The role of NGOs in global health security: A conversation with Tausi Suedi

By Nick Alexopulos

Tausi Suedi, CEO and executive director of Childbirth Survival International (photo by Larry Canner)

Tausi Suedi, CEO and executive director of Childbirth Survival International (photo by Larry Canner)

On July 30, the Johns Hopkins Center for Health Security convened more than 60 experts to gather input and recommendations for the forthcoming U.S. Global Health Security Strategy, a document that will codify U.S. support for the Global Health Security Agenda. Among the many discussion topics—disease surveillance, laboratory diagnostics, workforce development, emergency management, antimicrobial resistance, and more—was the role nongovernmental organizations (NGOs) play in overall global health security, and how to ensure those organizations are meaningfully included in an interagency U.S. strategy.

Tausi Suedi, MPH, championed this cause in her questions and comments throughout the meeting. She is the CEO and executive director of Childbirth Survival International, a grassroots nonprofit advocating for maternal and newborn health in the Sub-Saharan African countries of Tanzania, Uganda, Nigeria, Ghana, and Somalia. Suedi is also an adjunct professor of global health at Towson University. 

After the Center’s event, the Bifurcated Needle spoke with Suedi about NGOs’ contributions to the GHSA: 

What major point did you communicate to the group, and what key message were you hoping to hear from your fellow experts and panelists?

The Global Health Security Agenda requires partnership and collaboration, especially with grassroots nonprofits that are actually implementing some of these packages. When you look at our nonprofit, Childbirth Survival International, we particularly focus on some of those action packages. For example, workforce development, immunizations, and making sure healthcare workers on the front lines are being trained to quickly recognize irregularities and act quickly if they identify a threat. 

What I was hoping to hear and what I think I did hear was the U.S. government’s commitment to continue engaging with [low resource] countries in order to strengthen their healthcare systems. As we all know, many systems are still inadequate, especially as you move from the urban to the rural areas—and so a lot more effort is needed. And that needs to be a concerted effort. Of course the U.S. government is a major player in this and very well recognized in its role, and what I heard from experts in the room is that the United States is on track to continue making those changes in the world.

How does the GHSA benefit from the work of NGOs?

We bring extraordinary value because we’re at the grassroots. If you look at the GHSA, how it’s structured, a vital component of its mission is to actually respond to a threat. It’s there, waiting; if something happens, let’s go. But the NGOs, we’re already on the ground working every single day, building the health systems, training the healthcare workers, educating the communities, getting families to immunize their kids, and working on other factors to prevent disease. We’re doing this work constantly, and like GHSA we’re responding to an emergency at the particular moment when it happens.

Your organization works in five Sub-Saharan African countries. What does the GHSA mean for them?

They will benefit tremendously from GHSA efforts to strengthen their healthcare systems, which still rely a lot on donor funding and international NGOs. With this collaboration of the U.S. government and international NGOs working together on this GHSA package, you’re bound to find countries improving with strengthened healthcare systems. 

Now, some countries are part of GHSA and others are not. Somalia, for instance, is one of those fragile countries, and one of the countries my organization serves. For it to be part of this GHSA consortium, a lot more work is needed to build its healthcare system and health infrastructure.

Final thought?

As an American, as an African, as a woman leader, I think we’re doing great work to improve health around the world. But I think we should not lose sight of what makes this happen: focusing at the grassroots level, the community level, where there is the most hurt.

***

A summary meeting report is forthcoming and will be available on the Center's website.

Watercooler chat transcript: Plague in Madagascar

Excerpts from semi-organic conversations among Johns Hopkins Center for Health Security staff in their Slack #biosecurity channel (inspired by 538’s Slack Chats).

cmrivers (Caitlin Rivers): Today we’re discussing the outbreak of plague in Madagascar, which has been ongoing since August. First a little background. As of Oct 26 there have been 1,309 cases and 93 deaths. Two thirds of cases have been pneumonic (spread person to person). The case fatality rate is reported at 7%, which ProMed notes is quite low. Two cases were imported to Seychelles, both of which resulted in no secondary transmission [Update: the suspected cases in the Seychelles ultimately tested negative upon confirmatory testing]. A number of control measures have been implemented beyond the usual steps of contact tracing and isolation. The World Health Organization has released $1.5M in emergency funds, and eight specialized health centers have been opened. Public schools are closed and public gatherings are forbidden.

cmrivers: So, what do you make of this outbreak and how worried are you?

sanjana (Sanjana Ravi): My initial reaction -- I'm not super worried that this will escalate into an Ebola-level crisis, since, as an island, Madagascar is somewhat more geographically isolated and doesn't appear to have the same problem with porous borders that we saw with Guinea, Sierra Leone, and Liberia. I am a bit concerned that little has been said about vector control.

tara (Tara Kirk Sell): I don't think that this is another Ebola. Plague is endemic there (and I'm wondering if that may have a role in the low case fatality rate). It’s not good that it's in the cities but I just don't think that it's going to be as explosive.

cmrivers: I see the endemicity as a problem, actually. There's a whole dimension in the sylvatic cycle that we didn't have to deal with during Ebola.

tara: Well, I think that the endemicity means that the threat will never really go away but I also think that it means that it's not a rare event we are dealing with.

watson (Matt Watson): That said though, Ebola did show what can happen when a previously "rural" neglected tropical disease gets into cities. I don't think we know nearly enough about transmission dynamics and how to effectively intervene in those settings.

crystal (Crystal Watson): It seems to be behaving similarly to the outbreak in India in 1994. Like India, it is in a highly densely populated area with a mix of bubonic and pneumonic plague. Also, I think the close proximity of those who are infected is a huge driver. A lot of these pneumonic outbreaks occur in mine workers where they are close together in confined spaces.

cmrivers: Any guesses why this outbreak is unusually large compared to Madagascar's usual outbreaks? Is anything about the epidemiology here unusual?

crystal: I do wonder if there are plague superspreaders.

cmrivers: There are! The index case of this outbreak infected 30-some people, if memory serves.

meyerda (Diane Meyer): According to our Outbreak Observatory post, this outbreak has entered an urban and non-endemic area...perhaps that is why it is larger than normal.

michael (Michael Snyder): Also, there's a higher proportion of the more transmissible pneumonic plague variant than bubonic.

crystal: Also burials!

tara: Good point - burials are often a huge problem.

watson: Then there’s this story on families seizing plague victims’ bodies… If true, it may indicate a lack of trust in the government and international response.

cmrivers: That’s troubling. Rumors on that topic abound. One says that a “local tradition of dancing with dead bodies” is fueling transmission? Could this be true?

crystal: That would aerosolize bacteria for sure.

cmrivers: Y. pestis is non-spore forming, so I think that rumor is salacious and unfounded.

crystal: I think we chronically underestimate how long pathogens can persist in the environment. The literature suggests that it can survive for years in soil and on other surfaces.

nalexopulos (Nick Alexopulos, Communications Director): Aren’t there reindeer frozen in Siberian ice that carry transmissible plague?

cmrivers: That’s anthrax, which is spore-forming and very persistent in the environment.

nalexopulos: [goes back to writing tweets]

crystal: Plague seems to go dormant though.

cmrivers: But is it possible for transmission to happen years after death?

