Op-Ed: In an age of Zika and a threat of biochemical terror, health security must be everybody’s concern
My country South Africa lives with the world’s highest burden of HIV/AIDS, a preventable disease that brought widespread death, extraordinary misery and great hardship to our people.
Close to half of the 3.7-million orphaned South African children lost their parents to HIV/AIDS.
The reason for this human calamity is the political, leadership and moral failure to do everything in our power to promote safe-sex practices under circumstances where a vaccine was, still is and likely will be unavailable for a while.
In West Africa 11,312 people died of Ebola that, like HIV/AIDS, was preventable. The 11,312 people who died did not have to die.
I am still haunted by wailing of children as they witnessed their parents dying only for them to also perish in dark loneliness while their neighbours watched in terror from afar.
It was not because the health people did not know what to do. The political and moral failure of the West African leadership to invest in the public health and education of their people subverted trust in their governments’ health messages.
With Zika there too was political failure to act quickly, give honest advice and confront the abortion conundrum head-on, the result being that 3,000 and likely more children with microcephaly will test the emotional resilience and financial resources of their families to breaking point.
We should never cease to invest in the public health and medical science of disease, but it seems to me that our fundamental problem is not the quality of the health sciences but the grim mediocrity of our politics. Party-political bickering for short-term gain paralyses and drains the national effort in South Africa as much as it does in the United States, undermining our ability to see with compelling clarity the solutions the issues of the day deserve.
Health security is humanity’s shared concern. Promoting health and preventing death define us at our most altruistic and advanced. The Hippocratic Ideal, the concept of the physician as the guardian of human health, encapsulates a fundamental human quality common to all the world’s great religions. Medicine is one of the earliest and greatest human achievements because it is a co-operative enterprise involving highly skilled individuals; and it is as a result of cooperation – and our unusual ability for complex language – that cumulative civilisation is possible.
In the age of globalisation, it is health security, a recent Lancet editorial stated, that “is now the most important foreign policy issue of our time”. The rapid emergence and re-emergence of pathogenic infectious disease, of which Zika is the most recent, the slow but steady cumulative acts of nature associated with climate change, high-risk forced migration caused by desperation and war, the creeping reality of biochemical terror and the threat of nuclear war, propel human survival and well-being to the frontline of what today must be everybody’s concern.
The field of health diplomacy provides an unprecedented opportunity to build human solidarity. It is an area of human endeavour that cuts through inherited antagonisms. Governments that offer health improvements as part of aid to nations with whom they wish to develop stronger diplomatic links succeed in cultivating deeper cultural relationships precisely because of their direct benefit to citizens. To advance health diplomacy requires health leaders with an inclusive global vision...
At the heart of health diplomacy lie negotiations over intellectual property (IP), trade and access to medicines. Ebola and Zika focused attention on negotiations over rapid inter-governmental emergency responses, the role of the military in building infrastructure, the efficient movement of health professionals, medical therapies, innovative diagnostic and surveillance technologies, intervention methodologies and aid across regions and continents. More broadly, health diplomacy brings together the disciplines of medicine, public health, international affairs, law, economics, anthropology and engineering to influence and provide expert content that drive the global health policy environment and its practical field applications.
The deliberate release of dangerous chemicals in theatres of war such as in Syria remind us of the importance of making every effort possible to stop governments from poisoning people and the need for heightened vigilance over laboratory and health science biosafety protocols.
There is the looming spectre of a less secure nuclear environment.
New actors in health security include the rise and expanding reach of the Peoples’ Republic of China.
Of profound importance are the networks built around the Global Health Security Agenda (GHSA) working on the so-called “action packages” developed by the Centers for Disease Control and Prevention (CDC). They have become zones of energy and initiative that will require resources and ongoing sustainable commitment to keep ahead of the game, which is why the Trump administration’s stifling budget proposals to cut the CDC and the National Institutes of Health (NIH) sent shockwaves throughout the world.
Launched in February 2014, and given impetus by the deadly West African Ebola outbreak that killed 11,312 people, the Global Health Security Agenda has grown rapidly into a co-operative enterprise that involves more than 50 nations, international organisations and non-governmental organisations today. “A stuttering, unco-ordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands”, observed Mark Siedner and John Kraemar in The Lancet, “was followed by one of the most successful global partnerships between foreign and local governments and multinational aid organisations to stem an international health crisis.” (Mark Siedner and John Kraemar, ‘the end of the Ebola virus disease epidemic: has the work just begun?’ The Lancet Vol.5 no.4 (April 2017) pp. e381-e382.)
