It’s hard to put a value on avoided disasters. Firefighters are often praised for putting out fires. The inventor of the smoke alarm, not so much.
Humans are not very good at valuing preventative measures, which inevitably means we underinvest in disaster prevention. This phenomenon is amplified in democracies. Roselyne Bachelot was a minister in the French government between 2007 and 2010. In the face of the H1N1 swine flu outbreak, she ordered 1.7 billion face masks and millions of doses of the vaccine. Only a fraction of these supplies were used, and the remainder were thrown out. Bachelot’s political career was over, her reputation reduced to this single example of wasting taxpayers’ money.
This is a classic case of "outcome bias," in which people are judged by the outcome of their actions with the benefit of hindsight (in this case, buying supplies that were never used), rather than judging Bachelot’s decision by the information available at the time it was made (the threat of a pandemic outbreak).
Imagine two neighbors, with identical houses. Each decides to take out a home insurance policy that cost $50 a month. The next month the first neighbor’s house burns down, and the insurance company pays out the entire cost of his property. The second neighbor pays the insurance company every month for the next 40 years and never sees a dime in return. Which neighbor made the right call — the first neighbor, right? He paid the insurance company $50 and got hundreds of thousands in return. Wrong! It’s a trick question — the two neighbors made the same decision. To judge them otherwise is to succumb to outcome bias.
Politicians are rarely incentivized to invest in preparedness for unlikely, but devastating events. No one wants to be the next Rosylne Bachelot. But if there’s pressure from the electorate, politicians respond.
From 2015 to 2016, I worked on the UN’s Emerging Pandemic Threats program. The program had been set up in 2005 in response to the H5N1 avian influenza epidemic, and perpetuated through the 2009 H1N1 swine flu and 2014 Ebola outbreaks. The core goal of the program was to build disease surveillance capacity, sending experts to monitor potentially pandemic viruses in wildlife, and helping countries provide veterinary services and testing to catch outbreaks developing in livestock. In 2014, Ebola ranked third on the list of Americans’ top health concerns. As a result, the U.S. Congress passed an emergency appropriation of $5.4 billion to fund the Ebola response, allowing the UN’s pandemic preparedness work to continue. But societies have short memories. Whether it was a change in administration, or too much time between pandemic scares, last year the funding for this important work dried up. Many of my former colleagues had to find different jobs.
I recently caught up with Juan Lubroth, my former boss, who was the chief veterinary officer for the UN from 2009 to 2019. He noted that we know how to prepare for known threats — governments maintain armies in case of war, and people take out home insurance because, although they don’t know when a disaster might happen, they do perceive the risk of a disaster happening at some point. We also invest in ways to alert us to impending threats, with military reconnaissance and fire alarms. We need to have the same approach to pandemic threats. Yet before the COVID-19 pandemic, not only did we not have home insurance — we didn’t even pay for the fire alarms.
You could hear Lubroth’s exasperation as he explained, “It was different with influenza — we had a lot more knowledge about the virus, we did have a vaccine. The biologists, the wildlife people, even the veterinarians know quite a lot about coronaviruses. But we didn’t invest in that surveillance.” It’s clear now that we also didn’t keep up our insurance payments, as our health care systems were woefully ill-prepared and our emergency stockpiles were far too small.
When it comes to global health funding, it is also important to demonstrate the results of investments. Governments and philanthropists increasingly want evidence that their money is being well spent. But as Lubroth says, “If you prevented it, you can’t show the result.”
“Implicitly, we are talking about cost-benefit analysis” says Christian Luhmann, a psychology professor at Stony Brook University. Using a concept called intertemporal trade-offs, he told me, we calculate the present value of a future benefit, even if that benefit is uncertain. For example, when we decide to buy home insurance to protect us in the event of an accident, we are weighing the value of our property and the likelihood we will need to claim on the insurance sometime in the future. The problem comes when we can’t estimate the possible damage of a certain type of accident, or the probability — a problem known as epistemic uncertainty.
Pandemic preparedness is fraught with epistemic uncertainty, as well as the difficulties of showing that investments are effective. These inherent problems, combined with politicians’ fear of voter outcome bias, generated the perfect storm for pandemic unpreparedness, and laid the groundwork for the COVID-19 crisis.
Even though leaders knew that a pandemic like COVID-19 was possible, even inevitable, they failed to prepare. What can we do to stop this happening again?
First of all, we have to buy a fire alarm. We must adequately fund pandemic surveillance through an international coordinating body. The United Nations is the obvious choice to coordinate global pandemic surveillance. But the health agency of the UN, the WHO, has been struggling to secure adequate funding for many years, and its financial woes have only deepened now that the United States, its largest contributor, is considering revoking its funding. The financial burden of pandemic surveillance shouldn’t fall entirely on the United States – all developed nations need to contribute — but leadership from the United States has historically been instrumental in responses to disease outbreaks and that leadership is needed now more than ever. We must heed calls for investment now, but more important commit to long-term funding for pandemic surveillance and preparedness.
John Podesta, President Bill Clinton’s former chief of staff, who counseled President Barack Obama during the Ebola crisis, told me that while the UN bureaucracy “is thick and difficult to deal with … UN agencies have the credibility to succeed in places where even the coalition of the willing have a hard time standing up”. Podesta noted that “maybe more permanent structures like Gavi [an international vaccine non-profit], with different kinds of funding mechanisms, are necessary”. Gavi, an organization set up to increase global vaccine coverage, has had significant success using a mixed public/private funding model. “A Gavi-style model” explains Podesta, “might delink [the WHO] from its annual IV-drip of funding from the U.S. and other major donors.” Whatever the mechanism, there must be long-term, secure funding to overcome our short-term memory when it comes to pandemic threats.
Secondly, we need that home insurance policy — we must invest in health systems, and equipment stockpiles, to handle pandemic outbreaks. It is clear that the majority of developed countries were unprepared for COVID-19, with widespread shortages in medical equipment and hospital capacity. One can only imagine the situation in developing countries that struggled to provide basic health care services before the outbreak. This should be a wake-up call for governments to invest in health care capacity. Militaries keep stockpiles of weapons and run simulation exercises in preparation for war. We must do the same to prepare for disease outbreaks.
Matthew Burnett, who lives in Rocky Point, is a graduate student at Yale University and former scientific communications specialist for the United Nations Food and Agriculture Organization.
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