Responding to the challenges ahead

In the scope of human history, the idea of creating a coherent international organizational network regarding infectious disease threats is very new. The first attempts at building public health infrastructure began in the mid-nineteenth century, when the wealthy realized that in order to protect their financial interests and their own health they had to improve conditions among the poor. The problem became particularly acute in large cities with large populations of poor immigrants living in overcrowded, unsanitary conditions (Basch, 1999). As a result, urban trade and industrial centers began to develop basic public health infrastructures, and to use demographic data collection, leading to a greater understanding of how sanitation and hygiene play a major role in spread of disease. By the early twentieth century, megacities like London and New York had put in place the basic pillars of public health infrastructure - public sanitation, clean water, uncontaminated food and drugs, general vaccinations, epidemic-control programs, and basic preventive health measures (Garrett, 2000). The deadly cholera epidemics that devastated Europe in the 1830s also brought forth the first steps towards international collaboration. While the focus of the first international scientific meetings was mostly on sharing epidemic data, they eventually formed the foundation for future international agreements on disease surveillance, control, and treatment (Walt, 2005). Around the turn of the twentieth century, international collaboration became more organized. Eventually, the devastation wrought

Massive disaster or

Massive disaster or

Economic, political and social resources mobilized to strengthen public health infrastructure infectious disease that threatens overall health security

Achievement of health security in wealthier communities with shift of focus back to individual and local resour

Change of focus from individual to public health and local to global impacting health policies and priorities

Figure 16.2 Health policy cycle from local to global.

by two World Wars during the first part of the twentieth century gave birth to today's formal international system, intended to preserve global peace and foster collaboration among nations. Globalization has brought the world back full circle to the same fundamental challenges that public health pioneers in faced in the late nineteenth century, only on a global scale (see Figure 16.2).

There is a strategic framework for improving organizational response that can guide planning in both developed and developing nations (see Table 16.1). The response to an infectious disease outbreak begins at the local level, where, depending on the battleground, the first responder can range from a community health worker in a refugee camp in Africa to an emergency room doctor in a large city hospital. Thus, the global health emergency response infrastructure base is the health workers and resources available at the community level where the first incidents are detected (Kakar, 2000; WHO, 2000). The information and response then has to move outwards, depending on how the health system is organized, to a district level, then perhaps to a Ministry of Health, and then to an international responder, like the WHO. Or, if there is a very weak health system, the next level may be the country headquarters of an NGO, then the WHO, and back to the Ministry of Health. As in a ripple effect, beginning at the local source(s), the

Table 16.1 Recommendations for improving organizational response

1. Develop capacities at the frontlines

Strengthen and integrate long-term public health infrastructure in countries and communities where they are absent or weak. Give priority to struggling and middle-income countries, but do not ignore gaps in wealthier countries (Evans et al., 1981; Lee, 2004; Travis et al., 2004; US Government Accountability Office, 2005). Strengthen national leadership, policies and planning within the context of local historical, economic and social circumstances (ActionAid, 2005).

2. Strengthen capacities at community levels:

Allocate sufficient resources and mandate local planning, exercises, and adherence to clinical and other critical guidelines; ensure public understanding of emergency preparedness plans; develop clear national incident management structures, policies and roles among primary responders; develop communication structures that educate and inform individuals and communities about what to do in an emergency (Weinberg, 2000; HKSAR, 2003; PHAC, 2003; US Department of Health and Human Services, 2005; Medical News Today, 2005; Ballier et al., 2006; Mounier-Jack and Coker, 2006; Tregasis, 2006).

3. De-politicize health planning and global health governance:

While politics can neither be ignored nor eliminated, the goal is to move away from short-term response thinking that focuses on protecting those with resources, and towards developing consensus and collective action to protect the health of all (Weinberg, 2000).

4. Promote a whole system approach:

Move beyond organizational self-interest to reduce overlap and improve efficiency. It makes no public health or monetary sense to build different or parallel response structures for each disease or crisis response (PHAC, 2003; Chertoff, 2005; Earls and Hearne, 2005; Garrett, 2005). Tightly coordinate national emergency response structures with neighboring and global emergency response structures (Kakar, 2000; Mills et al., 2006).

