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How to stop a pandemic

Our leaders must learn from the Covid-19 crisis to prepare for the next virus.

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The past, as canny investors like to say, is no guide to the future. That adage escaped the attention of Macfarlane Burnet, a virologist who decided in 1972 that germs were over.

“The most likely forecast for the future of infectious diseases is that it will be very dull,” he pronounced, somewhat surprisingly, in a medical textbook on exactly that topic. Such dismissiveness from a Nobel Prize winner about his own field might then have been justified: smallpox was on the way to eradication and Richard Nixon had declared war on cancer, making the emperor of all maladies the specialism of choice for ambitious medics and scientists.

But such sentiments, plus the rise of non-communicable illnesses like heart disease, set the scene for a complacency over infectious diseases that has cost us dearly in the coronavirus pandemic, according to Debora Mackenzie in Covid-19: The Pandemic That Never Should Have Happened, and How to Stop the Next One. Our disease surveillance is patchy; our ability to act on that scant intelligence feeble. The world has been caught out badly by a new respiratory disease, our complex societies reduced to near-collapse. There are now more than ten million confirmed cases of Covid-19 worldwide, and over half a million dead.

Thanks to harsh lockdowns (some of which, as in the UK, might have come too late), the world economy is heading for the worst downturn since the Great Depression. As well as the immediate toll on the health and livelihoods of those affected, it may take decades to document fully the long-term hardship that Covid-19 has wrought – in lost education, the neglect of non-Covid health conditions, and social isolation.

Mackenzie’s is one of two important books already attempting a Covid-19 post-mortem and plan for the future. The veteran science writer offers a wealth of scientific detail and perspective drawn from decades of covering infectious diseases. She outlines how the infrastructure of global health should be redrawn and strengthened to detect and shut down future outbreaks more quickly. She also calls for public activism, of the kind that mobilised action on HIV-Aids in the 1980s, to demand our leaders do better.

The second book, The Covid-19 Catastrophe, by Richard Horton, is a surface skim of the same deep pond. Horton, editor-in-chief of the Lancet medical journal, is a tireless critic of the UK’s pandemic response. He echoes some of Mackenzie’s conclusions on the need to remake the global health order and adds some trenchant observations on the politics of pandemics.

Despite Covid-19 still being an unknown scientific quantity, Mackenzie wanted to write her impressively paced and comprehensive book “because we already know enough to say some important things, and we need to do that while the memories of these hard times are raw enough for people to hear them”. She is justified in arguing that a pandemic was predictable and, to some extent, preventable. In 2014, both the World Bank and the OECD rated a pandemic above terrorism as the top catastrophic risk.

Preparedness exercises are meant to keep us alert, but that only works if the lessons are acted upon. A mere month before the virus emerged in Wuhan, academics at the Johns Hopkins Bloomberg School of Public Health in the US ran a computer simulation of what would happen if a mild coronavirus began to spread. What emerged from that fictional scenario, called Event 201, was, Mackenzie reveals, distressingly similar to “what we are living out now: overwhelmed health care, disrupted global supply chains, needless death, economic dislocation. And a table full of officials from industry and government sitting there saying, ‘If this were to happen, there’s not much my sector/department/office could do.’” A similar exercise, called Cygnus, assuming a flu pandemic, was carried out in the UK in 2016; it raised worrying questions about readiness and capability. So two recent, vivid demonstrations of our impotence in the event of a viral pandemic gave fair warning.

That countries were caught unawares is even more of a failure in light of a previous deadly brush with a coronavirus. Sars (severe acute respiratory syndrome) killed around 10 per cent of the 8,000 people it affected in 2002-03 but was contained by an enormous public health effort. Notably, the WHO, then headed by the doctor and former Norwegian premier Gro Harlem Brundtland, did not shy away from upsetting China and advised against travel to some Chinese cities. Brundtland is now credited with stopping the Sars epidemic in its tracks. Interestingly, the countries that had Sars, such as China and Vietnam, have generally fared better against Covid-19; perhaps they knew the cost of complacency.

The 21st century has served up several infectious disease shocks: Ebola in West Africa in 2014; Zika in the Americas in 2015; and the swine flu pandemic in 2009. That last one, which is thought to have been no more deadly than seasonal flu, was regarded as a damp squib; countries were left with stockpiles of unused vaccines.

That brings us to an unfortunate paradox of tackling disease: if public health officials neuter a health risk, then citizens never see disaster unfold. If citizens never see disaster unfold, they become sceptical that the problem exists (this characterises some anti-vaccination rhetoric). Donald Trump, who often seems hostile to science, defunded and scaled back much of the White House pandemic-response machinery signed off by his predecessor, which might explain why the United States has been hit especially hard. Trump, casting around for a coronavirus scapegoat, has also withdrawn the US from the World Health Organisation (WHO), surely one of the least comprehensible actions of a national leader during a pandemic.

Could China have done more to stop the spread, as Trump alleges? The secretive superpower, Mackenzie concludes, certainly concealed for too long the fact that the Covid-19 virus could be passed from person to person. There is also evidence that internet chatter, an early indicator of novel diseases, was censored in the country. As the dissemination of vital information was impeded, the virus continued spreading unchecked. Modelling suggests shutting down Wuhan a week earlier than 23 January, coupled with travel bans before the biggest annual holiday exodus at Chinese New Year, could have cut China’s epidemic by 67 per cent, with knock-on benefits for the rest of the world.

