These lists are different, built for different purposes, and yet often are read and compared in the same way. Worse, the lists look alike.
They focus on the disease-causing pathogens, specifically. Infectious disease research portfolios are organized similarly. A consequence of this is that we miss opportunities to seek broadly applicable solutions to challenges in preventing and mitigating epidemics.
Why does plague not make the priority lists?
The common response from colleagues is that antibacterial drugs exist and can be easily distributed against plague, in particular fluoroquinolones such as ciprofloxacin, so plague should not be a priority. Ciprofloxacin has been around for years and yet we continue to have significant outbreaks of plague, recently a large one. A list and priority process performed completely differently, however, might ask what resources are needed to stop outbreaks rather than what pathogens need to be stopped. That list might have focused on the need for easily disseminated antibacterial therapies, as soon as they are needed. It might have sparked logistics or drug formulation research. Fights against pneumonic plague, such as those against MERS-CoV, pandemic influenza, and many other pathogens, would be helped by a listed need for better community-based infection, prevention, and control research, leading to measures that are practical, culturally acceptable, and fit for rapid field deployment. Many proactive risk management approaches would benefit from better research on interdicting animal to human crossover events.
A priority list based on necessary functions in the prevention and interruption of emergencies is completely different, and must yield different foci for research than pathogen-based processes that seek to incorporate broader concepts as an afterthought. There are some very specific research funding grant mechanisms that increasingly attempt to target needs that are non-pathogen based. The CEPI and the Defense Advanced Research Projects Agency both have launched calls for proposals that seek novel technology platforms for developing vaccines and other medical products faster, less than the 10- to 20-year horizon presently faced by product developers. The DARPA and BARDA also have funding calls for enhancing how people fight infections generally rather than how to fight a specific infection. These funding practices should be more broadly adopted. However, they are initiatives arising without a supportive discourse about the many actions that must be taken to prevent or mitigate a health emergency, rather than what must be on hand against a specific pathogen.
A modified approach for setting priorities could result in more funding stability, unlike what has been experienced recently. From 2013 to 2016, NIH awards for research on Ebola and related viruses increased 6-fold and funding for Zika virus went from zero to more than 60 million dollars. On the other hand, Nipah virus, Rift Valley Fever virus, and CCHF virus research awards fell 50–100% between 2013 and 2016, despite all three of them being listed in the WHO R&D Blueprint. Applicants for awards must follow the guidance for the grants. When these rapid changes occur, some laboratories must walk away from research progress against important threats to be eligible for continued funding, even when that progress can only be made over time in sustained work.
Finally, this change in strategy—redefining what makes a good list, and how it is used if at all—could have beneficial impacts on mitigating large, transformative infectious disease emergencies that traditional R&D programming finds difficult. Decades of R&D have curbed, but not quelled, HIV, malaria, TB, and cholera from their dominance in impacting vulnerable areas, nor has the impact of pediatric enteric and respiratory diseases diminished in import. These threats are pervasive, despite massive investments over decades toward their mitigation. Although details matter, one reason for their continued circulation may be that we have not looked more closely at those at risk; instead, we have focused too singularly on traditional product development pathways. Compounding this is that R&D goals and regulatory guidance are sometimes absent diverse and evolving perspectives.
No one can predict the future. We must ensure that as we prepare for public health emergencies caused by infectious disease threats, we focus on positively influencing prevention and response rather than too much on the tools themselves. We need a bit less attention on what makes specific infectious disease pathogens different, and more on how they are alike in the ways that they cause outbreaks and impact communities. We should emphasize the question of what we need to do, rather than what we need to have.