The thing that has surprised me most since I began my job leading foreign assistance for global health at the U.S. Agency for International Development is how much emergencies have defined my work. The bureau I oversee focuses on reducing the global burden of mortality and disease and on protecting the United States from health threats from abroad. Our work is supposed to primarily serve long-range goals — for instance, eradicating polio (after 35 years of effort, we’re down to just a handful of wild-type cases in the world) and ending the public health threat of H.I.V., malaria and tuberculosis by 2030. But from the moment I started, more immediate problems have diverted time, attention and resources.
In January of 2022, when I started this role, Covid was naturally the top priority. Then, in late February, suddenly it was Ukraine. The Russian government’s invasion cut off pharmaceutical supplies, attacked hospitals and the systems they depend on and drove outbreaks of disease among the displaced, potentially endangering even more lives than Russian weapons did. More than 100,000 Ukrainians with H.I.V., for example, were threatened with losing access to the lifesaving antiretroviral medications they needed. We had to move fast to help Ukraine solve how to keep pharmacies, clinics, hospitals and public health capacity functioning.
That same month, a wild-type polio case turned up in Malawi — a major setback after more than five years without a documented case in Africa. Over the following months, we faced deadly cholera outbreaks in more than two dozen countries, the global spread of mpox (formerly known as monkeypox) and an outbreak in Ghana of Marburg virus disease, a deadly cousin of Ebola. By mid-2022, waves of political violence and climate catastrophes forcibly displaced more than 100 million people — the largest number in recorded history — leading to increased disease and death from crowding, unsanitary conditions, malnutrition and the loss of basic health services. This past May, the World Health Organization reported a total of 56 active global health emergencies, a situation that Mike Ryan, the head of the W.H.O.’s health emergencies program, has described as “unprecedented.”
This is now the pattern: one emergency after another, often overlapping, diverting focus away from longer-term public health goals. And there’s no sign of this letting up. Displacement and activities like deforestation have increased contact between humans and wildlife — and thus the incidence of animal diseases leaping to humans. (The Ebola virus, for example, has been linked to bats as a possible source of spread.) The risk of outbreak-causing laboratory accidents is a significant concern as labs proliferate and safety measures lag. On average, between 1979 and 2015, more than 80 laboratory-acquired infections were reported per year, several involving transmission beyond those initially infected, and underreporting is rife. The growing field of synthetic virology has simultaneously generated lifesaving new treatments (mRNA vaccines, for example) and made it easier for bad actors to turn infectious diseases into weapons of mass destruction.
But we can break the pattern. Longer-range investment in local preparedness for such events — in building what I think of as a global immune system — could reduce the threat these crises pose and even reduce dependence on foreign aid to weather them. As dangers rise, so can our capacity to get ahead of them. With the right strategy, we could use the mishaps, malefactors and shocks we face to strengthen our capacity to adapt. This is not about developing resilience (the ability to recover from crisis) or robustness (the ability to resist crisis). It is about developing what the writer Nassim Nicholas Taleb has called antifragility — the ability to become stronger from crisis.
Our body’s immune system provides an example: It rapidly detects and neutralizes pathogens before they do catastrophic damage, while getting stronger with each exposure. Similarly, a global immune system would rapidly detect and neutralize health threats before they do catastrophic damage to the world, while evolving and strengthening with each event.
To be sure, the first line of defense against danger is prevention. Many across the U.S. government are tasked with this: We work with the W.H.O. and partner countries to upgrade standards of laboratory safety and security, support research to develop vaccines against potential pandemic diseases and work to keep bad actors from developing or disseminating bioweapons. But prevention is never enough.
A global immune system must be built for speed. Speed in detecting that a pattern of illness might be unusual and dangerous. Speed in diagnosis. Speed in alerting public health officials and tracing the path of exposure. Speed in getting treatment to the sick and preventive measures to the well.
Building such a system is a tall order. Many communities face herculean barriers to speed — because of remoteness, poverty, civil strife or insufficient health care capacity. All these barriers were present in December 2013, when a mysterious illness characterized by high fever, severe diarrhea, vomiting and a high death rate appeared in the West African country of Guinea. The disease circulated for three months before the correct diagnosis was made and an outbreak of Ebola was officially declared. At that point, just 49 cases were recorded. But it took several months to marshal an adequate response.
