50833 THE World Bank People, Pathogens and Our Planet Volume 1: Towards a One Health Approach for Controlling Zoonotic Diseases rEPorT no. 50833-GlB Agriculture and Rural Development Health, Nutrition and Population People, Pathogens, and Our Planet Volume 1: Towards a One Health Approach for Controlling Zoonotic Diseases Report No. 50833-GLB THE WORLD BANK AGRICULTURE AND RURAL DEVELOPMENT HEALTH, NUTRITION AND POPULATION © 2010 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org/rural E-mail ard@worldbank.org All rights reserved. This volume is a product of the staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. 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Johnson; Buffalo in Kenya by Curt Carnemark Contents ACKNOWLEDGMENTS v A B B R E V I AT I O N S A N D A C R O N Y M S vii FOREWORD ix E X E C U T I V E S U M M A RY xi The Impacts xi The Constraints xii The Actions xii Financing Needs and Funding Mechanisms xiv 1 Addressing Zoonotic Diseases at The Animal-Human-Ecosystem Interface 1 The Threat 1 2 Drivers of Emerging Zoonotic Diseases 7 Drivers in Human Living Environments 7 Drivers in Food and Agriculture Systems 9 Drivers at the Earth and Ecosystems Level 10 3 One Health 13 The Barriers to Change 14 Glimmers of Hope 20 4 Making One Health Operational 25 Adopting One Health 25 Institutions and One Health 26 The Current International Situation 30 Avenues for Improvement at the International Level 31 Building on Achievements 32 iii Contents 5 Funding Needs and Funding Mechanisms 33 Funding Needs 33 Funding Mechanisms 36 Annex 1: Economic Losses from Zoonotic Diseases 39 Annex 2: Basic Assumptions Regarding Financing Requirements 43 Annex 3: Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystem Interface 47 Annex 4: One World One Health: From Ideas to Action 51 References 53 iv Acknowledgments This report was prepared by staff from the World Bank with support from a number of other organizations. The team was led by Jimmy W. Smith (World Bank), and consisted of Cornelis de Haan, Gunnar Larson, and Silvia Robles (World Bank), and Ulrich Sperling (SAFOSO Inc.). Special input was also provided by Ron Bergevoet (Agricultural Economics Research Institute at Wageningen University); Esther Schelling (Swiss Tropical Institute); Jan Slingenbergh (FAO), who con- tributed to Chapter 2; and Purni Narayanan (Consultant, Health Canada), who helped with the discussions on SARS in Canada. The team is grateful for the contributions made by the following peer reviewers: Armin Fidler, Yewande Awe, Brian Bedard, Sandra Cointreau, Stephane Foreman, Jean Kamanzi, Francois Le Gall, Abel Lufafa, Laurent Msellati, Piers Merrick, Juan Pablo Uribe, Monica Des Gupta, Nwanze Okidegbe, Olga Jonas, and Nancy Morgan (FAO-World Bank liaison). The team is also thankful for the comments provided by Paul Gully (WHO), Joseph Domenech (FAO), Alain Dehove (OIE), and Osman Monsoor (UNICEF) on behalf of their respective organizations. The final product remains the responsibility of the authors. The team also thanks Juergen Voegele and Mark Cackler of the World Bank's Department of Agriculture and Rural Development for their guidance and support. The World Bank wishes to thank the Department for International Development (DFID) of the United Kingdom for their valued support of the Livestock Trust Fund, which contributed to the development of this report. v Abbreviations and Acronyms ASF African swine fever AHICP Avian Influenza Control and Human Pandemic Preparedness and Response Project ALive Partnership for African Livestock Development ALU average livestock unit AMA American Medical Association ARI advanced research institution AMVA American Veterinary Medical Association AU-IBAR African Union/Interafrican Bureau for Animal Resources BSE bovine spongiform encephalopathy CBPP contagious bovine pleuropneumonia CDC Centers for Disease Control and Prevention CFEZID Centre for Food-borne, Environmental and Zoonotic Infectious Diseases CITES Convention on International Trade in Endangered Species of Wild Fauna and Flora CSCHAH Canadian Science Centre for Human and Animal Health CVO Chief Veterinary Officer CWGESA Cysticercosis Working Group in Eastern and Southern Africa DALY disability-adjusted life year DFID Department for International Development DZC Danish Zoonosis Centre EID emerging infectious diseases EIN Emerging Infectious Diseases Network FAO Food and Agriculture Organization FETP Field Epidemiology Training Program FMD foot-and-mouth disease FVE Federation of Veterinarians of Europe GAO General Accounting Office GEIS Global Emerging Infections Surveillance and Response System GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GF-TADs Global Framework for Progressive Control of Transboundary Animal Diseases GLEWS Global Early Warning System for Major Animal Diseases GPAI Global Program for Avian Influenza vii Abbreviations and Acronyms GPHIN The Global Public Health Intelligence Network H5N1 not an acronym; avian influenza A HPAI highly pathogenic avian influenza IDRC International Development Research Centre IFPRI International Food Policy Research Institute IHR International Health Regulations INAPs integrated national action plans IOM Institute of Medicine MDGs Millennium Development Goals MRSA Methicillin-resistant Staphylococcus aureus OECD Organisation for Economic Co-operation and Development OIE Office International des Epizooties (World Organisation for Animal Health) OWOH One World One Health PHAC Public Health Agency of Canada PHEIC public health emergency of international concern PPR Peste des petits ruminants ProMED Program for Monitoring Emerging Diseases PVS Performance of Veterinary Services SAPUVET Sanidad Publica Veterinaria SARS severe acute respiratory syndrome TSE transmissible spongiform encephalopathy UNEP United Nations Environmental Programme UNICEF United Nations Children's Fund UNSIC United Nations System Influenza Coordination VPH veterinary public health WAHID World Animal Health Information Database WHO World Health Organization WWT Wildfowl and Wetlands Trust WCS Wildlife Conservation Society WNV West Nile virus ZVED National Center for Zoonotic, Vector-Borne, and Enteric Diseases viii Foreword Emerging and re-emerging infectious diseases that have the po- tential to become pandemic occur with alarming regularity, and a substantial majority of these are zoonotic in origin--that is, transmissible from animals to humans. Developing prepared- ness through effective surveillance and control systems has been complicated for a number of reasons, not the least of which have been the difficulties of establishing reliable communica- tions and consultation between public health and veterinary health agencies. Today we know that these channels of com- munication must be expanded to include monitoring of wild species and the health of ecosystems. Both natural habitats and those environments that are managed by humans, such as agricultural production systems and food supply chains, are habi- tats in which pathogens can emerge, circulate, change dynamics, and sometimes cross-host species. Recognition of the interrelat- edness of the respective health domains and of the risks that zoonotic diseases represent to public health has led to appeals for more horizontal interaction among the disciplines and the sector agencies, departments, and ministries that are responsi- ble for public health, medical professions, veterinary services, and the environment. The idea of "One Health," as it became known, would as- sume urgent practical significance in late 2003 with the emer- gence of highly pathogenic avian influenza (HPAI). Since then, the prevention and control of avian influenza have been in the crosshairs of high-level international attention, most notably at a series of ministerial-level meetings held in Beijing and Bamako in 2006, New Delhi in 2007, Sharm el-Sheikh in 2008, and a One Health consultation in Winnipeg in 2009. While the Global Program on Avian Influenza (GPAI), developed in re- sponse to the spread of HPAI, did not fulfill all the aspirations of One Health, it did establish a precedent of considerable prac- tical significance for emerging infectious zoonotic diseases. That progress now has to be built upon and developed further by the international organizations and national agencies whose man- dates involve disease prediction, prevention, identification and response, and control--including institutions that deal with ecological issues and wildlife health. While the general concepts are now well accepted, how to implement the One Health concept is still not clearly understood. ix Foreword Developing an institutional framework that control system that is established primarily for builds on the model of the GPAI and that broadens emerging infectious zoonotic diseases with pan- its scope to cover future pandemics is a global pri- demic potential can be readily improvised to ority with a wide consensus. One of the issues its address the endemic diseases that are a priority in planners need to confront is which aspects of that many developing countries, few of which have framework can be applied to long-standing en- the capacity or resources necessary to monitor or demic diseases that pose little or no risk of becom- control them effectively. Making One Health oper- ing pandemic, but that impose severe human and ational represents an extraordinary opportunity for economic costs on the developing countries in convergence and synergy between the priorities of which they persist. Many of these endemic diseases industrialized countries and those of developing are confined to the tropics, or have been effectively countries. This paper discusses the practical issues controlled in industrialized countries for genera- involved in making One Health a reality, and tions. Yet they clearly carry practical significance to argues that supporting the development of the the One Health perspective, recognizing the inter- national and international capacities and infra- relatedness of health issues in all domains. Because structure required to do so is a highly appropriate the burden of these diseases fall overwhelmingly area of investment on the part of the international on the poor, they pertain directly to the poverty development community. and health-related Millennium Development Goals (MDGs), and their control is therefore a Juergen Voegele global public good, even though many of them are Director, Agriculture and Rural Development local or national in range. A global surveillance and The World Bank x Executive Summary Whether living in urban or rural environments, humans tend to perceive the world around them as being shaped by culture and industry more than by natural history. Humans, however, are part of a biological continuum that covers all living species. Charles Darwin's 200th birthday in 2009 could serve to remind us of this. All animals, including humans but also plants, fungi, and bacteria, share the same basic biochemical principles of me- tabolism, reproduction, and development. Most pathogens can infect more than one host species, including humans. In 1964, veterinary epidemiologist Calvin Schwabe coined the term "One Medicine" to capture the interrelatedness between animal and human health, and the medical realities of preventing and controlling zoonotic diseases or "zoonoses" ­diseases that are communicable between animals and humans. One Medicine sig- naled the recognition of the risks that zoonotic diseases pose to people, their food supplies, and their economies. Given the interrelatedness of human, animal, and ecosystem health, the ra- tionale for some form of coordinated policy and action among agencies responsible for public health, medical science, and vet- erinary services is quite intuitive. Later, the term "One Health" came into use, and later still, the broader concept of "One World One Health," which is today used to represent the inextricable links among human and animal health and the health of the ecosystems they inhabit.1 THE IMPACTS Even as hunter-gatherers, humans were at risk of contracting diseases from the animals they used as food. The domestication and rearing of livestock in ever-increasing numbers and in close proximity to expanding human populations increased the risk of disease in both populations. While humans learned through experience and scientific research how to reduce that risk, the persistence of emerging infectious diseases of zoonotic origin was underscored early in the 20th century by the flu pandemic of 1918­1919 and later in the century by HIV/AIDS. More recently still, the emergence of severe acute respiratory syndrome (SARS), 1 "One World One Health" is today a trademark of the Wildlife Conservation Society. xi Executive Summary H5N1 (highly pathogenic avian influenza--HPAI), the balance between different species and can and influenza A(H1N1) has pointed to our contin- enable individual species to become dominant. The ued vulnerability. These diseases also have major second type of destabilizing factor occurs as the economic impacts. The emergence of BSE, SARS, result of increased interaction between human and H5N1, and influenza A(H1N1) have caused over wild ecosystems. This interaction gives rise to more US$20 billion in direct economic losses over the last opportunities for the exchange of pathogens, decade and much more than US$200 billion in in- including transmission to "naïve" or unprotected in- direct losses. Should HPAI evolve to relatively se- dividuals. Farming near rainforests, the consump- vere global pandemic--a prospect that has not yet tion of bushmeat, and ecotourism are examples of been eliminated--estimated losses of US$3 trillion the types of interactions that can create opportuni- have been projected (Gale 2008). Aside from ties for pathogens to "jump" species. Case studies emerging infectious diseases, the less headline- often reveal the two pathways to overlap and to grabbing but highly under-reported "neglected result in spillovers of pathogens into cultivated diseases" such as tuberculosis, brucellosis, and ecosystems. various forms of zoonotic parasitosis result from livestock to human transmission and impose sig- THE CONSTRAINTS nificant health burdens--most of which are borne by poor people. One of the most essential factors in the control of Despite important scientific progress, a variety any new emerging health risk is early detection of of forces drive the increased incidence of emerging the disease and understanding of its epidemiology. infectious diseases seen today. Intensified farming This can enable the agencies responsible for disease and concentration of animals, pressure on food control to attack the disease at its source, reducing production systems, and increasing global move- its spread and preventing it from becoming en- ment of people, animals, and animal products have demic. A number of cases visited in this document, led to evolutionary pressures on pathogens that including West Nile virus (WNV) and H5N1, re- present an expanding array of risks. The changing veal the persistence of avoidable time lags between demographic composition increases the global the emergence of a new disease and the implemen- share of vulnerable people. Public awareness of the tation of an appropriate control strategy. The risks of zoonotic diseases and political commit- delays can be attributed to a variety of reasons. ment to containing them tend to fade over time Limited human capacity and poor physical facili- after an outbreak has run its course and as other ties often cause emerging new diseases to remain priorities such as financial and food price crises unnoticed, particularly in the developing world. and climate change become more prominent. The Reporting is often delayed out of fear of the eco- continuity of resources devoted to disease surveil- nomic losses likely to result from trade bans and re- lance and control has therefore remained an duced tourism. However, delays are also caused by enduring concern. the piecemeal nature of work undertaken by pub- The sources of zoonotic disease are not limited lic health, veterinary, and environmental agencies to humans and their livestock. They extend to (and acting in isolation from one another along nar- from) wildlife as well, and this source is the most rowly sectoral lines. Discrete, purely disciplinary significant. Wildlife ecosystems are characterized approaches have led to delayed diagnoses and by a fine-tuned, dynamic balance among all their sometimes misdiagnoses of diseases and disease components, which consist of flows of organic and risks, and to the formulation of incomplete and in- inorganic matter and energy as well as living or- effective control strategies by public institutions ganisms. While pathogens are very much part of that do not effectively communicate with each this balance, they are prevented from exceeding other until the disease has spread widely. certain levels of prevalence through negative feed- back cycles such as induced resistance or host pop- ulation size. Conceptually, two types of factors can THE ACTIONS destabilize wild ecosystems and their role in global For professionals working in sector agencies, deter- health. The first is destruction and fragmentation, mining one's role begins with the question "What for instance through deforestation, which destroys am I responsible for?" The answer tends to be xii People, Pathogens, and Our Planet defined bureaucratically according to the division remains an area of marked weakness in many of labor that distinguishes the work of different resource-poor countries, is an important area of agencies. Overall, this makes for a vertical orienta- potential convergence and a necessary condition tion by the respective agencies concerned with dif- for more effective priority setting. Such a priority ferent aspects of an issue such as a newly emerging setting would identify "hot spots". Hot spots refer disease. Changing the organization of work across to those contexts in which climatic, social, and eco- disciplines to start with the question "What needs to nomic conditions--including the state of sanitation be done?" implies a substantial reorientation along infrastructure and services and the proximity of horizontal lines in which regular communication humans and animals--provide a particularly takes place between staff at work in different disci- favorable environment for diseases to emerge or plines and sectors. Substantial consensus can now re-emerge within. be found among informed human and animal health authorities, scientists, and policy makers that Joint Preparedness Planning effective prevention and control measures against emerging and re-emerging infectious diseases will The Global Program for Avian Influenza (GPAI), require multisector strategies and active collabora- and especially the preparation of the integrated tion across professional disciplines. This does not national action plans (INAPs), has shown the imply an amalgamation of work but rather the potential gains from joint planning exercises creation of a culture in which, for example, a veteri- between public health and veterinary services. nary epidemiologist is more likely to (and indeed More attention is still needed to reduce transaction expected to) relate findings of potential significance costs and to ensure that these plans are and remain to his or her counterparts working in public health. realistic and implementable, for example, through In fact, in this example, the veterinary epidemiolo- simulation exercises. gist is not just expected to communicate these find- ings, but doing so is an integral part of his or her Communicating Consistent Messages professional responsibilities, just as making practi- cal note of the findings is part of the public health Action is required at two levels. First, human and practitioner's responsibilities. In this setting, the veterinary health channels to communicate infor- epidemiologist who fails to share information about mation about disease outbreaks need to be harmo- a new pathogen in pigs, or a public health official nized. Currently in most countries, human and who fails to duly note it as something to monitor, are animal disease agencies have different and often both culpable of negligence. Responsibility is no completely separated disease reporting systems. longer conveniently divided according to bureau- Direct lines of communication at all (local provin- cratic mandate, and oversights are no longer the cial and national) levels of One Health actors need unfortunate but understandable byproduct of gaps to be established. Second, communication of the in jurisdiction. different agencies on a disease outbreak needs to be The actions that need to be taken to bring about coordinated. As shown in several instances, in- such a working environment apply to both national cluding the ongoing influenza A(H1N1) outbreak, and international institutions. National govern- different agencies often issue contradictory state- ments are, however, the principal agents, with ments to the outside world in the case of a new international agencies playing a largely supporting disease outbreak. It is essential that issues such as role. Improved coordination among public, veteri- how emerging diseases are being handled be nary, and ecosystems health agents will rely on the explained to the general public in a coherent way. following measures. The public, and in particular the different partici- pants in the animal source food chain, needs to un- derstand clearly the rationales behind existing Consultation on Priority Setting disease control strategies and the level of emer- Zoonotic diseases often fall between the foci of gency status an emerging infectious disease is agencies and institutions that specialize in human attributed at any given point in time. They also health, veterinary services, and wildlife conserva- need to understand the safety issues involved in tion. Developing capacity for risk analysis, which animal products that originate in affected areas. xiii Executive Summary Exchanging Select Staff and Sharing place through the exchange of memoranda of Facilities agreement among the different sector agencies concerned. The body itself may consist of or be With a proper legal framework and appropriate served by a number of working groups. training, certain select public health activities could · Coordinating authority conferred as a func- be shared--for instance, in surveillance by human tion of executive office, such as a prime min- and animal health field agents. Surveillance staff ister or deputy minister, who is served in this can especially be linked at the grassroots level. capacity by an advisory committee that oper- Sharing facilities such as transport and cold storage ates with his or her authority. facilities, once the risk of