With lessons that are relevant for the contemporary effort to eradicate COVID-19, an event at Resources for the Future about a decade ago covered research about the incentives for nations to disclose and address the spread of disease.
On March 11, 2020, the World Health Organization declared the coronavirus outbreak a pandemic, and policymakers—unsure how lethal, transmissible, or world-altering the virus would prove—ordered lockdowns.
A year later, much more is known about how to control the spread of the virus: masks have become ubiquitous in major cities, more schools and workplaces have reopened with proper social distancing protocols, and promising vaccine treatments are being approved by health officials and distributed around the world.
But an uncomfortable truth is that insights about controlling novel pandemics have long been available, and applying those insights could have prevented some slip-ups in the global response to the current pandemic and informed more effective policy. For instance, free-flowing air was essential for patients hospitalized with the 1918 flu, yet some contemporary health officials were slow to notice that enclosed spaces contributed to the spread of COVID-19, a hundred years after the flu infected one-third of the global population. Experts predict that pandemics could become more likely and spread more rapidly in the future, which means that taking a close look at the available data is essential for controlling COVID-19—and preparing for the next major public health problem.
In 2009, RFF hosted “The Economics of Pandemics,” an event at the height of swine flu that presented novel research about fighting pandemics and coincided with a special issue of Resources magazine themed around global health. As Ramanan Laxminarayan, an economist who spoke at the event, made clear, “What we’re really doing here is pushing out the boundaries of what we think of as the environment that we live in, to encompass more things that really affect our lives.”
Applying lessons from the past to predict the spread of novel diseases is necessarily a challenging and imprecise task; every new disease is different and comes with a host of unknowns, especially in the early days of outbreaks. (Indeed, early estimates of COVID-19 infection rates in India by a group of research institutions, including one headed by Laxminarayan, ended up significantly outpacing actual infections.) But key insights from past research could have informed the world’s floundering response to COVID-19, and we can still look to these insights to help shape strategies for the future.
Incentives to Share Treatment
At the event, RFF Senior Fellow Maureen Cropper explored research she was conducting with other scholars (which later became a National Bureau of Economic Research paper) about the incentives that motivate affluent countries to share antiviral drugs with the rest of the world. More than simply exploring the impacts of antiviral access, Cropper’s research asked whether broad, global access to treatment options—facilitated by wealthy nations—can in fact decrease viral spread in the wealthy nations, themselves.
“Are the benefits of these actions to rich countries,” proposed Cropper, “actually sufficient to justify these actions on selfish grounds?”
The answer depends on the following three factors: how infectious the new disease is, where and when the virus originates, and how quickly antivirals can be administered to those who are sick. A virus that is harder to control (e.g., easily transmissible, peaks during flu season, difficult to treat) would make antiviral sharing less fruitful for affluent nations and reduce their incentives for global cooperation.
For their study, Cropper and her coauthors use a global epidemiological model to simulate a range of possible influenza pandemics and assess in each case whether wealthier countries benefit from a lower attack rate at the end of a year after sharing antivirals with lower-income countries. In the end, the answer is that it depends. Under conditions in which a hypothetical virus is moderately transmissible, sharing antivirals “is welfare enhancing for wealthy countries, even when the fatality rate [from the virus] is zero.” Prioritizing the distribution of antivirals to the country where the outbreak originated is demonstrably cost-effective.
“These results … obviously don’t imply that you don’t want to do a strategy like this just because it [might not always] pay for itself,” Cropper said. “But it’s really important in determining the effectiveness of a strategy like this to look at realistic assumptions of how fast you can actually deliver something like an antiviral stockpile.”
Most conversations about COVID-19 treatments these days revolve around vaccine distribution, but Cropper’s research still has timely implications, given that COVID-19 vaccines primarily have been administered in wealthy countries thus far. If COVID-19 is here to stay in some form, as health officials suspect, then antivirals could be crucial in controlling the coronavirus (and any future variants) in the coming years.
