Human capacity for dealing with infectious diseases continues to improve, thanks to the lessons learned from recent outbreaks such as Sars and Ebola, and a growing global commitment toward improving public health. But factors such as population growth, urbanisation, natural disasters and climate change continue to leave many countries at higher risk from infectious diseases and pandemic outbreaks.
In an era of greater global integration, especially within East Asia Pacific and with the rest of the world, such outbreaks can spread quickly and with severe consequences. Southeast Asian countries, for example, have moved toward closer integration, allowing freer movement of people, goods and services. The huge jump in regional tourism made possible by rising incomes and falling airfares also increases the potential for re-emergence and rapid transmission of infectious diseases.
At the same time, public health systems are still not adequately prepared to prevent and respond to major outbreaks or a global pandemic. Although mechanisms such as the International Health Regulations (IHR) -- a legally binding instrument introduced by the World Health Organization (WHO) in 1969 and broadened in 2005 -- have a clearly defined goal to prevent the spread of disease and manage public health risks, recent assessments have found that 80% of countries have not complied with their legal obligations or updated their legal frameworks accordingly.
According to the World Bank, the world's focus historically has been primarily on responding to disasters as they occur, while prevention and preparedness have taken a back seat.
"Countries in the East Asia and the Pacific region have made tremendous efforts to tackle emerging infectious diseases. This is a good start. However, many challenges remain in ensuring adequate and efficient, sustainable financing for pandemic preparedness and response," said Toomas Palu, manager of the Heath, Nutrition and Population Global Practice at the World Bank.
Financing typically is raised for public health crises as they occur, while preparedness during uneventful periods is often neglected, Mr Palu told a recent conference in Bangkok co-hosted by the bank, the WHO and the government of Australia.
"This is often compounded by prioritisation of curative healthcare measures over preventive healthcare measures, public finance management challenges, fragmented external financing, inadequate government structures, and poor multi-sectoral cooperation -- all of which contribute to a significant financing and institutional capacity gap for pandemic preparedness," he said.
"So, the question is how can we get ahead of the curve, design and implement practical, long-term, sustainable solutions?"
When potential pandemics are framed as just a health issue, governments often find it difficult to justify spending money to avoid a seeming low-probability risk. As well, it is difficult to persuade the private sector when it may see little return on such investments. A greater focus on the economic impact of pandemics could change attitudes, however.
Yet, the key to mitigating the impact of a pandemic, as with any disaster, is in what happens during the pre-pandemic period, not what might happen after a catastrophic event is already under way, said a paper prepared by the World Bank Group (WBG).
A high-level UN panel has suggested that the World Bank, the WHO and other multilateral donors mobilise more financing for preparedness and establish mechanisms such as the Pandemic Emergency Financing Facility (PEF) that the bank launched in 2016, the study notes.
The PEF is an innovative insurance-based system that will provide grants to low-income countries to respond to high-severity outbreaks to prevent them from becoming pandemics.
PREVENTION CHEAPER THAN CURE
Major pandemics result in billions of dollars in economic damages that extend far beyond the losses experienced by families when a breadwinner dies of a disease. For example, the economic cost of the Zika virus outbreak, mainly in Latin America, has been estimated at US$3.5 billion. The damage caused by Ebola was roughly the same as that of the global financial crisis in 2008-09, in addition to the hundreds of deaths, said Sutayut Osornprasop, the senior human development specialist with the Health, Nutrition and Population Global Practice of the World Bank.
Damages varied, he said, depending on the different types of diseases. "Ebola in Africa, for example, is very severe. For anyone who caught it, the possibility of dying of it is so high, roughly a 60-70% chance," he told Asia Focus.
"Some viruses are more virulent than others. For example, bird flu is very virulent. It means that if we contact the bird flu virus, I would say that maybe you have only a 30% chance of living. As for H1N1 or swine flu, this H1 type of influenza is not that virulent. There are some deaths but normally a minority.
"When we first heard about H1N1, people were scared, but after society saw that not many people died because of it, people were not as scared. [Diseases] likely to cause more deaths or a high chance of dying have a greater impact on the economy because they make people scared and they don't want to engage in economic activity outside. Some are afraid even to go out shopping.
For example, he said, when Sars (severe acute respiratory syndrome) first broke out in Hong Kong and southern China in 2002, "people sat tight and did not go to work or out shopping. Few shop owners opened their stores during the outbreak. That causes huge economic impacts".
Impacts on direct investment will come afterward, noted Dr Sutayut. "During the Sars outbreak, for instance, people were afraid of flying so there are impacts on the travel industry."