CDCs action packages focus on:
- (1) prevention – antimicrobial resistance, zoonotic disease, biosafety and biosecurity and immunisation;
- (2) disease detection – laboratory systems, real-time surveillance, disease reporting and health workforce development; and
- (3) responses – establishing emergency centres, linking public health with law and multi-sectoral rapid response and advancing medical countermeasures and personnel deployment.
Various countries have signed up to lead some of packages. My own – South Africa – has teams working on five of the action packages we regard as priorities and is a co-leader on the one that deals with national laboratory systems.
Many countries have subscribed to external evaluations to objectively assess their national health security capacity under the International Health Regulations (IHR) and to identify the most urgent needs and priorities for enhanced preparedness, responses, actions and engagements with current and prospective donors and partners to target resources effectively. Armenia, Bahrain, Bangladesh, Cambodia, Eritrea, Ethiopia, Georgia, Jordan, Lebanon, Liberia, Morocco, Mozambique, Pakistan, Peru, Portugal, Uganda, Ukraine, United Kingdom, Qatar, Sierra Leone, Somalia, Sudan, Tanzania and the USA have had theirs done.
Successful projects supported by the agenda include:
- Building community resilience in Vietnam to identify potential outbreaks earlier to shorten response times and avert epidemics;
- Moving Congolese contact-tracing experts to Guinea to assist with disease and prevention detection efforts;
- Training engineers to maintain the 120-plus biosafety cabinets at Ethiopia’s national laboratories;
- Acute laboratory testing for pathogens in foodborne outbreaks in India to enable public health experts to link people with similar results;
- Developing a special public health approach to deal with the Hindu pilgrimage of Kumbh Mela in India, the largest gathering – 60-million people – on earth;
- Modernising Kazakhstan’s outdated laboratories using a step-wise improvement approach;
- Joint WHO – Mali Ministry of Health training programme of subject experts in surveillance for viral haemorrhagic fevers, polio and yellow fever;
- Training disease detectives in Pakistan to stop vaccine-preventable diseases like measles, diphtheria, pertussis, tetanus, hepatitis B and Hib disease;
- Post-Ebola development of Sierra Leone’s Integrated Disease Surveillance and Response System providing timely health data to decision-makers; and
- Community based disease surveillance training for volunteer community workers and health workers in Tanzania to investigate and report community-level outbreaks.
A new Africa Centres for Disease Control and Prevention (Africa CDC) was officially launched in Addis Ababa, Ethiopia, on January 31, 2017. It is Africa’s first continent-wide public health agency. The goal is to develop early warning and response surveillance systems, emergency response, specialist health professional capacity and appropriate technical expertise. Five regional centres located in Egypt, Gabon, Kenya, Nigeria and Zambia will develop the capacity to rapidly detect known and unknown pathogens and will serve as regional reference centres. In turn, every country is expected to have a public health institute.
But, as The Lancet editorialises, “Insufficient funding is the key element that could hamper implementation. Despite receiving funding from both the African Union and China, there is uncertainty regarding the impact that a change in the commitment of the new US government to support the Global Health Security Agenda could have on the Africa CDC.” (Editorial, ‘A new day for African public health’, The Lancet Infectious Diseases vol.17 no.3 p.237.)
Sam Loewenberg remarked: “In the wake of the Ebola crisis, the global health security agenda and the implementation of the International Health Regulations became major US priorities. Whether that will continue is uncertain. Although it might seem to be an area that the Trump administration wants to protect for self-interested reasons, the administration could easily go the other way and try to take an isolationist stance, such as (simply) imposing travel bans.” (Sam Loewenberg, ‘Trump’s foreign aid proposal rattles global health advocates?’ The Lancet Vol.389 no.10073 (11 March 2017) pp.994-5.)
Though it has the status of a budget proposal, the fear is being realised as we speak. The CDC, the vehicle for US funding for the Africa CDC, may see a shift towards block grant funding to support domestic state needs. Former CDC Director Tom Frieden says that block grants are often a precursor to funding cuts. He estimates that the CDC will lose $1.8-billion from its $7-billion budget, a 25,7% cut. In his experience, block grant funding is naïve and short-sighted. He cites the fact that block grants for TB control programmes gave rise to deadly outbreaks of drug-resistant TB that cost more than a billion dollars to deal with.
Furthermore, at the NIH, a proposed 18% cut including the complete elimination of the Fogarty International Center for Global Health, is huge. Taken together with cuts that will affect both the State Department and Health and Human Services, global health diplomacy will face serious financial constraints. For US public health there may be a silver lining: the proposal to establish a Health Emergency Response Fund much like a Disaster Relief Fund enabling rapid responses has found its way into the Trump budget proposals. But, as Frieden remarks, the devil is in the detail.
