You know that daydream where you suddenly come into a vast fortune? You could buy a castle or a tropical island hideaway, help out all your friends, do a bit of good in the world. But what if it was a truly incredible sum? What if you had $1tn to spend, and a year to do it? And what if the rules of the game were that you had to do it for the world – make some real difference to people’s lives, or to the health of the planet, or to the advancement of science.
A trillion dollars – that’s one thousand billion dollars – is at once an absurdly huge amount of money, and not that much in the scheme of things. It is, give or take, 1% of world GDP. It’s what the US spends every year and a half on the military. It is an amount that can be quite easily rustled up through the smoke and mirrors of quantitative easing, which is officially the mass purchase of government bonds, but which looks suspiciously like the spontaneous creation of money. After the 2008 financial crash, more than $4.5tn was quantitatively eased in the US alone. All the other major economies made their own money in this ghostly way.
And it is not just governments that have this kind of money. Two of the world’s biggest companies, Microsoft and Amazon, are each worth more than $1tn; Apple stock is valued at $2tn. The world’s richest 1% together own a staggering $162tn. That’s 45% of all global wealth. At the start of 2020, private equity firms held $1.45tn in what they call “dry powder”, and what the rest of us call “cash”: piles of money sitting around awaiting investment. Just imagine what you could do with it.
Since the coronavirus hit, as after the 2008 crash, money has suddenly been found. Tens of trillions of dollars in economic stimulus packages are being chopped up, partitioned, allocated, siphoned. What if we could spend that cash? If only we could divert some of it, scrape a bit here and there from governments and banks, or quantitatively ease $1tn into existence and spend it before anyone noticed. Imagine the possibilities. Imagine what we could achieve.
Let’s take just one example: healthcare. You could eradicate malaria – hell, you could attempt to cure all diseases. Let’s say our aim is to protect humanity from the next pandemic, create a new field of human biology, transform the human experience by curing, preventing or treating all known diseases. If it sounds like I’m getting carried away, all these ideas are projects that scientists are thinking about and even working on, but are hampered by lack of resources.
The full impact of Covid-19 is still playing out. At the time of writing, more than 2 million people have died, while hundreds of millions have had their lives disrupted or economically ruined. The economic impact is at $2tn and rising. But the tragedy could have been even worse. Unchecked, coronavirus could have caused 40 million deaths in 2020, according to a report from the World Health Organization (WHO). The virus itself could have been more virulent, and more deadly, and the miserable fact is that just because we’ve had this coronavirus doesn’t mean we can’t get another, even worse, pandemic. Covid-19 has changed the world, and its tragedy will be felt for years, but we need to use it to raise awareness of the threat of pandemic diseases. It gives us an inkling of the threat to the world from the climate crisis. Our response to this pandemic shows we can adapt and change our lifestyles, and it shows that, when needed, governments can find money to spend – and particularly on public health projects.
We knew the risk posed by pandemics. The UK maintains a risk register, a catalogue and assessment of the emergencies that could befall the country, and top of the list, at the start of 2020, was an influenza pandemic. Large-scale exercises in 2007 (code-named Winter Willow) and 2016 (Cygnus) showed what might happen to the health service, the economy and the population if a 1918-style disease took hold. We knew what was at stake, and now we have firsthand experience.
In 2018, one disease infected 228 million people and killed about 405,000, mostly children under five, and mostly in sub-Saharan Africa. That disease, malaria, has been with us for ever. The disease has killed perhaps half of all humans who have ever lived. Malaria is the world’s greatest scourge, but it is preventable and curable. In fact, we’ve done well: deaths from malaria have been halved in the past 20 years. But still it clings on and, if we’re looking for projects to stretch us and create a genuine legacy, the defeat of humanity’s most deadly enemy has a certain ring to it.
So that’s coronavirus and malaria on our list. What else might we be able to eradicate if we had $1tn to spend?
Tuberculosis is a bacterial disease that kills almost 2 million people each year, overwhelmingly in poor and middle-income countries. The factor holding back eradication has not been a lack of understanding the biology of the disease, but a chronic lack of resources, and the growth of resistance of the pathogen to our bacterial treatments. We can change this. We can tackle other tropical diseases, too, such as schistosomiasis, a debilitating parasitic disease that affects 200 million people a year.
