Drawing Lessons from AIDS to Prevent Future Epidemics

The opening chapter of “The End of Epidemics: The Looming Threat to Humanity and How to Stop It,” describes three of this century’s most devastating bouts with infectious pathogens—the 1918 influenza pandemic, the AIDS epidemic, and the Ebola outbreak in West Africa in 2014. In chilling details, Jonathan Quick, senior fellow and former president and Chief Executive Officer at Management Sciences for Health and instructor of Medicine at Harvard Medical School, and his co-author Bronwyn Fryer describe how these epidemics gained footing and spread rapidly, together killing hundreds of thousands of people.

For influenza, it was a mutation to the seasonal strain that allowed this virulent virus to erupt in far-flung regions of the planet just as the end of the first world war approached. In the end it killed between 50 and 100 million people worldwide, making it the deadliest flu pandemic in history. The ongoing HIV epidemic was the result of a chimpanzee strain of a related virus that jumped species, crossing into the human population at least five times. The last time it occurred in Cameroon, the virus mutated, allowing it to spread rapidly among humans there, and then across the globe. Since then, 76 million people became infected with HIV and 35 million of them died. The most recent Ebola epidemic began with a two-year old boy playing in a tree inhabited by Ebola-carrying bats in a small village in Guinea. Not long after this young boy died, the Ebola virus exploded in three West African countries, infecting nearly 30,000 people and killing more than 11,000 of them before it was snuffed out.

These three examples illustrate the deadly consequences that arise when a virus jumps from animals to humans, or mutates in such a way that humans have no prior immunity to it. It is scary stuff, and Quick and Fryer don’t hold back from conveying an impending sense of doom. “Somewhere out there a dangerous virus is boiling up in the bloodstream of a bird, bat, monkey, or pig, preparing to jump into a human being. It’s hard to comprehend the scope of such a threat, for it has the potential to wipe out millions of us…over a matter of weeks or months.” This threat, they write, overshadows that posed by terrorism, future wars, or even the devastating effects of climate change. It may sound like the stuff of movies but it isn’t. Infectious disease specialists that model disease outbreaks paint a grim reality. In the highly interconnected world in which we live, a new epidemic could spread and kill incredibly quickly—Quick reports that some models suggest a death rate of over 300 million people for some potential pandemics.

Given this stark reality, it is rather surprising that “The End of Epidemics” actually strikes an optimistic tone. “I refuse to accept that the inevitable local disease outbreaks will continue to explode into epidemics that kill thousands or millions,” Quick writes. Rather than dwelling on dire statistics, he instead proposes a call to action for the planet, referred to as The Power of Seven. It involves implementing decisive leadership, creating resilient national public health systems, focusing on prevention, communicating effectively, pursuing innovative science, securing the necessary financial investment, and maintaining committed advocacy from all citizens. While this may sound like a lot to take on, Quick thinks the world is up to the task of achieving this seemingly impossible goal. “If we can eradicate smallpox, mount the largest public-health treatment effort in history as we did for AIDS, stop SARS [severe acute respiratory syndrome] in its tracks, and stop hundreds of outbreaks every year, then surely we can use The Power of Seven to end devastating epidemics.”

For those who work on HIV, there are many familiar stories in “The End of Epidemics.” Quick and Fryer chronicle the earliest days of the epidemic and how fear and stigma stymied an effective response to the virus. They also detail the role activism played both in the US and abroad in getting treatment to those infected. There is even a brief section on both the challenges and encouraging developments in HIV vaccine research. Quick is clear about the need for vaccines against intractable pathogens such as HIV, and others too. “As a doctor, I know that nothing can protect people against illness as effectively as a vaccine. It is the single most cost-effective public-health tool we have.”

IAVI Report spoke with Quick about his book and an edited version of our conversation is below.

It seems as though there is more attention being paid to epidemic and pandemic preparedness, precipitated at least in part by the most recent Ebola outbreak. Why hasn’t it been more of a focus in the past?