5. Coordinate operational protocols:

In order to respond effectively to an infectious disease emergency, protocols must be in place that cover eight basic areas:

• Information: establish surveillance and intelligence systems to warn and inform

• Communication: establish vertical and horizontal channels to and from command levels, across responding agencies and organizations, and to and from individuals, affected communities and the public at large

• Chain of command: pre-determine and ready clear and organized responsibilities for who gathers what information, who reports to whom, who supports whom, and who supplies what area of expertise or service

• Keyresponders: plan advance identification, definition, and understanding of expertise and roles for all responders, including public and private sector agencies, NGOs, and private sector organizations

(Continued)

Table 16.1 (Continued)

• Legal framework of emergency powers: develop, define and authorize command authority and emergency powers at all relevant levels of responders; determine degrees of flexibility, standards and timetables, penalties for non-compliance

• Logistics, identify, establish, and protect essential goods and services and their supply chains

• Resources. identify, establish, pre-position, and pre-assign human, financial, material, and transportation resources

• Testing. continuously test and readjust, if necessary, these protocols to ensure preparedness.

References: HKSAR, 2003; PHAC, 2003; Earls and Hearne, 2005; Medical News Today, 2005;

US Department of Health and Human Services, 2005, 2006.

response of each "geo-political ring" to an expanding threat must be meticulous in terms of its surveillance, communication, planning, and implementation.

With an increasing awareness that the first response is local, there is increased realization that in both poor and wealthy countries more emphasis must be placed on building local and national emergency response networks. However, much of the focus continues to be on high-tech surveillance and the development, manufacture, and stockpiling of vaccines and anti-viral pharmaceuticals. Improving local planning and training, although widely encouraged, still often amounts to little more than detailed guidelines which contain few common frameworks, mandates, training, timetables, or chains of command.

The problems faced by low-income nations dwarf the challenges in affluent nations like the United States. However, disparities in preparedness and resource availability at the various response levels plague the system in different but no less serious ways in wealthy nations (Earls and Hearne, 2005; Ballier et al., 2006; Mills et al., 2006; Mounier-Jack and Coker, 2006). For example, in the United States, during a global pandemic the state and local health departments are typically the front-line responders to disease outbreaks (Zwillich, 2005). Yet support for local and state preparedness constitutes only about 10 percent of the $3.3 billion allocated to pandemic preparedness (US Department of Health and Human Services, 2006). While federal and state authorities provide detailed guidance and some financial support to states, the primary responsibility for planning, decision-making, and organizing is the responsibility of individual counties and municipalities, and capacity is uneven (Earls and Hearne, 2005). Thus, for example, New York State's preparedness for a potential influenza pandemic varies widely across localities. Wealthier communities have professional police, fire, and emergency medical service departments, and access to major medical centers, while less affluent ones depend heavily on part-time and volunteer police, fire, and emergency services, and have no access to a major hospital.

Most fall somewhere in between. Meanwhile, they are expected (but not mandated) to develop plans for, among other things, vaccine distribution, vaccination of priority groups, monitoring of adverse events, tracking of vaccine supply and administration, vaccine coverage and effectiveness studies, communications, legal preparedness, and ensure that health-care providers conduct initial screening, assessment, and management of patients. Individual counties are also responsible for conducting appropriate training in infection control and disease containment strategies, to prevent or decrease transmission and a host of related topics (New York State Department of Health, 2006). Left without adequate technical and financial support or strong integration into a common national emergency framework such as the US Department of Homeland Security's National Response Plan's National Incident Management System (NIMS), the US health infrastructure, particularly in poorer communities, might very well not be up to the task of containing or controlling a major influenza epidemic.

SARS erupted in countries with relatively strong health systems, and raised world concern that weak points in any health system can, in addition to undermining patient care, allow emerging infections to intensify and spread beyond local communities and borders. We were fortunate, as containment might have been impossible had the outbreak started in or spread to countries with weak health infrastructure (WHO, 2003). Still, both the Canadian and Hong Kong investigations into the SARS outbreak cited preparation and planning weaknesses, as well as organizational and structural flaws and conflicts in authority, as key reasons for response failures. Both committees recommend better contingency planning in the future, including the development of a clear public health organizational structure under a centralized authority, and a clear chain of command with clear policies, in order to provide effective leadership and action. In addition, both committees recommend that the public health infectious disease response structure form a part of an integrated command and management structure. They recommend pre-clarification of legal and regulatory issues, and pre-establishment of requisite local, regional, national, and international technical and communication networks and links. Both call for the formation of local infectious disease SWAT teams and human resource capacity building (HKSAR, 2003; PHAC, 2003).