But let’s think bigger even than curing all infectious diseases. Picture a world free of all disease. Thousands of scientists and doctors are striving to treat and cure the world’s biggest killers: cancer, cardiovascular disease and neurological disease. With an injection of cash, we could boost their chances, and see if we could transform the entire human experience by removing all illness. But if you want to make immense gains in public health on a global scale, and make them sustainable, there is one serious, ambitious, difficult, complex and expensive thing that needs to be implemented. This doesn’t seem to be something that is talked about or invested in by billionaires: universal healthcare.
The World Bank published its first analysis of global health, the World Development report, in 1993. Targeted at government finance ministers, the report showed that health expenditure could improve prosperity as well as individual wellbeing. To mark the 20th anniversary of publication, an international Lancet commission put together an investment framework to achieve what they call a “grand convergence” in health by 2035.
By this, they mean bringing deaths from infectious disease in low- and middle-income countries, as well as child and maternal deaths, to the levels seen in the best-performing middle-income countries: China, Chile, Costa Rica and Cuba. A grand convergence, the paper predicts, could prevent some 10 million deaths in 2035.
The team hammers out four key messages. First, the economic argument that is most likely to be repeated in the corridors of power: the returns from investment in healthcare are big. By avoiding long periods of poor health, we increase the value of additional life years (VALYs, in healthcare acronym jargon), which generates an economic return that outweighs the healthcare investment we’ve put in by a factor of between nine and 20. It’s striking that spending what seems like a huge sum of money will often deliver big economic returns.
The second point is that the convergence is achievable in less than a generation. Presumably this means that investors can look to make money relatively quickly, too. Governments can be confident of balancing their books fairly soon after a large initial outlay. To be able to see an effect in a matter of years helps turn the convergence from a vision document to actionable policy.
The third point is that governments are underusing fiscal policies in healthcare. In other words, by increasing the tax on tobacco and alcohol, deaths from noncommunicable diseases and from injuries can be sharply reduced in low- and middle-income countries. For example, a 50% price increase in cigarettes in China would prevent 20 million deaths and produce tax revenue of $20bn annually in the next 50 years. The same price increase over the same time period in India would save 4 million lives and bring in an extra $2bn a year in tax. Reducing the subsidies paid to fossil fuel companies also has the effect of improving general health, mostly through the reduction in respiratory diseases.
But it’s the fourth point that is most important for us: that universal healthcare is the most efficient way to achieve a convergence in global health. The Lancet’s framework was written before Covid-19, but the response of various countries to the crisis shows that universal healthcare is a good protector for pandemics, too.
Jeremy Farrar is director of the Wellcome Trust, one of the world’s largest medical research charities, with an endowment of about £30bn. As someone with experience of problem-solving in global health, he is well placed to advise us on how to spend the trillion dollars. “The bedrock of your spending must be on universal healthcare,” he told me. An equitable system of healthcare is necessary to improve maternal health, child health, to improve end of life care and to fight epidemics. “Almost anything else is not equitable, not efficient and will not deliver what you need sustainably.”
By the middle of 2020, when there were more than 2.5 million coronavirus cases in the US, and when numbers were growing at an alarming rate, Cuba had reported just 2,448 cases in a population of 11.3 million. One reason for their success in controlling the outbreak is likely to be the country’s strong healthcare system. Cuba has 8.19 doctors per 1,000 patients, which is the highest ratio in the world.
A trillion dollars isn’t enough to change the world’s healthcare system, so here’s an idea. We allocate some of our money to setting up a system of universal healthcare in one country. This country becomes a flagship, an advert to other countries of the benefits of universal healthcare.
I want to choose a large country, so that the transformation is both a challenge and a beacon. Take Ethiopia, for example. With a population of 100 million, Ethiopia has a large economy but only about three doctors per 100,000 people. Maternal and child mortality is relatively high, mainly because most births take place in homes, without the presence of a trained modern midwife. Poor sanitation and inadequate nutrition exacerbate health problems.
If we helped transform Ethiopia’s healthcare system, of the many benefits, one would be that trained professional medics would be more inclined to stay in the country rather than emigrate. We’ll need to look at and learn from other places, including Indonesia, with its ambitious attempt to introduce a system of universal healthcare, Jaminan Kesehatan Nasional, which by 2019 covered 221 million people, or 83% of the population.