cross-contamination is ad- · Special One Health teams, composed of rep- dressed, can greatly enhance surveillance capacity resentatives of the human, animal, and and result in significant economies of scale. ecosystem institutions, with particular re- sponsibility for diseases at the animal- Strengthening Education human-ecosystem interface. A review of curricula, with more emphasis on · Creation of an independent agency for public epidemiology and the wider effects of ecosystems health, including zoonoses and food safety. on human and animal health, is needed because The prospective institutional architecture for global public human and veterinary health services must surveillance and control is also considered. How shift from controlling to preventing diseases. World ecosystem health and wildlife organizations will be Organisation for Animal Health (OIE) initiatives represented in this architecture will be an impor- that support developing countries in devising more tant issue to resolve. The challenge of systematiz- appropriate veterinary curricula can lay the basis ing disease reporting internationally will entail for future generations of veterinarians to be better the establishment of clear financial incentives to acquainted with the One Health concepts. encourage early reporting and enforceable legal Providing the Appropriate Incentive restrictions to discourage under-reporting. Framework Incentives that lead people to place a premium on FINANCING NEEDS AND collaboration and resource sharing would need to FUNDING MECHANISMS be introduced. This can include shared budget lines between different agencies and systems of matching The funding requirements of a global surveillance grants, with increased cooperation leading to and control system are considerable. According to increased budgetary support. An overall increase in the Strategic Framework document Contributing to funding would have to be based on the results of the One World, One Health, presented at the Sharm el- risk assessment. Sheikh Ministerial Meeting, covering the 49 least- developed countries that are IDA eligible over the Providing an Appropriate Institutional next decade will cost an estimated $800 million an- Framework nually. This report argues that funding through conventional time-bound, project-based invest- If the current levels of cooperation that have been ments is inadequate for this purpose, and that more built around the GPAI are not institutionalized into reliable, sustained flows of financial resources will a more permanent arrangement, this cooperation is need to be established. How this longer-term fund- likely to fade. In that case, new cooperation mech- ing will be secured, and from what sources, are anisms will have to be improvised in the event of questions that will require purposeful deliberation. each new outbreak. A number of institutional al- Among international foundations and OECD ternatives suggest themselves, based in large part (Organisation for Economic Co-operation and on the current level of development that prevails Development) countries, emerging zoonoses that within a given country. have pandemic potential are generally the princi- · Apermanent body that coordinates the prepa- pal concern and are the most likely to attract ration and regular update of contingency substantial commitments of resources. Resources plans to deal with the eventuality of an out- may also become available through partnerships break. The coordination function might take between health organizations in developing xiv People, Pathogens, and Our Planet countries and those in industrialized countries. The more pressing priority. This report finds substan- imposition of levies on the trade of commodities tial latitude for synergy in the overlap between that are associated with zoonotic diseases, such monitoring the risk of pandemic diseases and as meat and pharmaceuticals, is also raised as a monitoring the risk and incidence of persistent en- possible source of funds. demic diseases. Both categories of disease are Surveillance and control systems that focus on likely to be found in similar conditions. Monitoring pandemic diseases can be applied to other diseases both therefore focuses purposefully on hot spots. as well. This represents an important area of con- An integrated surveillance system would not vergence between industrialized and developing discriminate between pandemic and endemic dis- countries, which sometimes have different priori- eases because the two are inextricably intertwined. ties with respect to disease control. Industrialized Areas that are heavily burdened by existing countries often focus more on managing the risk of diseases are also areas in which new diseases are pandemic diseases, in part because most endemic most likely to emerge, and some proportion of diseases have been under control in these countries these will have the potential to become epidemic or for years or even generations. In many developing pandemic. In this way a system that is put into countries, where these long-standing diseases place with the primary purpose of detecting pan- have never been effectively controlled, and where demic risk can be organized to track existing the human and economic costs associated with diseases as well, and to do so more economically them have remained high, these diseases are a than maintaining separate systems. xv 1 Addressing Zoonotic Diseases at The Animal- Human-Ecosystem Interface THE THREAT The Spanish flu pandemic that killed between 50 and 100 million peo- ple between 1918 and 1919 had largely faded from public memory by the late 1990s and early 2000s, when outbreaks of SARS and HPAI took place (Taubenberger and Morens 2006). The emergence of influenza A(H1N1) in March 2009 provided still another reminder of the persis- tent risk of emerging infectious diseases of zoonotic origin or zoonoses--diseases that are transmissible from animals to humans. This class of diseases has been the principal source of emerging health risks. Of the 1,415 known human pathogens, 61.6 percent are of animal origin (Cleaveland et al. 2001) On average, a new disease has emerged or re-emerged each year since the Second World War, and 75 percent of these have been zoonotic (King 2004). An analysis published in 2008 found that of 335 emerging infectious diseases in the US, between 1940 and 2004, 60 percent were zoonotic--more than 70 percent of which came from wild species (Jones et al. 2008). A mutation or re-assortment of the H5N1 virus could lead to the deaths of several million people worldwide, and to the deaths of over 1 million even in a relatively mild pandemic form (Burns et al. 2008). In addition to the potentially catastrophic impacts that zoonotic dis- eases have on human life and human health, the economic losses asso- ciated with these diseases are also enormous. The direct costs of outbreaks over the last decade surpassed US$20 billion--including pub- lic and animal health service costs, compensation for lost animals, and production and revenue losses to the livestock sector, and over US$200 billion of indirect losses to affected economies as a whole (see Annex 1). When indirect costs such as losses in other parts of the animal product chain, trade, and tourism are included, these costs multiply. In the UK, between 1990 and 2008, economic losses from bovine spongiform en- cephalopathy (BSE) totaled some US$7 billion (Pearson 2008). The out- break of SARS in East Asia and Canada led to losses of between US$40 and $50 billion (Box 1), and HPAI in East Asia alone has caused US$10 billion in direct losses to the livestock sector (Naylor et al. 2003). A number of less headline-grabbing "lingering" zoonotic and other diseases also cause significant human and economic losses. These "neglected zoonoses" such as rabies, bovine-induced human tuberculosis, brucellosis, and echinococcosis are major causes of mor- bidity and mortality among poor people. They are also almost cer- tainly the most under-reported diseases. More than 55,000 people die of rabies each year, and about 95 percent of these deaths occur in Asia 1 Addressing Zoonotic Diseases at The Animal-Human-Ecosystem Interface Box 1: SARS in Canada Canada experienced its first case of SARS when a Chinatown area. Canadian real GDP dropped by an guest of the Metropole Hotel--ground zero--in Hong annual rate of 0.3 percent during the second quarter Kong returned to Canada in February 2003. By August of 2003, the time period corresponding with the SARS of that year, there were 438 suspected cases of SARS crisis (Government of Canada 2003). in Canada, including 44 deaths. Health-care professionals working on the front lines The epicenter of the SARS infection lay in Toronto of the SARS crisis carried much of the disease burden. and its surrounding suburbs, an area that is home to In addition to social effects such as stigmatization and 5.3 million people and a thriving scene for the isolation, and psychological effects such as guilt or business, science, and arts communities. Canada's worry about spreading the disease, more than 100 economy suffered as vacationers and business health workers became ill and three died due to travelers avoided visiting the country. The accommo- probable SARS. Health-care costs soared. SARS- dation and food services sectors are estimated to have related and major one-time health costs for the declined by US$4.3 billion dollars between March province of Ontario reached $824 million in and September of 2003 (Keogh-Brown and Smith 2003­2004 (Government of Ontario 2005). 2008). The Conference Board of Canada estimated The handling of SARS by public health authorities losses of $570 million from the travel and tourism emphasized the fundamental need for a stronger sectors in the city of Toronto during 2003, and $222 public health system in Canada and a stronger integra- million from Pearson International Airport, a major tion between public health and emergency response Canadian airport and a hub for international flights systems. Provincial and municipal health authorities (Conference Board of Canada 2003). responded to the immediate medical threat of SARS, While many abroad chose not to travel to Canada, but issues such as outbreak containment, timely those living in Toronto attempted to minimize their access to laboratory results, surveillance, information risk of exposure to SARS. Restaurants, shops, and sharing, and communication to the public remained theatres remained empty, especially in the popular inconsistent and an ongoing problem. and Africa. Of the 1.6 million annual human deaths made sanitary standards a focal point of food trade from tuberculosis, between 2 and 8 percent is esti- policy. mated to be of bovine origin (Cosivi et al. 1998). The monetary costs of reduced productivity and The World Health Organization (WHO) reported market losses resulting from uncontrolled zoonoses that in 2005 alone 1.8 million people died from are often difficult to allocate per sector. In the public food-borne diarrheal diseases such as Escherichia health sector, these costs relate principally to diag- coli, Campylobacteriosis, and Salmonellosis. Food- nosis, treatment, and hospitalization. In the private borne pathogens were estimated to cost up to US$35 sector, they relate largely to out-of-pocket expenses billion in 1997 in medical costs and lost productiv- to the patient or animal owner, and to a variety of op- ity in the US (WHO 2007). A recent World Bank portunity costs. Comprehensive cross-sectoral analy- report estimated direct and indirect losses from sis can be applied to estimate the monetary benefits food-borne disease in Vietnam could be up to US$1 of control by sector, allowing proportional allocation billion per year (World Bank. 2006). Many of these of intervention resources. Such analyses have been food-borne disease-related costs are grossly under- carried out for brucellosis, echinococcosis, rabies, reported. A large proportion of these cases can be and Trypanosoma rhodesiense. Their results point to attributed to the contamination of food and drink- the high payoff and cost-effectiveness of control in- ing water including the contamination of those terventions--costing US$25 or less per disability-ad- sources by infected humans. The issue of food justed life year (DALY) averted (Roth et al. 2003; safety and the threat of zoonotic diseases being Coleman et al. 2004; Budke et al. 2005; Knobel et al. transmitted through food supply chains have 2005; Budke 2006; Fevre et al. 2008). 2 People, Pathogens, and Our Planet Recognizing the interrelatedness of the human flu-bearing animals."2 At WHO headquarters in and animal health domains that is manifest in Geneva the following month, a Meeting on Avian zoonotic diseases, the magnitude of these threats, Influenza and Human Pandemic Influenza brought and the need for more purposeful consultation be- together an even wider range of participants in tween medical and veterinary health, in the 1960s addition to health ministers. Among the proposals concerned scientists and science policy makers made at the meeting was one for the international began appealing for more systematic communica- community to support individual countries in tion with One Medicine. These would evolve into a developing integrated action plans. The proposal more expansive vision of One Health in which the would lead to the development of the integrated concept of active interdisciplinary collaboration national action plans now used for surveillance was extended to cover the additional domain of and response throughout much of Africa. Summ- wildlife health, including the health of ecosystems ing up the proceedings, the WHO Director General and the wildlife inhabiting them. One Health is the also stressed the need to reduce the viral burden subject of Chapter 3 of this report. It was the re- of H5N1 through "timely notification of outbreaks emergence of avian flu that prompted the interna- in birds, poultry culling and vaccination as indi- tional community into action, and while the global cated, including `backyard' flocks, and provision campaign against avian flu did not fulfill this aim, of appropriate compensation for farmers" (WHO it did make a number of important strides that war- 2005)." rant building upon in pursuit of the longer-term In Beijing in January 2006, the government of vision of One Health. China, the European Commission, and the World While the prospect of a global pandemic caused Bank co-sponsored the International Pledging by HPAI did not lead to the fulfillment or realiza- Conference on Avian and Human Pandemic tion of One Health, it did galvanize enormous in- Influenza, and was supported by the governments ternational resolve and unprecedented global of the United States, Japan, and many others. There collaboration. The importance and urgency of the the international community pledged US$1.9 bil- threat from HPAI were illustrated by the Secretary lion in financial support and held extensive discus- General of the UN naming David Nabarro as his sion on prospective coordination mechanisms, the representative and high-level coordinator of the parameters of a common strategy, and reiterated UN System response--the creation of the United the earlier meetings' call for emphasizing action at Nations System Influenza Coordination (UNSIC), the national level. Eleven months later, at the which has been indispensable to the global re- Ministerial Meeting and Pledging Conference on sponse. This was followed by a series of high-level Avian and Human Pandemic Influenza held in meetings that provided direction, and created and Bamako, Mali in December 2006, participants preserved momentum. In Ottawa in October 2005, agreed to the compensation guidelines that had an International Meeting of Health Ministers is- been prepared by the UN's Food and Agriculture sued a communiqué declaring their agreement that Organization (FAO), International Food Policy "a multi-sectoral approach, beginning with the Research Institute (IFPRI), OIE, and the World animal health and human health sectors, must Bank, and pledged an additional US$475 million in underlie global efforts towards coordinated pan- support. demic planning," and that the immediate global At the New Delhi International Ministerial public health issue is to work collaboratively with Conference on Avian and Pandemic Influenza in the animal health sector to prevent and contain the December 2007, the Indian government pre- spread of the H5N1 virus among animals, and sented its Road Map for the control of HPAI and from animals to humans." While the focus of the offered its use to the global community. Participants meeting was on H5N1, the international coordina- called for the formulation of a strategic framework tion, capacity building, and communications and pledged an additional US$400 million. The con- strategies they advocated applied to emerging sultation document Contributing to One World, One zoonotic diseases in general, including the formu- Health was subsequently tabled at the Sixth lation of veterinary policies with provision for "advice to farming communities to ensure appro- priate animal and public health standards for the 2 Global pandemic influenza readiness: an international meet- raising, handling, and transport of potentially ing of health ministers. Communique, October 25, 2005. 3 Addressing Zoonotic Diseases at The Animal-Human-Ecosystem Interface International Ministerial Conference on Avian and threat may be downplayed by many public Pandemic Influenza in Sharm el-Sheikh, Egypt in officials, however much it remains recognized October 2008. There the technical details of the by medical and veterinary authorities. Barring Strategic Framework were discussed, and the doc- the still-very-real possibility of the virus's re- ument was subsequently translated into a series of emergence in a new and more virulent form, the "key recommendations" at the Expert Consultation GPAI, for instance, will eventually run its course. on One World, One Health in Winnipeg in March For the time being, the program remains in place 2009. These are included at the end of this report as not only to provide resources to continue to fight Annex 2. The next Ministerial meeting on Avian the persistent threat of avian flu, but also, as of June and Pandemic Influenza will take place in and be 2, 2009, to fast track an additional US$500 million hosted by Vietnam in April 2010. from the World Bank to help countries finance The series of international meetings reflects an emergency operations to prevent and control out- unprecedented level of international cooperation, breaks of A(H1N1). Figure 1 illustrates the enor- which while it continues to exist, represents a mous success achieved in terms of pandemic profound opportunity to create an integrated preparedness by the global effort. It also illustrates international surveillance and control system. The that there is still considerable work left to be done. urgency of capitalizing on this opportunity arises It is therefore opportune to take stock of what out of changing priorities as the threat of an HPAI- has been learned from the experience of controlling related pandemic has faded from public awareness HPAI and to consider how the lessons of this expe- and as international attention has shifted to other rience can inform sustainable international pre- emerging issues such as food prices, the financial paredness for future emerging and re-emerging crisis, and climate change. The persistence of the infectious zoonoses. Figure 1: Global Pandemic Preparedness UN System Pandemic Preparedness Map Overall level of pandemic preparedness Sudden Pandemic Contnigency Planning More prepared Medium Less prepared The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Source: United Nations Pandemic Influenza Contingency, Office for the Coordination of Humanitarian Affairs. (Interactive map available at http://www.un-pic.org/web/) 4 People, Pathogens, and Our Planet The sum total of needs that prevail within the human, livestock, and wildlife health domains is Figure 2: Interacting Health Domains beyond the scope of any one discipline, and is certainly beyond the scope of this report. The focus of One Health, then, is on areas of conver- Ecosystem Services gence, in which these needs overlap and interact, and which therefore generally excludes diseases that lack the potential to jump species--from an- Humans imals to humans (Figure 2). This report examines the One Health concept as a framework for fos- tering more effective control across sectors. It also identifies a number of barriers to making Domestic Wildlife Animals the concept operational, including governance and institutional issues at local, national, and in- Ecosphere ternational levels, and considers ways to over- Zoosphere come them. Finally, it examines funding needs Climate One Health and prospective funding mechanisms for the control of emerging infectious diseases of animal the question of how to make it operational raises origin. While a broad consensus exists with re- a variety of issues that this report attempts to gard to the merits of the One Health approach, illuminate. 5 2 Drivers of Emerging Zoonotic Diseases The factors that drive the emergence of new diseases can be usefully classified into those that occur in one of three environments: in the en- vironment in which humans live, in the food and agriculture system, or in natural ecosystems. In human living environments, changing consumer demand, ur- banization, human and animal population density, the proximity of humans and livestock, changing demographics, increasing mobility, rates of poverty, and the deteriorating state of public health and vet- erinary services all serve as drivers of emerging and re-emerging zoonotic diseases. In food and agriculture systems, the number of livestock, the spatial concentration of livestock production, the exis- tence of mixed biosecurity regimes, growth in the export of animal source products, inappropriate vaccination and drug use, and ex- ploitative farming systems are prominent factors. In natural ecosys- tems, the effects of human encroachment and adverse land use such as deforestation, poaching, and trade in live animals and bushmeat carry considerable consequences in terms of habitat fragmentation, biodiversity loss, and climate change. For a variety of reasons, the emergence of pathogens within these domains is on the increase, as is the exchange of pathogens between them (Woolhouse 2008; Taylor et al. 2001). A more detailed descrip- tion of the factors driving increased disease emergence in each domain follows in Figure 3. DRIVERS IN HUMAN LIVING ENVIRONMENTS Changing Consumer Demand and Dietary Habits Increasing demand for animal source foods is being driven by both human population growth and rising incomes. Per capita GDP in developing countries is expected to increase 4.6 percent between 2010 and 2015 (World Bank 2008). The expenditure elasticity for meat in low-income countries is 0.78, and in middle-income coun- tries is 0.64.3 Per capita consumption of meat in the developed world would increase from 76 kg in 1993 to 83 kg in the developed world and from 21 to 30 kg in the developing world over the same 3 Percent increase in expenditure on an item with a 1 percent increase in total expenditure. 