The big question: Can the world learn to live with Covid-19?

By Romesh Ratnesar,

This is one of a series of interviews by Bloomberg Opinion columnists on how to solve today’s most pressing policy challenges.

Romesh Ratnesar: It’s been nearly a year since the World Health Organization declared Covid-19 a global pandemic. At least 2.4 million people have died from the disease worldwide and an estimated 120 million people have been pushed into extreme poverty. You’re the author of a new book, 'The Plague Cycle: The Unending War Between Humanity and Infectious Disease.' Judged by the length of this pandemic and its severity, how does Covid compare with other plagues over the course of human history?

Charles Kenny, senior fellow, Center for Global Development: In grand historical perspective, Covid-19 is not nearly as bad as say, the Black Death, where a third to a half of the European population died, or the afflictions that hit the Americas after Columbus arrived, where up to 80% or more of the population died. But it’s still awful. And it’s so much more awful than it needed to be.

The interesting thing about Covid is that the first year was basically taken up trying to use responses we’ve known about for a while. On the cover of my book is a picture published in a French newspaper from 1911. It’s an image of Death stalking Manchuria, which at the time was suffering pneumonic plague. That plague outbreak, thankfully, only lasted a few months. And one of the reasons why was that people were masking and they were socially distancing and there were travel restrictions. Those technologies have been around a while, and yet we don’t seem to have got too much better at using them — if anything, we got worse at using them in large parts of the world.

On the other hand, two or three decades ago the technologies behind the Covid vaccines that have been rolled out didn’t exist. We certainly would have been waiting a lot longer for a vaccine even a few decades ago. And a century and a half ago, we would have been waiting forever for a vaccine against Covid-19. So in some ways, we’re in a much better place.

RR: As you note in the book, the world has seen a highly uneven response — countries that had more recent experience with epidemics benefited from having already put into place the necessary measures to deal with this kind of outbreak.

CK: The last big pandemic health scare in the United States was Ebola, which wasn’t really a threat to the US at all. The countries where the last big infectious disease threat was SARS, on the other hand — a disease much closer to Covid-19 — have responded much better.

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If you look at South Korea or Taiwan, they very rapidly locked down and brought this disease under control using testing and tracing and quarantining people who had the infection. The disease is not a public health threat there at the moment in the way that it is here and in most of the rest of the world.

They learned the lessons from SARS, which is that we really need to track and test and so on. Meanwhile we were busy going, “Oh, look, we handled Ebola, it was nothing; we must be well-prepared for pandemics.” Clearly we weren’t ready for Covid-19.

RR: Were there missed policy opportunities that could have stopped this at an earlier stage?

CK: Very early on, the World Health Organization said, Look, this is an infection to really worry about. But in most European countries and in North America, five or six weeks passed after that before governments started to spring into action. Within weeks, the WHO had models for how to design a good Covid test; one of the things we got wrong in the United States early on was not designing and rolling out at-scale testing. I think the WHO largely got this pandemic right. One of the big lessons coming out of this is that if the WHO had had more power and money and the ears of the leaders in Europe and the Americas, this thing wouldn’t have got as bad as it did.

RR: Your book discusses the “exclusion instinct” — how throughout history, the natural human response to disease has been to try to shut ourselves off from it. We’re continuing to see that now, as countries close their borders to try to keep variants of the virus out. Is that sustainable going forward?

CK: The exclusion instinct makes an immense amount of sense if there’s a sick, infectious person near you. Keeping them further away is a wise move as a general rule — it’s what lies behind social distancing, for example. But applying it to borders in the 21st century is the wrong way to do it. The world became a global disease pool, if you will, pretty soon after Columbus hit the Americas. It only took four caravels crossing the Atlantic to bring a chunk of disease over. Those four caravels brought back syphilis to the Old World, which then was spread around, partially by Vasco de Gama going around the coast of Africa and to India. It doesn’t take very many people moving in order to move infections around.

We didn’t manage travel bans well at the start of Covid-19 for a number of reasons. The bans were put in too late. A lot of people with Covid-19 are asymptomatic and we didn’t fully understand the danger of the disease until long after it had already spread across most of the world. Also, when we put the travel bans in place, the immediate result was that a whole load of people traveled to get home because the bans weren’t absolute. Instead, countries said, “In a week, we are going to stop all travel unless you’re a citizen.” That gave people time to respond, time to hop on a plane and time to arrive at incredibly crowded airports, and hang around for hours next to a lot of other people. Exactly the kind of thing you don’t want happening in a pandemic, we helped to make happen.

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The much more effective way to reduce new mutations and the threat of spread is to control this disease where it is out of control. There aren’t new variants emerging in New Zealand or in Taiwan because they’ve got the disease under control. It’s in the places where it is raging and hundreds of thousands or millions of people have it that the problem emerges. So the best response is to use local methods — use social distancing, use lockdowns, use masks to reduce local spread. That’s the way we get this disease under control, not travel bans.

RR: There’s a great deal of frustration about the pace of vaccinations. Does that fit the historical pattern? And should we expect that things will get better?