So there’s some of our money to be spent on a demonstration of universal healthcare. Another good chunk should go to vaccines, both development and deployment. If this wasn’t considered much of a priority before the coronavirus crisis, it is now. We all understand only too well now that the development, testing and equitable distribution of a vaccine is a huge and costly undertaking, with results that are far from guaranteed.
The battle against polio provides a good illustration of the task we face. The disease is caused by a virus that mostly affects children, and can lead to irreversible paralysis and sometimes death. The eradication effort has been a huge success, with cases dropping from 350,000 a year in 1988, to just 33 in 2018.
The virus that causes polio was endemic in 125 countries in 1988, but today remains so in just two, Afghanistan and Pakistan. However, the virus is highly infectious. A single infected child could lead to hundreds of thousands of new cases a year around the world. So it must be completely stamped out, just as smallpox was eradicated in 1980. We could incentivise the push to eradication by increasing the funding, safety and resources for staff working in these incredibly challenging areas. In northern Nigeria, dozens of healthcare staff working to vaccinate and eradicate polio have been killed by gunmen thought to be members of Boko Haram. We will also need to improve the understanding of the safety of the polio vaccine to increase uptake. In Afghanistan, for example, we will need to counter the spread of anti-vaccine propaganda. In all countries, we will improve disease surveillance and data collection to better monitor the progress of eradication, and work to address people’s basic needs – fresh water, food supply – in remote areas where the virus clings on.
The effort to eliminate the polio virus has prevented 1.5 million deaths, and 18 million cases of paralysis.
In 2019, the WHO made a list of things it considered major health threats, including the problem of what it diplomatically calls “vaccine hesitancy” – which is at least as big a problem in rich countries such as the US, the UK and Japan as it is in poorer countries. The drop in the numbers of people willing to be vaccinated was a major concern even before coronavirus; it’s that much greater now, in the Covid era.
Vaccine hesitancy produces a terrible toll. In Japan, a fall in the numbers of people taking the HPV vaccine in 2013 (owing to coverage of a cluster of adverse effects) is predicted to lead to 5,000 deaths from cervical cancer that could otherwise have been prevented. As well as exposing people to illness and death, vaccine reluctance and outright anti-vaccine propagandists prevent eradication of diseases.
The WHO included on its 2019 list, with admirable foresight, a threat labelled “disease X”. Effectively they left a blank space that “represents the need to prepare for an unknown pathogen that could cause a serious epidemic” – a blank space duly filled the following year by Sars-CoV-2, which (almost certainly) crossed from bats and started spreading between humans.
Actually, it was quite predictable that a serious disease would cross over from animals. Other examples include HIV, rabies, anthrax, Ebola, flu, Mers and Sars (both from the coronavirus family) and bubonic plague. All of these are zoonotic diseases that jumped from animals. A lesser-known zoonotic virus, Nipah, is of serious concern. It crossed from fruit bats to pigs to humans and was first picked up in the Malaysian village of Nipah in 1999. It has a shocking death rate of between 40% and 75% (compared with 3% for coronavirus).
There is no treatment or vaccine, and if the virus mutated and became more easily transmitted between people – well, you can see the problem. We need an international institute for pandemic protection and response, perhaps working under the umbrella of the WHO.
In 2009, when the H1N1 swine flu pandemic threatened to take hold, the vaccines that were developed for it were snapped up by rich countries. Gavi, the Vaccine Alliance, is an international body that subsidises the cost of vaccines so poorer countries can afford them, and this is something we should do for any coronavirus vaccine, if it is not done by the goodwill of world governments (and we can’t rely on that). We should also support the Coalition for Epidemic Preparedness Innovations (Cepi), an organisation working on vaccines for many emerging diseases, including Covid-19. Cepi has an immediate need for $2bn to complete vaccine trials, but then more to ramp up manufacturing capacity to make sure there is enough vaccine for everyone who needs it.
It sounds like a lot of money, but it will pay for itself when we are able to facilitate the return to a normal kind of working life and economy. Our investment would support Cepi’s mission to provide successful vaccines fairly and affordably.
