‘One health’ solution for the next pandemic

Dr Sulzhan Bali, a World Bank health specialist, says investment in pandemic prevention remains low because the benefits are largely invisible and uncounted, in the form of crises that do not occur.

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A new report released this week indicates that as humans extend their footprint on the planet, encroaching on natural habitats and altering them, the potential for diseases to emerge has increased exponentially. Risk anywhere becomes risk everywhere.

“The next pandemic may already be on the horizon. There should be no surprise,” warns a report by the World Bank.

In the report, the international financial institution said the pace of emerging infectious diseases has accelerated, increasing at an annual rate of 6.7 per cent.

But most countries and leaders do not recognise the critical importance of pandemic prevention, which means stemming a local outbreak before it becomes a pandemic.

The report, “Putting Pandemics Behind Us: Investing in One Health to Reduce Risks of Emerging Infectious Diseases, says that to effectively address the challenges posed by pandemics, countries need to depart from the old cycle of panic and neglect.

“The business-as-usual approach to pandemics has been based on containment and control after a disease has emerged. It relies primarily on reductionist approaches to the vaccine and therapeutic development rather than on reducing the drivers of pandemic risk to prevent them before they emerge,” the report says.

The World Bank says strategies used by countries to fight pandemics are enormously expensive and insufficient to protect people from the serious economic and social consequences of large outbreaks or pandemics.

Pandemic prevention

The team, led by Dr Sulzhan Bali, a World Bank health specialist, said investment in pandemic prevention remains low because the benefits are largely invisible and uncounted, in the form of crises that do not occur.

The reason the world is likely to see more pandemics in future is that some drivers of pandemics – forest exploitation, extractive industry, livestock farming, and urbanisation – are closely tied to income generation and livelihoods, which can hinder necessary changes.

The report gives alternative approaches that address pandemic risk at its source and is grounded in One Health strategies, whole-of-society planning, and collaboration across disciplines at the human-animal-ecosystem interfaces as a central path to global health security.

On how to transition to more effective approaches, the report advises countries to have high-level discussions on designing an international accord on pandemics and a new financing mechanism for pandemic prevention, preparedness and response, and the benefits of investing in prevention and One Health for sustainable and human development

It also highlights the relatively modest cost of prevention compared with crisis response.

“Prevention guided by One Health principles is estimated to cost approximately $11.5 billion per year. This includes $2.1 billion per year to bring public veterinary services up to international standards, $5 billion to improve farm biosecurity, and $4.4 billion to reduce deforestation in higher risk countries.”

Cumulative output

The International Monetary Fund (IMF) has projected the cumulative output loss from the Covid-19 pandemic through 2024 to be about $13.8 trillion. The cost is unprecedented, and the damage done to social cohesion, human capital, poverty, and sustainable development will be incalculable.

“Prevention when done correctly would de-risk investments in preparedness and reduce the need for subsequent response-related costs. A pandemic prevented is a pandemic that is not seen,” it says.

It adds: “Every year, zoonoses cause more than a billion human infections and a million deaths, a trend that we must put an end to because it jeopardizes human development and breeds larger outbreaks such as Covid-19, bringing much higher death tolls. To decrease their burden, we must focus on prevention.”

The report proposes that countries invest in One Health, an investment in humanity's future, a way forward to reduce the risk of spillover.

“By stopping infectious diseases from spilling over to people and spreading to become pandemics, One Health provides a solid foundation for global health security and improved development outcomes at much lower societal and economic costs,” the report says.

The report builds on One Health’s successes and lessons from many public health failures that did not take an integrated approach.

It organises knowledge and understanding of the drivers of pandemic-prone emerging diseases and proposes to re-cast prevention to lessen the likelihood of spillover, de-risk investments in preparedness, and reduce the cost of response.

It calls for urgent, long-term attention to prevention, a critically missing link in our current approach to pandemic risk while proposing a framework for mobilising finance for prevention to reduce pandemic threats locally and globally.

Addressing the pandemic at the source, the report highlighted several recommendations for countries to prevent the spillover of pandemics.

First is understanding the drivers of spillover to reduce pandemic risk.

Some 75 percent of emerging infectious diseases and almost all recent pandemics are zoonotic in nature.

These diseases stem from increased contact among wildlife, livestock, and people, which allows microbes to spill over from animals into human populations.

Human activities influence the increase in pandemic risk. Humans have extended their footprint on the planet, encroaching on natural habitats, altering them to extract resources, globalising trade, and moving goods and people. The potential for infectious diseases to emerge and spread has increased.

Urbanisation and climate change are reinforcing this trend by increasing pressure on land use and food systems and providing new, potentially more suitable, conditions for pathogens and diseases to develop and spread.

Increase spillovers

Human population growth coupled with larger numbers of livestock needed for animal protein will only increase spillovers if nothing is done to mitigate risks.

The successful identification of risks at their early inception is at the heart of public health and environmental protection. Analyzing the causes of the pandemic can focus attention on high-risk areas and factors that can be addressed through policy interventions. 