crystal: It says here that “a growing body of evidence suggests that Y. pestis can survive without a host for extended periods under certain environmental conditions while, in many cases, retaining infectivity.”

crystal: I wonder what the mechanism is for plague to make the switch from bubonic to pneumonic though? Is it always that superspreader?

cmrivers: One way to get at your question is to look at chains of transmission and see how many generations they last.

crystal: The superspreading issue I think needs a lot more attention. There are so many examples of this now. It seems to be a major driver of a number of outbreaks.

cmrivers: I think so too. It was a major feature in SARS and Ebola. I think this is a place where better outbreak science would be helpful. There's not much real-time effort to reconstruct transmission chains, in part because it’s hard. But it does reveal a lot about the transmission dynamics.

crystal: Definitely. If we really committed resources to understanding transmission dynamics, it would reduce a lot of uncertainty.

tara: Like Crystal said, we should understand more about why someone gets bubonic vs pneumonic plague.

michael: It’s true -- given their different transmission pathways, it's almost like having to manage two separate (but related) disease outbreaks at the same time.

sanajana: So according to WHO, human-to-human bubonic plague transmission is very rare. It's almost always the result of a flea bite. The fact that there are so many cases suggests that most are of the pneumonic variety, OR that the vector control situation is really bad.

tara: I wonder if animals are common in the home, or if it is more pest control that is the vector control issue.

michael: The WHO has cited the poor environmental and sanitation conditions as a driving factor, so I imagine vector control is playing a big role for bubonic plague transmission.

watson: There’s often talk of plague “foci” where it persists as a zoonosis, for example, this paper.

tara: So based on that paper, are climatic conditions right for this year’s Rattus rattus explosion?

cmrivers: Well three-quarters of cases are pneumonic, so I think that speaks to Michael's point about two different but related outbreaks. Even without zoonotic cases there's still a major outbreak.

crystal: I think they are synergistic.

cmrivers: What should they be doing beyond vector control?

watson: [WHO has] moved in a small stockpile of antibiotics - that's good. And actually, at 1.2 million doses, it's not all that small.

cmrivers: That is pretty sizable. Contacts need 7 days of post-exposure prophylaxis though so...it adds up.

crystal: Also, probably a lot of supportive care is needed for pneumonic cases and isolation precautions.

michael: I think Crystal’s comparison to the 1994 plague outbreak in Surat, India, is interesting. That one had about 50 case fatalities but caused an estimated 500,000 refugees.

crystal: Yes. I wonder if that slowed the epidemic in India actually? People got out of town as soon as there was a confirmed case.

cmrivers: The refugees is an interesting twist. Can you say more about that?

crystal: People got out of town as soon as there was a confirmed case. Plague is historically very scary.

michael: Panic. Made only more fascinating by the fact that they never confirmed it was plague until about 6 years later.

cmrivers: Did they take any cases with them, spreading the disease?

crystal: They did, but not hugely. Plague is less transmissible than some people think, even pneumonic. [Our founder] DA Henderson always said that.

cmrivers: That brings us back to “why is this happening now in Madagascar?”

tara: I wonder if genetic analysis at a later date will tell us if this is all one introduction or many. My money is on many. It also brings us back to my question about climate conditions! Is there a global warming component?

cmrivers: There has been some work on predicting plague emergence, e.g. here.

crystal: It's the end of dry season in Madagascar. The rodents may be hungry and are venturing into the cities to eat, whereas normally they would eat in the wild. I wonder if the condition of the soil also makes a difference?

meyerda: This article states that warmer/wetter conditions cause rodent numbers to drop, sending fleas looking elsewhere for food.

cmrivers: I think from a public health perspective it's more prudent to focus on the rat-human interface...like keeping rats out of human homes. Climate is not a modifiable risk factor, but habitation conditions are.

tara: But rats aren’t the only animal that can maintain a flea infestation, which speaks to the importance of pets [as risk factors].

cmrivers: Ok back to our roots. As a tier 1 select agent, Y pestis is considered a candidate pathogen for biocrimes. Is there anything we should be learning either from this outbreak or the response that applies to biosecurity?

crystal: It's really hard to limit accessibility of Y pestis. It's everywhere. Here is a sign from the field near my parents’ house.

Plague 2.png

nalexopulos: And that "etc." in the parens does some HEAVY lifting.

watson: Yet more evidence to support my thesis that everything in the American West is trying to kill you.

cmrivers: We have most of the tickborne diseases out East. I feel pretty negatively about that. So Crystal, what are the implications here? Stop regulating research?

crystal: Research should still be regulated, but it will never be possible to stop access if someone really wants to collect Y pestis.

watson: From a violent non-state actor perspective, ISIS or other groups haven't yet gotten people all worked up about a "plague weapon" like they did w/ Ebola. (In fairness, they've got other things on their minds...).

sanjana: There's something to be said about how we need to get better at integrating/coupling microbial forensics with biosurveillance/early detection systems. Just thinking about connections between this outbreak and the 1994 Surat outbreak. To my knowledge, the origin of the Surat outbreak was never identified, although the outbreak itself was eventually curbed through extensive vector/rodent management and public health measures.

watson: To that point, from the article I linked to above... "Finally, the discontinuation of plague surveillance since 2006 (due to financial shortages) has contributed to the reappearance of plague in the capital's suburbs six years after the last reported case." Right there is why the world needs the Global Health Security Agenda (GHSA).

sanjana: I’m wondering if there is a way to integrate forensics into routine public health/epidemiological investigations to enhance our ability to ID biocrimes.

cmrivers: All good points. Any final thoughts?

michael: Just that there's a lot more to this story -- unanswered questions that will hopefully come to light. Seems odd that a country with so much experience with plague wasn't able to control this one - not like Ebola where it was a totally unexpected disease in West Africa!

cmrivers: l agree. I think at this point I'm past being surprised about the...tenacity of outbreaks though. Even diseases we think we know all about are full of surprises.

cmrivers: Thanks, all!

Johns Hopkins Center for Health Security Teams with NTI and the Economist Intelligence Unit to Develop a Global Health Security Index

We are very excited to announce that thanks to generous support from the Open Philanthropy Project and the Robertson Foundation, our Center is working with the Nuclear Threat Initiative (NTI) and the Economist Intelligence Unit (EIU) to develop a Global Health Security Index.

The mission of the index is to encourage progress towards a world that is capable of preventing epidemics of international impact (either natural, accidental or deliberate) from arising, or, should, prevention fail, respond quickly to contain them.

In the first phase of this project, our team is focusing on developing a framework (i.e., the value, principles, attributes, and major components) to assess and compare countries’ levels of health security. To help inform the development our framework, we are convening next month an international expert advisory group. Once we’ve developed our framework, we will begin the process of assessing, collecting, and analyzing data on a country-by-country-basis. 

Below we explain in more detail why we’ve embarked on this important project.

Why try to measure global health security?

Recent infectious disease outbreaks, such as the ongoing Zika virus outbreak, the Ebola outbreak in West Africa, and the spread of MERS-CoV in the Middle East, continue to show us that when individual countries experience difficulties detecting and effectively containing the spread of infectious disease outbreaks, they can quickly threaten the health, security, and economies of countries across the globe. The increasing frequency of events that threaten global health security illustrates how now, more than ever, there is a strong global need for collective action to bolster all countries’ health security capabilities.