7 Drivers of Emerging Zoonotic Diseases Figure 3: Interplay of Three Host Health Domains Human living environments - increasing population density and growth - increasing human mobility - growing poverty and inequality - increasing susceptibility - changing dietary habits - diminished quality of governance and service - lack of infrastructure Food and agriculture systems Natural ecosystems Disease - expanding agricultural production - human encroachment and emergence, - increase in stock numbers land use re-emergence, - globalization of production and - deforestation persistence supply - climate change - peri-urban livestock production - habitat fragmentation - spatial clustering of production - biodiversity loss plants - hunting, poaching, bushmeat - excessive scaling up of single plants trade, - irregular use of drugs and vaccines - unregulated tourism - trade in live animals and animal products - mixing small, medium, and large- scale production Source: Adapted from Institutes of Medicine 2009. period (Delgado et al. 2001). This increase of con- substantially reduce the risk of diseases in these set- sumption of animal source foods is driving the tings is often very limited. rapid expansion of the livestock sector in devel- The populations of eastern and southern Asia oping countries. make up over 50 percent of the world population. FAO estimates that China alone accounts for half the world's standing population of domestic pigs Urbanization and Human and Animal and an estimated 5.5 billion birds including Population Density chicken, ducks, and geese. The global distribution of emerging infectious disease events in humans The human population is also becoming more reflects this human and livestock density (Jones urban, and population density is therefore increas- et al. 2008). ing. More than 50 percent of the global popula- tion now lives in urban areas. In many urban and Changing Demographics peri-urban areas, people raise, and even share dwellings with, livestock as well as their pets. This Factors such as aging populations, the prevalence of level of proximity between humans and animals is a HIV/AIDS, the proportion of the population that is critical risk factor for zoonotic disease. Many of undernourished (notably the number of pregnant or these cities are in humid areas, and many have no lactating women who are undernourished)--in sanitation services or available means to dispose short, any demographic development that increases of wastewater or organic material. People often the number of people who are immunocompro- buy their meat at outdoor wet markets, where the mised fosters a favorable environment for the emer- animal is not inspected before it is slaughtered. gence and spread of infectious diseases, among Public awareness of hygiene measures that can which zoonoses are generally prevalent. 8 People, Pathogens, and Our Planet Mobility increasingly globalized, and the transport of ani- mals and animal products have become so extensive Populations are also becoming more mobile, espe- that food safety hazards and emerging infectious cially as incomes rise, and this dramatically facili- disease risks can travel rapidly and widely. tates the spread of diseases that can be transmitted between people. Outbreaks of infectious diseases The number of livestock is increasing rapidly in order that remained isolated to specific localities in the to meet rising demand for animal source products. past are far more likely to spread given this mobil- FAO estimates that the number of food animals ity. In 2008, the World Tourist Organization re- being processed each year will increase from about ported that international tourist arrivals reached 21 billion currently to about 28 billion in 2030. The 924 million, and this number is expected to increase major share of this growth will be supplied by to 1.6 billion by the year 2020 (World Tourism developing countries, where, between 2001 and Organization 2009). There are newly emerging pat- 2050, meat production is expected to rise 1.8 percent terns of movements of irregular migrants from the annually (FAO 2006). less-developed parts of the world to the developed countries in search of better opportunities. In addi- The Spatial Concentration of Livestock tion, it is estimated that there are 12 million inter- Production nally displaced people in Africa alone. This mobility implies also the mobility of culture, health The increase in animal numbers had led to a sig- beliefs, food preferences, and hence epidemiologi- nificant restructuring of how production is orga- cal factors (Apostolopoulos and Sonmez 2007). nized spatially, perhaps most notably in peri-urban Circular, intraregional, and irregular migrants may areas, and particularly with respect to pig and carry a higher risk of infectious diseases such as poultry production. The scale of large commercial tuberculosis (Markel and Stern 2002). farms has increased dramatically, and has become concentrated in relatively small areas. In Brazil, Poverty 85 percent of hens and 56 percent of pigs are con- centrated in 5 percent of the country's area. When Poor, food-insecure people are more vulnerable to transport facilities are poor, these large farms typi- both emerging and lingering zoonotic diseases. cally concentrate in peri-urban areas. With im- Rabies and livestock-induced tuberculosis and proved transport, large farms tend to move away brucellosis, for instance, are predominantly found from large cities to areas with abundant feed sup- among the poorer strata of the population. plies (Steinfeld et al. 2006). In Thailand, for exam- Impoverished people are moreover less likely to ple, in 1992 there were an estimated 1,700 chickens visit a health provider, thus reducing the chance per square kilometer within the 50-kilometer ra- for early detection of a new disease. In some areas dius of Bangkok and only an estimated 100 chick- poverty leads to greater reliance on bushmeat, ens per square kilometer within the 300-kilometer which represents one of the most direct risks of radius of the city (Steinfeld et al. 2006). contracting a zoonotic disease. Mixed Biosecurity Regimes Deteriorating government public health services and stagnating public health and veterinary budgets Livestock producers vary widely in their capacity in many countries have seriously limited disease to protect livestock from disease and to manage surveillance and other preventive operations (World disease risk at the farm level. Much of this variation Bank 2009). relates to the size of the enterprise, the scale of pro- duction, and the amount of capital that is available DRIVERS IN FOOD AND to its operators. Larger commercial producers can generally afford to invest in more sophisticated AGRICULTURE SYSTEMS forms of biosecurity than small producers, who Food and agriculture systems constitute a major continue to operate with little if any biosecurity. artificial ecosystem in which diseases can emerge Little attention has been given to innovations that or re-emerge. Many food supply chains involving can help small producers meet their biosecurity animals and animal products have become needs in their resource-poor circumstances. The 9 Drivers of Emerging Zoonotic Diseases coexistence of modern and traditional production, the system can introduce new disease agents often in close proximity to one another, poses mu- or present existing agents with opportunities to tual risk. Pathogens that are endemic remain a per- "escape" the habitat they are a natural part of. A sistent threat to both (Slingenbergh et al. 2004; variety of human activities may generate ecologi- Slingenbergh and Gilbert 2008). cal vacuums that are filled by invasive predators or parasites that may carry diseases that indigenous Export of animal source products has grown faster species lack immunity to (Slingenbergh et al. 2009; than production, as global trade has expanded by Sakai et al. 2001; Daszak et al. 2000). 6 percent per year and now constitutes about 13 While human and domestic animal diseases do percent of total food export, reaching US$37 billion sometimes affect wildlife, pathogens that are trans- in fresh and frozen meat and $20 billion in live food mitted from wildlife to humans, often through do- animals (International Trade Centre, UNCTAD mestic animals, are considerably more numerous and WTO 2009). (Cleaveland et al. 2001). These include HIV, Ebola, SARS, H5N1, Nipah, and hantaviruses, Lyme Inappropriate vaccination and drug use are also factors disease, Crimean-Congo hemorrhagic fever, tick in livestock and food chain systems. The inadequacy encephalitis, and West Nile virus. A number of of the health systems causes gaps in vaccination pathogens, including HPAI, have been transferred coverage and suboptimal use of drugs, leading from wild species to domestic ones in recent years. to drug resistance and hence increased risk of A diverse reservoir of influenza viruses circulates newly emerging pathogens. Adding antibiotics to also in wild birds, and contacts between these birds livestock feed for nontherapeutic purposes is and domestic poultry and pigs are common. These another cause of induced resistance to antibiotics in contacts lead to human exposure and to the ex- animal source foods. Methicillin-resistant Staphy- change of viruses and genetic material between hu- lococcus aureus (MRSA), circulating in pigs and mans and animals. These contacts lead to human calves and now a major threat in hospitals, is an exposure and to the exchange of viruses and example of the results of inappropriate drug use. genetic material between humans and animals. The pandemic risk these materials pose varies Exploitative farming systems in which working by type. RNA viruses, for instance, are known for conditions and animal housing conditions are poor their built-in instability, and their tendency to un- and prone to hazardous interactions between dergo replication errors gives them greater poten- livestock and humans, and between livestock and tial to invade any novel host niches that may be wild species, should also be considered. These available. Arthropod-borne viral infections are settings are well suited not only for the flare-up of prominent among the group of emerging disease novel agents, but perhaps more importantly, for agents, sometimes becoming manifest at medium- the persistence of existing agents, adding to the to-high latitudes. Insects, bats and birds, as well as endemic disease burdens that are already in place. humans are renowned spreaders of disease agents The interplay of complex factors provides opp- between continents. ortune environs in which many pathogens co- circulate. Most emerging disease events take place in these unregulated conditions, characteristic of Major Changes in Land Use and production throughout much of the developing Agricultural Intensification world. Once isolated, these hot spots are today The rapidly growing livestock sector has been a prin- increasingly connected to the larger world through cipal driver in the conversion of natural habitats into trade and human traffic in a context of globalization. pastures and cropland. More land was converted for the growing of crops between 1950 and 1980 than DRIVERS AT THE EARTH AND in the preceding 150 years (MEA 2005). The intensi- fication of agriculture with ever-increasing use of in- ECOSYSTEMS LEVEL organic fertilizer, together with increasing livestock In natural ecosystems, pathogens are natural density, has been a major source of water pollution, elements of biological diversity, balance, and re- and often provides favorable environments for novel silience. The impacts of human encroachment on pathogens to emerge in. 10 People, Pathogens, and Our Planet Land Use Change, Deforestation, Habitat (Institute of Medicine 2009). A Congressional Fragmentation, and Biodiversity Loss Research Service report estimates the illegal global trade in animals at a minimum $5 billion and Major land-use changes, including intensification potentially in excess of $20 billion annually and deforestation, lead to a variety of impacts on (Congressional Research Service 2008). ecosystems, including pollution, fragmentation of habitats, and changing host-pathogen dynamics. Degraded ecosystems with diminished biodiversity Climate Change tend to favor opportunistic or generalist species, many of which are disease reservoirs. Deforestation Changes in long-term and seasonal weather pat- in tropical regions is advancing at the rate of about terns will have major effects on disease behavior 130,000 square kilometers annually, driven by cat- such as spreading patterns, diffusion range, and in- tle ranching and feed production in Latin America, troduction and persistence in new habitats. The ex- by tree crop (oil palm) plantations in Southeast tension of vector habitats will be a major factor in Asia, and by smallholder farming in Africa. The ef- the impact of climate change on the spread of in- fects of habitat fragmentation on host-pathogen dy- fectious diseases, as, for example, shown by the ex- namics were evidenced in the epidemiology of the pansion of Rift Valley fever in East Africa. It might Nipah virus in Southeast Asia, where deforestation lead also to the emergence of novel pathogens and and large forest fires destroyed massive numbers of vectors such as the recent outbreaks of bluetongue indigenous fruit and palm trees. This caused the disease among sheep in Europe that was caused by fruit bat, the main transmitter of the Nipah virus, to a virus carried by a small African midge known as change habitat to mango trees in populated areas Culicoides imicola. The vector appeared in southern that were associated with pig farming. As a result, Europe in 2000 and led to the evolution of novel pigs became infected and transmitted the disease Culicoides species that also transmit the bluetongue to humans, causing a major outbreak of encephali- virus. The spread of the virus into more temperate tis with extremely high mortality. This led to a zones was very likely facilitated by the warming Malaysian government-sponsored culling program trend in the region's climates. of 1.1 million pigs. The evidence presented in this chapter corrobo- rates the vital need for a more complete under- standing of the drivers in the human and animal Increased Hunting, Poaching, zoosphere, and in particular in considering the and Bushmeat Trade health of the overall ecosphere in developing early It is estimated that 4.5 million tons of bushmeat are warning and response systems for the detection, extracted from the Congo basin each year. This prevention, and control of emerging and lingering meat is often consumed only partially cooked, thus zoonotic diseases. How the One Health approach bringing the principal source of a zoonotic pertains to this understanding, and how it can be pathogen in direct contact with human beings applied operationally at the interface of animal- (Wolfe et al. 2005). human-ecosystem health, are the subjects of the following two chapters respectively. Volume 2 of this report will discuss in more depth the drivers of Trade in Live Animals emerging and re-emerging diseases and how these Both legal and illegal trade in live animals has in- may be mitigated. In a perfect world, the subject creased rapidly over the last decades and is a major matter of Volume 2 would have preceded that of factor in the spread of diseases. While exact total this volume. The urgency of dealing with the issues figures are not available, the Institute of Medicine at the interface of the animal-human-ecosystem (2009) puts the figure at several US$ billion domains prompted this inversion. 11 3 One Health In the twentieth century, human and veterinary health professionals became increasingly specialized and technically, institutionally, and even culturally separate. During the 1960s, Calvin Schwabe, who many consider the founder of veterinary epidemiology, questioned the wisdom of so rigid a division of labor. In 1960, Dr. Schwabe coined the term "One Medicine" to capture the interrelatedness be- tween the health of different species, and to recognize the importance of reducing the risks that zoonotic diseases pose to people, their food supplies, and their economies (Schwabe 1964). In 1975, the FAO, OIE, and WHO followed suit in a joint report on The Veterinary Contribution to Public Health Practice, which established veterinary public health (VPH) as an area of cooperation among the three orga- nizations that years later would become an important facilitator in formulating an international response to avian flu. (VPH will be considered in greater detail below in Chapter 4.) The concept of One Health was later broadened to encompass the health of ecosystems as well as human, domestic animal, and wildlife health. In September 2004, the World Conservation Society convened a symposium at Rockefeller University titled "One World, One Health," based on the 12 Manhattan Principles appealing for more pur- poseful and systematic channels of communication among human, animal, and wildlife health services. The idea also involved a rejection of reductionist or piecemeal approaches and an embrace of systems thinking to accommodate intricate social and environmental interac- tions (Forget and Lebei 2001). The principle was perhaps best defined by the American Veterinary Medical Association Task Force in 2008 as "the collaborative efforts of multiple disciplines working locally, na- tionally and globally to attain optimal health for people, animals and our environment" (American Veterinary Medical Association 2008). One Health is used to refer to a more integrated or holistic approach to human, animal, and ecosystem health. Events would bear out the arguments for greater collaboration between public and veterinary health. During the early outbreaks of HPAI in Hong Kong in 1997, the disease was seen as one of domestic poultry. Only later were wild bird species implicated as the source--a determination that could have been made much earlier had field biol- ogists been consulted. The first research on the role of wild birds and ducks as a likely reservoir of the virus started only in late 2004. The UNEP (United Nations Environmental Programme) Convention on Migratory Species (CMS) established a scientific committee to assess wild birds as a vector in the transmission of HPAI in August 2005. 13 One Health Greater interaction between public health and ani- agencies lack necessary skills--even if the division mal health specialists working within their respec- of labor among them is not an issue. Most public tive organizations might have enabled them to health institutions are completely devoid of veteri- address the disease at its source earlier on during the narians, biologists, and ecologists, while public HPAI campaign. Instead, the campaign initially veterinary health institutions are usually staffed focused on building stocks of antiviral drugs to solely by veterinarians. Wildlife institutions have respond to a human pandemic. little in-house medical or veterinary expertise. In The WHO issued a worldwide alert regarding the absence of close working relationships between SARS on March 12, 2003. In early 2004, the civet cat professionals with different and complementary was identified as the source of the SARS coron- skill mixes, delays in the diagnosis and reporting of avirus, an announcement that led to massive disease outbreaks become more likely. culling of the animal. Only in September 2005 was the horseshoe bat identified as the real vector. Earlier detection of this vector would not only have Budgetary Constraints obviated the massive culling of the civet cat, but Sharing finances is constrained by low and unequal could have expedited earlier effective control of the budget allocations. Although public health is under- disease, thus reducing the massive economic losses funded in relation to health care, the human health the disease caused in East Asia and North America. sector generally has significantly more human and With the outbreak of the Nipah virus in financial resources available for disease control Malaysia in 1998, human cases were almost exclu- activities than environmental or animal health agen- sively confined to male pig farmers. A further out- cies. Moreover, over the last decades, the relation break in Singapore among slaughterhouse workers between staff salaries and recurrent costs to enable in 1999 confirmed the link with pigs. As a result, 1.1 the services to operate has deteriorated, leaving million pigs were culled in Malaysia. In 2000, the limited discretionary spending for all services. This press reported a suspicion among experts that fruit has been well documented for the veterinary bats were the actual disease vector--a suspicion services, in particular for sub-Saharan Africa that was confirmed in early 2001. (Leonard 2004; Gauthier and de Haan 1999; World Bank 2009). Environmental agencies are often the THE BARRIERS TO CHANGE poorest funded in the public sector. Why then, given the recognition of the existing con- tinuum of infectious disease from humans to animals Information Sharing and animals to humans, has there until recently been National public health authorities often use differ- so little progress in moving towards One Health? ent disease reporting procedures and communica- There are numerous barriers to the creation of health tion channels than the veterinary services. Despite systems that functionally integrate services that have the importance of understanding the life cycle of traditionally been delivered by individual sectors pathogens in humans, and in both domestic and with little or no collaboration or interaction between wild animals, most national and international them. Some of these barriers are erected inadver- health organizations monitor, and can only gener- tently by the bureaucratic division of responsibility ate information on, human or domestic animal dis- between institutions. Some of them relate to bud- ease but not both together (Kuehn 2006). In the case getary constraints, unequal institutional capabilities of the West Nile virus (Box 2), veterinary authori- and differing cultures, limited communication of ties actually learned about the human dimensions information, the absence of a shared vision, and of the outbreak only through media coverage. disincentives