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.
By Atul Gawande
Assistant Administrator For Global Health