Some measures have been taken by the World Health Organization (WHO) and more recently through the Global Health Security Agenda (GHSA). Although these are worthwhile, important initiatives, they have some limitations that an index could address.  

In 2005, updates were made to the International Health Regulations (IHRs) to improve countries’ abilities to detect, assess, notify, and report public health emergencies of international concern (PHEICs). Among the modifications, the revised IHRs created a set of 8 core public health capacities that countries must develop. To help countries assess their progress, the World Health Organization created a list of indicators for development of the IHR core capacities. But lack of funding, lack of political will, and a myriad of other factors have slowed implementation of the revised IHRs.  By its implementation deadline in mid-2012, approximately 80% of the 194 WHO member states had not reported implementation of the core competencies required under the IHRs. The results of those countries that do report are publicly available.

Recognizing the lack of progress toward implementation of the IHRs, the Obama Administration in early 2014 announced the launch of the Global Health Security Agenda. The initiative, which has since attracted the participation of more than 50 countries, attempts to establish common goals and methods to reduce the spread and impact of infectious disease by strengthening countries’ abilities to prevent, rapidly detect, and effectively respond to disease outbreaks. Participating countries have developed commitment packages and related targets under the GHSA.

The WHO recently launched an effort that is complementary to the goals of the GHSA. In developing the WHO IHR Joint External Evaluation (JEE) tool, the WHO has created a framework and process by which countries can measure their capacities to implement the IHRs. The JEE tool provides a standard metric by which countries can, on a voluntary-basis, assess their current baseline capacities and measure future progress toward full development of IHR capabilities to prevent, detect, and respond to public health threats, whether they are naturally occurring, deliberate, or accidental. Though the passage of the IHRs required countries to conduct self-assessments of their IHR capacities, the JEE enables countries to sign up for external evaluations by their peers. It is this peer-to-peer aspect that seems to be attractive for countries. Those involved in the JEE process have reported that countries that have volunteered to undergo a JEE have found the exercise to be helpful to their own planning effort. The positive reviews of the JEE process have spread, and countries continue to volunteer to undergo a JEE.

The GHSA and the JEE are important steps toward increasing accountability and transparency for countries’ efforts to improve their current global health security capacities. As we have written before, the international community—including the current US Administration--should continue to do all it can to support these efforts.

But the GHSA and JEE process alone will likely not fully address the need to motivate improvements in global health security. More work is needed to encourage those countries who have not yet signed up for the GHSA to participate. And work will be needed to ensure that all countries agree to undergo a JEE and—most importantly—take meaningful action to improve their scores in the areas that the JEE identifies as needing improvement.

Finally, the determinants of a country’s global health security are not entirely in the hands of the health sector. Larger political factors—such as land use policies and the presence of terrorist groups--can influence a country’s risk of experiencing an outbreak or bioattack. Societal factors, such as government corruption, social stability, and basic infrastructure, can be important determinants of how ably that country can contain the event before it spills across its borders.  These factors, while important determinants of global health security, are not incorporated into existing frameworks like the GHSA or JEE.

Why an index?

For the reasons articulated above, we think more work is needed to identify trends promoting global health security and to examine underlying conditions that contribute to or detract from favorable health security conditions. Metrics also are needed to identify areas in greatest need of improvement and to create political incentives for health security investments. A global health security index that is informed by international expert judgment, measured by a nongovernmental entity, and made publicly available could highlight current needs and add momentum to existing global health security efforts.

In preparation for this work, we have spent almost two years researching this topic and have learned that indices can be important tools in measuring and motivating progress. There is much evidence in the literature that national and international indices are influential in affecting government decision making. Policymakers tend to rely on these tools because decision-making processes that rely on indices can be presented as efficient, consistent, legitimate, transparent, scientific, and impartial. They also are relatively easy for the public to interpret.

Social science researchers have determined that indices tend to motivate policymakers to respond via three complementary mechanisms. First, indices can influence governments through the creation of international pressures (e.g., credit-rating agencies may respond to a country’s ranking in an international corruption index). Second, they can influence domestic political pressures (e.g., via mobilization of advocacy groups). Even the anticipation of negative publicity can prompt governments to review and modify domestic policies. Third, indices can have reputational effects on individuals or groups of policymakers and can motivate change through peer pressure.

We also have direct, favorable experiences in creating an index related to this topic. For several years our center director, Tom Inglesby, has been involved in the creation of the National Health Security Preparedness Index, which measures US states’ progress in preparing for, preventing, and responding to potential health incidents. Tom will bring to our team his experiences in developing and refining the NHSPI, which is now in its fourth iteration.

Why this team?

This effort will be jointly led by our Center and NTI, and developed with help from EIU.

NTI works to protect our lives, environment, and quality of life now and for future generations. They work to prevent catastrophic attacks with weapons of mass destruction and disruption (WMDD)—nuclear, biological, radiological, chemical, and cyber. Founded in 2001 by former U.S. Senator Sam Nunn and philanthropist Ted Turner, NTI is guided by a prestigious, international board of directors. Sam Nunn serves as chief executive officer; Des Browne is vice chairman; and Joan Rohlfing serves as president.

Economist Intelligence Unit (EIU) is the research arm of The Economist Group, publisher of The Economist. As the world’s leading provider of country intelligence, it helps governments, institutions, and businesses by providing timely, reliable, and impartial analysis of economic and development strategies. Through its public policy practice, the EIU provides evidence-based research for policymakers and stakeholders who are seeking measureable outcomes, in fields ranging from gender and finance to energy and technology. It conducts research through interviews, regulatory analysis, quantitative modeling, and forecasting, and it displays the results using interactive data visualization tools. Through a global network of more than 350 analysts and contributors, the EIU continuously assesses and forecasts political, economic, and business conditions in more than 200 countries.

NTI and EIU make for expert partners on this project, as we intend to build on their experience and success in developing the NTI Nuclear Security Index.  Created in 2012, this first-of-its-kind resource is designed to encourage governments to take actions and build confidence in the security of their nuclear materials. Now in its third edition, the NTI Index is recognized as the premiere resource and tool for tracking progress on nuclear security and identifying priorities.  

Zika Virus: An Introduction

Before November of this year, Zika virus was a relatively unknown viral pathogen, generating minimal attention compared to this year’s infectious disease all-stars such as the MERS coronavirus, influenza, and of course Ebola. Typical symptoms of infection are a rash, fever, joint pain, and red eyes and less commonly, muscle pain, vomiting, and headaches.[1] The infection lasts for about a week, and symptoms occur in 20% of cases. Management of patients is supportive, as there is no Zika specific therapeutic or vaccine available.[2] Transmitted by the Aedes aegypti mosquito, Zika virus causes a notably mild infection compared to other arboviral pathogens like dengue and chikungunya which cause more severe joint pain and, in the case of dengue, a high fever.[3-5] The mildness of the symptoms and, until recently, low incidence, have allowed this virus to slip under the radar, but there are now two factors which have promoted the Zika virus to an unprecedented position of fame.

