November 17, 2017
New and existing diseases tend to emerge and re-emerge in rural regions with limited public health systems. A disease jumps the species barrier, moving from animal to human host. Historically, these outbreaks would fizzle out close to where they began, as patient zero infected his community but the combination of death, immunity, and lack of new hosts stopped further spread of the pathogen.

Today, however, this cycle is exacerbated by two factors: a huge increase in livestock numbers, especially in the developing world, and the rapid growth of urban slums. With more animals living near humans, and humans living closer together than ever before, the chances of diseases emerging and spreading rapidly are significantly increased.

Our modern, hyperconnected world further heightens the potential for a disease to spread very quickly rather than simply burning out near its point of origin.  Early victims can now carry the disease across hundreds, if not thousands, of miles, infecting others and rapidly expanding the range of an outbreak. The combination of megacities and transoceanic air travel means that a global pandemic can emerge from a trip to the airport and some very bad luck—a reality demonstrated by past experiences with SARS, Ebola, and Zika, and one at risk of repeating itself in the waning but still ongoing plague outbreak in Madagascar.

An ‘unusually severe’ outbreak

In Madagascar, patient zero contracted the more infectious pneumonic form of the plague while travelling in the central highlands, where plague is endemic. While travelling back to the capital, Antananarivo, he infected thirty-one others, and before central health authorities realized the extent of the danger, the bacteria spread further, infecting more than 1,800 individuals and causing 127 confirmed fatalities by early November in what the WHO has described  as an “unusually severe” outbreak.

Although the plague is easily treated with antibiotics and can be contained by robust public health systems, imagine if what came out of the highlands in Madagascar was not treatable with existing medications or vaccines?  The lesson from Madagascar and previous pandemic outbreaks is clear: each country’s pandemic preparedness capacity is inextricably connected, and we are only as strong as our weakest link.

Evaluating the chain

“Only as strong as our weakest link” is the mantra behind the 2005 International Health Regulations (IHR), a binding international legal instrument designed “to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.” The document defines the public health rights and obligations of its 196 party nations, while centralizing international public health authority and oversight in the World Health Organization (WHO).

The IHRs initially required members to evaluate and report back their ability to meet minimum requirements for disease surveillance and response capabilities. However, with very few nations completing these evaluations by the 2009 deadline, the WHO adopted the Joint External Evaluation (JEE) tool in an effort to speed up the process.

The JEE framework evaluates nations on a 1-to-5 scale in nineteen separate categories, ranging from their ability to detect antimicrobial resistance to their capacity to respond to nuclear emergencies. The United States averages a 4.3; Saudi Arabia scores a 3.7; while Bangladesh scores a 2.5. Completed JEEs, especially when paired with evaluations of a country’s animal and agricultural systems, provide a comprehensive picture of national public health systems. This information, readily accessible at the start of a crisis, can save lives because national and international actors responding to an outbreak can target areas where public health systems are the weakest. Even more importantly, completed JEEs show countries and their international partners where to target their efforts to improve public health systems long before an outbreak starts.

Unfortunately, only sixty-one of the 196 nations party to the IHRs have completed their JEEs.  There are ten countries at greatest risk of infection in the current plague outbreak, according to the WHO. Six of them, along with Madagascar, have not completed JEEs. Without this information, the WHO has instead started from scratch, employing an abbreviated “plague preparedness checklist” to assess readiness and turned to ad hoc responses to bridge any gaps.

Since deploying to the island five days after first being alerted, the WHO has delivered 1.2 million doses of antibiotics, expanded laboratory capacity to test for new cases, and prepositioned supplies in other “at risk” countries. So far, these measures appear to have stopped the outbreak at its source. The number of new cases is decreasing, and no other countries have been affected, demonstrating the value of a rapid and effective response to an outbreak—factors which are even more vital in stopping more dangerous diseases.

Strengthening the chain

Next year marks the 100th anniversary of the Spanish influenza outbreak that killed as many as 50 million worldwide. A future influenza outbreak might kill even more, especially if countries do not use JEEs as roadmaps to strengthen their public health systems before the next pandemic.  In a crisis, a JEE gives an instant snapshot of an infected country’s response capacity, and identifies what national and local gaps need to be quickly filled. Regrettably, more than two-thirds of IHR party nations, both rich and poor, have incomplete JEEs, a critical gap in knowledge that weakens the global community’s ability to identify and respond to disease outbreaks before they become pandemics.

The plague outbreak in Madagascar is yet another alarm bell: more infectious diseases than ever before have pandemic potential, and the international community ignores the inadequacy of public health information at its peril. Developed nations should prioritize completing their JEEs, while helping fund JEEs in developing nations. WHO support to states for other global health issues should be contingent on timely completions of JEEs and national action plans for achieving core public health competencies. In the United States, as the Ebola supplemental funding ends in mid-2019, the Trump administration should ensure its next budget supports the US role as a leader of the Global Health Security Agenda, given that every dollar spent on public health abroad is an investment in the health of every American citizen.

After all, Ivato International Airport in Antananarivo is only one connecting flight from New York, Washington, and Los Angeles. Our distance from the source no longer immunizes us against disease. The chain of global pandemic resilience is only as strong as its weakest link.

Samuel Jeffrey is an intern at the Adrienne Arsht Center for Resilience. Follow him on Twitter @sjeffrey101.

Alex Paul is assistant director at the Adrienne Arsht Center for Resilience. Follow him on Twitter @AlexPinDC.