Epidemics Expert Jeremy Farrar: 'The Most Dangerous Emerging Disease Is Drug Resistance'
British medical expert Jeremy Farrar is a key figure in the fight against Ebola and other infectious diseases. In a SPIEGEL interview, he says that the development of vaccines is key because drug-resistant viruses and bacteria pose immense dangers.
SPIEGEL: Mr. Farrar, the Wellcome Trust has an endowment of around 22 billion and provides close to 880 million to support scientific and humanities research and public engagement each year. What is it like to be the master of so much money?
SPIEGEL: Currently, you are investing around 15 million in Ebola projects, approximately 5 million of that is for the development of Ebola vaccines. Already at the beginning of August, when hardly anyone thought seriously about this possibility, you argued for the use of experimental vaccines in this epidemic. Was that not risky?
Farrar: We do not live in the 19th century. We live in the 21st century. We have to use all the resources available to us, including those of modern science, to stop this epidemic. I think it is possible that this epidemic will continue well into the second half of 2015. If we had a safe and effective vaccine, this could play a major role. Not to mention in future epidemics.
SPIEGEL: You think there will be more outbreaks in the future?
Farrar: Yes, future epidemics are inevitable. There remains a big reservoir of the Ebola virus in animals, probably in primates and forest-living bats. Occasionally, when humans come into contact with those animals, they will get infected. The biggest worry I would have is that, as the virus spreads more widely, it could become established in domesticated animals in rats or in bats that live very close to lots of people in huge cities. So there could be more outbreaks of Ebola in in these big urban centers. To have a vaccine then would be crucial.
SPIEGEL: Is it possible to completely eradicate such an infectious disease?
Farrar: It is possible for some infectious diseases, such as smallpox, but not in an infection that has an animal reservoir like Ebola. Moreover, eradication is only possible with a vaccine. With other interventions -- drugs or behavior change, for example -- this is impossible.
Farrar: Exactly. These are three of the biggest killers in the world and are a very good example of what happens if we don't have a good vaccine available. There has been tremendous progress in all those three diseases, because we found effective drugs. Ten years ago, about 1.2 million people were dying of malaria every year. That figure is now less than 600,000 because of drugs and bed nets. But it is very important to understand we have not defeated these three diseases.
SPIEGEL: Tuberculosis can now be effectively treated with antibiotics.
Farrar: Yes, although drug resistance is a major problem. Some people now compare HIV to diabetes because of effective antiviral treatment. The HIV story has been a massive success over the last 30 years. But whenever drug treatment is the main method of control, development of drug resistance is inevitable.
SPIEGEL: Is that really such a big threat to global health?
Farrar: There's no doubt that the most dangerous emerging disease is drug resistance. Every year, hundreds of thousands of people die from drug resistant malaria, HIV or TB infections as well as from drug resistant infections in intensive care units over the world. Take the phenomenal Chinese herbal drug for malaria -- Qinghaosu, Artemisinin, one of the very, very few true wonder drugs. After about 20 years of use in Southeast Asia, we have started to see Artemisinin-resistant malaria in Cambodia and it's now spreading to Myanmar, Vietnam, Thailand and Indonesia. Inevitably, that could spread to Africa.
SPIEGEL: Resistant forms of tuberculosis have also become a serious threat.
Farrar: Yes, and also in HIV. HIV is not a disease like diabetes. A virus changes, it mutates, and at some stage today's medicines won't work as well. There are only so many targets for new drugs in this virus. I don't think this is going to happen tomorrow. But it will happen at some point. If we have not developed new ideas by then, and this includes developing a vaccine, then the diagnosis "HIV positive" could revert to becoming the same as it was in the 1980s and early 90s. I was a young doctor here in London then when HIV first came to London. It was terrible. All these mostly young people simply died, there was very little we could do. An untreatable infection. But I am not overly pessimistic. If we are innovative and we do the right things, we can stop these events from happening. The world can be better.
SPIEGEL: What other diseases should we be keeping our eye on?
