Op-Ed: In an age of Zika and a threat of biochemical terror, health security must be everybody’s concern

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    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:

    • Chikungunya;
    • 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

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