It’s spreading quickly. First described in Uganda in 1968, Zika virus was only reported in a few African nations, the South Pacific, and parts of Asia prior to its first big outbreak on Yap Island, Micronesia in 2007. Prior to this outbreak, there had only been 14-15 cases ever recorded.[2] In October of 2013, Zika showed up in French Polynesia, affecting roughly 11 percent of the population and spreading to nearby islands such as Cook Islands, New Caledonia, and Easter Island. The virus was first detected on Easter Island off the coast of Chile in February of 2014, and made its way to Brazil by May of 2015.[1]

Zika virus continues to spread at an unprecedented rate with presence in 14 Brazilian states and 10 countries in South and Central America, including Mexico and most recently Panama. Following in the footsteps of dengue and chikungunya, which are also transmitted by the Aedes aegypti mosquito, Zika is demonstrating that diseases that rely on mosquitos for transmission can expand rapidly.[6-8]

It has a suspected link to congenital birth defects. Both French Polynesia and Brazil have experienced an alarming surge in reported cases of congenital brain and spine malformation, particularly microcephaly.[2] Infants born with microcephaly in infants have a smaller and underdeveloped brain which usually causes developmental complications and can be lethal. The malformation can be caused by several different types of viral infections, but has never before been linked to Zika virus. As of December 8th, Brazil has had 1,761 cases of microcephaly this year, compared to 59 total recorded cases in 2014.[9] This is almost 30 times more cases than was reported last year. Though the recent introduction of Zika virus to the Brazilian population parallels the shockingly high number of infants born with microcephaly, data directly linking the two is limited. On November 28th, a newborn who died shortly after birth from microcephaly tested positive for Zika virus.[7] The discovery brought the recent surge in media attention to Zika virus and the outbreak in Brazil. Besides this case, there have only been two cases in which the virus was found in the amniotic fluid of expecting mothers with microcephalic babies.[3,10]

Similarly, in French Polynesia and Brazil, health care officials have reported an increase in central nervous system (CNS) disorders coinciding with the arrival of Zika virus. The most commonly observed CNS disorder is the neuro-degenerative Guillain-Barre syndrome (GBS). Again, definitive evidence to support this connection is lacking, and more research is needed. However, of the 42 Brazilian cases of GBS diagnosed this year, 62 percent were found to have symptoms consistent with Zika virus infection.[10] 

Judging from the recent increase in media mentions, it’s safe to say that the infectious disease world is starting to focus on this rapidly spreading disease. The next few months will be very telling not only as we watch to see where the virus will show up next, but also as researchers gather data and determine if Zika truly is the cause of the observed congenital birth defects and complications. Moving forward, both the Pan American Health Organization and the World Health Organization have released statements advising countries bordering endemic nations to watch for Zika virus infection symptoms and those in endemic areas, particularly expecting mothers, to take precautions to avoid mosquito bites.[10] The Brazilian Ministry of Health even goes as far as to encourage women to hold off on getting pregnant until Zika’s effect on prenatal development is fully understood.[12]

As is true of many arboviral pathogens, the best prevention strategy is to control or eliminate the vector population. Dengue, chikungunya and Zika virus have all been spreading quickly, and outbreaks of dengue have been reported in the US, making mosquito control an issue of international importance.[13,14] Because Aedes aegypti mosquitoes reproduce in stagnant water, ensuring that ponds and large puddles are filled in, and water collection devices are covered or empty, is critical for limiting the size of mosquito populations.2 Furthermore, limiting interaction with mosquitoes through repellents, screened windows, and long-sleeved clothing will help to decrease the likelihood of infection. Since the outbreak of the virus, the Brazilian army has been an active participant in draining unnecessary water barrels and other catchment devices for Zika prevention.[3] A proactive approach would benefit every country faced with this newly emerged disease.

 

  1. Zika Virus: Symptoms and Treatment http://www.cdc.gov/zika/symptoms/index.html. Accessed December 09, 2015.
  2. Belluz J. The Zika virus is spreading across Latin America. Here's what we know. Vox. 2015.
  3. McKenna M. Mosquitoes Bring Disease, Maybe Birth Defects, To US Border. Phenomena: National Geographic; 2015.
  4. Chikungunya Virus: Symptoms, Diagnosis, & Treatment http://www.cdc.gov/chikungunya/symptoms/index.html. Accessed December 09, 2015.
  5. Dengue Fever http://www.webmd.com/a-to-z-guides/dengue-fever-reference. Accessed December 08, 2015.
  6. Fox M. This Virus You Never Heard of May Be Causing Birth Defects in Brazil. NBC News; 2015.
  7. Dias T. This is the current state of microcephaly epidemic caused by zika virus in Brazil. Nexo Journal 2015.
  8. Zika virus infection – Panama. Disease Outbreak News. December 05, 2015.
  9. Herriman R. Brazil microcephaly update: Nearly 1800 suspected cases, Zika virus related microcephaly protocol published. Outbreak News Today. December 08, 2015.
  10. Epidemiological Alert: Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas. Pan American Health Organization, World Health Orgnization; December 01, 2015.
  11. Freire LF, Coutinho R. Zika virus can cause miscarriages. Folhape 2015.
  12. Zika Virus Causes Pregnancy Scare – Brazil Women Warned Not to Get Pregnant As Virus Linked to Rare Birth Defect. The Gleaner; 2015.
  13. Dengue fever, Chikungunya and Zika virus in the Pacific Islands. Safe Travel  https://www.safetravel.govt.nz/news/dengue-fever-chikungunya-and-zika-virus-pacific-islands. Accessed December 08, 2015
  14. Maron DF. Dengue Fever Makes Inroads into the U.S. Scientific American. 2013.

Joe Camel and MERS: Does His Mayhem Know No Limits?

via  Wikimedia Commons

via Wikimedia Commons

One of the hallmarks of a complete epidemiological investigation is the case control study. This type of study compares people with a condition of interest with those without the condition with the aim of identifying factors that may contribute to acquisition of the condition. For example, a case control study comparing those infected with hepatitis C to those without hepatitis C would likely determine injection drug use was more common in those with the infection compared to those without the infection. Analyzing the results of such a study will produce an important statistic known as the odds ratio. If this ratio is greater than 1, it illustrates an association between the attribute and the condition.

Such a study for Middle East Respiratory Syndrome (MERS) cases in Saudi Arabia--highly anticipated and long awaited - was just published in the journal Emerging Infectious Diseases.

MERS, a severe respiratory infection caused by a novel coronavirus, has infected over 1600 people since 2012, killing nearly 600. While 26 countries have been affected, the vast majority of cases (85%) originate in Saudi Arabia. The leading hypothesis regarding the viral ecology at play is that the virus originated in bats and spilled into camels—who have demonstrated antibodies to the virus—and then into humans. Human-to-human spread seems restricted to hospital-based superspreading events as well as infection control lapses. Sustained community spread has not occurred.

This study of primary MERS cases—those contracted from the environment and not from another person—occurring in Saudi Arabia in 2014 involved studying 30 cases and 116 age, sex, and neighborhood matched controls.

Important findings included:

  • Case patients were more likely to have a higher income than controls
  • Cases patients were more likely to have exposure to camels than controls (OR = 3.73)
  • Case patients were more likely to keep camels in or around the home than controls (OR = 3.34)
  • Case patients were more likely to have visited a farm with camels than controls(OR = 11.57)
  • Case patients who visited farms with camels were more likely to have milked a camel (OR = 10.36)
  • Underlying medical conditions were more likely in cases than controls (OR = 5.11)
  • No association was found with consumption of camel urine

Multivariable analysis revealed that exposure to a camel within the past 6 months and having diabetes, having heart disease, or tobacco smoking were the most highly significant associations.