This helps identify and evaluate risks and the combined effects of sparks (where an outbreak is likely to arise) and spread (how it may diffuse through human populations).

Secondly, the report recommends the adaptation of the One Health concept for prevention that needs to include the health of humans, animals and ecosystems.

One Health has been coming of age but leaders have been slow in knitting the approach into the Pandemic Prevention, Preparedness and Response (PPR) agenda.

The World Bank, with WHO and partners, is working on establishing a new Financial Intermediary Fund (FIF) for pandemic PPR, adopting One Health as a guiding principle, and responding to the urgent need for a new multilateral financing mechanism dedicated to PPR (World Bank 2022).

Countries and regional bodies are increasingly establishing One Health coordination platforms and strong political will and commitment are seen as key enablers of success.

“Multisectoral coordination and collaboration that is required for One Health is extensive with a high transaction cost and cannot be sustained on goodwill alone without strong political commitment and adequate institutional arrangements,” says the report.

The report gave the example of Vietnam, which is prone to the emergence of infectious diseases with pandemic potential. A combination of vulnerability to climate change, low access to health care, a growing livestock sector, proximity to wildlife and expanding urban areas create opportunities for spillover.

However, with the launch of the One Health Partnership Forum for Zoonotic Diseases by the Vietnamese government, now in its second phase until 2025, focusing on prevention by addressing the human-animal ecosystem interfaces, the One Health Vietnam case study provides further insights into the country’s profile and specific context for critical interventions.

Thirdly, countries have been advised to shift to pandemic prevention by moving away from a paradigm grounded in crisis response using emergency instruments and incorporating risk reduction, risk management, and long-term capacity strengthening in-country programmes and operations.

Because government leaders have much less interest in investments to prevent future events than they do in responding to current crises, an investment framework is needed to facilitate more critical interventions to bolster prevention.

“There is an economic argument for this shift. The cost of prevention is moderate, with high returns on investments,” the report says.

“Considering Covid-19’s heavy human and economic toll, the return on investment would most likely be much higher, especially if the set of actions addressed the broader spectrum of prevention and curbed key drivers across forests, food systems, and cities.” 

The G20 High-Level Independent Panel (HLIP) estimated the amount of international financing for pandemic preparedness that would be required every year for five years at $15 billion, along with significant increases in domestic spending to address current gaps.

The World Health Organisation and the World Bank recently estimated the total amount at $31.1 billion annually, of which $10.5 billion of international financing is needed annually for the next five years.

Investment in prevention would substantially reduce the likelihood of spillover and pandemic risk, thereby de-risking or reducing the need for investments in preparedness and reducing the cost of response.

“The economic case seems irresistible but, despite the obvious economic benefits, prevention is usually grossly underfunded. However, suggesting that more money alone will solve the problem is not credible,” the report says.

Even with financing available, the political economy of investing in prevention such as One Health is complex, and the benefits of successful prevention are less visible than expenses for response and relief. Thus, it is important to emphasise the significant co-benefits to investing in prevention as well as the high cost of inaction as the world is witnessing now with Covid-19.

The report recommends focusing on hotspots by mapping active interfaces between wildlife, livestock and humans and predicting where the next pandemic might originate and the costs of adopting comprehensive prevention measures in a certain location.

The best strategy in the face of uncertainty about when and where the subsequent emergence and outbreak will strike is to focus on areas and practices of higher risk, also called hotspots.

Hotspots are areas where the likelihood of spillover is highest.

“A robust assessment of spillover risks at the country level is needed to determine national risk profiles to guide prioritization in where to channel funds,” the report says.

Although it may not be possible to predict the next pandemic, analysing drivers can support country risk assessments and help identify interventions to reduce the likelihood of spillover. The likelihood of spillover is essentially the frequency of encounters between animal microbes and humans.

The report says countries must focus on the diversity and abundance of animal hosts and their microbes, risk behaviours that bring people and animals into contact and provide the interface for transmission, environmental changes that drive spillover across these interfaces and where there are many humans and host species it is more likely that there are active interfaces.

Most active interfaces are in low- and middle-income countries because of the high density of human and domestic animal populations.

“These high-risk areas are not just of local concern but also pose potential global threats. Because of the world’s interconnectedness, risk anywhere is risk everywhere, and there is a strong need for collective accountability, incentives, and disincentives,” the report states.

The report also recommends de-risking farms, forests and urban sprawl to mitigate the risk at the source.

It states that the proportion of the world’s population living in urban areas by 2050 is projected to increase from 55 percent to 68 percent, or close to seven billion people. The average annual forest loss has significantly increased in low-income countries.

Growth in the consumption of meat is projected to increase by 12 percent in the next seven years, steering an increase in livestock production.

“Depending on their risk profiles, countries need to limit disturbance of ecosystems by restricting human and domestic animal access to these ecosystems, improving biosecurity in production, transportation, and retailing of livestock and restricting contact with humans through appropriate barriers (fencing, dedicated clothing when working on the farm, and controlled extensive grazing),” the report says.