Ebola surged across the region, spreading through simple contact with the bodily fluids, even the sweat, of the sickened. As the disease exhausted local capacity and health workers succumbed, routine health services ceased to function. Businesses and schools closed. The economy ground to a halt.
Soon the disease reached Italy, Spain, the United Kingdom and the United States. A traveler to Dallas infected two nurses and died. Ending the emergency took more than two years and required a massive global humanitarian response, including the U.S. military. By then, 28,652 cases and 11,325 deaths had been recorded.
That searing disaster prompted action to do better. The United States launched a partnership with West and Central African countries to build greater readiness for outbreaks. U.S.A.I.D. and the Centers for Disease Control and Prevention joined with the W.H.O. and others to modernize equipment in local laboratories and train frontline health workers to recognize potential contagions. We worked with government officials to establish emergency response centers and increase their public health expertise. We supported education for community and religious leaders about infectious risks and how to control them. The scaffolding of a speedier regional immune system was being built.
Initially, the effects were hard to see. In a 2018 outbreak in the Democratic Republic of Congo, the Ebola virus circulated for three months before being identified. The response of the D.R.C. and its neighbors was better organized, but remained characterized by major gaps and delays. The disease was largely contained to the country of origin, but it still took two years and a giant global assistance effort to end the outbreak. There were fewer cases (3,470) and deaths (2,287) than in the outbreak that started in Guinea in 2013, but the numbers were still high.
As capacity and experience grew, however, the tide turned. In 2020, the D.R.C. had yet another Ebola outbreak, but this time it took local clinicians just 15 days to identify the virus. Government authorities responded rapidly and effectively, keeping the disease from spreading beyond the eastern region of the country. Instead of thousands of deaths, there were 55.
The Ebola experience in Africa suggests that an effective global immune system is feasible. But building it requires a sustained, collective commitment to investing in the people and capabilities needed at the front lines of care worldwide. Despite our political and geographical divides, the human race has actually made a strong start.
Last year, the Group of 7 committed to supporting 100 countries that have not met international standards for preparedness to address biological threats. Under President Biden’s National Biodefense Strategy, the U.S. government is following through by supporting more than 50 of these countries. From its first day in office, the Biden administration worked with other leaders, the World Bank and the W.H.O. to establish the Pandemic Fund, which has raised almost $2 billion from 25 countries and philanthropies. Last summer, the fund made its first grants to 37 countries for pandemic preparedness. And this support has continued after the Covid emergency subsided. In December of 2022, a bipartisan majority in Congress even increased funding for global pandemic preparedness and prevention, recognizing its importance for protecting America’s health and economy. That funding is building capacity both at home and across the globe to more quickly deliver tests, treatments and vaccines whenever and wherever the early warning system is triggered.
We have a long way to go, there is no doubt. The onslaught of health disasters continues. A few months into my job at U.S.A.I.D., I determined that our Global Health Bureau needed an emergency department, the way hospitals do — a team dedicated to triage and rapid response. We call it our Global Health E.M.S. Now we in Washington are ready to move at faster speed when necessary, too.
And we are starting to see what the speed of a global immune system can do. In April of 2022, I was notified of a new Ebola outbreak in the D.R.C., in a city of a million on the Congo River. A 31-year-old man who had experienced a week of mounting fever arrived at a clinic and died soon after. Now, though, the medical officer on duty had received enough training to recognize possible signs of Ebola. The medical team had the gear on hand to protect themselves as well as the right lab equipment. They made the diagnosis and alerted the national public health authorities that very afternoon.
Within 48 hours, they had people on site identifying contacts, and newly developed vaccines were shipped for the exposed. The result: Just five people died. The disease never spread beyond the local community.
A response that once took years and hundreds of millions of dollars now took mere days at a tiny fraction of the cost. This is what antifragility looks like. My team didn’t have a thing to do. The country required no emergency assistance at all.
Atul Gawande is a surgeon, public health leader and writer. He currently serves as the assistant administrator for global health at U.S.A.I.D.
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