Gerardo Bravo Garcia, Avian Flu Series, 2006, Oil & Gold Leaf on Canvas -
Courtesy of the World Bank Art Program
This blog is based on the World Development Report 2014: Risks and Opportunity - Managing Risk for Development , which discusses pandemics in Chapter 8 on global risks.
Pandemics do not start in a vacuum. A staggering 2.3 billion infections by zoonotic (animal-borne) pathogens afflict people in developing countries every year. Some pathogens become capable of easy human-to-human spread, like AIDS, flu, or severe acute respiratory syndrome (SARS). The diseases harm health, nutrition, and food and income security. The poorest are hit the worst, as they tend to live with livestock or near wild animals in settings where animal disease incidence is high and public health standards are low.
This zoonotic disease burden persists because of weak veterinary and human public health systems that fail to detect diseases and allow them to spread. The onset of pandemics is thus shaped by human action. Any country’s failure to stop contagion early at its animal source can cause a pandemic in today’s globalized economy, which is interconnected by trade and travel.
A severe flu pandemic would more than double the total burden of disease, but other impacts would be even more costly. Economies would suffer from worker absenteeism, cascading disruptions in goods and service markets, and human reactions to fear and rumors, which can spread faster than the disease itself. Recently declassified U.S. government planning documents characterize the impact as a global war . Poor countries, especially fragile ones, may be least able to cope.
What does it take to prevent a pandemic? The main cause of pandemic risk is low capacity of veterinary and human public health systems. Bringing them up to meet minimum international standards requires only modest resources: $3.4 billion a year for all developing countries, compared with the current level of barely $450 million. The expected annual benefits of robust systems are at least $37 billion, more than 10 times the costs.
Pandemic risk is undermanaged. Prevention and preparedness tend to be sidelined, especially in the health sector, where the responsibility often rests. Health authorities focus on immediate problems and do not readily work with veterinary authorities to prevent diseases of tomorrow or coordinate society-wide preparedness and plans for continuity of operations in key sectors.
Why such neglect? The economic and social impacts of contagion are often ignored, so the total risk is underestimated. Recent experience shows how wide this gap can be. The 2003 SARS outbreak, which killed about 10% of the 8,000 people it infected, caused $54 billion in economic damage (mostly canceled travel, lost retail trade, and associated cross-border economic shocks). A severe flu pandemic could cost 4.8% of global gross domestic product (GDP), or more than $3 trillion, triggering a global recession. Recall that four flu pandemics occurred just in the last 100 years, and other pathogens with pandemic potential continue to emerge, so in any year the probability of pandemic onset is not zero.
The international community has not yet expressed its demand for pandemic risk reduction by adopting explicit goals but instead resorts to emergency responses that are costly and contain the threat only temporarily. Because risk governance is not backed by resources and authority, numerous weak links persist in global defenses against contagion. To stop contagion, it is essential to act early, at the source, and quickly. Early warning requires cooperation from communities. If farmers who report disease are punished by having their livestock destroyed without compensation, they will hide disease from the authorities. Fearing trade and travel restrictions, countries may hide diseases, facilitating their spread.
Governments with resources try to protect their own populations by spending large amounts on ex-post measures (e.g., vaccines, masks, and antivirals), although prevention at the source of the threat has much higher benefit-cost ratios. In particular, the promising One Health  approach to reducing disease risks through bridges between animal and human health services is underfunded and too often dismissed by human health policymakers. This is surprising since 75% of pathogens that cause human disease are now zoonotic, and the burden of zoonotic diseases on the poor is a formidable obstacle to eliminating poverty and boosting shared prosperity.
The international community has already eradicated two devastating scourges: smallpox in 1979, and rinderpest (cattle plague) in 2011. Rinderpest, with its high fatality rate, decimated herds and economies for centuries. The campaign against it catalyzed the founding of the World Organisation for Animal Health (OIE) in 1924.
Intergovernmental cooperation, science-based strategies, mass vaccination, and surveillance were among the elements behind these successful campaigns. The disease risk was reduced to zero. The benefits are lasting and already outweigh the control costs many times over. Coordination among strong public health agencies broke the chain of transmission of SARS. Faced with the H5N1 avian flu threat, the international community rapidly mobilized and deployed $4 billion for zoonotic disease control and pandemic preparedness. This impressive multisectoral response to a global public health emergency focused on prevention, but it dissipated when the threat left the headlines.
The young and future generations face far worse odds of experiencing a pandemic than present-day adults. They stand to benefit substantially if governments were to set a goal to reduce pandemic risk. The goal would empower international organizations to raise risk awareness and motivate prevention and preparedness; provide relevant knowledge, capacity building, and technical assistance to developing countries; assess the performance of national veterinary and human public health systems and their collaboration; and mobilize resources for strengthening these systems.
Follow the World Bank health team on Twitter: @worldbankhealth 
World Development Report 2014 
UN System Influenza Coordination 
OneHealth Global Network 
One Health Approaches Facebook Group 
Background Paper for WDR 2014: Pandemic Risk 
Report: People, Pathogens, and Our Planet: The Economics of One Health 
Connecting Sectors and Systems for Health Results