncertain when the Covid-19 epidemic began, but by the time it was reported in Wuhan, China, in late December, and in January, the virus had already spread widely in that country as well as to several neighbouring countries.

Although there were many unknowns about the Sars-CoV-2 virus at the time, its identification as a coronavirus closely related to Sars-CoV-1 and our experience with other epidemics meant that we knew, if there was human-to-human transmission, the high potential for pandemic spread via modern transport.

However, it was not until March 12 that the World Health Organisation declared Covid-19 a pandemic. Unfortunately, the disease already had near-global distribution then. This delay, in attempting to allay fear and panic, was likely to have caused many countries to delay their preparation and response to the potential Covid-19 threat, facilitating further rapid spread of the virus.

A few places, such as Singapore, Taiwan and Hong Kong, took early steps of containment and mitigation, having institutionalised lessons learned from the 2003 Sars epidemic.

For example, in 2007, Singapore funded the development of Duke-NUS Medical School’s new programme in emerging infectious diseases, of which I am the founding director, and which played an instrumental role in Singapore’s effective early control of the Covid-19 epidemic.

Singapore, with its much-lauded science-led approach, provided a model for the first innovative use of antibody testing, by my colleagues at Duke-NUS, to support contact tracing and containment measures, preventing fatalities for the longest time compared to peer countries and, even now, keeping the fatality rate among the lowest in the world.

By all accounts, the country has done just about everything right. But many are now asking, what went wrong?

Singapore has seen a resurgence in Covid-19 cases, driven initially by returning residents who had travelled to countries where the pandemic had stealthily become established and community infections were occurring unknown to health authorities.

Although some question whether the measures undertaken by the Singapore government were as effective as once thought, the hard truth revealed by this and all previous pandemics is that no country is safe unless all countries are safe, a truism now echoed by many commentators.

International health agencies have spent 25 years preparing for such occurrences, with global efforts led by the US Centres for Disease Control and Prevention and the WHO to help countries develop pandemic response plans and update their laboratories.

Plans were put to the test during the 2009 H1N1 influenza pandemic, which was highly transmissible and spread rapidly around the world. However, that virus had a low fatality rate and, as a result, public health efforts were perceived to be an overreaction.

Moreover, drug companies that invested in vaccine development lost financially because the pandemic had ended by the time vaccine candidates were ready for clinical trials.

Two operational failures in the implementation of the response plans have occurred since 2009. During the 2014 Ebola epidemic in West Africa, the virus was introduced to the US without detection for several days and, this year, with Sars-CoV-2 spreading rapidly in China and Asia, proactive surveillance of the virus was delayed for weeks, enabling it to spread globally.

The reasons for such failures are complex. Nonetheless, several lessons can be learned. First, epidemic infectious diseases do not occur regularly, and when the period between them is prolonged, an “out of sight, out of mind” mentality kicks in, resulting in deprioritisation of funding for surveillance and emergency response plans.

Second, administrative changes and long inter-epidemic intervals result in the loss of first-hand knowledge and experience from personnel who have weathered at least one major epidemic. Third, while emergency response plans are developed by public health officials, implementation of the plan is a political decision.

Most policymakers do not like to initiate emergency response plans until it is certain that there is a true public health emergency, to avoid criticism for overreacting and potentially wasting public funds. By that time, however, it is usually too late to effectively contain the disease.

To conclude, if we are to successfully reverse the trend of epidemic infectious diseases and prevent pandemics, we must develop the following capabilities:

First, effective communication is needed to prevent complacency and keep awareness of emerging infectious diseases top-of-mind during extended inter-epidemic periods – community engagement is critical and outreach programmes must be transparent, factual and science-based. Panic and fear among the public should not be allowed to drive policy decisions.

Second, we need effective laboratory-based infectious disease surveillance, prevention and control programmes that are intersectoral and involve urban planners, demographers, economists, environmentalists, sociologists and community-based groups, in addition to animal health, public health and infectious disease experts.

Third, epidemic response plans – which include guidelines to trigger an automatic response by local, national and global public health communities, with regular drills by key agencies to maintain operational readiness – are vital.

Fourth, there must be full responsibility at country level for developing and supporting public health infrastructure and operational programmes without an overreliance on international sourcing and funding.

Fifth, we need high-level funding for research to develop new and innovative tools for surveillance, prevention and control of infectious diseases, including vaccines, drugs, diagnostic tests and vector control.

Implementing these measures will not be easy, but global public health and economic security depends on reversing this trend of emerging epidemics of infectious diseases.

Dr Duane J. Gubler is an emeritus professor and founding director of the Emerging Infectious Diseases Signature Research Programme at Duke-NUS Medical School, Singapore, and chair of the Global Dengue and Aedes-Transmitted Diseases Consortium

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