The study’s implications are important for future control efforts and lend more evidence to the hypothesis linking camels to primary MERS infections. Control efforts can now be more exactly focused on delimiting exposure to camels, especially amongst those with underlying medical conditions. Additionally, vaccination of camels against MERS will become an important strategy to be pursued. 

On Statelessness and Health Security

Recent stories describing the hardships faced by Rohingya Muslims fleeing oppression and poverty in Myanmar and Bangladesh are sad reminders of the prejudices that prevent many marginalized populations from leading safe, healthy lives. An estimated 6,000-20,000 Rohingya migrants – living aboard ships abandoned by human traffickers – were initially denied refuge in Thailand, Malaysia, and Indonesia, before ultimately gaining entry into the latter two nations.

The Rohingya Muslims’ misfortune echoes the plight of other migrant groups. Between April 13th and 20th of this year, for instance, five boats carrying some 2,000 Middle Eastern, African, and other migrants to Europe sank while crossing the Mediterranean, resulting in over 1,200 deaths. Vessels carrying migrants across the Mediterranean were also wrecked in March 2009, April 2011, October 2013, and September 2015.

Events like these – while undeniably traumatic for the individuals involved – also raise important questions for their rescuers: how and why should states care for the stateless, (of which there are an estimated 10 million worldwide)? And what are the health and security trade-offs of granting or denying refuge to stateless populations?

Let’s first consider the relationship between nationality, health, and security. Nationality -- the legal relationship between an individual and a state -- grants states jurisdiction over their citizens while affording citizens protections and access to certain services within those states. When a person becomes stateless, he or she also loses access to state-sanctioned protections and services like healthcare. And, as demonstrated by the Rohingya Muslims, those who leave their nations of origin due to persecution, war, or other similarly disruptive forces typically report deteriorating health due to poor living conditions, a problem that can rapidly escalate without access to basic medical care.

There are several international treaties, declarations, and protocols that establish nationality as a human right, prohibit signatory parties from arbitrarily denying an individual his or her nationality, and codify protections afforded to stateless individuals:

  1. The Universal Declaration of Human Rights, adopted in 1948 by the United Nations General Assembly, establishes nationality as a human right and stipulates that no person “shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.” Though the Declaration does not carry the legal weight of a treaty, many consider it to be a powerful diplomatic tool for compelling states to comply with its provisions.
  2. The 1954 Convention Relating to the Status of Stateless Persons is a treaty adopted following World War II. It was designed to improve the legal status of stateless persons displaced by the war, and has since evolved to including stateless persons who are not considered refugees. The Convention covers issues such as non-discrimination, religion, residential rights, property, artistic rights, employment, housing, education, travel, and naturalization. Currently, 80 countries are state parties to the 1954 Convention.
  3. The 1961 Convention on the Reduction of Statelessness is a treaty that outlines steps states can take to avoid the problem of statelessness, by explicating the principles for granting nationality. The content of this treaty deals primarily with issues of acquiring, retaining, and changing one’s nationality, and offers solutions to potential interstate nationality challenges. Currently, there are 55 signatory states to the 1961 Convention.

Though both Conventions strive to ensure that stateless persons enjoy basic legal rights and have their welfare needs meet, neither makes any explicit reference to health. Furthermore, enforcement of these mechanisms is slow and inconsistent at best, which means that stateless persons can remain in limbo for months or years before being repatriated into their nation of origin, or into a different country.

But what role would a state have in resolving these issues? From a nation’s perspective, repatriating stateless individuals presents major legal and logistical challenges. Additionally, from the perspectives of Myanmar and Thailand, (both Buddhist-majority states), repatriating Rohingya Muslims could also introduce or exacerbate existing ethnic and religious tensions within their borders. Denying statehood to the stateless, however, could cause new health and security threats to emerge.

For one, stateless individuals are more vulnerable to the threat of communicable disease. Individuals living outside the scope of state-sponsored health services and/or in subpar conditions often report low rates of immunization, and are vulnerable to a host of infectious diseases -- tuberculosis, sexually transmitted infections, HIV/AIDS, viral hepatitis, measles, mumps, rubella, and polio, gastroenteritis, and acute respiratory infections, to name a few.[1] The prevalence of these diseases among refugee and stateless populations often fuels stigmatization based on the misperception that such populations are unclean. Furthermore, if, like the Rohingya Muslims, a stateless population is forced to travel from place to place in search of refuge and essential health services, the risk of such diseases spreading increases. Even those Rohingya who remain in Myanmar encounter this challenge due to restrictions on their movement within the state that prevent them from traveling to local hospitals. [2]

Secondly, disenfranchisement and economic insecurity are important drivers of civil unrest. [3] [4] Lack of representation in civil and political affairs and few opportunities for upward economic mobility are common driving forces behind social and civil unrest. Prolonged civil unrest, in turn, has well-documented, deleterious effects on population health, as well as on states’ social and economic well-being.

There are some steps that nations and other members of the international community could take, both to improve the health of stateless persons and protect national interests.

  1. Currently, only 63 states have signed and ratified the international conventions on statelessness. Gaining more widespread adoption of these treaties could help make reducing statelessness a key priority on the international agenda.
  2. Additionally, state signatories to the international conventions on statelessness might consider adding protocols that explicitly mandate sufficient provision of health services to stateless persons. Allying with non-governmental organizations working closely with stateless populations could help ensure that such provisions are met and enforced.
  3. Creating more resilient funding mechanisms for state and non-state actors that play active roles in repatriating and/or resettling stateless populations could help ensure that the health needs of those populations are met in as quick and timely a manner as possible, thereby averting possible health and security threats to regional stability.

There is a strong moral imperative for addressing the needs of the stateless, and the additional health and security payoffs of doing so strengthen this imperative. In our increasingly globalized world, considering health threats outside the context of state lines and interests could offer new perspectives on strengthening global health security.

 

  1. Rechel B, Mladovsky P, Devillé W, et al. Migration and Health in the European Union. European Observatory on Health Systems and Policies Series. http://www.euro.who.int/__data/assets/pdf_file/0019/161560/e96458.pdf  
  2. Forced Migration Review. Issue 32, April 2009. http://www.fmreview.org/FMRpdfs/FMR32/FMR32.pdf 
  3. Kett M and Rowson M. Drivers of violent conflict. Journal of the Royal Society of Medicine. September 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963391/  
  4. Putzel J. Regional and global drivers of conflict: consequences for fragile states and regions. Crisis States Research Centre. October 2009. http://www.lse.ac.uk/internationalDevelopment/research/crisisStates/download/others/RGDriversOfChangeOct09JP.pdf

 

Counterfeit Medicines and Global Health Security

The American Journal of Tropical Medicine and Hygiene recently published a supplement titled “The Global Pandemic of Falsified Medicines: Laboratory and Field Innovations and Policy Perspectives,” which features pieces by Tim Mackey, Margaret Hamburg, Ramanan Laxminarayan, and numerous other drug policy experts. The supplement highlights the wide-ranging health, legal, economic, and technical challenges generated by the persistence of substandard medicines in both legitimate and illicit drug supply chains. For example, Dr. Mackey and his colleagues reported 1,799 different detections of counterfeit medicines in legitimate supply chains alone, over a 36-month period between 2009 and 2011. The biggest culprits? Anti-infectives, or “drugs used to treat diseases caused by infectious agents including antimicrobial drugs, antivirals, antifungals, and antiprotozoans.” Such drugs comprised an alarming 21.1% of the counterfeit drugs identified in Dr. Mackey’s study.

