Offline: From 1918 to 2018—the lessons of influenza

Abstract

Estimates of mortality during the 1918–20 influenza pandemic range from 20 million to 100 million deaths. Mortality between countries varied enormously. A large part of this variation was related to wealth. Resource-poor countries, with weak health systems, pervasive undernutrition, and widespread poverty, had higher death rates. When 1918 mortality rates are modelled for the modern era, an epidemic of influenza with similar virulence and pathogenicity would cause around 62 million deaths, with younger age groups especially vulnerable. 96% of these deaths would occur in developing countries. The centenary of the 1918 influenza pandemic is a moment to pause and think carefully about the world's present capacity to respond to another worldwide epidemic. The conclusion will be troubling, even alarming. President Trump's first year in office has seen America turn its back on multilateral efforts to defeat threats to human health—withdrawal from the Paris climate agreement, reintroduction of the “global gag rule” (banning US global health assistance from funding, counselling, and advocacy for abortion), cuts to foreign aid, and an overall diminution in American engagement in global health. But publication of President Trump's National Security Strategy in the closing days of 2017 suggests the US Government not only understands the immediate threat of disease pandemics, but also promises to do more to protect countries from their consequences. The US National Security Strategy is based on four pillars—protecting the American people, the homeland, and the American way of life; promoting American prosperity; preserving peace through strength; and advancing American influence. The first pillar—protecting the American people—includes a section entitled, “Combat biothreats and pandemics”. The strategy notes that, “Naturally emerging outbreaks of viruses such as Ebola and SARS, as well as the deliberate 2001 anthrax attacks in the United States, demonstrated the impact of biological threats on national security by taking lives, generating economic losses, and contributing to a loss of confidence in government institutions.” Three priority actions are offered. The first is detecting and containing biothreats at their source. This commitment will involve improving country capacities to detect and deal with infectious disease outbreaks early. Part of this response will be to “encourage other countries to invest in basic health care systems and to strengthen global health security”. (The two additional policy actions are to support biomedical innovation and to improve domestic emergency responses.) America's National Security Strategy suggests a pivot to engage more aggressively in international actions that demonstrably benefit the US—a practical realisation of President Trump's promise to put “America First”. What does America's vision for its own security mean for global health? Optimisitically, it should mean that President Trump will invest in universal health coverage (UHC). Last month, the Japanese Government hosted a UHC Forum in Tokyo. The Declaration from that conference united WHO with the World Bank and UNICEF in a commitment to strengthen global and country momentum towards UHC by 2030. An important new international target was set—that by 2023 (the midpoint between 2016 and 2030) essential health coverage will have been extended to an additional 1 billion people. This target is challenging. Currently, at least half the world's population does not have coverage with essential health services. What is lacking—in President Trump's National Security Strategy and WHO's General Programme of Work—is any detail about how this promise will be fulfilled. The grand commitments of governments and UN agencies risk being little more than empty words. There are no new programmes or initiatives offered on health financing, expanding the health workforce, or extending the coverage of essential medicines and services. And that is where the lessons of the 1918 influenza pandemic become important. UHC is the right goal for the health sector to pursue. But if we are to provoke governments to turn their words into deeds, UHC will not be the lever to do so. What will trigger political action is the fear and threat of another pandemic—and the urgency of strengthening “basic health care systems” to address those fears and threats. In 2018, the single most important priority for WHO must be to make pandemic preparedness a central objective for the national security of all its member-states. This strategy will deliver UHC. The centenary of the 1918 influenza pandemic is the best opportunity we have for making global health security the foundation for achieving UHC.