CK: The global vaccine campaign, much like our response to Covid as a whole, has been terrible, but better than ever before. For a start, we have seen this amazingly fast timeline between the first emergence of Covid-19 and the rollout of very effective vaccines. Usually, that’s a process that takes 10 or 15 years, in the best of circumstances. That we managed to do it so fast is an amazing statement of human ingenuity. Various different countries have produced really effective vaccines, which is also great, because it means we’ve got a wider spread of different types of vaccine, which makes it more likely that some will be more robust against future mutations should they occur. And even if the rather grim forecasts that it will take another two years until most countries in Africa get fully vaccinated turn out to be right — and I hope they’re wrong — that would still be, by far, the fastest ever in history that we’ve managed to vaccinate the entire planet. We wiped out smallpox, partially through a global vaccination campaign, but it was nearly two centuries after the vaccine had been invented.

So we’re moving a lot faster than we have in the past. But we could be moving so much faster, and we could be getting the death rate down so much faster, if we were doing this in a more globally equitable way. I admit I’m part of the problem — I want my vaccine now. And despite the fact that I’m at a much lower risk than an 80-year-old person in Brazil, I want the US government to vaccinate me first. A bunch of people acting like me are pushing the United States to keep the vaccines for itself and sign contracts with vaccine manufacturers saying you can’t sell vaccines to anybody else until you’ve given the U.S. this many vaccines. And that means that more people will die.

RR: You spent 15 years as an economist at the World Bank. When did you start to see a connection between combating infectious disease and economic development?

CK: When I was at the World Bank, everybody was doing what was called cross-country growth regressions. You basically stick all countries’ experiences into one big algorithm and try to explain why some countries grew fast and some countries grew slow. While doing that, I started wondering, why are we only measuring per capita income? I started playing around with health measures, among other things. And I found what others, including the demographer Samuel Preston, had seen before: that if you looked at countries at the same income over time — so, say, a country with a per capita GDP of about $1,000 — the health outcomes they were getting for their money kept on improving. The life expectancy in a country like that 100 years ago might have been 30; now it’s closer to 70. Same money, much better results. And that led me to ask why. And the answer is, we’ve got a whole bunch of cheap health technologies that we didn’t have 100 years ago. We’ve got vaccines, we’ve got antibiotics, we understand about oral rehydration, which stops people dying from diarrheal diseases. So we’ve got all of these new cheap techniques that allow us to save lives at much lower cost. And that sort of led me down the road of looking at what effects that’s had.

In the book, I suggest there are connections between the decline of infection and everything from economic growth to changing social attitudes toward homosexuality to the role of women in society to war and peace and education — name your subject and you can make a link back to the levels of infectious disease declining over the last two centuries. Even with Covid being a very sad coda, it is a good news story. It’s a story of why humans have progressed.

RR: A decade ago you wrote a book called “Getting Better,” which documented this progress, particularly the massive drop we’ve seen in the number of people living in extreme poverty. How much will the Covid crisis jeopardize those gains?

CK: For all of the misery of the last year, to some extent it puts our progress in even starker relief. Covid has knocked us back maybe five years in terms of poverty reduction. It knocked us back maybe a few more, maybe a few less, in terms of life expectancy worldwide. But we’re going to recover those losses and we’re going to keep on seeing progress. It’s certainly not that the world is in a perfect place, or that we’re making progress as fast as we did in many of these dimensions 10 years ago, but I still think that the long-term trend is positive. It’s possible that 2019 marked the peak for global carbon dioxide emissions, for example. As with Covid, our response to the global challenge of climate change has been disastrous, but we are still making progress. I think there’s grounds for optimism, with the caveat that it’ll take a lot of people working really hard to keep on making the world a better place. Without that, we’re stuck.

RR: Speaking of which, in recent weeks there’s been wider acknowledgement among public-health authorities that Covid is going to be endemic and that we’re going to be living with this virus globally for years even decades to come. Drawing on history, what are the implications of this? How can societies successfully deal with endemic disease?

CK: Covid-19 will probably be endemic but a rather minor killer. With the vaccines, only 5% of people still get the virus. If you look at their impact on death rates and serious cases, the effectiveness of the vaccines is above 95%. Put that together with the fact that we hope nearly everybody worldwide will eventually be vaccinated — remember at the start of all of this when people were saying, “Oh, it’s no worse than the flu?” That will become true.

History tells you that even really horrible diseases become comparatively bush league killers, if you make sure you vaccinate everybody and figure out decent treatments. It is what we’ve done with measles. We’re making remarkable progress against malaria, which is a much more difficult disease to wipe out. We know how to turn diseases from major killers into minor killers. And I think all the signs are we should manage it with Covid-19.

RR: What’s the bottom line? What should policy makers learn from history about how to manage future pandemics?

CK: Infectious disease risks are largely a result of progress. They are the result of a lot of people and animals living closely together in a connected environment. They’re the result of urbanization and globalization and all sorts of things that have made the world the place it is today, and a much better place for it. Of course, it’s much easier for a disease to spread globally now than it was 200 years ago. So we really have to be on our game — but not cut ourselves off from the rest of the planet or go back to living in the countryside and so on. We have to take advantage of the massive economic, social and technological power that we’ve been bequeathed by globalization and urbanization to make further progress. That does mean working together, it does mean a stronger World Health Organization, it does mean accepting the fact that the risk of a pandemic somewhere is a risk of a pandemic everywhere. We have to support other countries to be better prepared. And we have to do a better job of preparation here at home, not just for our own sake, but for the sake of the rest of the world.