Surveillance systems also can be better integrated. Since the early 1990s, there has been widespread recognition that we need better coordination, standardization, and integration of epidemic surveillance activities at national, regional, and global levels (Gouvras, 2004). In 1988 the Institute of Medicine in the United States recommended developing a standardized national data set, but reported only limited progress in its 2003 report (IOM, 2003). It suggests that fragmentation and incompatibility of surveillance efforts at federal, state, and local levels exist because authority rests across local and state entities, and because funding historically tended to be disease-specific (IOM, 2003). Similarly, collaboration among European Union members has often been hampered by differing opinions about priorities, division of roles and responsibilities, and resistance to greater centralization (Gouvras, 2004). Coordinating surveillance systems for the 192 member states of the WHO, therefore, is a daunting task. National sovereignty is a hurdle. The WHO does not have the authority to take control when local governments resist, even when the health of the local and global community is at risk. According to the United States General Accounting Office review of the lessons learned from SARS, the WHO's ability to respond was primarily stymied by the initial lack of cooperation of the Government of China (US Government Accountability Office, 2004a). Without proper authority to intervene to protect global public health, the WHO can only offer guidance and technical support, and must rely on individual nations' willingness to share information. In the United States, the Centers for Disease Control struggles with similar turf issues. These hampered its ability to trace international travelers that might have been exposed to SARS in 2003. Airlines questioned the CDC's authority, and refused or delayed providing passenger information (USGAO, 2004a). Authority to obtain passenger information has still not been resolved.

Even though an unprecedented number of nations, agencies, and organizations are working hard to address the challenges of global infectious disease, there continue to be the common and interrelated systemic problems we already have mentioned: inadequate infrastructure in areas most vulnerable to epidemics, political barriers, too little coordination and funding (ActionAid, 2005; OECD, 2005), and the segregation of long-term health infrastructure from emergency response - especially in low- and middle-income countries (Barnett et al., 2005) There seems to be an ongoing process of dividing and subdividing the organizations that make up the international response network. Planning and funding is accomplished on a program-by-program basis. The WHO's 2006-2007 budget request for "essential health interventions" includes: HIV/AIDS; child and adolescent health; communicable disease prevention and control; making pregnancy safer; malaria; mental health and substance abuse; reproductive health; tuberculosis; emergency preparedness and response; epidemic alert and response; and immunization and vaccine development. Despite their seeming interrelatedness, they are in fact funded as separate programs. Combined, these items constitute 53 percent of the WHO's budget against 11 percent allocated to health policies, systems, and products (WHO Proposed Programme Budget, 2006-2007).

Humanitarian disasters in the 1990s, including the AIDS pandemic and regional wars and civil strife, produced an explosion in the number of non-governmental organizations and public-private partnerships (PPPs) involved in world health (Walt, 2005). With this enormous increase in international funding and effort, there is an even greater need to reduce overlap and improve inefficiency (Worley, 2006). Funding from large philanthropic foundations, like the Rockefeller and the Bill and Melinda Gates Foundations, is changing the landscape of intervention (Cohen, 2006). In addition to funding new initiatives, they are linking the private sector, academic institutions, and non-governmental and multilateral organizations to produce inter-sector groups with unprecedented political and financial influence to tackle specific diseases. While no one knows for certain what the long-term impact of a proliferation of new major initiatives, like the Global Fund to Fight AIDS, TB and Malaria, the Roll Back Malaria campaign, and the Global Alliance for Vaccines and Immunization, will be on international organizational response, the process remains characterized by weak local capacity, politicization, and fragmentation of funding and efforts. To improve global capacity to respond to outbreaks, systemic emergency response capabilities, primary care and prevention activities, and basic infrastructure must be integrated and strengthened locally and globally.

The good news is that progress is being made. Since the late 1990s, the WHO has also helped to reduce competition and pool resources by getting a host of partners, such as the CDC, Health Canada, and the network of Pasteur Institutes, to operate under its auspices. Programs are in place to expand the availability of new technologies, like antibiotics, vaccinations, and insecticides, for developing nations. And in the United States, as of publication, the Department of Homeland Security is making progress moving the National Response Plan from paper to practice, using an all-hazards approach.

Although research and technological advances have a tremendous impact on disease containment and control, our greatest challenge may be to develop the global organizational and operational capacity to provide access to effective emergency response and long-term prevention and care. Once again, wealthy communities need to improve the conditions that cause and spread disease in the world's most vulnerable communities, or risk the loss of their own health and prosperity to the re-emerging threat of infectious disease. It would be shameful if history were to show that the lion's share of today's resources went to emergency response SWAT teams and disease-specific programs, while leaving behind the same weak health system and thereby once more the potential for the reoccurrence and expansion of more epidemics in the future (Neusy, 2005).

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