Well the reason it hasn’t been a focus in the past is that there is this cycle of panic and neglect, or panic and complacency. We’ve seen it repeatedly. With the first new pathogen in the 21st century, SARS, there was a lot of panic. SARS came out of China in 2003 and rapidly spread to 27 countries and there was a huge outpouring of interest. Hundreds of pages of reports were done and a lot of promises were made. But a few years later, nothing much had changed. Then we had Avian Flu in the mid-2000s and then the 2009 Swine Flu. Each time it’s been the same cycle of panic, lots of study, unmet promises of improved preparedness, and a slow drift back into complacency.

What I think has put pandemic preparedness back in the world’s attention is the Global Health Security Agenda, which was a US-catalyzed global initiative that actually was launched in February of 2014, just before the Ebola outbreak. This was a really well conceived effort to attack the core reality that only one of out of three countries worldwide have the ability to prevent, rapidly detect, and quickly respond to outbreaks. Only one out of three countries! There is no mystery what should be done. The World Health Organization (WHO), through the International Health Regulations, has made it excruciatingly clear what is needed. Now the Global Health Security Agenda has 60 committed countries and a lot of supporters.

You then had Ebola, which really exploded at the end of 2014. There was a big horror factor associated with it that really got into the headlines. Ebola is actually not that contagious, and we saw how quickly it came under control once the people of West Africa understood what needed to happen. Then, a year later Ebola was followed by Zika, which is a virus that had been sleeping quietly in West Africa for 70 years. Then all of a sudden, a decade ago, Zika started moving eastward across the Pacific until in 2015 it exploded in Brazil. It was almost like one of these forest fires that gets going in the roots and then all of a sudden, poof—the whole forest is on fire.

So it was the Global Health Security Agenda that began raising the profile of epidemic and pandemic preparedness, and then Ebola, Zika, and now the ongoing Yellow Fever outbreak that were the main factors. It is also the hundredth anniversary of the Spanish Flu of 1918 that killed between 50 and 100 million people.

So what could be done differently to be keep the focus on potential epidemics?

Well if you consider the contrast between the response to SARS and Ebola, it is really striking. SARS was the first new pathogen of the 21st century and it was one plane flight away from getting into countries that couldn’t control it. But it was wrapped up within six months because of the initiative taken by the then Director General of WHO, Dr. Gro Brundtland. When I asked what made her decide to build WHO’s outbreak response capability and to be so decisive against SARS, she responded that people in positions of leadership have everybody coming to them with their issue. The reason she took action on infectious disease was that the responsible WHO team made a very strong case for stopping SARS.

We need to recognize that businesses and international organizations are very much victims of the “economics and the politics of now.” And so, what we need to do at multiple levels is keep the bell ringing and really work on getting a broader base of support for these efforts. Not just in international organizations, but also within the business community. Businesses have the most to gain from getting this right, and the most to lose if we continue to leave ourselves vulnerable.

You write in the book about how furious you are that the international community isn’t investing sufficiently in preventing potentially devastating epidemics/pandemics, but rather choosing to spend an extraordinary amount of financial resources trying to control epidemics when they happen. As you say, “in both economics and epidemics, prevention always far surpasses even the best efforts at cure.” Is this changing now?

Well, I will say that following Ebola and with the Global Health Security Agenda, there have been some dramatic investments in building epidemic preparedness. The WHO partnership platform mapped out at least 20 governments, international agencies, and foundations that have made commitments and contributions. So there has been a good outpouring of support to accelerate preparedness efforts. There is also the Pandemic Emergency Financing facility that the World Bank established, and the commitment to CEPI [the Coalition for Epidemic Preparedness Innovations], which are really important investments and commitments. There’s also been some notable contributions on the side of the private sector, especially by Unilever, Johnson & Johnson, and the members of the Private Sector Roundtable. I think it’s a matter of sustaining those investments.

Many experts predict that the next pandemic will likely be caused by influenza. If another flu pandemic is inevitable, why do you think there hasn’t been more public and private support of better flu vaccines?