When such outbreaks happen, there are negative ripple effects throughout the health system as resources are diverted to deal with the crisis. This underscores the need for countries to invest in improved capacity to detect, prevent and respond to infectious diseases.
The World Bank report cites recent evidence showing that responding to outbreaks once they have happened is far more expensive than investing in preparedness.
"Governments all over the world have to think that when a pandemic happens, the impacts are not on human health alone. The effects are also seen on the economy and these are much larger," said Dr Sutayut.
"You cannot prevent outbreaks, mainly because there are some mutations of diseases, but we can prevent outbreaks from becoming pandemics. If we can stop an outbreak or contain it in certain areas, then the economic damage will be less."
Preventing and responding to pandemics has become much harder as human health security is not the only factor to take into account. It is estimated that 75% of infectious diseases in humans, and 60% of all new human diseases each year, are of zoonotic origin, meaning they are transmitted from animals to humans.
Human and animal health are thus interdependent and bound to the health of the ecosystem in which they exist. Sars, Nipah virus, avian influenza A (H5N1) and A (H7N9), and Ebola are major examples of infectious diseases that emerged at the human-animal-ecosystem interface. Diseases of animal origin that can be transmitted to humans such as bird flu, rabies, Rift Valley fever and brucellosis pose worldwide risks to public health.
Globally, 13 zoonotic diseases, together account for 2.2 million deaths and 2.4 billion illnesses each year. The vast majority occur in low- and middle-income countries.
The World Bank report also pointed out that investing in preparedness yields significant returns on investment. System improvements in public health and animal health to meet the minimum standards of the WHO and the World Organization for Animal Health (OIE), would cost $3.4 billion a year, but past zoonotic outbreaks between 1997 and 2009 -- which did not even become pandemics -- cost $80 billion or $6.7 billion annually. The benefit of better preparedness is worth roughly $36.7 billion a year, 10 times the estimated investment.
SUSTAINABLE FINANCING
Another lesson learned from previous pandemics or outbreaks is that financing preparedness is of little help without good governance and institutions to coordinate and manage resources effectively.
In any case, current preparedness funding levels remain inadequate while capacity to deliver relevant health services remains "suboptimal" in most countries in East Asia and the Pacific, according to the International Working Group on Financing Preparedness (IWG).
"This is partly because governments tend to focus on more immediate priorities, overlook pandemic preparedness for disease outbreaks in the future and ignore the multiple benefits of health security investment," it said.
"Given the complexity and multi-sectoral nature of pandemic preparedness, better understanding of the current financing landscape and levels of capacity would enable an informed dialogue on financing and service delivery gaps and how best countries can optimise existing resources as well as increase domestic financing and capacity to improve heath security."
Funding now comes from many sources ranging from domestic and external resources to emergency funds, disease-specific global funds such as the Global Fund to fight Aids, Tuberculosis and Malaria (GFATM), development banks and bilateral donors. However, domestic and external financing is often fragmented and donor coordination is a challenge.
"Most of the countries we work in historically rely on external financing for the disease prevention and preparedness side," said Dr Sutayut. "In the past there were developed countries that acted as donors. They had the financial resources and they saw health security as an important issue.
"But this model of financing is not reliable. When there is a global economic crisis, these developed countries are affected and then their contribution will be reduced."
For example, HIV prevention in the past were supported by donors or external financing, but when they were economic crises or shocks, or when developed countries changed their priorities, they channeled the money in other directions.
"So that's why one of our efforts tries to get developing countries to be able to stand by themselves, partly through mobilising domestic resources for pandemic preparedness," he said. "Countries do have money and resources, but it's the government that decides where to put this money, whether it's infrastructure, education or health.
"In the past we saw lot of developing countries put their own money into infrastructure, so why not put it into pandemic preparedness? If a country invests in pandemic preparedness ... then it actually saves a lot economically in the longer term."
Thailand is a good example among countries that can mobilise domestic resources for pandemic preparedness, while China, which has become richer in recent years, has been able to sustain itself in this area for some years. In Africa, Uganda is a low-income country but the finance ministry sees the value of investing in pandemic preparedness, and in recent years it has not experienced any health crises.
"There was no Ebola pandemic there, and when the virulent Marberg virus outbreak hit Africa (in 2017), Uganda had only three cases because the country was able to prevent this virus from spreading further," Dr Sutayut noted.
The World Bank report stressed that rational and increased financing require stronger leadership, a common financing framework, effective national legal and regulatory frameworks, and effective government structures at the national and local levels.
"By linking financing for pandemics with all sectors of the economy, preparedness would be 'mainstreamed' in the development plan," it concluded.
