A summary of the recent history of infectious diseases – Learning from the past and looking to the future

Since the beginning of the 20th century, deaths from infectious diseases have declined substantially in high-income countries. In the United States, the infectious-disease mortality rate fell from about 800 per 100,000 people in 1900 (accounting for approximately 50% of all deaths) to 50 per 100,000 in 1950 (about 6% of deaths).

Over the past 30 years, a similar transformation has occurred in low- and middle-income countries (LMICs) in Asia and sub-Saharan Africa. Childhood vaccination coverage has risen to 80% worldwide, while deaths among children younger than 5 have fallen by more than 50% in countries with effective vaccination. Global maternal deaths have also fallen by around 50% during this period, malaria deaths have decreased by 60%, and the rate of HIV infection has dropped by more than 40%. Poliovirus (the cause of polio) is now on the verge of eradication.

The key to better health: investment in public health

Many factors explain this remarkable progress, including increased investment in health systems and public health infrastructure. These include;

• preventing infection through cleanliness / hygiene (for example, water chlorination),
• advances in diagnosing and treating infectious diseases, and
• the development and distribution of safe, effective vaccines.

Much of the effort to expand global access to lifesaving interventions has come from multilateral organizations and partnerships such as the World Health Organization (WHO). These include UNICEF, Gavi, the Vaccine Alliance, the Global Polio Eradication Initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as US AIDS and malaria initiatives.

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These efforts remain as vital as ever, because health inequalities exist everywhere and all countries face new threats, including antimicrobial resistance. COVID-19has clearly shown that emerging infectious diseases also pose major challenges to global health security, and the same conditions that fostered broad-based gains in health and well-being have made people increasingly vulnerable to outbreaks.

The past 60 years of pandemics

In recent years, previously isolated zoonotic pathogens have regularly caused outbreaks and spread among humans, and some have spread rapidly between people and across borders.

Zoonosis is a term describing any infectious disease transmitted from vertebrate animals to humans and from humans to vertebrate animals. Many serious and important diseases fall into this category. Examples include rabies (caused by the rabies virus), bird flu (influenza virus), swine flu (influenza virus), mad cow disease (caused by a prion) and, of course, COVID-19 (SARS-CoV-2). Zoonoses are caused by zoonotic pathogens.

Experts had pointed out the risk

Between 1980 and 2017, more than two dozen such outbreaks were reported worldwide. Years before COVID-19 emerged, many observers noted a rising risk of an outbreak caused by a rapidly spreading virus, occurring once or twice a century. The US National Academy of Medicine (formerly known as the Institute of Medicine) has long worked to raise awareness of emerging infectious diseases, including through the Forum on Microbial Threats, launched in 1996, and the Commission on a Global Health Risk Framework. The Commission on a Global Health Risk Framework for the Future convened in response to the 2014-2016 Ebola virus outbreak in West Africa. Yet, given other urgent needs, it proved difficult to sustain public attention, political will and funding for pandemic preparedness, even after the Ebola outbreak showed how unprepared the world was for an international health emergency.

These predictions were not unique to US experts. Public health experts in many countries around the world had warned of the risk of a pandemic on this scale. This can be compared with scientists who predict earthquakes: major earthquakes occur at certain intervals along particular fault lines, and scientists who analyze both historical and geographical features well make accurate earthquake predictions. A similar situation applies to infectious diseases caused by viruses.

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An important response to the Ebola crisis was the establishment of the Coalition for Epidemic Preparedness Innovations (CEPI) in 2016. CEPI was designed as a public–private partnership to accelerate the discovery and development of "just in case" vaccines against known pathogens, such as Ebola, Nipah virus, Middle East Respiratory Syndrome (MERS) and SARS. Innovative vaccine-development platforms supported by CEPI, including messenger RNA (mRNA) and DNA constructs, were used to develop vaccines rapidly against COVID-19 and could be mobilized to produce just-in-time vaccines against newly discovered pathogens in the future. CEPI’s greatest challenge involved the need to rely on a fundraising-based financing strategy rather than securing adequate funding before an emergency. Although many high-income countries provided financial support for vaccine research and development, major donors such as the United States remained outside the coalition until recently.