Without access to effective, life-saving drugs, populations across the world remain vulnerable to the threat of infectious diseases. The scale and nature of this problem thus equate to big challenges for global health security-strengthening efforts.  

Counterfeit medicines are difficult to track and test

There aren't many systems in place for detecting counterfeit medicines in global supply chains before they reach consumers. Ensuring drug quality might require regulators to use an assay to detect drugs with wrong or missing active pharmaceutical ingredients, APIs. Or, they might take a more quantitative approach, such as assessing tablet hardness and/or rates of disintegration and dissolution.[1] Regulators might also analyze drug packaging, serial numbers, and inserts to determine legitimacy. As a result, verifying the integrity of a given medicine is often a laborious process. Exhibit A: this flowchart, which illustrates the algorithms used by the Counterfeit Drug Forensic Investigation Network to detect and classify substandard drugs.

 

IOM

Markets for counterfeit medicines exacerbate existing disease burdens 

Fake antimalarials and antibiotics like artemisinin, penicillin, and Zithromax are among the most prevalent counterfeit drugs sold today, and have serious consequences for consumers. Conflict in Myanmar, for example, has led to dramatic increases in the number of malaria cases among civilians. Concurrently, the market for fake antimalarials containing little or no API has also exploded. As a result, many who fall sick are often unable to access effective treatment. And, because many medicines in Myanmar are easily obtained without a prescription, it’s even harder to stop counterfeits from reaching patients. Furthermore, drug makers in Myanmar who create and distribute fake medicines have become highly skilled at replicating the holographic stickers used to differentiate between real and phony antimalarials, thereby making it nearly impossible to track and eliminate these drugs from legitimate supply chains.

Sub-therapeutic doses of anti-infective medication can also lead to poorer patient outcomes, contribute to the emergence and spread of drug-resistant pathogens, and weaken health systems. Robust markets for counterfeit medicines have already contributed to spikes in antibiotic and antimalarial resistance in many parts of the world. Additionally, patients could experience adverse effects after taking phony drugs, or lose confidence in medical institutions lacking the means to deliver effective treatment.

Counterfeit medicines undermine epidemic and pandemic preparedness by contributing to shortages of effective drugs

Disease outbreaks of all sizes could potentially amplify the dangerous consequences of counterfeit medicine distribution and use. Without access to reliable supplies of medical countermeasures, health authorities could encounter challenges in treating cases of infectious disease and preventing additional spread. Counterfeit medicines could also hinder medical surge capabilities by penetrating legitimate supply chains and displacing authentic drugs. However, conducting surveillance for illicit drugs requires considerable time, money, and resources, all of which are typically in shorter supply during public health emergencies.

Eliminating counterfeit medicines will require considerable multisectoral efforts on the parts of policymakers, regulators, and health authorities. Furthermore, many counterfeit medicines are manufactured, financed, and distributed by organized crime outfits and terrorist organizations. Hezbollah, the Irish Republican Army, the Basque Homeland and Freedom Group, and various groups from Chechnya and North Africa, for example, have all been involved in counterfeiting medicines for profit.[2] Therefore, getting law enforcement and intelligence experts on board is also crucial.

Additionally, there are some precautionary steps that stakeholders around the world, at all levels of public health and healthcare practice, industry, and government might consider taking to lessen the impacts of counterfeit drugs on the market.

1)      Continue investing in systems to secure pharmaceutical supply chains and monitor them for phony products. Many government agencies worldwide, like the US Food & Drug Administration, are aware of the risks associated with counterfeit medicines, and have begun collaborating with other public- and private-sector agencies to secure their nations’ pharmaceutical supply chains. Countries with large counterfeit drug markets might benefit from learning best practices from those with more resilient drug supply chains.

2)      Disincentivize counterfeiting by encouraging stricter enforcement of anti-counterfeiting laws. Counterfeiting activities generally carry lighter penalties than drug trafficking. Collaborating with law enforcement officials to more proactively indict and prosecute offenders could help deter others from manufacturing phony drugs.

3)      Educate vulnerable populations about the dangers of consuming counterfeit medicines. Helping the public understand how to recognize potentially phony products, and informing them of whom to contact in the event they experience adverse reactions could go a long way in protecting the health of populations at risk of consuming potentially dangerous drugs

In the context of our post-SARS, post-H1N1, post-Ebola world, the questions of who can access medicines and who is most affected by the sociopolitical factors that drive counterfeiting are more important than ever. Though the problem of counterfeit medicines is an old one, its persistence makes it worth revisiting, especially in light of this renewed energy around global health security. Aggressively addressing the problem of counterfeit drugs is a step in the right direction to make the world safer from the threats of treatable infections and suboptimal healthcare.


[1] Countering the Problem of Falsified and Substandard Drugs. Institute of Medicine. http://www.iom.edu/Reports/2013/Countering-the-Problem-of-Falsified-and-Substandard-Drugs.aspx

[2] The Infiltration of Terrorist Organizations Into the Pharmaceutical Industry: Hezbollah as a Case Study. http://www.tandfonline.com/doi/abs/10.1080/1057610X.2013.813244

Public Health Preparedness: Going Global

This guest post to the Bifurcated Needle was written by Malaya Fletcher, MPH. Ms. Fletcher is a Public Health Preparedness Planner at the Philadelphia Department of Health, and a 2015 Fellow in the Emerging Leaders in Biosecurity Initiative.

This year’s Public Health Preparedness Summit focused on Global Health Security: Preparing a Nation for Emerging Threats, and opened with a talk by Mike Walker, senior consultant with the Center for Homeland Defense and Security. Walker reviewed a large number of high-consequence, emerging threats, such as drought, asteroids, terrorist groups like the Islamic State of Iraq and the Levant, supply chain network vulnerability, and the vulnerability of our power grid. These myriad threats can be overwhelming. How DO you plan for large-scale disasters, especially when critical infrastructure may not exist post-event?  Discussions of nuclear winter, for example, conjure up images of broken governmental structures and a return to communal living à la Alas, Babylon (Pat Frank’s novel of the post-nuclear age). In addition, most agencies are dealing with insufficient staff capacity, incident-specific grant restrictions, knowledge management issues, and too many competing priorities. In a resource-scarce and inherently reactionary system, maintaining a long-term view while playing perpetual catch-up can feel like a Sisyphean task.

With our ever-evolving and interconnected world, we must be cognizant of the broader context of our work. This has been illustrated with the current Ebola outbreak, and the disease surfacing in Texas and New York after healthcare workers returned from affected West African countries. ISIL may seem far away, but the potential for a domestic terrorist event, and the corresponding mental health impact on our nation’s psyche, are real. Following the Oklahoma City bombing, a study by North et al. found that 34% of survivors developed PTSD.1 During the Summit, I went to a number of sessions that covered water emergencies, where health departments had to bring water in when their systems became contaminated. This makes me think of the situation in Vanuatu, where more than 100,000 people still have no clean drinking water a month after a cyclone struck.2 Hurricane Katrina resulted in the displacement of large numbers to various cities throughout the nation. Climate change and the resultant loss of land mass are a major threat to low-lying areas and many island nations, such as those in the Pacific. Population displacement will continue to be something for which we need to plan. Maintaining a global perspective allows us to be aware of future threats and take inspiration from others who have faced similar challenges.

