As concern grows about H7N9 in China, this post explores the importance of managing such pandemic risks through collaboration, innovation and systemic thinking
In the month of World Health Day (April 8th), the latest outbreak of bird flu in Asia provided a sobering sense of the challenges the international community still faces. To date, H7N9 has killed 21 people, infected 104, shut down poultry markets across Asia, and has led to Chinese shares tumbling.
The WHO originally announced that the likelihood of this latest pathogen is transmittable between people is low, and that the world should not ‘get into a flap’ – as one observer memorably put it. The potential of bird flu to be the source of the “Next Big One” means however that we cannot be complacent. In terms of global catastrophic risks, it is hard to think of one more serious than the 1918 avian influenza epidemic which killed 50-100 million people worldwide – 3-5% of the global population. This was so devastating in part because the virus had acquired mutations that allowed it to cross from birds to humans, and then to ‘go pandemic’. Based on analysis of the mutations in H7N9, scientists fear that this latest variant may have the same potential.
But there is still a lot we don’t know about H7N9. Where has it come from, why, and how? What is its relationship to earlier variants? How might it mutate? What impact might it have in the future? What does it mean for our ongoing, historically loaded, battle with avian flu?
To answer such questions, we need to draw on a variety of disciplines: epidemiology, molecular biology, virology, all of which fit nicely with the current models of public health. The problem is that many of these models set us, humans, apart from nature. Diseases, the standard narrative goes, encroach on our territory and we need to fend them off. The reality is in fact the exact opposite.
It is now widely acknowledged that many – the majority, in fact – diseases are born in the intersection between society, environment and economy. More than 2/3 of all human infectious diseases are zoonotic in origin, meaning that they somehow crossed species boundaries. The terminology likely to be adopted in future Hollywood blockbusters on the topic is simple but evocative: ‘spillover’. Primates, birds, bats, pigs, rats, mice, dogs, insects – any creature we co-exist with can act as sources or carriers of pathogenic lifeforms.
Spillover is driven by a pattern of activity which is becoming all too familiar. Deforestation: 4% increase can lead to 50% increase in malaria rates. Hunting has led to HIV-AIDS, Ebola, all crossing the species boundary. And, to bring it back to bird flu, livestock. Around 70% of the rural poor and 10% of the urban poor are dependent on livestock. Livestock conditions are increasingly creating tremendous opportunities for pathogens to cross from wild birds to caged birds, and onto humans. And the demand for animal-based protein is expected to grow 50% by 2020, much of it in the developing world. This problem is not going to go away any time soon.
Leapfrogging on the success of the human race, trade and transport linkages provide a morbid global transmission network. The rate at which new diseases are emerging and spreading is nothing short of shocking. Zoonotic diseases have increased in the past 40 years, with at least 43 identified outbreaks since 2004. ILRI estimates that 1.7 million people die each year thanks to spillover diseases. By way of comparison, the highly respected CRED crunch on disaster epidemiology found that the 2001-2010 average annual deaths from natural disasters was 107k per year.
Ecological and evolutionary principles are vital in understanding these complex system effects on a more solid scientific basis. Experts at the University of Florida made the point in pithy fashion a couple of weeks ago, “If we don’t understand the reservoir and the ecology of the virus, it’s hard to design interventions to protect humans.” But such understanding is – with a few exceptions – still under-utilised in public health.
Of course, every disease is different, every context is unique. But the process by which spillover happens is similar. We can point to ecologies under stress. Life forms under duress. As an excellent briefing by colleagues in the Consortium on Disease Dynamics (CDD) puts it, “The health of people and animals are… interconnected and inextricably linked to the environments both inhabit. Given the complex pathways that lead to spillovers, it is important that prevention and control measures are undertaken with a strategic approach and an understanding of the many interdependencies.”
What does this challenge add up to for the global risk management community? The work by the CDD gives some very useful pointers.
First, multi-disciplinary approaches are vital. The WEF Global Risks report has for some years now been calling for better disciplinary collaboration in order to think about emerging risks. With avian influenza there is a clear need for better collaboration between public health specialists, disease ecologists and evolutionary biologists. Some important work is already happening, under the auspices of entities such as the global One Health initiative, organisations like the EcoHealth Alliance, and initiatives like the USAID-funded Predict, and this work needs to move firmly to the centre of the debate.
Second, anticipation and warning systems – new investments in surveillance are urgently needed to establish and maintain necessary systems at multiple levels – community, national, regional and global. We need multi-stakeholder information platforms, bringing together government, civil society and the private sector in new kinds of networks, in order to establish ‘systemic surveillance approaches’. This needs to move beyond a focus on specific disease to looking at the whole system, looking at the intersection between disease drivers, disease incidence, and socio-economic factors.
Third, new approaches – especially in the realm of complex adaptive systems – have a lot of relevance for how we think about such outbreaks in the future. Methods such as systems thinking, network analysis, agent-based simulations, and dynamical systems theories can help develop a more precise and accurate understanding of the complex dynamics of disease. Together with the rise in ‘big data’ approaches, there is scope to develop new models and theories of how pandemics unfold which are more appropriate to our ‘hyperconnected world’. We need to be careful however to ground this science in local, community understanding – to support affected communities to become the frontline of defence: adaptive managers of emerging risks.
Fourth, we need changed funding models – funding prevention, not just response, and linking pandemic risks to high-risk development activities, and ensuring that we don’t forget history too quickly. There needs to be attention even when the threats may not be imminent. The private sector, with interests in business continuity, can be key actors here. Done right, such investments can engender what might be seen as positive spillovers. As the CDD work suggests, investments in prevention of avian influenza can provide the basis for such work on other potential pandemics.
In closing, if we want to take a wide-angle lens on the problem of disease outbreaks like HN79, to understand why these diseases are occurring at an increasing rate, we could do worse than taking a lead from Nathan Wolfe. A globally renowned virologist, a couple of weeks ago Wolfe wrote a tub-thumping piece on the WEF blog about the continued risks of unregulated hunting, especially bushmeat, which gave birth to human immunodeficiency virus (HIV). His basic argument was by ignoring the implications of our food production systems, we are running an unacceptably high risk of terrifying global scourges in the future.
Clearly, we all need to start pay much more attention to the intersection of economy, society and the environment if we are serious about proofing ourselves against the Next Big One.