Farrar: Well, the list is long. Chikungunya is becoming more important, a viral disease with high fever and terrible joint pain. It is a huge problem at the moment in the Caribbean and South America, where there have been hundreds of thousands of cases. It is spread by the same family of mosquitoes that spreads Dengue fever. Chikungunya is moving closer to southern Europe, where we have already seen cases of Dengue fever. Dengue is a tropical disease that causes 25,000 deaths worldwide every year, and is increasing and spreading globally. In contrast to the mosquitos that carry malaria, the Dengue mosquito is beautifully adapted to urban living. It benefits from the worldwide trend to urbanization, increased movement and change in environment. The same is true of plague, which is currently causing a major epidemic in Madagascar. There are many people living in very close proximity combined with excellent environment for rats, the host of the plague-transmitting fleas. This makes it easy for the plague to spread.
SPIEGEL: In other words, our modern world, with its unprecedented hygiene standards, also favors the spread of infectious diseases?
Farrar: Yes, in many ways. Even diseases associated with modern living, like diabetes or cancer, can help promote infections because they weaken the immune system. Communicable diseases and non-communicable diseases very often overlap. If you've got diabetes, your chance of getting TB is higher because your immune system is weaker. If you have HIV and it's not treated well, your chances of getting certain cancers are higher. But first of all, infectious diseases are transmitted between people. We are much more interconnected today, we move more and faster and that drives the global spread of these diseases. I was born in 1961 in Singapore and lived on four different continents as a child. When I came to the United Kingdom for the first time, we came by ship. This took eight weeks. If I had been infected with a dangerous disease on that trip, I would either have been dead by the time of our arrival in Southampton or have recovered. I would not have infected anyone in Europe.
SPIEGEL: Today, 40 years later, you could make such a trip in just a single day.
Farrar: It's just remarkable how the world has changed in a single generation. And that has profound implications for the spread of infectious diseases.
SPIEGEL: Before you became the Director of Wellcome Trust a year ago, you spent 18 years leading a large medical research center in Ho Chi Minh City in Vietnam. Southeast Asia is, along with Sub-Saharan Africa, one of the regions that continually produce new infectious diseases. Why is that?
Farrar: New diseases typically arise in places where humans and animals live in close proximity to one another. Pathogens that once only infected animals can adapt to humans, just as the Ebola virus came from bats, HIV from monkeys and influenza from poultry. Sixty percent of the world's population lives in Asia, as do a huge number of the world's chickens, ducks, pigs and other animals of all kinds, both wild and domesticated. This creates the perfect environment for the emergence of new diseases. And interestingly, a trend today is the increased movement of people between Africa and Asia, which will also impact the spread of infections between these continents.
SPIEGEL: What explains the uptick in the number of people travelling between Africa and Asia?
Farrar: As Asian investments in Sub-Saharan Africa increase, the number of flight connections and the number of people moving between these two continents grows exponentially. The number of people from Asia working in Sub-Saharan Africa and vice versa is on a scale that has not been seen in recent times. This will have profound implications for the movement of infectious diseases between those two continents.
SPIEGEL: Did you witness the emergence of new diseases when you were in Vietnam?
Farrar: Yes. I was there when SARS arrived.
SPIEGEL: The respiratory illness that dominated global headlines in 2002 and 2003 and killed more than 700 people. Today it is virtually forgotten.
Farrar: Wrongly! SARS remians a very dangerous virus. A very good friend and colleague of mine, Carlo Urbani, who also worked in a hospital in Vietnam, was the first doctor to notice that something odd was happening. Suddenly, many patients, particularly young people were coming in with very severe respiratory infection. Not only that, but nurses and doctors were becoming infected. He persuaded the hospital authorities to shut down the hospital, so that it was almost impossible to enter or leave. Many people tragically died in the hospital, including himself. But the actions saved the rest of the country, because had he not done so, there is no doubt that Vietnam would have suffered like China, Singapore, Hong Kong and Canada.
SPIEGEL: Did you also see SARS cases in your hospital?
Farrar: That was a worrying time. We had patients with suspected SARS in our hospital, but no confirmed SARS cases.
SPIEGEL: Why did SARS suddenly disappear from public view? Where did it go?
Farrar: We have no idea. We haven't seen it again. It isn't clear whether it has disappeared completely from its animal reservoir or whether it could come back.
SPIEGEL: And where did it come from in the first place?
Farrar: We also don't really know for sure. It probably jumped across to humans from bats and civet cats. It was probably happening at a very low level in southern China for some time, with people having become infected from animals without being able to transmit the virus to other people. Similar to what is happening with the MERS virus in the Middle East
SPIEGEL: a virus which is closely related to SARS.