With militaries playing an important role in rapid response logistics and infrastructure development during health emergencies, defence authorities have become involved more and more in frontline public health services, which carries considerable risks for non-partisan neutrality in foreign locations. With the Trump administration’s goal of expanding the budget of the defence authorities, spending on military-driven health security may well increase, which is good for defence-specific health and medical research and development, but under circumstances where the military does not always understand where security ends and health diplomacy begins.
Historically, the US military is perhaps unique in making the understanding, preventing and treating infectious diseases a priority throughout its history. To protect its servicemen and women from infectious disease the world over, it has invested in infectious disease efforts that led to a number of scientific, medical and public health contributions. The Department of Defence organises its support in three ways: medical research and development; health surveillance, and education and training of US personnel. (Kellie Moss & Josh Michaud, The U.S. Department of Defense and Global Health: Infectious Disease Efforts (The Henry J. Kaiser Family Foundation, October 2013)
The US Military has a global footprint that can be leveraged. The US Army Medical Research Unit in Kenya and the Armed Forces Research Institute of Medical Sciences in Thailand – they also have field sites across their respective regions – allow Defence personnel and Defence partner staff to conduct in-country research. Along with the US Navy’s global laboratories, they serve as Defence’s forward research centres for a number of infectious diseases.
The Naval Medical Research Centre oversees most naval research and development in infectious disease, targeting malaria, bacterial causes of traveller’s diarrhoea, dengue fever and scrub typhus. It conducts active surveillance for diseases that affect military personnel and their dependents with an emphasis on respiratory and enteric pathogens. Globally, there are research stations in Cambodia, Egypt, Ghana, Peru and most recently, Singapore.
Finally, there are highly specialised programmes supported by Defence, among which the medical biological defense research and development effort is of special importance, as it addresses naturally occurring and emerging infectious diseases that have the potential to be used as biological agents such as anthrax and novel influenza viruses.
Defence expenditure on health security are notoriously difficult to ascertain, but if increased under the Trump administration more momentum will be given to the securitisation of health worldwide, to the detriment of diplomatic efforts. The fact is that many if not most of the difficult and complex issues in health security are solved by diplomacy and negotiations requiring highly skilled health attaches at embassies and high commissions. Health diplomacy is the front office of health security, Defence its back office, and for good reason: Defence must never be embroiled in partisan struggles for it weakens its capability to execute on its core mission, which is national security.
It would therefore be a moral failure of extraordinary proportions if the US were to voluntarily vacate its leadership role in global health. No doubt other major powers should step up to the plate and all countries must certainly devote a decent budget to the health of their populations. But, at the very moment when the Global Health Security Agenda has developed unprecedented momentum, it would be extreme folly for the US to cut back on the global battle to deal with infectious disease threats that respect no boundaries or distinctions of class, age, race or gender.
The challenge is daunting. The World Health Organisation identified the following top emerging pathogens likely to cause severe outbreaks in the near future (World Health Organisation (WHO), Research and Development Blueprint for action to prevent epidemics, plan of action (May 2016):
- Crimean Congo haemorrhagic fever virus;
- Filo virus diseases (Ebola and Marburg);
- Highly pathogenic emerging coronaviruses relevant to humans; (Middle-East Respiratory Syndrome coronaviruses and severe acute respiratory syndrome coronavirus);
- Lassa fever virus;
- Nipah virus;
- Rift Valley fever virus; and
- Any new severe infectious disease.
The WHO also identified serious diseases necessitating further action as soon as possible:
- Severe fever with thrombocytopenia syndrome; and
- The subject of today’s meeting, congenital abnormalities and other neurologic complications associated with Zika virus.
Why is Zika last on the WHO list? Why does the list suggest that Zika may not re-emerge in epidemic form when the summers roll along again? As the New York Times’ Donald McNeil put it: “In Year One, in every city in the Western Hemisphere – except Miami – what stopped Zika wasn’t a vaccine, a drug, a pesticide, a larvicide, window screens, bednets, DEET or any other medical intervention. What stopped it was cold weather.” DM
Extract of a keynote speech given at a meeting titled A Paediatric Menace Wrapped in a Protein: Zika and the Global Health Security Agenda, Columbia University Medical Center, New York City, 3 April 2017.
Photo: Doctor Ewelina Krol from the Intercollegiate Faculty of Biotechnology of the University of Gdansk and the Medical University of Gdansk during her work in the university laboratory in Gdansk, Poland, 04 October 2016. EPA/ADAM WARZAWA