First you have to consider the history of the flu vaccine. The first flu vaccine was developed in 1938 and was used in World War II to protect US military forces. Among the researchers who developed it was Jonas Salk, who later used his flu vaccine experience to develop the polio vaccine in 1952. The flu vaccine is 80 years old this year, and yet it’s the least consistently effective vaccine that we have. You have to ask, why?

Influenza is a complex enemy but I think there was also complacency on the part of the scientific community and on the part of the broader public health community because flu was seen as just a seasonal irritant. We didn’t really focus on the fact that it kills as many as 56,000 people a year in the US in the worst years.

I think another factor is that the seasonal flu vaccine is a steady market for the pharmaceutical industry and there is a huge opportunity cost of investing in a universal flu vaccine that will be tough to develop. So I think it’s a really egregious example of both government and market failure that we do not have a better flu vaccine.

The good news is that there are probably a dozen different efforts going on now to develop a universal flu vaccine, which is really exciting. It’s good that pharmaceutical companies and the US National Institutes of Health [NIH] are also supporting new methods of vaccine production, which will enable us to produce more vaccine, more quickly in the event of an overwhelming flu pandemic.

But I think we need to look back and ask why did it take us so long to wake up to the need for a more effective flu vaccine? Mike Osterholm from the University of Minnesota has been saying since 2011 that we need a billion dollars a year for flu vaccine research. There is finally a bill in Congress proposing that. So I hope it happens.

Another topic you cover in the book is the role climate change and deforestation have on the emergence of infectious pathogens. You pose the question in your book of whether we might be entering the century of pandemics. Why?

First, there is the fact that the current population of the planet is four times as big and twice as urban as it was 100 years ago, with 50 times as much international travel. So that’s one dynamic. One of the ways that epidemics start is when humans come in contact with pathogens, viruses in this case, for which you don’t have immunity. When people are going in to the forest and cutting it down, they disrupt the reservoirs for the virus, whether it is a monkey or a bat or whatever, and that’s when you get outbreaks. So part of it is that deforestation creates greater proximity between humans and the viruses.

The other thing is that if you map places where the Anopheles mosquito that carries malaria, and the Aedes aegypti and its cousin mosquitoes that carry Zika, Yellow Fever, and dengue, are, you see that they are starting to appear over a much larger geographic area. And that will only continue with climate change. The Aedes and related mosquitoes are already in at least 30 US states. It’s almost a certainty that there’s another virus out there like Zika that’s just been lurking out there, and if that new virus gets into those mosquitoes, it’s a real concern.

One of your seven recommendations to prevent future epidemics is to strengthen national health-care systems. I was struck that the number of ancillary deaths from the Ebola outbreak because of the breakdown in public health services was nearly as high as the death toll from Ebola infection—there were 10,600 reported deaths from AIDS, tuberculosis, and malaria, and more than 11,000 reported deaths from Ebola. What can be done to shore up health services to prevent this from happening again?

When you actually look at the dynamic of what happened in West Africa, one of the critical things was that West Africa wasn’t ready. They were living under two bits of received wisdom, both of which were wrong. One of them was that Ebola wasn’t in West Africa. Of course it was in the textbooks and all, but nobody really learned about it. The other was that just five months before the case in Guinea that started the outbreak, the Oxbridge Biotech group classified Ebola as a “dead-end” event. That is, they concluded that if an outbreak occurred it would burn out so quickly it couldn’t explode into a major epidemic. As a result, there were no practices in place to deal with this situation.

So when people with Ebola started flocking to facilities, and health workers were reassigned to handle Ebola, the health facilities became sort of no-go zones for people who needed primary care. As a result, you have stories of women delivering babies on the street. This is where better planning and a more integrated approach to early detection become really, really important. It’s not just in countries with weak health systems where services are disrupted. An analysis done by the Department of Homeland Security in relation to a pandemic here in the US suggested we would have services closed and millions of people would be affected.

The key thing is you need to plan ahead. There need to be annual drills, particularly in health services, so you can review the chain of command and all your responses that so you can move quickly. You can’t start doing the planning when you’re in the middle of an overwhelming epidemic. You may not have a major event for five or ten years or whatever, but that preparation is necessary.