to working horizontally. The normal bureaucratic constraints to sharing information among and within human and animal Institutional Capabilities health agencies lead to such missed opportunities. There are major gaps in the capacities of sectoral The reporting of a suspected human or animal institutions involved in disease control. Given the disease often causes disruption of tourism or the complex interaction among human, animal, and imposition of trade embargos by importing coun- ecosystem domains, understanding the epidemiol- tries. This may have serious economic conse- ogy of a disease can be delayed when one or more quences for the reporting country or sector, and 14 People, Pathogens, and Our Planet Box 2: The West Nile Virus The first incidence of a hitherto unknown disease in the up-to-then separate investigations converged the Americas, with massive mortality, emerged in thanks to the efforts of a veterinary pathologist at the wild birds in June 1999, and the first human cases Bronx Zoo. occurred in New York City in early August 1999. In early October the connection between the two These were retrospectively identified as cases of diseases was confirmed. West Nile virus. That month, a major incidence of Dr. Laura Kahn observed that "physicians treating bird deaths was also reported. In early September, the initial patients in New York City in 1999 might the disease in humans was misdiagnosed as St. Louis have benefited if they knew that in the previous encephalitis. Animal health officials learned of the months and concurrently, veterinarians in the outbreak in humans through the news media and surrounding area had been seeing dozens of crows began to suspect that the unknown disease in birds dying with neurologic symptoms similar to those of was linked to these human cases. In late September the affected humans." Source: Kahn 2006. trigger political pressure to delay reporting and Common reporting procedures and communication limit communication of information. The first channels in the event of an outbreak will be an reports of the HPAI outbreak in East Asia, for important step in encouraging timely reporting of instance, were delayed by national authorities, emerging or re-emerging diseases. Establishing responding to pressure from political and these channels is not only a matter of bridging economic agents who feared economic losses from professional and institutional divisions that trade (Dolberg et al. 2005). This does not necessar- separate public and animal health agencies, but ily imply corruption or collusion between also one of bringing greater consistency to the economic interests and political decision makers-- incentives and regulatory framework that govern understanding the likely costs involved naturally national disease reporting. Human health report- creates pressure to be certain of a public health sit- ing is governed by the International Health Regula- uation before announcing it to the world. Yet there tions (IHR), which legally binds countries to report has been gradual progress in international cooper- a disease that may constitute a PHEIC to the WHO ation and information sharing during recent within 24 hours, although it is not yet clear how decades. Indeed, this progress has accelerated countries are sanctioned in the case of delayed since the outbreak of HPAI. Box 3 depicts a num- reporting (Hitchcock et al. 2007). Beyond the legal ber of the principal international information sys- obligation, IHR also introduces a strong element of tems. One enduring challenge relates to the very peer pressure, authorizing the Director General of number of institutions or networks at play in the WHO to act on informal disease reports from CSOs current global system. Some of their roles are and networks such as ProMED. This is initiated complementary, others overlap. through a formal request to the "state party" of the While a grand design to promote global collab- country in which the disease has informally been oration might not be feasible, or even desirable, the reported, asking for verification. If the public international community can take measures to re- health event may be a PHEIC and if no adequate duce gaps to a minimum. Some of these gaps are reply is received, the Director General of WHO is geographic, leaving resource-poor countries in- authorized to share the information with other completely covered although the main risk factors state parties. The incentives and legal frameworks for emerging diseases are found within these coun- for animal disease reporting are somewhat tries. The international community can also de- different. Animal disease reporting often has major velop incentives for information networks to trade implications. Under OIE's Terrestrial Animal interact and improve their coordination. Health Code, OIE member countries have accepted 15 One Health Box 3: Global Disease Information Systems The Global Public Health Intelligence Network tracking of diseases among animals in high-risk (GPHIN) focuses primarily on four human diseases: areas. The two zoonotic diseases it currently focuses influenza, polio, SARS, and smallpox. The GPHIN on are HPAI and Rift Valley fever. Its principal was developed under the auspices of the WHO and is source of data is the FAO, although it uses informa- open to governments on a user fee basis. In addition tion from the OIE and WHO as well. It also uses a to its four focal diseases, the network also monitors for number of advanced databases such as ProMED, certain diseases in which an outbreak would consti- and the GPHIN. tute "a public health emergency of international The World Animal Health Information Database concern" (PHEIC). (WAHID) is used to store and summarize information The Global Outbreak Alert and Response Network on diseases reported to OIE. is in place to follow up on any such outbreak Med-Vet-Net is a European network that maintains identified by the GPHIN. It provides support to a database for the prevention and control of zoonoses national governments on disease identification and and food-borne diseases. characterization, outbreak preparedness and aid to The Global Emerging Infections Surveillance and affected populations. It is also under the auspices of Response System (GEIS) of the US Department of the WHO. Defense focuses on infectious disease with a potential The Program for Monitoring Emerging Diseases health risk for US military personnel. (ProMED)4 is a disease reporting system of the ArboNET, the US national surveillance system for International Society for Infectious Diseases. It is arboviral diseases, has a surveillance system for West based on formal and informal sources of information. Nile virus that can serve as an integrated system at the Data on human, animal, and plant diseases are national level. collected by volunteers and screened by expert The Emerging Infectious Diseases Network (EIN), moderators. Most sources of information come from developed by the University of Iowa under the aus- the US. Reporting by developing countries, pices of the US Centers for Disease Control and particularly in sub-Saharan Africa, remains weak. Prevention (CDC), is based on a network of pediatric, The Global Early Warning System for Major internist, and public health officials. Animal Diseases (GLEWS) was set up to improve the Source: Institute of Medicine and National Research Council 2008. Achieving Global Sustainable Capacity for Surveillance and Response of Emerging Diseases of Zoonotic Origin: Workshop Report. The National Academies Press. Washington, DC. the legal obligation to notify the organization of an confirmation. OIE figures show only a 70 percent emerging animal disease. This obligation was response rate to such requests (see Table 1). reiterated in May 2009 by OIE's highest organ, the Improving this rate and exploring the possibility of General Assembly. In addition, OIE collects and bringing OIE and WHO regulatory frameworks analyzes data from other sources and verifies such into line are the topics of ongoing discussion. In information with the Chief Veterinary Officer May 2009, the OIE General Assembly decided to (CVO) of the country concerned. But it cannot take make disease reporting a legal obligation, an formal action, such as the recommendation of an important step in this direction. export ban, until such information is officially confirmed by the CVO. However, the OIE Under-reporting members do not always reply to these requests for Under-reporting or late reporting is still frequent, however, and given the importance of this issue to 4 ProMED is the only system that brings together information on human, animal, and plant diseases--a feature that must early detection of disease outbreaks--and for min- either be brought to other systems, or which new systems may imizing the cost of control--under-reporting war- have to be designed to accommodate. rants in-depth discussion. There are many reasons 16 People, Pathogens, and Our Planet Table 1: OIE Verification Requests and Responses to Them # of OIE Official Invalidated Verification Answers No Answers Notifications Non-Official Year Requests (% of Requests) (% of Requests) (% of Requests) Information 2002 32 18 (56%) 14 (43%) 18 (56%) 0% 2003 29 24 (79.2%) 5 (20.8%) 14 (48.27%) 30.93% 2004 85 67 (78.8%) 18 (21.2%) 39 (48.75%) 30.05% 2005 97 74 (76.28%) 23 (23.71%) 36 (37.11%) 39.17% 2006 113 80 (70.79%) 33 (29.20%) 66 (58.40%) 12.38% 2007 140 103 (73.57%) 37 (26.42%) 71 (50.71%) 31.06% Source: Institute of Medicine and National Research Council. 2009. for under-reporting, and a good understanding of entirely on farmers and veterinarians reporting these is a prerequisite for the design of improved suspected cases--a system of passive surveillance. reporting. While the reasons for under-reporting When the system was changed to targeted active often differ from one case to another, a number of surveillance, many more cases were detected. In factors commonly prevail. These are presented fact, it was estimated that only one out of six cases graphically in Figure 4. was reported under the passive surveillance Programs to reduce under-reporting often focus scheme ProMED 1997). on technical means and may address disease The absence of sufficient diagnostic capacity is detection, disease reporting, or both. Detection is another cause of limited ability to detect diseases. the limiting factor more often than access to Lack of infrastructure and facilities such as reporting channels, and is commonly the result of properly equipped laboratories with well-trained insufficient awareness of a disease among farmers staff, or simply the lack of affordable diagnostic and field veterinarians--particularly at the begin- tests of sufficient sensitivity, can lead to this ning of the reporting chain. To improve early constraint. Rapid tests for transmissible spongi- detection rates, these agents must not only be form encephalopathy (TSE) in early subclinical aware of the existence of the disease, but also have phases of disease development illustrate how an understanding of the threat that it represents. higher test sensitivities would lead to higher case In the case of endemic diseases, people can often numbers. Lack of appropriate samples can also be become accustomed to the fact that some ani- a critical limiting factor. In Uganda, for instance, mals fall victim to them from time to time. This mortality from sleeping sickness was suspected habituation effect is particularly common with to be under-reported by a factor of 12 owing to slowly progressing production diseases such as difficulty in detecting the disease before parasites tuberculosis or brucellosis that do not cause pass from the blood to the brain (Odiit et al. 2005 sudden death among large numbers of people or and ProMED 2004). The most recent example in animals. which a rapid and broadly accessible test was ab- Yet awareness of a disease and its threats may be sent altogether, therefore preventing the disease limited not only in the field but also among central from being detected or reported, was the very planning and surveillance programs, where self- first phase of the outbreak of Influenza A(H1N1) sustaining or even enhancing cycles of unaware- in North America. ness or neglect may occur. Poorly designed Some programs focus more on the access to re- surveillance programs can also cause large num- porting channels, assuming that disease detection bers of cases to be overlooked if the populations is not or not alone limiting. They address techno- at high risk are not sufficiently sampled. This was logical aspects such as access to the Internet in the case when BSE surveillance in Europe relied remote areas and often rely on mobile phone 17 One Health Figure 4: Reasons for Disease Underreporting Lack of awareness of a disease Inability to detect Lack of diagnostic capacity Inability Lack of communication with technical resources Inability to report Lack of communication with administrative resources Reasons for Underreporting International trade (OIE, SPS) Consequences for trade Domestic trade (movement restrictions) Unwillingness National reputation (e.g., tourism) Consequences for reputation Individual reputation (harbinger of bad news) Lack of compensation for farmers technology to enable communication.5 Less often, The reluctance to report animal disease out- access to proper official communication channels breaks is often rooted in the existence of disincen- is limiting, but unclear processes and case defini- tives. For reporting to be improved, these tions can hinder disease reporting. The former disincentives must either be removed or compen- was indicated as the major issue around under- sated for. One of the principal disincentives relates reporting of communicable diseases by doctors in to the consequences of disclosure for international New York, whereas the latter played a role during trade of animals and animal products. The the outbreak of SARS in China (Konowitz et al. Terrestrial and Aquatic Animal Health Codes 1984 and ProMED 2003). of the OIE are WTO-recognized standards that link the animal health status of a country to the right to trade certain products. The prevalence of 5 For examples see: "Global Infectious Disease Surveillance and reportable diseases can have a major economic im- Detection: Assessing the Challenges--Finding Solutions, pact on a country's farm industry. In extreme cases, Workshop Summary (2007), Board on Global Health." The National Academies Press. http://www.nap.edu/catalog such as BSE, a single case of a disease can bring the .php?record_id=11996 (accessed May 25, 2009). trade of certain products to a halt. How often this 18 People, Pathogens, and Our Planet actually results in hiding or denying an outbreak is Bank, FAO, OIE, and IFPRI published guidelines a question that by its nature defies proper analysis. for compensation payments in Enhancing Control of The reporting of disease outbreaks, of course, Highly Pathogenic Avian Influenza in Developing has important consequences for domestic as well as Countries through Compensation. The guidelines for international trade. Outbreaks of highly infec- were adopted at the Ministerial and Pledging tious diseases are often controlled by restricting the Conference in Bamako in December of that year. In movement of live animals and animal products. addition to informing owners about the potential The anticipated decline in market value often leads liabilities and consequences of violating the law, farmers to clandestinely transport their animals to owners must also be educated about the rationale places outside the restriction zone in spite of the behind those laws, because laws that are perceived suspicion or even knowledge that the animals are as being arbitrary or unfair are usually more diffi- infected. The CVO of a country with an emerging cult to enforce. or re-emerging disease is often under pressure Not all of the potential consequences of report- from powerful commercial and political interests ing infectious diseases are economic. Some conse- to conceal an emerging infectious disease This ap- quences concern the reporter's social and pears to have been a major contributing factor to professional reputation. The fear and stigma the rapid spread of H5N1-infected poultry in associated with being the first to report or with Indonesia in 2003 and to the ineffectiveness of the corroborating early reports cannot be overstated, technocratic approaches that were employed to and in some cases has led to suicide among ani- control the spread--and with significant loss of mal owners who were suspected of having been human life (Forster 2009). Ensuring adequate inde- the source or an outbreak, or of having missed or pendence of the Veterinary Service is therefore concealed one (ProMED 2004a). Social pressure to important. OIE's assessment tool, the Performance not report may, of course, also stem from threat- of Veterinary Services (PVS), therefore attaches ened economic interests. One's "hunch" that the considerable weight to the independence of the animal symptoms that one is observing might veterinary service in disease reporting. Owing to be the early signs of an outbreak may after all informal peer pressure and the PVS assessments, come to nothing. But during the interim, while the under-reporting has been reduced according to threat is being evaluated at whatever pace the OIE officials. But the independence of veterinary concerned public surveillance agency deems fit, services should be a central point in international business may well be closed for everyone in one's efforts in strengthening early warning systems. district or area. If the suspicion is found to be Vigilant policing and strict law enforcement are groundless, then, in hindsight, all the losses that vital elements in deterring animal owners from have resulted from the unwarranted report are at- concealing possible outbreaks and subverting sur- tributable to the reporter. If the suspicion is sub- veillance and control measures. They are not, how- stantiated, then the reporter may be suspected ever, sufficient, especially, of course, in countries in within his or her community of having caused the which the capacity to monitor compliance is lim- problem. Ultimately, highly contagious diseases ited. Fostering cooperation by owners also entails are impossible to conceal, and the disincentives balancing these deterrents with positive incentives that discourage people from reporting them tend such as eligibility for indemnity and compensation to be concentrated in time during the early phase so that complying with the law does not entail of an epidemic. relinquishing the basis of one's livelihood. At the policy level, the prospects of allocating Concealing a disease outbreak may, after all, be the public revenues to compensation and insurance only rational economic decision an animal owner services are to be considered within a larger con- can make. Yet even where compensation mecha- text of limited resources. These services are gener- nisms are in place and accessible, animal owners ally at a disadvantage in "competing" with other will still compare the value of their animals to the demands for public resources in that the issue of compensation offered for culling them, unless the farm animal health is almost always assigned to the healthy remainder of the herd or flock can be ex- public institutions responsible for agriculture, in- pected to be saved by sacrificing the diseased part. stitutions that are much less politically influential This calculation becomes straightforward when than other institutions such as public health or there is no compensation at all. In 2006, the World finance ministries. The matter of political clout 19 One Health will be addressed in greater detail in the following It was in this context that the HPAI scare again chapter. created momentum to bring national and interna- In summary, there is a multitude of underlying tional stakeholders together. At the national level, reasons for under-reporting, and more often than public and animal health agencies have come to- not, more than one are at play simultaneously. gether into joint health-agriculture task forces while Many programs to improve compliance with re- INAPs have been prepared to coordinate their ac- porting duties have failed because they addressed tivities. At the international level, a global campaign only one reason, leaving others unattended to. All against HPAI brought together a variety of agencies. reasons for under-reporting must be addressed The establishment of UNSIC and the Global comprehensively, a Herculean task that nonethe- Program on Avian Influenza Control and Human less must not be avoided. Pandemic Preparedness and Response (AHICP) in particular established more regular channels of communication among the FAO, the World Bank, GLIMMERS OF HOPE the OIE, and UNICEF. The campaign made the pre- While disease outbreaks and the threat of bioter- vention and control of emerging and re-emerging rorism have led many countries to revise their pub- diseases with pandemic potential the focus of high- lic health systems, the interconnectedness of health level attention by the international community. issues in different countries in the larger context of There are a number of practical examples of col- globalization has made it increasingly clear that laborative human and animal health in the plan- countries cannot act effectively in isolation. Recent ning of One Health activities. However, there is zoonotic disease outbreaks have already had a less to show in the actual implementation of the major impact on how national and international concept as a whole. Moreover, the involvement of public human and animal health institutions wildlife health specialists in most institutions is communicate and interact. The emergence of weak, if not completely absent. SARS in particular was a major impetus for the The National Center for Zoonotic, Vector-Borne, finalization and adoption of the WHO's revised and Enteric Diseases (ZVED), which was orga- International Health Regulations of 2005. The nized in April 2007 under the auspices of the CDC, Regulations constituted a paradigm shift in which is a good example of an operational One Health the reporting of human diseases would no longer unit. ZVED provides leadership, expertise, and be limited to individual diseases, but rather would service in laboratory and epidemiological science, cover "illness or medical condition, irrespective of bioterrorism preparedness, applied research, origin or source, that presents or could present sig- disease surveillance, and outbreak response for nificant harm to humans." The applicability of the infectious diseases. The Center's vision is to Regulations to human disease in general was piv- improve health by reducing the