We can help boost vaccination rates around the world, but we can also change the dial at a basic, research level. The development of vaccines is still largely based on a 200-year-old technology, and we have vaccines for fewer than 30 diseases. As well as Covid-19, effective vaccines against HIV, malaria and TB would be transformational.
Then there are the emerging infectious diseases that have been identified just since the 1940s – more than 320 of them. We will fund new approaches to vaccine development, including RNA and DNA vaccines. These contain the genetic instructions to make proteins found on the surface of a disease-causing viral or bacterial cell. When the body is given the genetic vaccine, its cells read the instructions and make these proteins. This stimulates the immune system to mount a response, so provides protection if the real pathogen is ever encountered. The Pfizer/BioNTech and Moderna vaccines are both RNA vaccines.
If we can create a universal flu vaccine, we would be protected from what is still one of the greatest health threats to our species: the emergence of a flu pandemic. It’s the thing we were worried about when coronavirus came along, and perhaps the fact that Covid-19 was caused by a coronavirus and not an influenza virus is what wrongfooted the response of some governments. The development of a universal flu vaccine is therefore vital, and would help counter the rise of antimicrobial resistance. The evolution of superbugs immune to treatment, the problem of antibiotic resistance, is another item on the WHO threat list. Each year more than 1.5 million people die because the thing infecting them is resistant. It’s a problem that could easily escalate.
We can add to this. Jessica Metcalf, an infectious diseases biologist at Princeton University, has proposed a Global Immunological Observatory, a global programme of immune-system sampling from the general public that would allow scientists to pick up signs of new pathogens as they emerge.
For malaria, we can add to the World Health Organization’s efforts. The WHO is putting $8.7bn a year into its 10-year malaria strategy. If we added, say, $100bn, what could we do? The classic idea in epidemiology is to eliminate the common cold by giving everyone a wonder drug at once. Bingo, cold gone. With our windfall we could try to ensure that everyone in need, throughout the world, received the best available antimalarial drugs (at the moment, the artemisinin-based combination therapy). But, even with our money, we can’t reach everyone in remote places and, without also controlling the mosquito population density, malaria will come back instantly. So we’d need to fight the insect as well as the disease. Malaria is caused by a parasitic microorganism, Plasmodium, carried by a mosquito. We’ve tried over the years to eradicate it, but, every time, the parasite or the insect – or both – have clung on, evolved resistance to our control methods and bounced back.
So we need to take out the mosquito reservoir, and to do that we need a method of beating evolution. Target Malaria, an international research consortium, is working on a solution. They want to use a method of genetic modification called gene drive, which causes female insects to become infertile, but in a way that has proven immune to the evolution of resistance.
Rolled out on a big enough scale in the wild, with a huge modification and breeding programme, we can eliminate local populations of malarial mosquitoes. If you are wondering about the ecological wisdom of eliminating an entire species from an area, it’s a valid concern.
But note that we have often tried to eliminate mosquitoes using chemicals, which have horrendous and damaging off-target effects, so removing one species without insecticide is an improvement on that. In addition, few animals rely on malaria mosquitoes for food: a study looking at the effect of getting rid of mosquitoes found that removal is unlikely to have a big impact on the local ecosystem.
It seems outrageous – hubristic, even – to suggest that we can cure, prevent and treat all disease by the end of the century. But Cori Bargmann, a geneticist and neuroscientist who heads up the Chan Zuckerberg Initiative, takes the long view. “Going back in time a similar distance, much of modern medicine would have been unthinkable,” Bargmann says, “from organ transplants and deep brain stimulation to treating cancer by manipulating the immune system.”
In 80 years, we will almost certainly have made changes that make our best medicine look like crude guesswork. We may even have reduced the incidence of illness and disease to that of extreme rarity.
When the dust settles on the Covid-19 disaster, we should have learned that preventing disease from spreading – or at least limiting it as much as possible – not only spares lives and improves our physical and mental wellbeing, but also saves jobs and the economy. And we will understand that prevention of illness through vaccines has to be equitable and it has to be global. Investment now in healthcare and in preparation for future threats prevents deaths and economic destruction later. And it opens the way to a longer, happier life – it opens the way to achieving more human potential.
• This is an edited extract from How to Spend a Trillion Dollars: Saving the World and Solving the Biggest Mysteries in Science by Rowan Hooper, published by Profile and available at guardianbookshop.com