By Jeffrey T. Jensen, MD, MPH, Editor
SYNOPSIS: The human population explosion, international travel and migration, urbanization, and environmental exploitation set the stage for pandemics, and the trend likely will continue and intensify.
SOURCE: Madhav N, Oppenheim B, Gallivan M, et al. Pandemics: Risks, impacts, and mitigation. In: Jamison DT, Gelband H, Horton S, et al, eds. Disease Control Priorities: Improving Health and Reducing Poverty. The International Bank for Reconstruction and Development/The World Bank; 2017.
The World Bank published the latest edition of the monograph Disease Control Priorities: Improving Health and Reducing Poverty in 2017. Chapter 17 details “Pandemics: Risks, Impacts, and Mitigation.” Although I typically would prefer a more recent reference, this provides a sobering commentary on our current situation.
The chapter defines pandemics as large-scale outbreaks of infectious disease that increase morbidity and mortality over a wide geographic area and cause significant economic, social, and political disruption. The likelihood of pandemics has increased over the past century because of increased global travel, urbanization, and extensive exploitation of the natural environment — trends expected to continue and intensify with human population growth. The 2003 severe acute respiratory syndrome (SARS) pandemic led many countries to devise pandemic plans and the World Health Assembly to update the International Health Regulations (IHR) to compel all World Health Organization member states to meet specific standards for detecting, reporting on, and responding to outbreaks. Despite this initial cooperation, many countries have been unable to meet basic requirements for compliance, particularly in resource-limited settings.
Although pandemics have occurred throughout history, data suggest an increasing frequency, largely as a result of an increasing emergence of viral disease from animals. The likelihood of a pandemic is driven by the combined effects of spark risk (where a pandemic is likely to arise) and spread risk (how likely it is to diffuse broadly through human populations). Unfortunately, geographic regions with high spark risk, such as Central and West Africa, lag behind the rest of the globe in pandemic preparedness. In addition to widespread increases in morbidity and mortality (disproportionately higher in low-resource nations), pandemics also cause economic damage for multiple reasons, including the need for social isolation. Although these present challenges to rich nations, countries with weak institutions and legacies of political instability are particularly vulnerable to social unrest.
The report advocated for strategic investments in high-risk regions to strengthen core public health infrastructure, increase the situational awareness needed to rapidly extinguish sparks that could lead to pandemics, and grow global cooperation to develop surge capacity. No widely accepted, consistent methodology for estimating the economic impacts of pandemics exists. Responses from high-income countries (HICs) bias results, and poor reporting also contributes to weak data on economic effects.
The “zoonotic” transmission of pathogens from animals to humans presents the most likely source of a future pandemic spark. A zoonotic spark can arise from the introduction of a pathogen from either domesticated animals or wildlife. Risk drivers for wildlife sources include bush meat hunting, the use of animal-based traditional medicines, natural resource extraction, and the extension of roads into wildlife habitats, largely driven by population pressure. After a spark, pathogen-specific and human population-level factors influence the risk of pathogen spread. Dense population concentrations, in particular urban slums, act as foci for disease transmission and accelerate the spread of pathogens. Poor living conditions also increase individual susceptibility to infection. The high mutation rates of ribonucleic acid viruses (influenza, novel coronaviruses, filoviruses [Ebola], and flaviviruses [Zika]) may contribute to their predisposition for zoonotic transmission.
Pandemics cause large morbidity and mortality spikes by overwhelming health systems. In many cases, the number of indirect deaths may be more than double that of direct deaths. For example, during the 2014 West Africa Ebola epidemic, deaths caused by the lack of routine care for malaria, HIV/AIDS, and tuberculosis reached 10,600, nearly equal to the 11,300 deaths directly caused by Ebola.
To curtail pandemic spread, nations require a strong public health infrastructure capable of identifying, tracing, managing, and treating cases; adequate physical and communications infrastructure to channel information and resources; and the financial resources to pay for the disease response and the resulting economic shock. Specific competencies critical to detecting and managing disease outbreaks include surveillance, mass vaccination, and risk communication.
One of the most interesting sections of the report detailed the costs of responding to a pandemic. Contact tracing, face masks, and surveillance provide the greatest return in terms of lowest costs per deaths prevented. Social distancing and quarantine have the greatest cost per death prevented, because of the amount of economic disruption caused by those measures. Evidently, macroeconomic model simulations have identified school closures with the highest cost per death averted, due to productivity loss during a moderately severe pandemic. The report also discussed the importance of conducting further benefit-cost analyses related to assembling stockpiles of vaccines, antiviral drugs, and protective equipment in advance of a pandemic.
To summarize, combating pandemics requires situational awareness, defined as having an accurate, up-to-date view of potential or ongoing infectious disease threats (including thorough traditional surveillance in humans and animals) and the resources (human, financial, informational, and institutional) available to manage those threats. While most pandemic preparedness activities focus on reducing morbidity and mortality after a pandemic has spread, the report urged a broader approach to prevent pandemics that considers human health, animal health, and the environment. The full report provides additional important details.
Public health officials need to provide accurate information, and identify and address misinformation, rumors, and anxieties. The report highlighted that, in unstable contexts, people tend to believe rumors that confirm their preexisting beliefs and anxieties, and that countering rumors with facts alone will not be sufficient.
As of March 23, 2020, the COVID-19 pandemic has progressed across the country, and social distancing has progressed to include school closures and shelter-at-home orders in many states. Our hospital has shut down elective operations to prepare for an influx of severe cases in the coming weeks.
I decided to highlight this report from 2017 to demonstrate that experts throughout the world have anticipated this pandemic and have thoughtfully considered the best approaches for prevention or management. Although this topic does not directly relate to obstetrics and gynecology, I feel that as clinicians we have an obligation to provide accurate information to our patients and communities as public health specialists.
While the pulmonologists and infectious disease specialists will get us through our short-term crisis, we as obstetricians and gynecologists hold the key to the future. All the root causes of pandemics link directly or indirectly to the growth of Earth’s human population. With better policies, increased financial resources, and luck, our collective work in family planning will slow the rate of population growth.
United Nations estimates suggest that our current population of about 7.7 billion will peak at close to 11 billion about year 2100 before gradually stabilizing or declining in the next millennium.1 Attaining this goal requires rapidly achieving a global total fertility rate of about 2.1, a feat yet to be accomplished. Putting in those intrauterine devices and implants matters, as does support for international family planning efforts.
Perhaps we have reached the tipping point when pandemics will join global warming and loss of biodiversity as signals of the nonsustainable impact of human numbers. Family planning is the most humane and viable strategy for human survival.
- United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Volume I: Comprehensive Tables. https://population.un.org/wpp/Publications/Files/WPP2019_Volume-I_Comprehensive-Tables.pdf