The Biden administration reportedly is aiming to support several large trials that will test whether existing drugs can address COVID-19, and the National Institutes of Health is beginning a major push to develop new antivirals. Policy decisions about distributing antiviral drugs will become even more relevant as effective treatments are discovered and when higher-income nations, like the United States, develop antiviral stockpiles that are large enough to share.
“There are humanitarian reasons for sharing antivirals among countries, in addition to any positive externalities,” Cropper says now, reflecting on her earlier research. “However, quantifying the extent of positive externalities is important and requires tailoring the analysis to the nature of the virus, as researchers are now doing for COVID-19.”
Incentives to Share Information
Also at the event, Anup Malani, a University of Chicago Law School professor and at the time an RFF university fellow, discussed a working paper (later a journal article) he coauthored with Laxminarayan about how early efforts to respond to pandemics require clear information about the spread of the disease and a willingness to cooperate by the nation where the disease originates.
“Discovery of the disease is not automatic,” Malani said. “We’re worried about whether or not countries would reveal that they actually had an outbreak and tell the world community where the outbreak was.”
His research notes that nations which disclose emerging health risks can access foreign medical assistance from other nations that are eager to stop the spread of the novel disease. But nations also have incentives to hide unflattering data or simply avoid devoting resources to monitoring novel diseases, especially if they fear economic consequences from reduced business or travel. Understanding these incentives is critical for controlling outbreaks.
For instance, Malani points to China’s response to SARS in 2003 as an example of a nation weighing the benefits and consequences of transparency—and ultimately opting to conceal the evidence of a disease. “China failed to report the outbreak and allow [World Health Organization] experts to help contain it,” Malani and Laxminarayan write in an accompanying Resources article. “A pathogen that was more virulent and transmissible than either SARS or the recent H1N1 could have done far more damage.”
Using a game theory model, Malani and Laxminarayan conclude that the threat of sanctions influences a country’s willingness to disclose public health data, though they note that being perceived as lacking transparency on public health issues could impose its own economic burdens. In other words, the threat of economic consequences could encourage transparency, given that a “preemptive sanction” imposed on countries perceived by the international community as untrustworthy could hurt business, too. The scholars also stress that efforts to improve disease detection technology might not incentivize nations to disclose outbreaks, given that more definitive information could actually “trigger harsher sanctions.” Instead, they note that monitoring rumors of disease spread could be a way for international health officials to detect outbreaks in nations that might fear disclosing too much information on their own.
Most conversations about COVID-19 treatments these days revolve around vaccine distribution, but Cropper’s research still has timely implications, given that COVID-19 vaccines primarily have been administered in wealthy countries thus far.
The takeaways: nations weigh the possible economic consequences of not reporting relative to reporting, and private information can be as valuable as public information in detecting new outbreaks. These lessons are especially salient today, according to Malani. Reflecting on his 2009 research now, one year into the COVID-19 pandemic, Malani sees close parallels between a nation’s incentive to report an outbreak and an individual’s incentive to disclose adverse symptoms. “If people face costs for revealing true information, you will get less information,” Malani says. “Out of a sample of about 1,900 households in India’s Karnataka state, as part of a serological survey from June to August 2020, only seven people reported symptoms. When we asked why, people said they were worried about being quarantined.
“It helps to think of imaginative ways to control the infection without discouraging reporting,” Malani adds.
Malani’s research also seems prescient in the context of China’s early response to the virus. While a full picture remains elusive for how COVID-19 has afflicted more than a hundred million people around the globe, recent reporting suggests that local officials were slow to sound the alarm about a potential public health crisis in Hubei province, and policymakers in China were reluctant to share information with the World Health Organization as details about the virus began to emerge. The first major warning about the potential dangers of the virus came not from public statements from government officials, but from rumors circulating online; Wuhan-based doctor Li Wenliang had posted about a SARS-like illness that he rightly feared was spreading rapidly.
But if we’re being honest, the first warning signs about the potential for a new pandemic to spread swiftly across the globe came long before Li Wenliang noticed strange symptoms in his patients. A more effective future response will require us to adapt to novel circumstances based on the lessons we’ve learned—during this and prior pandemics—and acting before a new illness takes hold.