Seth Berkley warns of an era of ‘polyepidemics’ as cooperation crumbles

The health of the world’s population exists on shaky grounds amid widespread cuts in foreign aid and the U.S.’s withdrawal from global cooperation. Devex sat down with Dr. Seth Berkley, the former head of Gavi, the Vaccine Alliance, on the sidelines of the Africa Health Agenda International Conference held recently in Kigali, to discuss what this could mean for the world and where priorities should lie. Berkley served as head of Gavi from 2011 to 2023, and now works in advisory roles for organizations, such as the Serum Institute of India, in areas such as vaccines, and other interventions for diseases impacting low- and middle-income countries. His tenure at Gavi included a tumultuous period where there was extraordinary need for international solidarity and cooperation: The COVID-19 pandemic. This cooperation was present in some ways as countries banded together to create COVAX, the world’s attempt at vaccine equity — which Berkley led. But in other ways, it fell completely flat, including when wealthy countries hoarded vaccines. And now, the world is, yet again, in an unprecedented moment as the systems of foreign aid that have existed for generations rapidly crumble, leaving countries scrambling. The U.S. spent an estimated $12 billion annually on global health funding before the Trump administration rapidly gutted the U.S. Agency for International Development. The United Kingdom, Netherlands, and Germany have also announced foreign aid cuts. “I don’t think we’ll really understand the effects of [the U.S. aid cuts] for a year or two. It’s not that there won't be acute things we’re going to see immediately — but how the system rearranges and reprioritizes is what’s going to be critical here.” --— Dr. Seth Berkley, former CEO of Gavi, the Vaccine Alliance Berkley said it will take time to understand the true fallout of what’s transpired in the past two months; vaccines must continue to be prioritized despite dwindling resources; and each country in the world must stand prepared to enter into a new “era of polyepidemics.” The system rearranging The last two months have been confusing for organizations that have worked with the U.S. The Trump administration abruptly halted all programs in January and then began terminating many of them. But in recent weeks there’s been confusion over which projects were actually terminated with some level of finality — as some organizations received termination letters followed by notices rescinding some of those terminations. On the manner in which the U.S. went about dismantling foreign aid, “of course, it could have been done in a different way,” Berkley told Devex. “That’s not the way we normally do these types of things. We normally do them in a planned, careful way to make sure that the harm is as little as it can be.” And it’s also too early to understand the full scope of impacts. “As the financing changes, more broadly, there’s going to be shifts in other funders to make up for important priorities,” he said. If a program was cut, another donor might shift funding towards that programming, but that could move money away from another program they previously funded. “I don’t think we’ll really understand the effects of this for a year or two,” he said. “It’s not that there won't be acute things we’re going to see immediately — but how the system rearranges and reprioritizes is what’s going to be critical here.” Some acute areas Berkley said he’s particularly concerned about are ongoing research, where people are enrolled in critical clinical trials, as well as care for people living with HIV, access to contraception, and other preventative tools. “It is going to be a difficult time,” he said. Investing in vaccinations With fewer resources, prioritizing cost-effective interventions that prevent disease at the primary-care level becomes increasingly critical. “It’s kind of paradoxical, but the richer the country is, the more it can spend money on things that have low cost-effectiveness. The less amount of money [a country] has, the more critical it is to prioritize,” he said. “The real bang for the buck is going to be in primary health care and working at the community level.” He called vaccines “the most cost-effective health intervention,” with an estimated $54 return on every $1 spent. For example, the efforts to eradicate smallpox globally are now paid for in savings, in terms of what it would cost to vaccinate the world’s population annually, and managing the burden of that disease, he said. The world has also made great strides in eradicating polio but reaching that is an “extraordinary goal” and it’s expensive to reach the last mile, Berkley said. The New York Times reported last month that the U.S. terminated a $131 million grant to UNICEF’s polio immunization program. “We can't go back to a world where we have 350,000 polio paralytic episodes a year, which is where we would be if we stopped vaccinations, and if all we do is mitigate it,” he said. “This is something that really needs attention.” U.S. support for Gavi’s core programming wasn’t terminated amid the Trump administration’s mass cancellation of programs but the U.S. Congress must still appropriate funds to the organization moving forward. “It’s going to be really critical to make sure that those [vaccination] programs continue, regardless of the funding stream,” he said. Beyond immunization, clean water, nutrition, sanitation, housing, and prevention of other communicable diseases as well as epidemic and pandemic response and preparedness should be prioritized, he said. And he said this is where the world has seen progress — over the past two centuries, life expectancy has more than doubled. “That wasn’t from CAT scans, organ transplants, and sophisticated activities like that. That was from these basic public health interventions,” he said. An era of ‘polyepidemics’ In recent months, the world’s seen an outbreak of Ebola in Uganda, an mpox outbreak that hasn’t come under control, avian flu spilling over into people, and outbreaks of Marburg in Tanzania and Rwanda — the latter having not seen the disease before. “My own view is we’re going to enter, now, an era of polyepidemics,” he said. This comes as climate change alters the nature of where and how diseases spread, and population growth crowds people in dense settings, often encroaching upon wildlife that leads to zoonotic spillovers. The world’s interconnectedness also means a pathogen can move to a new region by airplane within hours. Looking back about 10 or 15 years ago, there were very few Grade 3 health emergencies — the World Health Organization’s highest ranking for emergencies — Berkley said. “Now, we’ve consistently had more and more of those occurring,” he said. “We’re going to likely see increasing numbers of pandemics. It’s evolutionarily certain.” WHO wrote last year that it’s “responding to more frequent, more complex and longer lasting health emergencies than at any time in its history.” And the threat goes beyond hemorrhagic fevers or respiratory viruses — it includes growing levels of antimicrobial resistance, Berkley said. This happens when pathogens outsmart medicines, which becomes a global problem — and the U.S. cuts to HIV and tuberculosis programming could fuel this. People could stop taking treatment or take half a tablet to try to stretch their pill supply for a longer duration, he said. The U.S. has also played a critical role in global networks of disease surveillance, Berkley said, including the U.S. Center for Disease Control and Prevention serving as one of the world’s best reference laboratories. USAID has also provided staffing to ensure technical experts and testing has been available at outbreak sites. WHO is the lead agency coordinating significant outbreaks, but U.S. President Donald Trump announced the country’s withdrawal from the organization, which includes halting its role in “negotiations on the WHO Pandemic Agreement and the amendments to the International Health Regulations.” In January, U.S. CDC staff were ordered to stop communicating with WHO. “The fact that those two institutions aren’t able to work together has a profound effect,” Berkley said. He added that the pandemic treaty is now “all but dead” and “WHO’s role is obviously diminished in this time period.” And the broader ecosystem is changing. The U.K. also has important reference laboratories and “we don’t yet know how those may or may not be influenced” by the country’s aid cuts, he said. Berkley said in some countries, outbreak preparedness has moved under the umbrella of arms of governments focused on national security, as opposed to health. “I personally like it when it’s in the health area but the advantage of putting it in the defense area is that there’s more sustained, longer-term financing and planning capabilities,” he said. The real global challenge moving forward is ensuring every country is prepared to manage outbreaks with adequate levels of expertise, financing available at the onset of emergencies, and that there’s global logistic systems to move medical countermeasures such as tests, treatments, personal protective gear, and vaccines “to anywhere in the world, at any time,” he said. “It’s easy to say: ‘I want to look after my country,’” he said. “But you are not safe, because you can’t control what will come into your country.”