Winning the battle against emerging pathogens

Abstract

Technological advances in the life sciences hold out the promise of controlling or eliminating stubborn diseases. They also increase the risk that malevolent actors will learn to produce new and highly dangerous pathogens, a prospect that deeply concerns security professionals in developed countries. In the developing world, meanwhile, where many nations struggle mightily with diseases such as AIDS and malaria, public health concerns tend to focus more on the here and now—or, when it comes to emerging threats, on how to contend with natural rather than human-made pathogens. Authors from four countries—Oyewale Tomori of Nigeria (2014), Louise Bezuidenhout and Chandre Gould of South Africa (2014), Maria José Espona of Argentina, and Iris Hunger of Germany (2014)—explore how governments, institutions, and professionals in both the developed and developing worlds can make the world safer from emerging pathogens, whether natural or human-made.

Outbreaks of emerging pathogens, whether natural or human-made, are not just health issues. They present challenges along several other dimensions—legal, political, economic, and military. Improved disease surveillance is at the heart of meeting many of these challenges.

Disease surveillance entails gathering information about the current and past prevalence of diseases in specific countries and regions and provides context necessary for understanding new disease outbreaks and determining, among other things, if they are natural or human-made. Such information is gathered, for the most part, by national health organizations, which forward it to entities such as the World Health Organization, the Pan American Health Organization, and the Centers for Disease Control and Prevention. There, information is compiled into databases and published. But it’s not always good information.

I have worked closely with disease statistics for more than a decade. Sadly, I have found that information about disease prevalence, whether in the developed or developing worlds, often contains discrepancies (Espona, 2011). For example, Argentina, Brazil, and Bolivia were reporting cases of dengue fever some years ago at a time when Paraguay was not. From a geographical and disease-transmission perspective, this was impossible. The discrepancy was not resolved until Paraguay provided updated numbers.

Faulty disease statistics are quite troubling in a world where international travel is easy and controls on passenger health are loose. They are troubling because urbanization has created very poor areas where crowding, inadequate hygiene, and low-nutrition diets allow diseases to flourish.

Inaccurate statistics also represent a major impediment to national initiatives in both public health and defense. If you cannot say with confidence which diseases exist in your country, how can you develop a strategic plan to fight disease? How can you gauge the impact of diseases on your population? How can you prevent malevolent individuals from doing harm with deadly pathogens? Better data about the prevalence of disease are also essential for helping researchers perform their jobs more effectively and fulfilling commitments to instruments such as the Biological and Toxin Weapons Convention. If more effective systems for disease surveillance are to be established, improvements are necessary in two main areas: the legal and institutional realm, and the educational realm.

An international legal and institutional framework already exists for emerging diseases, comprising a health component and a weapons component. On the health side, the World Health Organization oversees efforts to combat many diseases. On the weapons side, the Biological and Toxin Weapons Convention, the Geneva Protocol, and the Australia Group (an informal export-control entity) are intended to inhibit the development of biological weapons. But there is considerable overlap between the two realms—for example, yellow fever and dengue fever are relevant both to the health side and the weapons side. This leads to much duplicated effort, as individuals and institutions responsible for disease reporting often must report data to multiple entities. Thus the odds increase that data discrepancies will appear. These problems could be remedied if international health and weapons institutions came to regard disease surveillance as a natural point of contact between their respective endeavors.

But no matter how close the coordination might be between health-oriented and weapons-oriented organizations, data on disease outbreaks will remain flawed if—as is often the case—local health professionals lack the education and training they need to fulfill their duties in disease surveillance. Nations and individual health professionals sometimes lack the ability to identify diseases. Sometimes they don’t clearly understand which diseases to report, or whether to report individual cases or only major outbreaks. They may be unsure whether to report all cases or only fatalities. And there may be confusion about whether reports should be filed yearly, monthly, or whenever a worrisome event occurs.

The good news is that these problems can be resolved through improved education for health professionals and officials. The bad news is that little is being done at the international or national levels to improve education. Entities such as the World Health Organization should develop educational programs to address these problems, monitor their performance, and coordinate their efforts with related national initiatives. But bottom-up efforts can also be useful. For example, the University of Bradford has developed excellent tools, relevant to the Biological and Toxin Weapons Convention and the activities carried out under it, that can be used to train health care professionals on issues such as bioethical responsibilities (University of Bradford, 2014).

Creating a world safer from emerging pathogens requires that players at all levels—from municipal to national governments, and from regional to global organizations—do their part to improve systems for disease surveillance and reporting.

Systemic approach

But bad data are just one aspect of the inadequacies in communication and coordination that afflict the global health system, including its efforts to control emerging pathogens. Often, stakeholders in health systems don’t even know who the other key players are, what those individuals’ responsibilities are, and how to go about working together.

To remedy this, nations must establish systemic approaches to battling pathogens. One way to make efforts systemic is to organize them around the stages of a disease’s evolution—that is, to make plans corresponding to the times before, during, and after an outbreak.

Before an outbreak, the most important issues are to evaluate readiness and to predict the needs that will emerge once an outbreak occurs. Accordingly, officials must gather good statistics regarding past and present epidemiological conditions. Individuals responsible for resource allocation must identify needs for equipment and personnel. Response plans must be formulated in line with plausible outbreak scenarios. Scientists, medical doctors, nurses, and even politicians (all stakeholders must be involved) must receive the education and training that they will need in the event of an outbreak. This includes knowing the identities and roles of other key players. Finally, those responsible for treating disease (doctors, nurses, and administrative personnel) and those who study disease (scientists in research laboratories) must prepare to work collaboratively, and they must be provided incentives as necessary. Changing health care’s need-to-know culture into a need-to-share culture is fundamental.

During an outbreak, officials once again must gather good statistics. They must decide where to allocate emergency resources, including money, equipment, instruments, professionals, and so on. Political decision makers must provide support for disease-fighting efforts. The mass media must do their part to provide necessary information to the public.

The aftermath of an outbreak amounts to a learning opportunity, a chance to judge the adequacy of plans made before the outbreak and of implementation during it. Evaluations made at this time—not only of health care itself, but also of communications efforts and the political aspects of disease response—should be fed back into planning for the next outbreak. Thus a new cycle begins.

All of this sounds fairly straightforward, but pathogens’ refusal to stay within one country complicates everything. Regional and international cooperation is imperative—this is where the World Health Organization, with its ability to coordinate national efforts, plays a very important role. If it’s difficult to build a successful response program within a single nation, doing so across several nations presents enormous difficulties.