Could the WHO, then, have intervened earlier? Its director-general is tasked with being a diplomat rather than a detective: the organisation does not have a mandate to march into countries to investigate suspected outbreaks. The agency must be invited. By any measure, Beijing did so too late. This is just one of many weak points in a global disease surveillance structure that sometimes seems set up to fail, despite the incalculable costs that failure can incur. It is nobody’s job to join the viral dots and act.

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Mackenzie’s prescription for improvement is clear: create an authoritative system for bringing countries and international agencies together in a spirit of openness; beef up surveillance and develop drugs and vaccines for diseases on WHO’s watchlist; stockpile personal protective equipment (PPE) and ensure there is surge capacity in manufacturing; listen to scientists who raise warnings, as many have done on pandemics since the 1990s (one hopes politicians will now heed the irrefutable consensus on climate change); and steer clear of bats and bat products.

That last one is critical: she explains, with clarity and eloquence, the frightening catalogue of bat-borne viruses that have the potential to jump the species barrier from animals to humans. The answer is not to exterminate the bats – they play a vital role in ecosystems, including crop production. But users of traditional Chinese medicine could give up applying bat faeces as eye medicine (yes, really); we could stop destroying bat habitats during farming and development.

Mackenzie suggests that disease-causing pathogens should be monitored as strictly as chemical weapons and nuclear material, under a binding “Pathogens Treaty” that would authorise surprise inspections and establish norms around compliance. I am sympathetic to her plea that we contemplate these tricky matters now, in the heat of battle, before we “drift back into a status quo of spending on wars and weapons”. Humanity has a history of forgetting.

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Horton’s speedy analysis stresses the same need for radical change as Mackenzie, in a shorter, angrier, more politicised UK-focused format. “Their staccato decision-making suggested a mounting atmosphere of confusion and fear,” he writes of the British government’s painful dithering in February and March in the face of the coming storm.

The catalogue of political missteps is well-rehearsed: a failure to grasp that what happened in China and Italy would happen in the UK; a failure to consult widely, especially with those experienced in the logistics of responding to health emergencies; a failure to secure supplies of PPE; an almost negligent attitude to the viral horror unfolding in care homes; abandoning community testing against WHO advice and taking too long to scale it back up again.

This exercise in British exceptionalism, executed in hubris or incompetence, is likely to leave us near the top of the global league table for Covid-19 deaths and economic damage. Horton’s polemic is steeped in vitriol: “Every [Covid-19] death was evidence of systematic government misconduct – reckless acts of omission that constituted breaches in the duties of public office.” He accuses scientific advisers of being in cahoots with their political masters in presiding over the biggest science policy failure in a generation. He sees hope in the renegade advisory group convened by David King, a former chief scientific adviser. “Independent Sage”, as it calls itself, holds public online meetings, in pointed contrast to the secrecy that shrouds the official committee.

Horton rounds on Britain’s medical establishment – royal colleges, medical associations, public health bodies, think tanks – for its silence, which he describes as a “grubby betrayal” of the sick, the vulnerable and front-line workers.

It should be noted that Horton has made his own mistakes in this pandemic: in June the Lancet was forced to retract a highly influential paper on hydroxychloroquine as a possible Covid treatment, bringing its peer review process into serious question. His full-frontal attack on how most Western democracies failed their citizens can also be interpreted as a tacit exoneration of China and the WHO. Horton, whose journal published early research from China on the virus, has vigorously defended both, leading to accusations that he is a propagandist for the authoritarian state. Horton writes: “There are questions for both the Chinese government and WHO to answer. But to blame China and WHO for this global pandemic is to rewrite the history of Covid-19 and marginalise the failings of Western nations.”

The WHO may be an imperfect institution, he admits, but success stories such as New Zealand and South Korea prove that competent national leadership has a clear role in pandemic management.

Usefully, he zooms out to consider the pandemic within a broader political and social context, suggesting that a “lack of political vigilance was compounded by a decade of austerity economics that followed the global financial crisis of 2008-09”. There should now be questions, he urges, about how we fund our health system so that it is better prepared for the next outbreak. There is no doubt the pandemic has deepened existing inequalities, with people from black and ethnic minority communities dying in proportionally greater numbers. The poor have been hit harder than the rich.

Covid-19 should, he says, prove a watershed, prompting us to change society, rethink government, reconsider citizen expectations, integrate human and animal medicine, and develop ways of speeding up scientific processes for developing drugs and vaccines. Healthy pessimism, rather than misplaced “boosterism”, will ultimately serve us better.

Perhaps Horton’s most profound political point, though, is that Covid-19 victims should be remembered as individuals with valued lives, rather than numbers to be ­dispensed at a lectern. The UK has amassed around 65,000 excess deaths, a tally that is all the more numbing because it was optional. “Our [numerical] way of describing the impact of the pandemic erased the biographies of the dead,” Horton thunders at the beginning of the book. “The science and politics of Covid-19 became exercises in radical dehumanisation.”

By the end, the righteous anger has softened into sorrow: “The virus took so many lives. We can’t allow ourselves to return to our old worlds as if that fact can somehow be elided. To honour the lives lost, we have to live differently.” 

Anjana Ahuja is a science writer

Read more from this week's special issue: “Anatomy of a Crisis: How the government failed us over coronavirus”

Anjana Ahuja is a science writer

This article appears in the 03 July 2020 issue of the New Statesman, Anatomy of a crisis