The sessions I found most useful addressed cross-cutting topics (e.g., decision-making and ethics) and skills building (i.e., new methods for data capture and evaluation). I noted the incorporation of mixed methods approaches, such as root cause analysis and CASPER. One session of particular interest was by New York City Department of Health and Mental Hygiene  and discussed how to develop an after action report/improvement plan database. The insights provided by other people’s struggles, triumphs, and lessons learned are invaluable.

Yet, it is the informal information exchange that I most enjoyed. Late-night conversations are a great way to crowd source my daily challenges to thousands of peers and learn about the innovation occurring outside of my own backyard. The practices I learned about cut through the decision fatigue and information overload and turn preparing for the unthinkable into strategic, pragmatic steps. As one panelist said, we can no longer use the past to predict the future; we can just build resilience. The new frontier is daunting, but the Summit shed light on what we can do to better prepare ourselves for that future.

 

1. North, CS, et al. Personality and posttraumatic stress disorder among directly exposed survivors of the Oklahoma City bombing. Comprehensive Psychiatry 53 (2012) 1-8.

2. Mis, M. Almost half Vanuatu people lack clean water, month after cyclone. Thomas Reuters Foundation. 22 April 2015. http://www.trust.org/item/20150422152940-1im08

2015: The year of Global Health Security, Millennium Development Goals, and Neglected Tropical Diseases

2015 is poised to be a big year for global health security and human development. Following the introduction of the Global Health Security Agenda last year, there has been renewed energy around tackling infectious diseases across the world. Only two months into 2015, though, we already have our hands full with several major infectious disease challenges:

From. UN.org

From. UN.org

1)      The Ebola outbreak in West Africa appears to be dying down, and the global community is starting to consider long-term needs for strengthening health systems, rebuilding economies, and preparing for future outbreaks.

2)      Chikungunya and dengue fever continue to proliferate rapidly throughout the Americas and South Asia.

3)      Measles made an unwelcome comeback in the US, drawing attention to the impacts of vaccine hesitancy and refusal on herd immunity.

4)      A recent outbreak of carbapanem-resistant Enterobacteriaceae at UCLA underscored the threats of antimicrobial resistance and healthcare-associated infections.

5)      On a more positive note, South Sudan, Mali, Chad, and Ethiopia are inching closer toward eliminating dracunculiasis, more commonly known as guinea worm disease. If they succeed, dracunculiasis will become the third disease ever to be eradicated, following smallpox and rinderpest.

2015 is also the United Nations’ specified deadline for achieving the Millennium Development Goals (MDGs), a set of directives for resolving various dimensions of extreme poverty, including health. Specifically, Goal 6 outlines targets for combating HIV/AIDS, malaria, tuberculosis and other diseases. Additionally, Goal 8 – which identifies the need for building global partnerships for development – includes a target for cooperating with pharmaceutical companies to ensure affordable access to essential drugs in developing and least developed countries.

In light of the aforementioned infectious disease threats, the 2015 deadline for achieving the MDGs, and the synergies that exist between health and development, the imperative for tackling the infectious diseases afflicting the world’s most impoverished populations has never been stronger. And the challenges posed by neglected tropical diseases (NTDs) are a good place to start.

What are NTDs?

The NTDs comprise a class of diseases that are especially prevalent among low-income populations in Asia, Africa, and the Americas. In fact, the burden posed by NTDs in sub-Saharan Africa is nearly equivalent to half of the region’s malaria burden and more than double its TB burden.[i]  Examples of NTDs include Chagas disease, leishmaniasis, dengue, and chikungunya. In all, the World Health Organization has identified 17 priority NTDs

Despite their prevalence, NTDs are often overlooked because of their relative absence in wealthier, industrialized nations, and are typically overshadowed by larger caseloads and funding streams for relief efforts around HIV/AIDS, malaria, and TB. Furthermore, many NTDs have long incubation periods, which make them harder to detect. As a result, current figures likely underestimate the true global burden of these diseases. 

The burden of NTDs

Many NTDs present as co-infections with HIV, malaria, and TB, and exacerbate the severity of those diseases. NTDs are also accompanied by the “hidden burden” of social stigma, since they cause physical deformities that affect patients’ self-esteem and social relations, and are frequently responsible for poor school attendance among infected children. Some NTDs may even result in chronic, non-communicable health conditions: Chagas disease, for instance, can lead to cardiovascular disease, while diseases like schistosomiasis and toxocariasis can cause cancer and chronic pulmonary disease, respectively.

Additionally, certain NTDs affect women disproportionately, and have been shown to worsen existing gender disparities in access to medical care. NTDs also inflict enormous economic burdens. WHO reported in 2010 that trachoma and lymphatic filariasis infections alone generated $2.9 billion and $1.3 billion in productivity losses, respectively.[ii]  Though many NTDs are easily preventable and in many cases, treatable and curable, the regions most affected often lack the medical capacity and access to pharmaceuticals required to reduce their NTD burden.

Why tackle NTDs?

In light of recent outbreaks of non-neglected diseases, and growing emphasis on the burdens associated with non-communicable diseases, NTDs are at risk of becoming even more overlooked. So, why ensure that NTDs remain a future global health security priority?

1.       Reducing the prevalence of NTDs could translate into major economic gains for low- and middle-income populations across the world.

Targeting the health needs of those at the bottom of the pyramid is one way of accelerating economic mobility among currently impoverished populations. And it’s important to remember that these gains aren’t just for developing and least-developed countries. An alarming number of NTD cases occur among the “bottom billion,” many of whom live in pockets of poverty in wealthier economies; notably, the BRICS countries and other G20 nations in Asia and the Americas.[iii] This phenomenon, described in detail by Dr. Peter Hotez, is known as “Blue Marble Health.”

2.       Changing climates and increasing globalization could mean that the pathogens and vectors responsible for NTD transmission are introduced to less-affected regions.

Changing climates and increased world travel could contribute to changes in the movement of vectors and pathogens responsible for NTD incidence. Cases of malaria, dengue fever, and chikungunya, for example, have recently emerged in the US, underscoring the potential of any communicable disease – neglected or not – to pose transnational threats.

3.       Increased investment in NTD mitigation, elimination, and eradication could enhance ongoing efforts to resolve national security challenges.

NTDs and conflict are inextricably linked and frequently exacerbate each other’s consequences. Among the NTDs, lymphatic filariasis, Chagas disease, yellow fever, and leishmaniasis are frequently associated with conflict settings; leishmaniasis, in fact, has been called “a disease of guerrilla warfare.”[iv] Conflict weakens or destroys the fragile health infrastructure of NTD-prone populations, which further limits the ability of those populations to access basic health services. Economically disempowered individuals, in turn, may further fuel civil unrest.

Thus far, nations across the world have acknowledged their shared vulnerabilities to communicable diseases, and have recognized the need for – and importance of – initiatives that strengthen global health security and advance human development efforts. Given the alignment between these activities and NTD elimination, it remains up to policymakers, public health practitioners, and healthcare professionals in those nations to make NTDs a priority for 2015 and beyond.


