Mutually Assured Protection

Strategies for responding to pathogens

(1) The first priority is enhanced pathogen discovery and surveillance. The identification of the viral pneumonia later designated COVID-19 was announced on December 31, 2019, by the Municipal Health Commission of Wuhan, the Chinese city where the virus jumped from animals to humans. But Wuhan did not enter lockdown until January 23—far too late to prevent travel by infected individuals to other cities. Indeed, recent evidence suggests that the virus had already spread well beyond China and beyond.by the last quarter of 2019.

The next pandemic virus likely already exists in an animal reservoir or human host. Scientists know HIV was present in humans as early as the 1950s, and the same may be true of many pathogens considered newer threats. We should develop capabilities to sample these viruses, sequence their genomes, and build new computational models to explore evolutionary trajectories, characterize mechanisms of pathogenesis, and identify high-risk scenarios. We could then complement these discovery tools with information technologies that spot and monitor actual and potential pathogen outbreaks as they emerge. Nations already collect some of the surveillance data that might mitigate pathogen threats, including information on everything from livestock market trends to cell phone movement patterns. But that data needs to be put to better use and combined with insights from new, purpose-designed technologies. Ultimately, we will want much of this data to be transparently shared and integrated into public health decision-making.

(2) Armed with better data and models, the world should also engage in pathogen control, in the tradition of wildlife or forest management, in order to minimize the opportunity for people to be widely infected. Such pre-prevention approaches could include tracking and control of pathogen reservoir species; novel sterilization techniques similar to the trial release of genetically modified mosquitoes to limit the spread yellow fever, dengue, and Zika; or the widespread installation of building-scale protective equipment such as next-generation air filtration systems.

(3) Because some pathogens will overcome even the best precautions, humanity must preemptively prepare to treat infected populations. The third strategy, therefore, should be to create what Noubar Afeyan, the CEO and founder of Flagship Pioneering, has described elsewhere as a capability “primed to develop new treatments and vaccines against novel diseases and deploy them at scale.” Rapid response will not be enough: We need to go beyond being rapid to being pre-armed with the necessary knowledge, and beyond response to readiness. The term instant protection best describes the goal for which we should strive: the construction of a standing research and production pipeline so that new vaccines, antibodies, antivirals, antibiotics, and other agents can be deployed as soon as possible after an outbreak or new pathogen strain emerges. Instant protection would also include the development and stockpiling of interventions that might act as firewalls to slow the spread of pathogens through vulnerable and high-risk populations. AI and machine learning can aid in rapid intervention discovery and development, and agile manufacturing and delivery networks can help with the distribution of vaccines as well as personal protective equipment, sterile glass vials, syringes, and other medical supplies.

(4) Because many pathogens can have highly damaging effects on their hosts for weeks, months or even years after the acute infection has subsided, one final strategy should be long-term mitigation to monitor individuals for disease risk and prior infection and provide suitable protective or therapeutic solutions. As an example, COVID-19 has proven to be a complex multisystem disease with devastating long-term health consequences—many of which we are only beginning to realize. Integral to a worldwide effort to respond to pathogens, therefore, will be technologies to establish and address the vulnerability of individuals and specific groups to these impacts.

Implementing all of these strategies may call for entirely new models of healthcare delivery and international cooperation. As one possible example, it may be necessary to create an international force of healthkeepers, trained in primary care and epidemiology and prepared for rapid international deployment, analogous to armed United Nations peacekeeping forces. These front-line fighters would help local healthcare professionals when required, and they would also gather data and coordinate with public health agencies to look for patterns and tactics to stem a pathogen’s spread. Imagine the impact of an international body of healthkeepers collecting and sharing real-time data from Chinese, Italian, and U.S. clinics in January 2020.

Principles for action against pathogens

Before any strategies for a pathogen response can be implemented, societies will have to agree on a few basic principles for addressing infectious diseases.

The first and most obvious principle is that a global effort must be truly global. During the COVID-19 pandemic, government responses have ranged from swift containment to denial and delay. But whether effective or disastrous, the responses were mostly national. A patchwork of responses allows novel viruses to spread rapidly. Because we live in a global society, we must learn to work collectively; advocates from industry, NGOs, foundations, academia, and patients’ groups must lean on national leaders to cooperate with other governments. Such an effort should be global in another sense: It must address most pathogen threats—not only those with pandemic potential—and encompass every aspect of pathogen defense, from the discovery of new pathogens to the mitigation of chronic health effects associated with infection.

Next, one way to fund an international effort of this importance will be through public investment. Traditional markets lack the incentives to invest in the development, testing, and deployment of systems for pandemic prevention and response. Early in the coronavirus pandemic, world leaders committed around $8 billion for development and deployment of diagnostics, vaccines, and other treatments, but this spending was restricted to COVID-19, and the U.S. did not participate. In place of this reactive and limited approach, health security will require predictable, long-term public funding, with nations investing on their citizens’ behalf in the same way that employers invest to protect the health and productivity of their employees. This is not to say that new private sector reimbursement will not emerge. Part of any global response to pathogens will involve the design and implementation of new business models and associated incentives.

Finally, as we design and build new institutions and processes to fight pathogens, we should adopt a systems view of risk and mimic the defense-in-depth strategy used by high-reliability organizations such as nuclear power plant operators and aircraft carrier crews. Like most large-scale disasters, the catastrophic U.S. response to COVID-19 cannot be traced to a single failure but to a cascade of them. Psychologist James Reason at the University of Manchester, in the U.K., suggests viewing health security as a series of “slices of Swiss cheese” where failures are anticipated but are contained by additional layers of risk mitigation. The first cases of a virus might be detected too late, contact tracing might miss superspreaders, or vaccines might take longer to develop than hoped, but other layers in the system would check and contain these failures. So long as the “holes in the cheese” are not aligned, catastrophe is avoided. “The basic premise in the system approach is that humans are fallible, and errors are to be expected, even in the best organizations,” James Reason writes. In 2020, public health officials have relearned this lesson the hard way.

Flagship Pioneering is actively working to create breakthroughs and build first-in-category companies across every major area described above—starting with Global Pathogen Shield discovery, early warning, and instant protection tools and approaches. According to Noubar Afeyan, “The threat posed by pathogens is to all humanity, not just to a country here and a country there.” It’s time to implement global strategies that will provide broader, more robust defenses than ever before against the scourge of infectious disease.