What do you think is the best model going forward for epidemic preparedness? Is it partnerships between the public and private sectors? Or something like the recently launched CEPI?

The foundation for epidemic preparedness is strong national health systems that are capable of preventing, rapidly detecting, and quickly responding to infectious disease outbreaks. This is where the continued commitment of national governments worldwide to the Global Health Security Agenda is vital to make the world safer from major epidemics. I also think awareness on the part of the private sector can really be helpful. There are several private companies that have been champions of epidemic preparedness. Having strong individual champions is also important, such as Peter Sands, who comes out of banking, was very involved with the World Bank, then at Harvard, and is now head of The Global Fund to Fight AIDS, Tuberculosis and Malaria. He’s a great champion. Having people such as Sands, Bill Gates, and the economist Larry Summers talk about these issues is really critical. You also need multi-organization alliances among non-governmental organizations, governments, and the private sector.

In terms of CEPI, I think it is a superb creation. CEPI begins with the end in mind. They look at the whole chain of activities from start to finish—every piece that needs to be put in place to get from a great idea to an effective vaccine that is widely available where needed. That perspective is really important. They’ve done the difficult task of priority setting and they have a pragmatic outlook on who can contribute and add best value at each step in the process. I think their biggest challenge is on the resourcing side. The ideal situation would be to have a billion dollars a year, which is actually not that much given the gaps that we have in vaccines and technologies.

The first of the seven actions that you propose in your book is quick and decisive action by government and public health leaders. Given the proposed cuts to both the US Centers for Disease Control and Prevention and the NIH, do you think this type of decisive leadership on pandemic preparedness is realistic?

I think it’s a greater challenge, for sure. It always helps if you’ve got somebody who did what George W. Bush did for AIDS or Barack Obama did for global health security. It always helps if you’ve got a willing and enthusiastic champion. But when you don’t, you can’t just say, “Oh, well, we’ll write off this half decade or this decade.” You have to continue getting the message out there. Cutting the CDC’s budget is just madness because there’s no question in my mind that we’re going to pay heavily—both in financial terms and in human lives—if in fact these cuts are made.

That’s why 200 organizations and leaders came out with a strong letter saying this doesn’t make sense. I also think that, again, having private sector leaders clearly send this message is important. This is something that Peter Sands argues for. There are a lot of different stakeholder groups that need to keep the pressure on when the current leadership is not getting the picture.

Even though your book describes the devastating effects epidemics have, you also manage to strike an optimistic tone. Why are you hopeful?

The reality is there will continue to be local disease outbreaks. There are also going to be regional epidemics. But I believe we can stop devastating epidemics and global pandemics. The scientific and public health community know what needs to be done. With the right leadership and strategic investments, we can do it. The difference between a local disease outbreak and a major epidemic is human action or inaction.

With smallpox, it wasn’t until 1951—when Europe and North America had already proved that they could eradicate smallpox—that the conversation started at WHO on worldwide smallpox eradication. It took 15 years before the world’s health leaders agreed to mount an eradication effort. But once that decision was made, it took only a decade to successfully eradicate the virus. The tragic part is that in the 15 years during which doubting health officials and Cold War politics were preventing decisive action, 30 to 40 million people died.

I’m also hopeful because when I look back, I’ve seen the impossible happen multiple times. We use the example in the book of when President Kennedy said that we would send a man to the moon and return him safely by the end of the decade. When they got working on that, they didn’t have the technology to do it. Yet the leadership said we’re going to the moon, and they did.

Look at what the picture was in 2000 with AIDS treatment. I remember those conversations. At a cost of US$12,000 per person per year, the majority of the global health community would have said it was impossible to mount large-scale treatment programs. Yet today we have approximately 21 million people on treatment.

So I think there’s no question we can make the world safer. For most pathogens, if we detect them early enough and institute good public health measures, we’ve shown they can be contained. For other pathogens, we need a combination of getting the right vaccines and other medical measures in place. I think we have to give it our absolute best shot.