[i] Hotez PJ and Kamath A. Neglected tropical diseases in sub-saharan Africa: review of their prevalence, distribution, and disease burden. PLOS Negl Trop Dis. August 25, 2009. http://www.ncbi.nlm.nih.gov/pubmed/19707588

[ii] World Health Organization. Working to Overcome the Global Impact of Neglected Tropical Diseases. 2010.  http://whqlibdoc.who.int/publications/2010/9789241564090_eng.pdf

[iii] Hotez PJ. Blue Marble Health: A New Presidential Roadmap for Global Poverty-Related Diseases. http://bakerinstitute.org/research/blue-marble-health-new-presidential-roadmap-global-poverty-related-diseases/

[iv] Beyrer C et al. Neglected Diseases, Civil Conflicts, and the Right to Health. The Lancet. 2007. http://ac.els-cdn.com/S0140673607613014/1-s2.0-S0140673607613014-main.pdf?_tid=a2ef0740-c1c4-11e4-9b1b-00000aacb360&acdnat=1425401282_48181496d9bfd816d91e31359c33bc2b

Reforming WHO in a Time of Ebola

As a prelude to the 136th World Health Organization (WHO) Executive Board session (January 26-February 3, 2015), 36 countries and the EU member states drafted recommendations based on the WHO efforts in the ongoing Ebola epidemic in West Africa.  While the majority of the resolution affirms or reaffirms institutional dedication to addressing and managing the international response to the Ebola crisis in West Africa, several  recommendations and their corresponding deliverables, indicate a commitment to building an improved, more responsive WHO.  What follows is a summary of some of the most notable recommendations put forward to the Executive Board.

As noted in OP 39, the WHO acknowledges that “short-comings in…human resources systems and processes slowed down the Ebola response,” and this theme permeates many of their recommendations.  This draft resolution seems designed to prompt organizational change that will facilitate more efficient coordination, both within the WHO and with external stakeholders.  From developing mechanisms to increase emergency response workforce and capacity to implementing better screening and training processes for country representatives to independent review of the Ebola response, the language of the draft resolution indicates that organizational change may be forthcoming at all levels of the WHO.  Specifically, OP 2 clearly states the need to “accelerate ongoing reform of the Organization.”

Under the umbrella of improving leadership and coordination, several measures are recommended to provide the Director General with additional support to deal with large-scale response issues.  OP 5 recommends that the Director General consider appointing a Special Representative [1] to direct coordination at the county, regional and global levels and direct WHO response for the Ebola epidemic.  Additionally, OP 54 suggests establishing an advisory group “composed of operations experts from relevant stakeholders…to provide advice on administrative and logistical support” for future incidents.  The magnitude of the Ebola epidemic posed considerable challenges that the drafters determined to be beyond the capacity of the Director General to handle directly.  The resolution recommends that additional support to address response coordination from the outset of an incident would be beneficial, both in the context of the current Ebola response as well as for future public health emergencies. 

Another priority identified in the draft resolution is bolstering communication and information sharing capabilities. OP 9 specifically mentions the need for the WHO to “improve communication, coordination, and information sharing” with the UN Mission for Ebola Emergency Response (UNMEER) in order to support engagement by Member States. The resolution also requests that the Director General develop and improve mechanisms for international sharing of information on “diagnostic, preventive and therapeutic products” in order to improve the ability to rapidly employ them during an emergency.  In order to facilitate this, the resolution calls for creation of a global database of identified and stockpiled medical assets at the national and regional level (OP 32).  In light of the ongoing Ebola epidemic, it is recommended that the initial population of this database begin with hemorrhagic fevers.

Some of the suggestions reiterate previous recommendations from the 2011 International Health Regulations (IHR) Review Committee to strengthen the worldwide public health response workforce.  Specifically, OP 42 advocates developing a plan to establish and maintain “comprehensive emergency response teams” that can be deployed and sustained to support emergency response activities.  In particular, the recommendation lists three required capabilities of this surge program:

1.  Recruiting and training personnel to provide “internal surge capacity”

2.  Improving and expanding cooperation with organizations such as the Global Outbreak Alert and Response Network and Global Health Cluster to increase local public health capabilities

3.  Enhancing coordination with other United Nations agencies to provide scalable response

Additionally, OP 48 calls for the establishment of a contingency fund to respond to “the need for adequate resources for the preparedness, surveillance and response work of the [WHO].”  A report by the Director General to the 68th World Health Assembly will outline options for the scope, potential funding sources and other aspects of the contingency fund plan.  In addition to the 2011 recommendations, the resolution charges the Director General with formalizing agreements to provide use of existing surge capability and regional humanitarian aid, sharing available resources in order to decrease response time in future emergencies (OP 23).

As mentioned above, the WHO acknowledges that its internal processes hindered the progress of Ebola response in West Africa, and several of the recommendations call for review of some internal processes as well as the response effort as a whole, specifically citing a need for increased “transparency and reliability of health-related needs-assessment processes” (OP 10).  First, OP 52 recommends commissioning an independent assessment by a panel of experts on “all aspects of WHO response, from the onset of the current [Ebola] outbreak.”  This recommendation specifically calls out resource mobilization—a process, in particular, that delayed the initial WHO Ebola response—as requiring an investigation.  OP 53 requests that the Director General direct an internal review of the IHR with respect to “prevention, preparedness and response to the Ebola outbreak and the effectiveness of the IHR in facilitating that response.”  Of specific concern are the measures recommended by the 2011 IHR Review Committee that were and were not implemented and identifying future measures to “improve the functioning, transparency, and efficiency of WHO’s response…in future outbreaks.”  In addition to reviewing internal response policies and mechanisms, the resolution calls out the “selection, training and performance review” processes for Country Representatives (OP 40).  This recommendation even goes as far as to provide explicit support to the Director General in the use of her authority to “add or change staff…at the country or regional level,” indicating again a commitment to organizational change on multiple levels.

In addition to organizational reform designed to increase efficacy and efficiency of emergency response, the WHO affirms its role in guiding research and development of pharmaceuticals.  With respect to Ebola, the draft resolution calls for the Director General to maintain sustainability for the therapeutic drug and vaccine clinical trial working groups. Of specific concern are providing proper regulation under emergency conditions to ensure patient safety and developing “quality, safe, effective and affordable vaccines and treatments” (OP 33).  Furthermore, OP 34 addresses establishing priorities for Ebola-related research and appropriately utilizing data from clinical trials. This data will be valuable in determining the efficacy and safety of therapeutic drugs and vaccines; however, special consideration must be given to the limitations of studies conducted under current conditions.

There are many additional recommendations (57 OPs, in all); however, those listed above all bear the burden of specific deliverables. Many of them require some form of report, either to the 138th Executive Board or to the 68th World Health Assembly.  By delineating methods to ensure accountability, the WHO again illustrates its commitment to change and improvement. The outcomes of these recommendations will likely take months or years to come to fruition, and the magnitude of necessary changes and reorganization are not specified. It seems at this point, however, as though the WHO has good intentions in reviewing their actions and coordination over the course of the Ebola epidemic and implementing measures to improve future response.

 

1. On February 3, 2015, Dr. Bruce Aylward was named as the WHO Special Representative for Ebola Response.