impact of infec- otal because it extended coverage to diseases that tious diseases using a comprehensive approach to will emerge in the future. ensure that human interactions with animals, By adopting the 2005 International Health animal products, wildlife, and the natural environ- Regulations, countries committed themselves to a ment are healthier and safer (National Center for revision of their core public health surveillance ca- Zoonotic, Vector-Borne, and Enteric Diseases 2009). pacities by 2009. Governments appointed national In November 2007, One Health was identified as IHR focal points to be the spokesperson in urgent the top priority for the veterinary profession in communications between state parties and the Europe by the Federation of Veterinarians of WHO regarding events that may constitute a public Europe (FVE). In 2008, the European Academies health emergency of international concern. The Science Advisory Council prepared a policy report WHO, however, can take into consideration unoffi- on the control of zoonoses, urging a closer integra- cial reports and obtain verification from state par- tion of human and animal health (European ties concerning such events. The Director General of Academies Science Advisory Council 2008). the WHO needs only to consider the recommenda- In Canada, the limitations of the public health tions of an emergency committee of international system were thrown into sharp relief by the out- experts and does not need the country's concur- break of SARS in 2003 and the epidemic that fol- rence to declare a "public health emergency of in- lowed. The Minister of Health established the ternational concern." National Advisory Committee on SARS and Public 20 People, Pathogens, and Our Planet Health to assess the factors that limited the effec- the health of different components of an ecosystem, tiveness of the campaign against SARS and to including human health. The IDRC is also a partner recommend improvements in the country's pre- in the International Association for Ecology and paredness and responsiveness to future disease out- Health, which publishes the journal EcoHealth and breaks. The committee recommended that the which also stresses the interdependencies among national government create an agency mandated to development, human health, and healthy ecosys- coordinate federal and provincial public health tems. The Canadian Science Center for Human and responses, a departure from relying on provincial Animal Health (CSCHAH) and Denmark's departments. In 2004, the government established Zoonosis Institute promote collaboration between the Public Health Agency of Canada. The Agency medical and veterinary health and are described in goes far in resolving two issues that are common to some detail in Boxes 4 and 5. In 2005, the "Canary many countries: the fragmentation of functions and Database" was established at Yale University for the responsibilities among public institutions, and a lack use of animals as sentinels of human and environ- of authority among public health entities. Box 1 de- mental health risks, including emerging infectious scribes the Canadian experience in greater detail. diseases (Rabinowitz et al. 2008b). In Kenya, the National cross-sector and interdisciplinary work- International Emerging Infectious Disease Program ing groups and task forces have been established in has established joint surveillance systems and uses a number of countries. In Canada, the C-EnterNet its diagnostic facilities for both human and animal (pronounced "centernet") is facilitated by the Public specimens. Health Agency of Canada to monitor for infectious Both the American Medical Association (AMA) enteric diseases, surveying sentinel sites to detect and the American Veterinary Medical Association new threats, including zoonotic ones. Canada's (AVMA) established One Health task forces in International Development Research Centre (IDRC) 2007. In June 2008, the US National Academy of hosts the Ecosystem Approaches to Human Health Science, through the Institute of Medicine (IOM) Program, which assesses the relationships between established a panel on "Sustaining Global Capacity Box 4: The Canadian Science Center for Human and Animal Health The CSCHAH is a research and diagnostic facility that allow researchers to work on less pathogenic agents. contains specialized laboratories for human and The CSCHAH provides a unique environment for col- animal health. Located in Winnipeg, Canada, the laboration between researchers working on animal CSCHAH houses the National Microbiology diseases and those working on human diseases. Laboratory and National Centre for Foreign Animal Among its many activities, the National Disease. The Laboratory is part of the Public Health Microbiology Laboratory offers reference microbiol- Agency of Canada, and the Centre is part of the ogy services and supports epidemiology, surveillance, Canadian Food Inspections Agency. As such, the and emergency response programs. During the H1N1 CSCHAH represents the integration and close partner- outbreak in April 2009, the National Microbiology ship between these two federal agencies on issues Laboratory was the first laboratory to completely concerning human and animal health. sequence the genomes of the H1N1 viruses from The CSCHAH is an internationally renowned facil- Mexico and Canada. ity that is among an elite group of laboratories capable The CSCHAH continues to look forward and to of working with the world's deadliest pathogens. The innovate. Recently, the facility added a new opera- facility is the only one in Canada to operate at level 4 tions center outfitted with a state-of-the-art commu- containment, allowing researchers to work safely with nications network. The CSCHAH uses the operations pathogens such as Ebola, Marburg, and Nipah. The center to coordinate activities among the provinces, CSCHAH also contains level 2 and level 3 laborato- other areas of the federal government, or interna- ries, which make up the majority of the facility. These tional organizations. Source: The Public Health Agency of Canada 2009. 21 One Health Box 5: The Danish Zoonosis Centre The Danish Zoonosis Centre (DZC) was established Funding comes partly from the Danish Government, in 1994 as a separate unit within the Danish Veterinary partly from research and advisory service. The profes- Institute under the Ministry of Food, Agriculture, and sional staff consists of approximately 13 people, with ad- Fisheries (now the National Food Institute, Technical ditional general support from the National Food Institute. University of Denmark). The reasons for the creation Coordination at the national level takes place in regular of DZC were the implementation of the EU Zoonosis meetings with industry and NGOs as well as with official Directive (92/117/92), an increasing incidence of administrative institutions and ministries and with re- reported zoonotic infections in humans, and an search partners. Tasks performed by the DZC include to: increased awareness of the occurrence of zoonotic · Maintain the national statistics on zoonoses agents in pork and poultry products In Denmark. · Carry out surveillance of antibiotic-resistant Before 1994 several institutions were responsible bacteria for control along the food production chain, resulting · Trace sources of infection and uncover routes of in suboptimal communication and coordination. The transmission--sporadic cases and outbreaks solution was the formation of DZC as a coordinating · Conduct epidemiological research body that integrates all data on the occurrence of · Disseminate information zoonoses in animals, food, and humans in one place. · Coordinate activities between institutions and Furthermore, a zoonosis epidemiological research unit authorities was established. The objective of DZC is to guide prevention and con- Strong research areas were and are still the basis for trol of food-borne zoonoses in Denmark, and DZC is the success of DZC. In particular, the "contamination based on an agreement between the Danish Veterinary source model"--which ties together the risk associated Institute (food and animal data) and Statens Seruminstitut with occurrence of specific types of zoonotic micro- (human data). DZC has no power to make risk manage- organisms in production animal species, in food originat- ment decisions, but exerts its tasks through scientific as- ing from these species, and in the human cases of these sessments and advice to the risk-managing institutions infections--has been instrumental in setting up monitor- such as the Danish Veterinary and Food Administration. ing and tracing of food-borne zoonotic infections. for Surveillance and Response to Emerging of operational coordination among human, animal, Diseases of Zoonotic Origin." The panel was spon- and wildlife health services, and there are glimmers sored by USAID. Its report was published in of hope also in the developing world. At the sub- October 2009. In 2001, the United Kingdom Saharan African level, the CDC center in Nairobi also Zoonoses Group was set up at the ministerial level, seems to have a well-integrated disease surveillance bringing together representatives of veterinary and system, and is a good example of the integration of public health and other services on a permanent the different disciplines. The Cysticercosis Working basis. Innovative research like the zoonoses re- Group in Eastern and Southern Africa (CWGESA), search program of the German government pre- which brought together medical, veterinary, and an- scribes compulsory cooperation between physicians imal production scientists and professionals to coor- and veterinarians. dinate research and development activities targeting These examples of cooperation between public this zoonotic disease, is mentioned as an example of health and veterinary services and the incorporation institutional innovation promoting cross-sectoral of wildlife and ecosystem health in disease surveil- collaboration for research targeting a specific disease lance need to inform similar initiatives in develop- (Boa et al. 2003). However, the Group does not ap- ing countries, including the institutional models pear to have contributed substantially to increased used to foster new forms of collaboration. coordination between medical and veterinary insti- However daunting the barriers to institutional co- tutions in controlling cysticercosis in the countries ordination may appear, there are practical examples involved (Randolph et al. 2007). 22 People, Pathogens, and Our Planet In southern Sudan, for instance, mixed nomadic children for measles and whooping community-based teams provided both human cough, and the compulsory cattle vaccination for an- and animal health services in the midst of civil war, thrax, blackleg, and contagious bovine pleuropneu- carrying out human health activities such as polio monia, increased the number of people vaccinated vaccinations and guinea worm eradication while per day to 130 in joint vaccination campaigns from animal health workers on the teams carried out 100 without participation of the veterinary services. rinderpest vaccinations. In Mauritania, where It also resulted in a reduction in the delivery costs of cases of high fever were mistakenly diagnosed by about 15 percent. Furthermore, pastoralist families the country's public health service as yellow fever, vaccinated their livestock and children more spon- contacts with the livestock services revealed that taneously (Schelling et al. 2007). Though limited in these were in fact cases of Rift Valley fever scale, these experiences suggest that the coordinated (Digoutte 1999; Nabeth et al. 2001). Finally, in delivery of human and animal health services and Chad, the combination of the vaccination for surveillance is feasible at the village level. 23 4 Making One Health Operational While a number of countries employ, or are planning to introduce, in- tegrated disease surveillance, prevention, and control systems along the lines of One Health, few existing systems can be classified as fully functional applications of the principle. Optimally, such a system would actively fulfill a number of functions. It would enable shared surveillance to improve the capability to detect the emergence of a disease event, thus fulfilling a prescription set forth in the International Health Regulations. It would allow the preparation of joint strategies for prevention and control, clearly defining roles, re- sponsibilities, and accountabilities. A One Health approach would also facilitate joint preparation and testing of emergency prepared- ness plans and the joint formulation of internal and external report- ing and communication plans. Sharing facilities and exchanging staff in surveillance and control operations would foster capacity through- out the system's membership. Finally, it would enable participating institutions to employ new modalities for mobilizing financial re- sources for joint planning and response to emergency and ongoing operating needs. ADOPTING ONE HEALTH The division of labor among public institutions makes for a seg- mented or vertical organization of work, in which institutions oper- ate independently of one another and from the perspective of their discipline or sector. This unavoidably leads to gaps, and sometimes to overlaps. For practitioners working in this framework, the starting point for action tends to revolve around the question "What am I re- sponsible for?" rather than "What needs to be done?" Figure 5 pre- sents these two orientations. Changing the organization of work across disciplines to start with this latter question implies a substan- tial reorientation along horizontal lines in which regular communi- cation takes place between practitioners at work in different disciplines and sectors. This does not imply an amalgamation of work but rather the creation of a culture in which practitioners are more likely to understand the significance of a finding or event within their own field for practitioners in other fields. 25 Making One Health Operational Figure 5: Vertical and Horizontal Orientation in Disease Prevention and Control Classical Approach Integrated Approach What do I have to do? What am I responsible for? Is this my job? What needs to be done? Disease 1 Disease 1 Disease 2 Disease 2 Disease 3 Disease 3 im alth th ism e s im alth th ism e s er er ad ad al al th th ur ur Tr Tr he he he he O O To To an al an al um um An An H H INSTITUTIONS AND ONE HEALTH a country's ministry or department of health and are responsible for emergency preparedness and A number of areas suggest themselves as worth planning, including surveillance of infectious building upon in adapting the campaign against diseases, identification of possible syndromes, and HPAI and A(H1N1) into a more general, permanent pandemic planning. These roles are part of a broader system for coordinated national and international institutional division of labor that includes strategic surveillance and control. Such a system would planning and resource mobilization. In some coun- certainly entail more regular channels of collabora- tries the supervision and regulation of private health tion than the current communication between providers and quality control over pharmaceuticals agencies that prevails to date, which is based on may extend to actively supplementing private firms temporary arrangements formed in response to var- in providing clinical services. ious contingencies. Better-defined joint-operational National veterinary services are generally agen- mechanisms would facilitate responsiveness by cies within the ministry of agriculture. They are averting the need to negotiate agencies' respective typically responsible for ensuring the protection roles on the fly, and would greatly reduce the likeli- of animal health, for the safety of food products of hood of duplications of effort. More fundamentally, animal origin, and for the eradication of major however, a more systematic approach to surveillance animal diseases. They are often responsible for the and control would be more inclusive in terms of sec- quality control of veterinary pharmaceuticals and tor and discipline, and would expand access to agen- the oversight of clinical services provided by cies and institutions concerned with environmental private operators. Most veterinary services also health, and wildlife health in particular. While joint oversee the sanitary aspects of international trade actions presently focus overwhelmingly on diseases in animals and animal products, and may enforce at the human-livestock interface, more than 70 per- animal welfare standards. In many developing cent of new zoonotic diseases originate in wild species countries, the public veterinary service still (Jones et al. 2008). This represents a fundamental supplements the private sector in the provision of disconnect between human health priorities and the clinical services, although these "private good" practical demands imposed by reality, one that needs functions are increasingly performed by private to be resolved. veterinarians. In some countries, the veterinary service is also responsible for monitoring and National Level Structures controlling wildlife diseases. Responsibility for the surveillance and control of Issues that impinge on the health of ecosys- zoonotic diseases within countries is typically tems, including pollution related to livestock divided among a number of ministries and husbandry, generally fall under the jurisdiction agencies. Public health agencies usually belong to of environment ministries. The ministries' 26 People, Pathogens, and Our Planet involvement in wildlife is largely limited to the and endangered species. Zoonotic diseases often management of parks and related matters con- tend to fall between these foci. cerning biodiversity conservation. Their interest National risk assessments and analyses of the in wildlife diseases normally starts when the oc- potential costs and consequences of the principal currence of a disease becomes a threat to the sur- zoonotic disease threats are likely to increase the vival of the affected species. In most developing profile of those threats, and support the argu- countries, these services are greatly under- ments of those advocating increased levels of funded. They are generally not allowed to use the funding to address them. Compiling and com- revenues generated by the parks for their own municating this information places zoonotic dis- operation and management costs. eases more firmly on the public agenda and among the priorities of public agencies. The risk assessments should identify hot spots upon Avenues for Improvement which the efforts of surveillance systems can The quality of a disease surveillance and control focus, and in which the monitoring activities of system depends in large measure on the speed different agencies can converge. with which potential health risks are identified and measures to mitigate them are undertaken. The Joint preparedness planning has been exemplified in rate of spread and the human and financial costs of the formulation of INAPs under the aegis of the emerging and re-emerging diseases can increase Partnership for African Livestock Development significantly, and sometimes exponentially, during (ALive). As of October 2009, rapid assessments had the interim between when the disease emerges and been undertaken in 26 sub-Saharan Africa countries when it is reported and control actions are taken. to evaluate their preparedness for avian and human Delayed reporting also leads to a substantially influenza and to identify what was required to increased risk of spillovers to other countries. strengthen their response plans. The assessments Limited capacity to diagnose diseases and poor were conducted by multidisciplinary teams from infrastructure are among the principal causes of FAO, OIE, the African Union/Interafrican Bureau delay in reporting and responding to outbreaks. for Animal Resources (AU-IBAR), and the WHO's Many outbreaks occur in poor rural areas, where Regional Office for Africa and consisted of there is very little if any coverage by human or specialists in animal health, human health, veterinary staff, and where laboratory systems for communications, and finance. The results of the timely diagnosis are entirely lacking. However, assessments were used as the bases for INAPs, most poor capacity is not the only cause. Organizational of which were then endorsed by their respective and legal constraints inhibit fast and reliable national governments. Several of the INAPs were disease identification, reporting, and control. To used as input into externally supported projects to address those constraints, a series of important enhance influenza preparedness. These projects, measures are warranted, and most of them relate such as the World Bank-funded Uganda Avian and directly to One Health. Human Influenza Preparedness and Response Project provided a balanced distribution of respon- Consultation in priority setting between human and sibilities and resources. Among the principal veterinary health agencies is an important area of challenges encountered when preparing the action potential convergence. Health ministries in low plans were the high transaction costs of assembling income countries tend to focus primarily on multidisciplinary teams with members from reducing mortality among pregnant and nursing multiple institutions, and the need to adapt inter- women and children under five years old, and on ventions to the needs of individual countries. While controlling HIV/AIDS, malaria, and tuberculosis-- the ALive initiative is widely considered a unique functions closely aligned to the health-related experience in intersectoral cooperation, the INAPs Millennium Development Goals. Veterinary services themselves still need to be tested through simulation often give the highest priority to the "diseases of exercises, such as have been conducted by countries trade," such as foot-and-mouth disease (FMD), in other developing regions. classical swine fever, and contagious bovine pleuropneumonia (CBPP). Wildlife agencies are Coordinating surveillance services may go far in mainly concerned with conservation of threatened preventing the kinds of delays that were experienced 27 Making One Health Operational in diagnosing the West Nile virus and HPAI as world in the case of a new disease outbreak. It is es- a result of the disconnect between public health sential that the way emerging diseases should be and veterinary surveillance systems. Coordinating handled--that is, the most appropriate strategy to grassroots surveillance systems through the partici- control an emerging disease, the safety of animal pation of community representatives proved quite products from the diseased areas, the level of emer- successful