A second important step was the launch of the Global Preparedness Monitoring Board (GPMB) by WHO and the World Bank Group in 2018, in response to recommendations from the United Nations Secretary-General’s Global Health Crises Task Force. Comprising political leaders, heads of multilateral institutions and scientific experts, GPMB was established to assess the steps needed to prepare the world to respond rapidly and decisively to global health emergencies. The board published its initial recommendations in its 2019 report A World at Risk, then updated them in its 2020 report A World in Disorder. Despite the positive steps taken by CEPI and GPMB, the COVID-19 outbreak arrived before global leaders had fully implemented these recommendations.

In their 2020 report, the co-chairs of the Global Preparedness Monitoring Board (GPMB) wrote, "The COVID-19 pandemic has exposed a collective failure to take pandemic prevention, preparedness and response seriously". Reflecting on lessons from COVID-19, the board noted that traditional standards for national pandemic preparedness had failed to predict how countries would behave during a major outbreak. COVID-19 rates rose when national leaders ignored public health guidance and residents were unwilling to adapt their behavior to reduce the risk of transmission.

Another important lesson outlined in the 2020 report is that planning for future pandemics must include stakeholders outside the health sector. The severe effects of COVID-19 on national economies and household incomes show how willing countries must be to mobilize emergency funds to cushion financial shocks and provide social protection for those at greatest risk of serious health problems or impoverishment for social reasons. As GPMB describes it, pandemic preparedness must cease to be a responsibility funded and managed by health ministries, and must cease to be a responsibility prioritized by finance ministers and involving all affected sectors as part of a government-wide approach. Under such a strategy, preparedness budgets would increase at least 10-fold, and non-health sectors would have a clear stake in national preparedness.

We were partly unprepared, but responded quickly

The speed of the pharmaceutical industry’s response to the COVID-19 pandemic highlights its capacity to develop and scale up the production of the vaccines, diagnostics and therapeutics needed to end the acute phase of the pandemic. The most important market failure in this case is the lack of access to vaccines in low- and middle-income countries (LMICs). The gap between the existence of global public goods and industry incentives to deliver those goods must be bridged. Doing so will require innovative public–private partnerships.

Panic and neglect

As world leaders develop strategies to end the COVID-19 pandemic, we believe they must abandon the cyclical phases of “panic and neglect” that characterize responses to health emergencies. Instead, leaders must commit to a new framework of prevention, detection and response. Such an approach would focus more resources on detecting emerging zoonotic threats and finding and containing them while they remain localized and manageable.

Implementing such an initiative would require strengthening national, regional and global institutions and scaling up public health workforce development, including increasing the number of community health workers. Such efforts would strengthen surveillance systems, enable countries to report threats early and help countries respond quickly, which they were unable to do for COVID-19.

As part of these efforts, we need robust research and development capacity that can be activated rapidly on a global scale. Private-sector manufacturers need adequate financial guarantees from governments to reduce the risks associated with investing in pandemic preparedness and response, and preclinical and clinical research capacity must be developed at both national and regional levels in LMICs. We also need widely distributed sites for products that meet global needs and regulatory systems prepared to provide emergency approval and rational distribution of new products, prioritizing distribution to regions where products could be most effective in stopping a pandemic’s progress.

Scientific collaboration in the digital age

Finally, in an age of almost unlimited digital potential, we can use information-age tools to detect new pathogens, accelerate product development and share the data needed to expand pandemic response efforts. Countries must work together to remove barriers to data sharing while taking steps to protect privacy and prevent misuse.

The 1-year cost of COVID-19: 11 trillion dollars

The annual cost of making these investments would be billions of dollars. GPMB reported that adequate investment in preparedness would require an average of 5 $ per person worldwide each year. By contrast, economists estimate that the world has already spent more than 11 trillion dollars fighting COVID-19 and that the pandemic will gain another 10 trillion dollars from future lost earnings. The National Academy of Medicine will continue to play an important role in these discussions. Recently, for example, the National Academies of Sciences, Engineering, and Medicine published a consensus study report on a framework for equitable allocation of the COVID-19 vaccine (Framework for Equitable Allocation of Covid-19 Vaccine).

We believe the time has come for world leaders to heed the warning signs, abandon half-measures and commit to the global system we need to respond to the ever-present danger of emerging infectious diseases. We cannot afford the alternative.

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