Farrar: Exactly. But at some point, the SARS virus changed so that it could easily be transmitted from human to human. The question is: Will the MERS virus become a similarly dangerous virus as SARS? And will SARS come back? We do not know.
SPIEGEL: Shortly after SARS disappeared, cases of severe respiratory illness reappeared in Vietnam.
Farrar: Yes. We thought it was the return of SARS, but then we realized that this was a new disease: bird flu, avian influenza.
SPIEGEL: In the case of bird flu, authorities pursued the successful strategy of culling millions of chickens and ducks where outbreaks were identified. When swine flu appeared in 2009, by contrast, the World Health Organization warned of a pandemic that never arrived -- completely exaggerated, it turned out later. Now, with Ebola, experts underestimated the severity of the outbreak for some time. Why is it so difficult to react appropriately to new diseases or outbreaks?
Farrar: The problem is that you need to make decisions early and based on incomplete data. You mentioned the swine flu outbreak in 2009; I was in Mexico when it first started.
SPIEGEL: Were you involved in sounding the alarm?
Farrar: I was involved in the decision process, yes. But you have to imagine, there are four hospitals in Mexico City within the radius of a few kilometers, these were full of young people with very severe lung infections. What do you do? Do you wait three months to see what happens to the epidemic? You have no choice. You need to act. The vaccine production alone takes at least six months. In retrospect, we now know that what we initially saw in Mexico was not typical for the swine flu. Ultimately, 16 to 20 percent of the global population was infected with the H1N1 virus and it mostly caused mild disease. But we did not know that in the initial few weeks.
SPIEGEL: When it comes to Ebola, was the reaction delayed because experts didn't want to make the same mistakes made with swine flu?
Farrar: This will inevitably have been one of the reasons. And the overreaction (in retrospect) to swine flu was influenced by the earlier experiences with SARS and bird flu.
SPIEGEL: Is the World Health Organization still a body that is capable of reacting appropriately to today's crises like Ebola?
Farrar: WHO was established way back in 1948 when the world was a very different place. Today more than ever, we need a global organization to combat diseases and epidemics worldwide. It can't be left to individual states or small groups of states. In Germany, you saw during the swine flu and the EHEC epidemics the chaotic situation that can arise when 16 provincial health ministers are all somehow jointly responsible for the control of epidemics.
SPIEGEL: So everything should be left as it is?
Farrar: I didn't say that. The fact that we need WHO does not mean that it does not need to change and reform. But it must be properly funded. All countries, including Germany and the UK, have reduced their funding for WHO in the past few years. Only with sustained funding from all countries can a reformed WHO attract the best people and have the authority to be the effective global organization we all critically need.
SPIEGEL: Do you believe that social networks might be able to help bring epidemics under control?
Farrar: Definitely, but we're not there yet. Do you remember initial overly optimistic reports of "Google flu trends"?
SPIEGEL: Yes. That was a few years ago. Google claimed that its search engine and data analysis could identify approaching flu outbreaks faster than the authorities could.
Farrar: Yes. In fact, all it could probably predict was the start of the seasons. Nevertheless it shows you in which direction this could develop. Mobile phone technology, for example, may have a very important role to play. Not many have land-lines in Sub-Saharan Africa, but many people have mobile phones. That could be a really important path for communication and information.
SPIEGEL: But false alarms spread via Twitter or Facebook could be quite damaging.
Farrar: We have to accept that there will be some misinformation. But in time, good information will prevail. In West Africa, for example, there was huge suspicion, mistrust and rumors spread initially by the social networks: (People said) Ebola was invented or it was intentionally brought in from somewhere to damage West Africa. Now social media has been incredibly helpful in countering these rumors and as a way to spread the right messages -- for example on how to prevent infection in communities. Communication with the population and trust are absolutely essential during such an epidemic.
Farrar: I think this has to do with the fear factor. Most people only have experience of epidemics from history books, literature and films. There was always someone getting nasty diseases, the plague or the Spanish Flu, or recently the film "Contagion". This stimulates the imagination. Who in Europe over the last 50 years has directly experienced a deadly epidemic? Here, the chances of dying in a road accident are higher. But we must never underestimate the force and impact of infectious diseases. They have not gone away.
SPIEGEL: Mr. Farrar, thank you very much for this interview.
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