in the control of HPAI in Indonesia gency status--is presented to the general public in (Scoones and Forster 2008). Such grassroots systems a unified fashion. For example, the major economic are well suited to link human and veterinary health losses experienced by the pig industry in several services. Sharing facilities such as transport and cold developing countries as a result of the premature storage equipment is often met with resistance, identification of influenza A(H1N1) as swine flu partly out of fear of cross-contamination of human shows the importance of close cooperation in and animal specimens as we have seen. Such national and international communication with the integration, however, must take into account priori- media (Box 6). tization of sample processing, specimen testing, and other services provided to ensure that animal and human health needs are met in times of high Legislation that Facilitates Selective demand or pandemic outbreaks. Interaction Between Medical and Veterinary Services Communicating Consistent Messages Veterinarians are not allowed to treat human pa- As shown in several instances, different agencies tients, and paraprofessionals often are not allowed often issue contradictory statements to the outside to handle certain human and animal drugs or to Box 6: What's in a Name? The general public's awareness of the threat of and pork products from countries reporting human zoonotic diseases, especially those that spread quickly cases of influenza A (H1N1). Responding to the name around the world as a result of human movement, was of the influenza virus and associating it with pigs, con- heightened by the outbreak of influenza A (H1N1) in sumers reduced their purchases of pork, and prices late April 2009. This outbreak and spread inflicted slid in many markets. In a few countries, governments enormous social and economic costs on countries even ordered the culling of pigs, despite the lack of globally, but particularly on Mexico where it was first the disease and in disregard of the potential livelihood reported. In addition to the deaths and widespread losses for poor affected farmers. Markets have re- illness caused, a very significant portion of the mained depressed in most places of the world. Much economic costs are associated with pandemic effort was subsequently made to reassure the public preparedness and disruption of economic activity. that pigs were not the source and that consumption of Some of the disruption to trade and to livelihoods pork products did not pose risk of exposure to the for those concerned with pigs may have been disease, but these had little effect as the name was minimized had it not been for the misnaming of already well established. the disease. Hence, blame for this component of the economic Although the genetic makeup of the influenza A losses suffered has been attributed to the name "swine (H1N1) virus proved to be a combination of human, flu," which, in the context of a pandemic threat, cre- swine, and poultry genomes, at the time of the outbreak ated a fear of disease transmission even though pigs and the name "swine flu" took hold, the virus was not and the consumption of pork products don't spread it. detected in pigs, and up to the present time few diag- While political or economic winner and loser calcula- noses of the disease in swine have been made. tions should not be a consideration for reporting or Within days of the official announcement of the naming the source of a disease, inadvertent conse- new flu strain, international tensions rose as trade quences such as this should and could be avoided by bans were announced that did not comply with exit- designing and following appropriate procedures at ing trade rules, and that restricted the import of pigs both national and international levels. 28 People, Pathogens, and Our Planet perform simple interventions. These restrictions technicians is seldom seen, although it could en- apply even in remote areas, where neither accred- able trainees to play a critical role in the early de- ited physicians nor veterinarians are available. The tection of emerging zoonotic diseases. There are, establishment of private health providers in these however, some examples of integrated training contexts is constrained by the inability of potential programs. One is the CDC-sponsored Field clients to pay in such remote and resource-poor Epidemiology Training Program (FETP), which areas. Even in these settings, combining medical and originally focused on public health officials but veterinary practices to expand coverage is generally more recently has also begun accepting veterinari- not recommended by the public health and veteri- ans and biologists (CDC 2009). Another is the EU- nary authorities, owing to public health concerns sponsored Sanidad Publica Veterinaria (SAPUVET) regarding the possibility of cross-contamination and program, which links universities in Europe and of cheaper veterinary drugs being used on humans. Latin America and focuses more on veterinary (In fact, the relative prices of human and veterinary health. OIE is launching a major initiative to pharmaceutical products drive a major black market strengthen veterinary schools in Africa. A clear pri- for these products.) With a proper legal framework ority in establishing these and other initiatives as and appropriate training, however, certain select centers of excellence is to develop interdisciplinary public health activities could be shared--for curricula around topics such as wildlife disease instance, in surveillance by human and animal and surveillance systems, communications, and health field agents. Patient care would, of course, re- the perception of risk among human populations. main the sole responsibility of the human health agents. Providing an Appropriate Incentive Framework Strengthening Education Although public health is underfunded in relation The number of veterinary schools has expanded to health care, the human health sector has signifi- dramatically in recent decades. In Africa, for in- cantly more human and financial resources avail- stance, the number has increased from three to 40 able for disease control activities than have schools since 1965. However, both veterinary and environmental or animal health agencies. Hence, medical education systems remain weak in most public health efforts to increase attention to developing countries, and many schools lack suffi- zoonotic diseases often fail because of the lack of cient resources to provide quality instruction. In funds from the veterinary and environmental the former Soviet Union, and to a lesser extent else- agencies. In Kenya, the Ministry of Health de- where in Eastern Europe, the quality of instruction ployed five times more staff in response to Rift varies widely, and curricula are often more theo- Valley fever than the Veterinary Services were able retical than practical. Limited western-language to (Schelling and Kimani 2007). The latter, it should skills have been an important constraint be noted, are in charge of controlling the main (Schillhorn van Veen 2004). In China, the combina- source of human RVF infection. Incentive policies tion of formal and nonformal training systems that place a premium on collaboration and re- prepares students for the traditional role of a vet- source sharing should therefore be introduced. erinary clinician, but do not address the needs of This can include shared budget lines between dif- the modern livestock sector or adequately cover ferent agencies and systems of matching grants, public health or food safety issues (Bedard 2004). with increased cooperation leading to increased Much like in western countries, interdisciplinary budgetary support. An overall increase in funding training that relates human, veterinary, and would have to be based on the results of the risk ecosystem health is also very scarce. Veterinary assessment. faculties tend to focus on clinical skills that pertain to meat and milk production, and often operate Providing the Appropriate Institutional under the auspices of their country's agriculture Framework ministry. Human health faculties often focus on control or eradication programs on specific dis- The campaign against avian flu has over time led eases such as malaria or HIV/AIDS. Joint training to increased cooperation among national agencies of community health technicians and animal health within countries, including in the 26 African 29 Making One Health Operational countries that have prepared INAPs as of August that "the best functioning National Steering 2009. These current levels of cooperation are, Committees are those chaired by the president's or however, likely to fade if the risk of avian flu prime minister's office, so that a top-down com- continues to be contained. Unless countries find mand structure exists which can, in case of outbreak ways to institutionalize more permanent channels emergencies, issue direct orders with authority to between their responsible line ministries and the lower levels and expect to have these complied sector agencies, new coordination mechanisms with forthwith." At district and provincial levels, the will have to be built from scratch in the event of a degree of cooperation varies, depending in large new outbreak. The goal is to design institutional measure on the trust between the main persons relationships and mechanisms--and perhaps even involved (Brandenburg, 2008). new institutions--that facilitate effective and efficient prevention, detection, and control of zoonotic and other diseases of national or interna- Establishing Trust Among the Different tional significance. Depending on the capacity of Actors public institutions within a country, a number of options are available. Mutual confidence between the concerned par- ties, and between physicians and veterinarians in · Creating a special permanent cross-sectoral particular, is a necessary condition for effective coordination mechanism (which could have collaboration. According to Joann Lindenmayer several working groups), either through the at the Cummings School of Veterinary Medicine exchange of memoranda of agreement be- at Tufts University, "Veterinary medical profes- tween the different ministries and agencies sionals always mentioned human and animal involved, the primary responsibility of which health together; public health and medical pro- is to prepare prevention strategies and regu- fessionals always spoke of them separately" larly update contingency plans to address (Lindenmayer. 2007). Physicians are less inclined eventual new or re-emerging outbreaks. to analyze the role of animals in the transmission · Establishing a coordinating authority at the of zoonotic diseases, and to regard that analysis executive level of government, such as at as being properly within the purview of veteri- the prime minister or deputy prime minister narians (Kahn 2006). In addition to the customary level, to which the agencies responsible for pub- division of labor between them, the two disci- lic health, veterinary services, and the environ- plines are characterized by different modes of ment must all report. This may take the form of operation, with physicians more often using a a task force assigned to define an integrated syndrome approach and veterinarians more often strategy, oversee the preparation of contingency using a "causative agents" approach (GAO 2000). plans, and ensure their full implementation. Education, and assigning more importance to · Establishing special One Health teams joint operations (such as in One Health teams), composed of representatives of the human, can help to increase opportunities to bridge these animal, and ecosystem institutions, with professional gaps and to form interfaces. particular responsibility for diseases at the Institutional and cultural change is long term in animal-human-ecosystem interface; or nature and requires deliberate and sustained · Creating an independent agency for public efforts to achieve. health, including zoonoses and food safety, with characteristics similar to those estab- lished in Canada and Denmark. THE CURRENT INTERNATIONAL Experiences in the preparation and, in particular, the SITUATION implementation of the HPAI emergency projects by the World Bank confirm the need for stronger coor- Cooperation at the international level is generally dination. In a number of countries, a committee or good. In 1975, the FAO and WHO published a task force at the executive level to ensure coordina- joint report titled The Veterinary Contribution to tion needed to be established. An internal World Public Health Practice, and the WHO developed a Bank evaluation of the HPAI campaign confirms program on veterinary skills in what has been 30 People, Pathogens, and Our Planet called veterinary public health, which was further AVENUES FOR IMPROVEMENT defined by WHO in 1999 as "the sum of all con- tributions to the physical, mental and social well- AT THE INTERNATIONAL LEVEL being of humans through an understanding and Greater Involvement of Ecosystem Health application of veterinary science" (WHO 2009) and Wildlife Organizations Zoonotic diseases are the core domain of veteri- There is no UN agency or other international or- nary public health, which provides a valuable ganization that is formally responsible for the channel between the FAO and OIE, although surveillance or control of wildlife diseases.6 FAO has no human medical skills among its staff. UNEP hosts the secretariats for the Convention OIE sets animal health standards, whose imple- on International Trade in Endangered Species of mentation FAO supports through technical assis- Wild Fauna and Flora (CITES) and the CMS. OIE tance. The three organizations are also partners in has a committee that oversees wildlife diseases, the Codex Alimentarius Committee, which sets and GLEWS records wildlife diseases, but these food safety standards, and in the Global Early diseases are mostly not part of the official moni- Warning System for Major Animal Diseases, in- toring and reporting system of the veterinary ser- cluding Zoonoses (FAO 2007). These established vices. Because wildlife diseases have been left instruments of collaboration among the FAO, largely to NGOs, the involvement of interna- OIE, and WHO would prove important in facili- tional institutions dealing with wildlife has been tating the international community's response to limited and generally unofficial. FAO and WHO, HPAI. however, have established strong relationships Despite the noteworthy levels of cooperation with a number of NGOs including Wetlands among these international organizations during International, Wildfowl and Wetlands Trust, UK the HPAI campaign, a number of impediments (WWT) and the Wildlife Conservation Society also became clear, particularly during the initial (WCS), developing new forms of networking. phase of the outbreak. Different legal and Strengthening the capacity of the FAO and OIE to financial frameworks, as well as business models monitor wildlife diseases is worth considering as and operational procedures, remain hurdles to a suitable priority. fuller collaboration. Much of the cooperation remains informal, and is the product of personal relationships among decision makers in the Coordinating International Disease organizations--relationships that would likely Reporting quickly dissolve with changes in personnel. How While a country's IHR focal points are responsible to make these informal channels into formal, in- for reporting human outbreaks to the WHO as stip- stitutional ones that are an integral part of the ulated by the International Health Regulations, its terms of reference and performance expectations CVO is responsible for reporting animal outbreaks of professionals working within the organiza- to the OIE as stipulated by the Terrestrial Animal tions is the next challenge. While how the spe- Health Code. The Director General of OIE can also cialized international agencies is organized falls ask a country's CVO to verify informal reports that outside the remit of the World Bank, the institu- he or she may have received, but replying to this tion does have a particular interest in this subject request is not obligatory as it is under IHR. As because the development mandate encompasses explained in Chapter 3, the response to these all these areas. Also, the partnership with the requests has been wanting. international agencies is indispensable to the Efforts should therefore be made to authorize Bank's work. The international community could the Director General to disseminate publicly infor- aim for the improvement described below. In that mation received from nongovernment sources, in regard, a report published by authority of the the event OIE member states fail to confirm or United Kingdom's House of Lords in July 2008 sought to initiate dialogue on this and related matters, and the recently released report of IOM 6 UNEP has only played a limited role in the control of HPAI, confined, in a later stage of the outbreak, to some work on (2009) also has a number of recommendations in the role of wild birds. This was done in cooperation with this respect (House of Lords 2008). conservation-focused NGOs. 31 Making One Health Operational convincingly deny such information in a timely responding to a newly emerging or re-emerging manner. This recommendation has also been made highly infectious zoonotic disease. This represents an by the recent IOM panel (2009). ad hoc and reactive orientation to emerging diseases that requires considerable improvisation on the part of the institutions involved. It is, moreover, based on Capitalizing on Comparative Advantages the assumption that the HPAI model is more or less While the WHO is quite strongly decentralized with directly applicable to all emerging diseases in general. significant in-country staff, FAO and OIE have a The second option is to strengthen the existing much smaller in-country presence. The WHO's joint Global Early Warning System by improving stronger country presence and IHR facilitate early disease surveillance and reporting procedures from detection and action on emerging diseases, and, within countries. This option could be strengthened with appropriate authorization, could also support by streamlining with the WHO's International FAO and OIE mandates. FAO, which has some Health Regulations, with similar responsibilities, in- country-level presence (although mostly outside the centives, and penalties, applied to livestock/wildlife. animal health sector) can support national efforts Incentives could include linking access to funding of even more effectively than is the case now by longer-term control operations to the availability of strengthening field presence at least at the regional appropriate contingency plans, which include the level. OIE would then be able to focus more on set- improvement of communication channels, the avail- ting of standards and monitoring enforcement. This ability of emergency funds, and the agreement to separation of responsibilities between standard set- mandatory early reporting (OIE 2007). ting and standard enforcement is in line with inter- The third option, and the one that is advocated national good practice to avoid conflict of interest. in this report, is to strengthen the coordinating role of UNSIC, or introduce a similar high-level UN Joint strategy formulation by the WHO, OIE, and FAO mechanism to facilitate consultation with con- would address the current lack of a formal cerned international organizations such as the mechanism to arrive quickly and efficiently at FAO, OIE, and WHO, and to expand this consulta- agreements on common strategies and priority tion to include institutions specializing in wildlife actions. The need for such joint collaboration was and environmental health and others concerned. illustrated by the debate in the first years after the This coordinating role is by definition unintrusive outbreak of HPAI between WHO and FAO/OIE and avoids impinging on the mandates of the on critical issues such as stocking up of antiviral organizations and institutions involved, limiting drugs versus strengthening veterinary services for itself to building consensus and to formulating early HPAI detection, and on culling versus mutually agreed-upon strategies to employ during vaccination as the most appropriate policies to the early phases of an emerging outbreak. This control this disease. Taking stock of these would imply appropriate and secure funding, and experiences would lead to further clarification of extending UNSIC's mandate, which is now ex- roles and responsibilities that could in turn pected to run out by the end of 2010. improve and expedite collaboration. Whichever option is arrived at, three related im- peratives require explicit action. First, a stronger global awareness program is needed that empha- sizes the risks of emerging zoonotic diseases. BUILDING ON ACHIEVEMENTS Second, the low-income developing countries need Three general options are discussed next--from financial and technical assistance to strengthen their business as usual to more far-reaching and system- health systems in the context of the One Health ap- atic approaches that fundamentally change how proach. Third, the provision of improved interna- international organizations act and interact. tional research capacity for the control of zoonotic The first option is to proceed using the model that diseases is needed, that creates an active interface was established by the GPAI and consisted of a task between medical and veterinary science. This re- force administered by the FAO, OIE, and WHO. search agenda needs to underpin efforts to develop Theoretically, this model can be expanded on a case- and operate an efficient and effective global surveil- by-case basis to include other concerned agencies as lance system and to anticipate technical challenges well, depending on the challenges that are implicit in to controlling disease outbreaks. 