Bjorg Palsdottir Susan H Baker and Andr Jacques Neusy

The roots of global public health are found in the economics and interface of war, trade, and health, reaching significant proportions during the Age of Exploration, slavery, and colonialism from the early fifteenth century (Kickbush and Buse, 2005). One of the earliest examples of public health policy in action was the routine short-term use of quarantine and isolation of trade ships in order to combat plague, beginning in the fourteenth century (Basch, 1999). Efforts at long-term prevention leading to institutionalizing response began much later.

Today, the social ecology of infectious diseases links the fates of peoples and ecosystems around the globe. Because the world has not dealt with a pandemic caused by a highly contagious, rapidly spreading infectious disease since the 1918 influenza epidemic, assessment of today's true organizational response capacity is speculative at best. Hurricane Katrina, which hit the Gulf Coast of the United States in 2005, illustrates that capacity on paper does not always reflect how people and plans perform during emergencies. The potential for a global outbreak of avian flu in the near future makes the topic politically sensitive, and the existing figures and plans moving targets.

Effective organizational response to the threat of infectious disease involves the integration of two basic models: emergency response, and primary health care and prevention. The emergency response model is a direct response to a specific disease threat. Its main goal is to control, contain, or eliminate an imminent threat. The primary care and prevention model is concerned with prevention and control of a myriad of disease threats through the ongoing supply of basic public health infrastructure and primary health care.

At the time of writing, our research suggests that the bulk of international aid resources for infectious diseases go to short-term technical emergency response measures - this despite the 1978 Alma Ata Declaration, signed by WHO and 134 nation-states, committing to "Health Care for All by the Year 2000," and the acknowledgment that improving primary care services and strengthening weak health systems in the long term is of great importance. The focus tends to be on specific health interventions, such as the development and stockpiling of vaccines; or drug distribution for specific conditions like HIV/AIDS or avian influenza. The overall system is a fragmented and informal collaborative network of a relatively few elite organizations and partnerships that intervene by government invitation and act to bolster weak local and regional public health capacity. As we shall describe, the efficacy of such a system has intrinsic problems based on inadequacies in public health infrastructure; on political, economic and social conditions; and on the inherent difficulties of coordinating the response of numerous diverse organizations operating under different command structures.

A combination of political commitment, infrastructure, and the availability of resources and technical expertise determine a nation's ability to respond to infectious disease threats. The front-lines of the international organizational response to infectious disease threats often are where public health infrastructures are weakest. In the poorest countries, in particular, there is little government planning, few paved roads, no public transportation, limited or no access to electricity, minimal sanitation and clean water supply, no reliable communication and information systems, and a limited supply of goods and services (Ndikuyeze, 2000). Education and veterinary and human health care also may be inaccessible or very much below acceptable standards. Impoverished nations often share borders with countries that have similar problems, thereby creating regions deficient in basic and vital resources. The front-line context of infectious disease control also includes conditions of natural disaster, civil strife, population dislocation, violence, and terror. International health responders thus often function in the face of great insecurity (Connolly, 2000; Kakar, 2000; Shoo, 2000; Human Security Centre, 2005). Even countries with burgeoning economies and rising GDPs, like Brazil, Singapore, South Africa, China, and India, present enormous challenges to health responders because the rural poor are migrating in vast numbers to cities that have ad hoc and destitute districts which lack clean water, sanitation, and access to health-care services (Brower and Chalk, 2003; see also Chapter 4).

The front-line responders during epidemics are health workers in public and private agencies, institutions, and non-governmental organizations (NGOs). Controlling global disease threats requires adequate resources, capacity, and action at every decision-making level in every corner of the world - from the international and regional to the nation and its communities. It necessitates close coordination across borders and sectors, and among and within organizations. As we shall describe, organizations like the World Health Organization (WHO) and the United States Centers for Disease Control (CDC) have made great strides to improve coordination in their own efforts and across responders, and to streamline emergency response activities generally. Still, it is fair to observe that the global emergency response infrastructure in both poor and wealthy nations is characterized by weak local capacity, politicization, and fragmentation of funding and effort. The present international focus too often is based on "fire-fighting" through periodic, isolated rapid response to emergencies. We believe this has to change. The effectiveness of international medical SWAT teams is inevitably constrained by the weak or absent health systems where epidemics are most likely to arise. A long-term solution requires improving local primary care and prevention, as well as economic and social infrastructure.

The legal structure for global infectious disease control is provided by the International Health Regulations, administered by the WHO. Adopted in 1951, the IHR require the WHO member states, and other signatories, to report to the WHO the occurrence of infectious diseases in their country, and follow standards and norms to prevent the international spread of these diseases while minimizing impact on trade and travel. In the latest revision, effective in 2007, regulations no longer focus on specific diseases, but require nations to notify the WHO of all events that could potentially constitute an international public health emergency (WHO, 2007). Moving to strengthen the emergency response model, the new IHR establish a unified code of routine procedures and practices at border crossings, ports and airports to prevent the spread of pathogens without unduly disrupting trade and travel. They also provide the legal framework for the WHO and other organizations involved in surveillance, detection, alert and response to global outbreaks and epidemics. They address concerns regarding economically damaging travel and trade restrictions that have created reluctance among some to report disease incidence and outbreaks. The new IHR recommend measures for contending with specific public health threats, and define the basic public health capacities that must be in place at each level within every nation to be able to identify pathogens, and report and take action against public health risks that could spread across borders. While the regulations are binding, they, as many other international agreements, do not include enforcement mechanisms. Hence, compliance is dependent on individual government's willingness and ability to act.

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