32 5 Funding Needs and Funding Mechanisms Reducing the enormous risks posed by the emerging and re-emerging zoonotic diseases will require, as a prerequisite, improving the in- stalled physical and human resource capacity to predict, prevent and to control them. Such risk reduction is an important public good. While OECD countries are able to assess their respective needs and to develop the necessary physical and institutional capabilities to meet the challenge, that is not the situation in the low-income developing countries. Since the integrity of a global disease prevention and con- trol capacity is dependent on a minimum capability of each member of the community and "the chain is only as strong as its weakest link," it is necessary to help the poor countries to make the necessary investments to install the requisite capability--physical and human. Estimates of what this will cost are presented below. Presented as well are suggestions for some financing mechanisms that could be used to make the up-front investment and maintain a response capability at both national and international levels. As the contributions of the international specialized agencies are indispensable to a global effort to predict, prevent, and control highly infectious diseases, including zoonoses, adequate funding for them must also be provided. FUNDING NEEDS An effective and efficient global surveillance system is key to reducing the risks associated with zoonotic diseases. The establishment and maintenance of such a system will require a substantial and reliable flow of financial resources. The first priority will be to carry out the on- going international campaign to bring the pandemic risk of HPAI fully under control. Building on the model that has been established by the GPAI, funding mechanisms will then be needed to expand the model into a global human and animal disease (domestic and wildlife) sur- veillance and control system that covers emerging and re-emerging zoonotic diseases. The institutional architecture that is set up to mon- itor and control those diseases should also be well placed and wield substantial capacity to monitor and control the neglected zoonotic diseases, "diseases of trade" and other endemic ones as well. Completing HPAI Control Activities The framework document Contributing to One World, One Health, pre- pared for the Inter-Ministerial meeting at Sharm el-Sheikh in 2008, reported that US$2.7 billion had been pledged at the preceding 33 Funding Needs and Funding Mechanisms international inter-ministerial meetings. As of costs in relation to "the level of risk deemed ac- October 2008, $2.054 billion of this amount had ceptable to the global community." More detailed been firmly committed or already expended for the individual country cost studies will clearly be re- human and animal control cost of HPAI. $853 mil- quired but the estimates presented here are suffi- lion, or 42 percent of this amount, was directed cient for planning investments by the international to national programs. $512 million, or 25 percent, donor community. These investments are urgently went to international organizations. $301 million, needed. The cost estimates used in the framework or 15 percent, went to regional programs. The document, and hence in this chapter, are based on remaining 19 percent ($386 million) went to other the figures for unit costs presented at the Bamako programs, including those involving research. HPAI Conference in 2006 (ALive 2006). Individual This distribution of expenditures over the vari- countries were used as the basic unit. These cost es- ous groups differs from what was envisaged in the timates are based on human and livestock popula- declaration of the first Inter-Ministerial Meeting tions and distributed over the costs of developing on Control of HPAI in Beijing in January 2006. The and maintaining infrastructure. They take account declaration stated, among other things, that "indi- of the previous investments already carried out vidual countries are central to a coordinated re- under the ongoing GPAI and were calculated for sponse." Yet national programs received less than each country for human, veterinary, and commu- half the total available funding. This was in large nication services. These figures were adjusted for: measure attributable to the novelty of the HPAI · The country's income level, covering all threat, which required extensive globally coordi- World Bank client countries, differentiating nated epidemiological research and international the funding needs between low-income, and stockpiling of antivirals. Future funds should be low-middle to high-income countries.7 OECD directed more towards national governments. countries were excluded. The lower-income- The framework document Contributing to One level countries were estimated to have a higher World, One Health presented at Sharm el-Sheikh need but lower per-unit cost for infrastructure reported a shortfall of US$836 million in the current and maintenance, including staffing. programs, mainly as a result of a lack of grant · The economies of scale in surveillance and early financing for country level activities. US$440 mil- response costs, with a progressive decrease lion of this shortfall concerned sub-Saharan Africa. in per-animal unit cost if other species are This was at first glance a surprising finding given covered in addition to the HPAI-related costs. the priority which the international development · The economies of scale in surveillance costs community generally assigns to Africa and the dire for wildlife disease monitoring assuming needs of health systems there. However, HPAI declining financial requirements as livestock arrived in Africa about 18 months after the dis- density increases--that is, countries with a ease's outbreak in Asia, by which time the fear of a relatively low livestock density need a rela- major pandemic had already subsided, and fund- tively larger fraction of their total funds for ing availabilities had diminished. Whatever its rea- wildlife monitoring. sons, the funding shortfall for Africa represented a · Characteristics of the country with higher lev- missed opportunity to build on efforts of the ALive els of intensity in wildlife disease monitoring platform and its members, with support from the if a country was considered a hot spot. EC, to develop INAPs discussed earlier. · Costs of preventing and controlling HPAI. This included also the need to complete the Developing Global Capacity current campaign resulting from a consider- able number (140 by September 2008) of al- The One World, One Health framework document ready prepared INAPs. The annual additional made a very approximate assessment of the costs financing need over the next three years would of a permanent global surveillance system. In its be US$542 million to US$735 million. section on tailoring monitoring and control sys- tems, the document acknowledged that "produc- ing an estimate of the global financing needs to 7 Low-income countries are defined as having per capita gross national income of US$935 or less. Low-middle income coun- implement this Strategic Framework is an art, not tries are defined as gross national income per capita between a science," owing to the complexities of estimating US$935 and US$11,450. 34 People, Pathogens, and Our Planet Table 2: Estimated Cost of Funding the OWOH Framework to 2020 (US$ million) 49 Low-Income Countries All 139 Eligible Countries Public health services 1,264 3,083 Veterinary services 3,286 5,476 Wildlife monitoring 1,495 2,495 Communication 583 1,167 International organizations 3,180 3,475 Research 420 420 Total 10,228 16,116 Average per year 852 1,343 Average per country for the period 208 116* *US$65 million per country for the middle-income countries only. Source: Adapted from Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystem Interface. 2008. · Additional information on these assumptions The benefits of controlling these diseases are not is provided in Annex 2. exclusive to any particular country and therefore fulfill the nonexclusion principle that is sometimes Applying these assumptions, estimates of total illustrated with the example of the benefits of a costs over the next decade are presented in Table 2. streetlight. Moreover, by benefitting from the Owing to the poor state of services in low-income control of these diseases, one country does not countries, funding needs in those countries are diminish the benefits that other countries enjoy, estimated to be much higher than those in middle- and control therefore also fulfills the non-rivalry income countries. character of global public goods. As a global public good, the control of these diseases falls firmly Funding Responsibilities within the mandates of international institutions, How financial responsibilities are divided between and the activities that provide that control are international and national public sources requires clearly eligible for funding by international sources. considerable deliberation. The responsibility for Applying the same principles, public goods that funding an activity or function is in principle de- are national in scope are generally assigned to termined by whether the good that is provided national-level institutions. The control of diseases through that activity is global, national, local, or that affect specific countries but that do not repre- private in scope. Owing to their transboundary sent direct threats to human health on a global scale nature, protection from highly infectious zoonotic are less likely to be eligible for international sup- diseases with pandemic potential is generally port. The control of less infectious and more local considered a global public good. Control of these diseases such as rabies or bovine tuberculosis diseases clearly fulfills the criteria that are defined yields benefits that are mostly local public goods by the International Task Force on Global Public and private goods. The responsibility for funding Goods (International Task Force on Global Public their control can therefore be delegated to local Goods 2006). "Issues that are broadly conceived as levels of government and to private individuals. important to the international community, that for Neglected zoonotic diseases may fall short of the most part cannot or will not be adequately satisfying the criteria of a global public good in some addressed by individual countries acting alone and respects but not entirely. First, their impacts have that are defined through a broad international con- been and remain important factors that actively sensus or a legitimate process of decision-making." contribute to world poverty and that undermine 35 Funding Needs and Funding Mechanisms Table 3: Activities for the Prevention and Control of Diseases at the Animal-Human-Ecosystem Interface and Their Status as a Public Good Disease of Low Disease of Moderate to Activity Human Epidemic Potential High Human Epidemic Potential 1. Preparedness Risk analysis Global Global Preparedness plan National/regional Global Animal vaccine development Private8 Global 2. Surveillance Public health, veterinary and wildlife Global Global Diagnostic capacity Global Global Managerial and policy arrangements National Global 3. Outbreak control Rapid response teams National/regional National/global Vaccination National/regional/private Regional/global Cooperation among human, veterinary, National Global and wildlife services Compensation schemes National/private Global 4. Eradication plans National/regional/private Global 5. Research National/regional/private Global Source: Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human- Ecosystem Interface 2008. economic growth in every region of the developing indicates that low-income countries, with so many world. These impacts disproportionately and some- other, often more direct needs, can't provide sus- times overwhelmingly fall upon the poor and vul- tainable funding for the early detection of and nerable. They therefore assume far more than local response to zoonotic diseases, even though they significance in terms of achieving the poverty- and generally have the most numerous and urgent health-related Millennium Development Goals-- needs to do so. Considering the global public which, of course, are global public goods. goods involved, and the public health and eco- Moreover, disease pathogenesis does not dis- nomic benefits that the international community criminate between diseases that are endemic and derives from early detection and control, interna- those that have epidemic or pandemic potential. tional funding is clearly warranted. A variety of Nor do disease surveillance systems. While control options are available for funding work related to measures are generally disease specific, surveil- these public goods. lance systems monitor all categories of diseases-- Funding has generally been provided in the existing, emerging, and re-emerging. Any disease form of time-bound (mostly three to five years), surveillance system will therefore also monitor the project-based investments. The financier is usually prevalence of diseases of a lower or nonpandemic a bilateral or multilateral donor or financing agency risk. These considerations are reflected in Table 3. that funds most of the infrastructure costs such as laboratory and transport facilities, and some initial operating costs. The recipient country is then re- FUNDING MECHANISMS sponsible for funding part of the operating costs and is expected to continue funding the activity There is general agreement that industrialized and after the time-bound project closes. Long-term middle-income nations should be responsible for financing by these international agencies is often funding their own surveillance systems. Experience not possible owing to administrative constraints related to exigencies such as parliamentary 8 This may also be a global public good depending on diseases approval cycles, policy changes, and a variety and context. of geopolitical considerations. There are usually 36 People, Pathogens, and Our Planet significant financial constraints on the national Third, a levy on certain articles or commodities share of operating costs even during the life of the might be used to channel resources into a global project. These constraints become more pro- fund or funds. This could provide the regular nounced as the project ends and international fund- stream of income needed to sustain a global sur- ing stops. The commitments that governments veillance and early detection system. This option sometimes make to fund maintenance costs follow- was considered in Contributing to One World, One ing the project period are difficult to enforce. Health, in particular for fragile states, and pro- Activity levels typically remain high during the pro- posed in the IOM's Sustaining Global Surveillance ject's implementation when external financing is and Response to Emerging Zoonotic Diseases. The available, and then slackens--often precipitously-- articles or commodities to be levied could be when that funding ends. For a system that is ex- selected according to a number of criteria. They pected to provide a continuing service to the global would be generally recognized as being related to community, such a "boom and bust" model is the spread of zoonotic diseases, so that the parties grossly inadequate. The instability also represents a levied would understand the purpose of the source of global risk because diseases that emerge in levy--thus increasing the acceptability of the countries with few resources and with little capac- levy's cost. The levy would have to be relatively ity can spill over into the rest of the world. easy to collect and preferably have a limited effect Establishing a global funding mechanism that on the poor. facilitates a constant and permanent flow of re- sources of about US$800 million annually is there- · A levy on meat exports. This would be directly re- fore needed. lated to the global public good of control of A combination of different funding sources can zoonotic diseases. It would directly benefit be envisaged. First, the global community could middle- and high-income countries by protect- seek to establish a permanent obligation on the part ing their livestock sectors against the introduc- of high- and middle-income countries to support tion of contagious animal diseases such as low-income countries in the operation of their foot-and-mouth disease. Its cost to low-income surveillance and early response systems. Such a countries would be moderate given that their contribution is not foreseen under the WHO's meat exports account for only 5 percent of International Health Regulations, which is consid- exports globally.9 Its costs could also be limited ered one of its main weaknesses (IOM, 2009). It if based on a clear and well-established system could take the form of long-term twinning arrange- of collection. The levy would preferably not ments between veterinary and human health ser- apply to live animals in order to avoid driving vice agencies in industrialized and developing live animal trade further underground into countries. Or the annual Ministerial Meeting on illegal channels--this despite the fact that live Avian and Pandemic Influenza could be "fixed" on animals are important transmitters of zoonoses the international events calendar and be used as a with pandemic potential. With the total volume permanent mechanism to formulate and drive the of meat trade from the middle- and high- One Health agenda, to secure pledging from its income countries estimated at about 20 million members, and to and monitor the funding for the tons (FAOSTAT), the incremental costs per global program. kilogram would vary between US$0.04 (all Second, nonconventional donors and founda- costs) and US$0.02 (operating costs only). tions, such as those devoted to individual diseases, Additional contributions from the nonconven- may provide financial support as many of them are tional sources described above could further able to commit funds over longer periods of time reduce these costs. than conventional bilateral donors. The funding · A levy on processed meat products, which has a they provide may be on a regular basis or channeled more indirect link with zoonotic diseases than through an endowment that is established for a meat but is also easy to collect and is typically specific set of purposes. Adequately resourced, a product of wealthier consumers. such endowments are a highly appropriate solu- tion, but are unlikely to be able to fund the amounts 9 Source: Calculated from ITC 2005 data set, http://www. required in the near future. Additional sources intracen.org/tradstat/sitc3-3d/ep001.htm (accessed March therefore need to be identified. 14, 2009). 37 Funding Needs and Funding Mechanisms · A levy on pharmaceutical products, which would potential is far greater. This apparent dilemma, how- also have a rather direct link with zoonotic ever, becomes less important, and might disappear diseases, would also be easy to collect, but, altogether if the opportunities for convergence and if restricted to products to control zoonotic synergy implicit in an effective surveillance system diseases, would directly affect the poor. are taken. Monitoring for the potential pandemics that are the chief concern of contributing countries Such dedicated levies have been used at the and investing donor agencies may be the raison national level. In the Netherlands, for example, a d'être of a surveillance system, but that system will levy is charged on each animal slaughtered, and also be able to apply its capacity and some proportion the proceeds are used to fund national emergency of its resources to monitor lingering zoonoses and disease control measures--compensation mecha- diseases of trade. nisms in particular. These have not yet been used at the international level (although France has Operation of the Mechanism proposed a similar scheme to generate funds for a global public good by levying airlines to control The management of a global surveillance system global climate change). may be delegated to an international organization. Access to these funds by resource-poor countries Activities may then be implemented through tech- would be conditional on a proven political com- nical agencies such as WHO, OIE, FAO, and others mitment to cooperate. That commitment would be that specialize in areas such as communications determined by the countries' performance in inte- and wildlife management. In order to avoid grating human and animal health systems and their conflicts of interest, none of these technical agen- gradual contribution to the operating costs of the cies would be charged with the overall manage- surveillance and response systems. A more de- ment of the surveillance system. Alternatively, tailed discussion on criteria for access to such a individual developed countries may maintain their fund can be found in a 2007 OIE-World Bank study own systems based on national priorities and on the feasibility of establishing a global fund for preferences--following the example of the HPAI animal disease emergencies (OIE 2007). campaign after the Beijing Conference. A global fund for the control of zoonoses has Prompt disbursement of the available funds been proposed by FAO among others. The option with appropriate fiduciary controls is essential for is specifically described by Zinstag et al. 2007, who emergency response. The general picture that suggest global subsidiary contributions from coun- emerges from the HPAI campaign shows a very tries that are currently free of certain contagious satisfactory disbursement rate from bilateral grant diseases to countries where those diseases are en- funds but a stagnating flow of funds from the demic. Care would have to be taken to ensure that multilateral development banks. By April 30, 2008, such a vertical funding approach does not under- multilateral development banks had committed mine funding for health systems as a whole, as can just US$403 million (41 percent) and disbursed only occur with this mechanism. $87 million (9 percent) of the $968 million that was Resource mobilization can be a contentious issue pledged at the Beijing Conference in January 2006. because there is often a disconnect between the Bilateral donors, on the other hand, had committed resources and the priorities of high- and middle- all $1.4 billion they had pledged, and disbursed income countries and those of low-income countries. $1.266 billion (90 percent) (UNSIC and World Bank In low-income, resource-poor countries in which the 2008). The main causes of this delay were the reluc- human and economic costs of neglected zoonotic tance of many governments to borrow funds for diseases have persisted over generations, the control what is considered a global public good, elaborate of these diseases is deemed by them to be far more approval procedures for loans, and the strict pressing than potential pandemics. However, fiduciary requirements of multilateral development emerging zoonoses that have pandemic potential are banks. Before any decision is made regarding the assigned higher priority by governments and eventual involvement of a multilateral bank or other international agencies in wealthier countries, where international finance institution, these administra- resources are relatively abundant and fund-raising tive and policy constraints need to be addressed. 38 Annex 1: Economic Losses from Zoonotic Diseases 39 40 Direct losses/costs Indirect losses Economic Losses from Zoonotic Diseases Sources of Loss/ Amounts Amounts Disease Location Data source Period Costs (US$ millions) Sources of Loss (US $ million) BSE UK UK BSE inquiry10 1988­1996 Vet service costs 150 Health services 6 Compensation 360 Research 60 OECD review11 1986­1996 Total/year 935 1997­2000 Total/year 850 CDC (2005)12 2003­2007 Total 11,000 Nipah virus Malaysia CDC (2005) 1999 Total 400 FAO (2002)13 1990­1999 Culling 97 Lost export trade 120 Income loss farmers 124 Lost tax revenue 105 Hosono et al. 1998­1999 Culled animals 90 Ripple effect to other 170 (2006)14 livestock industries SARS East Asia Asian Development 2003 Direct costs 18,000 Ripple effect to 60,000 Bank15 other sectors Canada Darby 2003 Total C$1,500 or 0.15 percent of GDP Global CDC (2005) Total 50,000­120,000 East Asia Wong (2008)16 GDP growth-- 1.2 %YY changes in visitors arrivals 2 percent in East Asian GDP or US$200 billion Canada17 2003 Health costs one 12 hospital HPAI East Asia EU18 2003­2006 Total 8,000 East Asia Elci19 Dec. 2003­Feb. 2006 Total 10,000 Thailand Safman20 2004 (first wave) Compensation 132 Lost trade 500 Rift Valley fever East Africa See case study in box on social impact Lingering Zoonotic Diseases Rabies Asia Africa WHO21 Annually Total 590 Porcine India WHO22 Annually Health and 150 cysticercosis/ production taenosis Cystic Global Budke et al. (2006)23 Annual Livestock losses 140­220024 N.A. Echinococcosis DALY 194­76525 N.A. Food borne US WHO26 1997 Total 35,000 Vietnam World Bank27 Annual Lost products 250 Hospital cost 250 and lost labor 10 UK Government Web Archive. 5 May 2009. 11 OECD (2003) "Food Borne Diseases in OECD Countries. Present State and Economic Costs." 12 Presentation by Dr. Lonnie King (CDC), Washington. 13 FAO and APHCA (2002) Manual on the Diagnosis of Nipah Virus. Bangkok Thailand FAO. 14 Hosono H., Kono, H., Ito, S., and Shirai, J., 2006. "Economic Impact of Nipah Virus Infection Outbreak in Malaysia." Proceedings 11th. International Symposium on Veterinary Epidemiology and Economics. 15 Asian Development Bank 2003 . 16 Wong, R., and Siu, A., 2008. Counting the Economic Cost of SARS: 213­230. 17 VIGILAIR 2005. 18 European Commission Health and Consumer Protection Directorate-General 2006. 19 Elci, C., 2006. 20 Safman, R., 2009. 21 WHO 2009a. 22 Ibid. 23 Budke, C. M., Deplazes, P., and P. R. Torgerson. 2006. 24 Depending on under-reporting assumptions. 25 Ibid. 26 WHO 2007. 27 World Bank, 2006. 41 People, Pathogens, and Our Planet Annex 2: Basic Assumptions Regarding Financing Requirements This annex describes the assumptions used to cal- costs for maintaining the infrastructure, and split culate the different components of the financial out for: gaps and needs provided in Chapter 5. In sum- · Human health services (in US$ per 1,000 mary, the cost estimate is based on individual people); countries as the basic unit, and takes account of · Communication (in US$ per 1,000 people); the countries' human and livestock population and and land area for wildlife. As the requirements · Veterinary services (in US$ per ALU). will depend on the development level of a county, the costs are further based on each These unit costs were adjusted for: country's income level, differentiating between · The economies of scale in surveillance and low-income (LI), low-middle income (LMI), early response costs, if other species are to be upper-middle income (UMI) and five high-in- covered in addition to poultry. The calculated come countries (HI). Only IDA and IBRD coun- costs per ALU were therefore converted with tries were included, not included were OECD 0.7 for the second species and 0.15 for the countries and other non-World Bank clients. third species to be covered. No additional Table 1 Annex 2 provides the details on a regional costs were assumed if more than three species basis. were included. The estimated unit costs per country were based · The infrastructure funded from previous invest- on the cost figures provided in the paper prepared ments according to Table 2 Annex 2. for the Bamako HPAI conference (ALive 2006). Following this paper, the costs were divided This led to the unit costs for human and live- into costs for infrastructure development and stock services as shown in Table 3 Annex 3. Table 1 Annex 2: Background Data of the Countries Included in this Study Human Area of Land # countries Population # ALU in Million Region* LI LMI UMI HI Total in Million in Million** km2 AFR 34 8 0 0 42 806 167 24 EAP 6 12 3 0 21 1931 335 103 ECA 3 9 11 1 24 466 100 24 LCR 1 11 16 4 32 555 178 20 MNA 1 9 2 0 12 310 44 9 SAR 4 4 0 0 8 1567 231 12 Total 49 53 32 5 139 5635 1055 192 *AFR: Africa Region; EAP: East Asia and Pacific Region; ECA: East Europe and Central Asia Region; LCR: Latin America and Caribbean Region; MNA: Middle East and North Africa Region; SAR: South Asia Region. **ALU: Average Livestock Unit. 43 Basic Assumptions Regarding Financing Requirements Table 2 Annex 2: Assumptions on Percentage of Total Costs Already Covered by Previous Investments Region Veterinary Services Human Health and Communication Wildlife Monitoring AFR 0% 0% 0% EAP 50% 50% 0% ECA 75% 75% 0% LAC 75% 75% 0% MNA 75% 75% 0% SAR 50% 50% 0% Source: Background paper to Strategic Framework paper. Table 3 Annex 2: Unit Costs (US $) Used in the Calculations for the Investment Needs for Different Income Level Countries Veterinary Service/ALU28 Human Health Service/ Communication/ 1st 2nd 3rd 4th Income Level 1,000 Humans 1,000 humans species species species species Infrastructure LI 437.616 111.491 10.728 7.663 1.533 0.000 LMI 466.790 118.923 11.443 8.173 1.635 0.000 UMI 525.139 133.789 12.873 9.195 1.839 0.000 HI: 525.139 133.789 12.873 9.195 1.839 0.000 Maintenance LI 466.723 57.594 1.746 1.247 0.249 0.000 LMI 466.790 61.434 1.862 1.330 0.266 0.000 UMI 525.139 69.113 2.095 1.496 0.299 0.000 HI: 466.790 61.434 1.862 1.330 0.266 0.000 To these unit costs per country for human and and monitoring intensity (three levels), as shown in livestock disease surveillance systems, the cost of Table 4 Annex 2, assuming that countries with a low wildlife disease monitoring still has to be added. livestock density. For example, the humid, tsetse fly- However, there were no reliable data on unit costs of infected areas of Central Africa have weaker veteri- such monitoring programs available, and a more in- nary services, but in most instances larger wildlife direct method, based on the assumption that coun- populations. tries with a relatively low livestock density need a To the surveillance (including communication) relatively larger fraction of their total funds for costs of emerging diseases, the cost for eradication wildlife monitoring, was adopted. Based on this ra- HPAI still had to be added. The main cost elements tionale, the share of the total veterinary service cost are: for monitoring zoonotic diseases in wildlife was · Compensation costs, estimated at $2 per made dependent on livestock density (four groups) chicken; 28 Average livestock units. Data refer to the number of animals of the species present in the country at the time of enumeration in terms of livestock unit (LU). It includes animals raised either for draft purposes or for meat and dairy production or kept for breeding. Live animals in captivity for fur or skin such as foxes, minks, and so on, are not included. The enumeration chosen, when more than one survey is taken, is the closest to the beginning of the calendar year. Live animals data is reported in livestock unit (LU) for com- parison of different species across geographical regions. The conversion factors used to calculate ALU for number of animals are: cattle 0.9, sheep and goats 0.1, pigs 0.2, chickens 0.01, and ducks and geese 0.03. (Source: http://www.fao.org/es/ess/os/ envi_indi/annex2.asp.) 44 People, Pathogens, and Our Planet Table 4 Annex 2: Assumed Percentages of the Total Animal Monitoring Costs Related to Wildlife Monitoring for Three Different Monitoring Strategies and Four Different Livestock Intensities Monitoring intensity Group Maximum ALU/km2* Intensive Medium Extensive 1 1.2 80% 50% 20% 2 6.3 60% 30% 10% 3 11.6 40% 20% 5% 4 39.5 20% 10% 5% *ALU/ km2 average livestock units per square kilometer of counties area. · Culling and destruction and disinfection, Finally, the strategy also should be able to address assumed at US$1 per bird; outbreaks of previously unknown diseases, · Vaccination costs, at US $ 0.38 per bird, for which it is assumed that during an outbreak similar to the costs of the last vaccination 1 million average livestock units would have to be campaign in Vietnam (of which vaccine cost culled. Analyses of historic data indicate that the is US$$0.18).29 emergence of new zoonotic diseases occurs on aver- For the number of new outbreaks, the number of age once every two years. With the farm gate price outbreaks during 2007 and up to July 2008 of HPAI of US$234 per ALU, this would result in a total fund- in low- and medium-income countries not endemi- ing need of US$ 234 million per outbreak.31 cally infected30 was defined, and it is assumed that Finally, a special assessment was made for the the frequency and location of new outbreaks would funding needs of the 43 low-income countries, in be similar to those in the past one and a half year. To line with the recommendations of Chapter 5, which calculate the costs for the ten-year period, it is as- would make the costs of surveillance and eradica- sumed that the HPAI outbreaks continue for an- tion of HPAI a global public good and therefore the other three years before the disease is controlled. responsibility of the global community. Table 5 Annex 2: Low-Income Countries Afghanistan Haiti Rwanda Bangladesh Kenya São Tomé and Principe Benin Korea, Dem Rep. Senegal Burkina Faso Kyrgyz Republic Sierra Leone Burundi Lao PDR Solomon Islands Cambodia Liberia Somalia Central African Republic Madagascar Tajikistan Chad Malawi Tanzania Comoros Mali Togo Congo, Dem. Rep Mauritania Uganda Côte d'Ivoire Mozambique Uzbekistan Eritrea Myanmar Vietnam Ethiopia Nepal Yemen, Rep. Gambia, The Niger Zambia Ghana Nigeria Zimbabwe Guinea Pakistan Guinea-Bissau Papua New Guinea 29 For Africa, due to distribution of poultry units and backyard flocks, the costs were estimated at US$0.90 (of which vaccine cost is US$$0.18). 30 Based on the number of outbreaks in 2007 until July 2008 in low- 31 Average from value of African and Asian ALU (Source: and medium-income countries. (Source: http://www.OiE.int.) FAOSTAT 2005). 45 Annex 3: Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystem Interface EXECUTIVE SUMMARY needed, under the broad perspective of the "One World One Health" (OWOH) principles Humanity faces many challenges that require (see Annex 1). The following Strategic Framework global solutions. One of these challenges is the has been developed jointly by four specialized spread of infectious diseases that emerge (or re- agencies--FAO, OIE, WHO, and UNICEF--and emerge) from the interfaces between animals and by the World Bank and UNSIC in response to the humans and the ecosystems in which they live. New Delhi recommendation. This is a result of several trends, including the The Strategic Framework focuses on EID at the exponential growth in human and livestock popu- animal-human-ecosystem interface, where there is lations, rapid urbanization, rapidly changing farm- the potential for epidemics and pandemics that ing systems, closer integration between livestock could result in wide-ranging impacts at the coun- and wildlife, forest encroachment, changes in try, regional, and international levels. The objec- ecosystems, and globalization of trade in animal tives and outputs of the Strategic Framework focus and animal products. on some of the major drivers for the emergence, The consequences of emerging infectious dis- spread, and persistence of EID. The approach pur- eases (EID) can be catastrophic. For example, esti- sued in the Strategic Framework builds on lessons mates show that H5N1 HPAI has already cost over learned from the response to ongoing HPAI H5N1 US$20 billion in economic losses. If it causes an in- infections. fluenza pandemic, it could cost the global economy The objective of the Framework is to establish around US$2 trillion. Therefore, investments in how best to diminish the risk and minimize the preventive and control strategies are likely to be global impact of epidemics and pandemics due highly cost-effective. to EID, by enhancing disease intelligence, surveil- Concerns about the potential for a pandemic lance, and emergency response systems at national, have spurred worldwide efforts to control the regional, and international levels, and by support- H5N1 virus subtype. This virus spread out of the ing them through strong and stable public and People's Republic of China in late 2003 into the rest animal health services and effective national com- of Asia, then Europe and Africa. The success of munication strategies. National authorities play a these control efforts is reflected in the fact that over key role in devising, financing, and implementing 50 of the 63 countries affected by the virus have these interventions. Successful implementation managed to eliminate it. But H5N1 HPAI remains will contribute significantly to the overall goal of entrenched in several countries, and it still has the improving public health, food safety and security, potential to cause a pandemic. and the livelihoods of poor farming communities, Participants in the December 2007 New Delhi as well as protecting the health of ecosystems. International Ministerial Conference on Avian There are five strategic elements to this work: and Pandemic Influenza recommended that the international community draw on experiences · Building robust and well-governed public and with HPAI and develop a medium-term strategy to animal health systems compliant with the address EID. It was agreed that a better under- WHO International Health Regulations (IHR standing of the drivers and causes around the 2005) and OIE international standards, through emergence and spread of infectious diseases is the pursuit of long-term interventions 47 Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystem Interface · Preventing regional and international crises to prevent, detect, and respond to disease by controlling disease outbreaks through im- outbreaks proved national and international emergency · Ensure functioning national emergency response capabilities response capacity, as well as a global rapid · Better addressing the concerns of the poor by response support capacity shifting the focus from developed to develop- · Promote interagency and cross-sectoral ing economies, from potential to actual collaboration and partnership disease problems, and through a focus on · Control HPAI and other existing and poten- the drivers of a broader range of locally tially re-emerging infectious diseases important diseases · Conduct strategic research · Promoting wide-ranging collaboration across sectors and disciplines Implementation of the Strategic Framework will be · Developing rational and targeted disease guided by key principles. These include the adop- control programs through the conduct of tion of a multidisciplinary, multinational, and mul- strategic research. tisectoral approach; the integration of technical, social, political, policy, and regulatory issues; and The overall objective of the Strategic Framework the establishment of broad-based partnerships represents an international public good. Its achieve- across sectors and along the research-to-delivery ment will involve the strengthening of existing continuum. They will include engagement of animal and public health surveillance, response, pre- wildlife and ecosystem interests, the human and vet- vention, and preparedness systems at the country, erinary medical community, and advanced research regional, and international levels. institutions (ARI). Priority interventions and associated actions National authorities will be encouraged to will be established by officials at the country level build on national strategies on EID, to engage and will be prioritized with the help of experi- with the private sector to strengthen local capac- enced international agency personnel. They will ity and to promote long-term sustainability. This be identified based on known areas of risk (hot would include the strengthening of institutions spots) for disease emergence and on research already in existence, in addition to the structures, findings that point to new risks. The Strategic mechanisms, and partnerships that have been Framework does not propose prioritization of dis- developed in response to the HPAI crisis among eases to target; instead, it brings benefits to poor international agencies (FAO, OIE, WHO, and communities and agricultural sectors by reducing UNICEF) such as UNSIC, GLEWS, the Global the risks of infectious diseases that are important Framework for Progressive Control of Trans- locally--for example, Rift Valley fever, tuberculo- boundary Animal Diseases (GF-TADs), and the sis, brucellosis, rabies, foot-and-mouth disease, FAO/OIE Crisis Management Centre (CMC-AH), African swine fever (ASF), and Peste des petits as well as those developed between the public and ruminants (PPR). This approach will not only animal health sectors. This would be done with- control existing and often neglected infectious out requiring the integration or fusion of their diseases, but will also promote surveillance for roles. The Strategic Framework will encourage the EID at a grassroots level by embedding global formation of flexible, formal, and informal net- concerns within a local context. works of partners, and will promote pro-poor Based on these considerations, the following actions and interventions. six specific objectives have been identified as In considering options for financing implemen- areas for possible priority emphasis by national tation, key issues to be addressed include the authorities: benefit-cost ratio of various options, long-term sus- · Develop international, regional, and national tainability, public versus private goods, and the capacity in surveillance, making use of in- political commitment of key stakeholders. Donor ternational standards, tools, and monitoring funding will be sought, including a combination of processes grants and loans. · Ensure adequate international, regional, and This joint Strategic Framework will be presented national capacity in public and animal as a consultation document at the International health--including communication strategies-- Ministerial Conference on Avian and Pandemic 48 People, Pathogens, and Our Planet Influenza in Sharm el-Sheikh, Egypt, October Framework and consider how best to reach a con- 25­26, 2008. It will be discussed by high-level sensus on sustained efforts to control EID. In due participants from countries, international technical course, national authorities should consider the agencies, regional organizations, ARIs, donors, degree to which they are ready to make long-term and the private sector. This should provide an op- political and financial commitments for validation, portunity for the key stakeholders to discuss the implementation, and monitoring impact. 49 Annex 4: One World One Health: From Ideas to Action REPORT OF THE EXPERT CONSULTATION The Strategic Framework was first released at MARCH 16­19, 2009, WINNEPEG the International Partnership on Avian and Pandemic Influenza meeting in Egypt in October 2008. At that meeting, PHAC offered to host a CONSULTATION OVERVIEW AND consultation to further discuss the objectives in the KEY RECOMMENDATIONS Strategic Framework. Over the course of the three-day consultation, The Public Health Agency of Canada's (PHAC) experts from 23 countries shared their knowledge Centre for Food-borne, Environmental and of best practices, challenges, and barriers to imple- Zoonotic Infectious Diseases (CFEZID) hosted the mentation of an OWOH approach. Representatives One World One HealthTM Expert Consultation in of the six international organizations discussed Winnipeg, Manitoba, from March 16­19, 2009. their vision of the Strategic Framework and an- ("One World One Health" is a registered trade- swered questions from the participants. A number mark of the World Conservation Society.) of experts provided presentations and case studies The One World One Health (OWOH) concept on key areas, and participants had the opportunity proposes an international, interdisciplinary, cross- to work in small groups to discuss issues such as sectoral approach to surveillance, monitoring, surveillance data gathering, management and prevention, control, and mitigation of emerging ownership, interdisciplinary training, and main- diseases, as well as to environmental conservation taining political will. Recommendations included (from OWOH Strategic Framework, 2008). It rec- creating transdisciplinary networks for infor- ognizes the linkages among animal, human, and mation sharing, developing a "Global Health" ecosystem health domains. Broadly stated, the university curriculum, and engaging grassroots OWOH concept provides a framework for pre- involvement in animal, human, and ecosystem venting emerging infectious diseases of animal health initiatives. origin, instead of simply responding to them once In her closing remarks, Danielle Grondin, they have occurred. Acting Assistant Deputy Minister of the Infectious International and Canadian experts from acade- Disease and Emergency Preparedness Branch, mia, government, NGOs, United Nations organi- PHAC, encouraged participants to take the spirit zations, and the private sector gathered together at of OWOH and apply it in whatever sphere of the Fort Garry Hotel to discuss "Contributing influence they might have. to One World One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at KEY RECOMMENDATIONS the Animal-Human-Ecosystems Interface." The Strategic Framework was the joint product of six The following key recommendations emerged over major international organizations: the FAO, WHO, the course of the consultation. They represent areas OIE, UNICEF, the World Bank, and UNSIC. The of focus for moving forward the animal-human- document sets out six priority objectives for coun- ecosystem interface concepts of OWOH and the tries to consider, such as developing capacity in objectives presented in the Strategic Framework. surveillance, promoting interagency and cross- · Foster political will--Multilevel, multi- sectoral partnerships, and ensuring functioning ministry political will is crucial to driving the national emergency response capacity. OWOH concept forward. 51 One World One Health: From Ideas to Action · Support partnership and collaboration--Finding require investment in training. Working with new ways to work together and build new atti- the media is critical to getting information to tudes is essential. 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