Keynote: One Health and Preventing Pandemics
Presented by Eric Goosby, University of California, San Francisco
The workshop featured a keynote address delivered during a session moderated by Casey Barton Behravesh. Eric Goosby, professor of medicine at the University of California, San Francisco, and former United Nations (UN) special envoy on tuberculosis (TB), provided an overview of the One Health concept and the shared responsibility across the international community that is needed to establish universal pandemic detection, response, and prevention capability. He outlined gaps in current surveillance and response efforts, described key sectors in creating a comprehensive system, and discussed the role of universal health coverage in such a system. Goosby also discussed strategies for increasing support of the One Health concept within the medical community, governments, and the general public. He cited examples pertaining to detecting and responding to the current coronavirus disease 2019 (COVID-19) pandemic throughout the presentation.
THE ONE HEALTH APPROACH
Goosby commented on the remarkable nature of the current moment, in which an orchestrated response to COVID-19 uses divergent strategies, funding lines, and human resources. Various geographic outbreaks are managed with a focus on outbreak intensity, while also addressing equity issues and compassionate service rollouts. The pandemic has required local, state, and national responses, as well as international efforts to understand how donor resources enter countries and match, synergize, or fail to fit with domestic resources. On a smaller scale, professionals are faced with
determining how to integrate foundation and research efforts into creating strengthened local responses. A huge amount of surveillance, Goosby said, is required to understand what is taking place in the outbreak and response at any given time and geographical location. Applying that knowledge to decision making requires accessing and distributing substantial resources—including human, drug, and testing resources—at both state and city levels, a challenge that continues to present barriers. Goosby noted this was initially the case with testing supplies and currently is an issue with the vaccination effort.
The One Health approach can contribute to raising awareness of the need for an open and orchestrated understanding of how resources move and delivery systems interface with specific at-risk or target populations, said Goosby. Understanding how delivery systems interface—or fail to interface—with populations has been a challenge at the global level during outbreaks of human immunodeficiency virus (HIV), TB, and now COVID-19. In addition to strengthening the ability to detect outbreaks, effective surveillance efforts also inform a system that allows for expanding preparedness efforts and tailoring a response to the specific needs of the relevant populations. Goosby stated that this process is a recurring, repetitive challenge. The COVID-19 response capability has varied greatly in different parts of California, as was the case in most settings. Although prevention strategies often rely on the initial understanding of an issue, surveillance needs to continually inform decision makers and policy makers so they can institute corrective action in as close to real time as possible, said Goosby.
Approximately 60 percent of infectious diseases arise from pathogens shared with animals (Taylor et al., 2001). Goosby stated that, historically, paradigms for addressing zoonotic disease outbreaks—such as HIV, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS)—have largely been reactive. Current understanding of where a surveillance system is needed and would be most effective are limited because the mapping capacity required for this has not yet been developed. Furthermore, the ability to track how a potential threat changes over time is still largely aspirational, said Goosby, stating that economic losses resulting from outbreaks can be astounding—as highlighted by COVID-19. For comparison, the 2003 SARS outbreak that infected just over 8,000 people caused a global economic loss of $40–$54 billion (IOM, 2004). With the COVID-19 outbreak ongoing and economic impacts likely to persist for years, its total loss cannot yet be quantified. Goosby remarked that the economic effect on travel and entertainment alone, most notably in the airline industry, is catastrophic.
Goosby highlighted that antimicrobial resistance (AMR) is a topic for which One Health is applicable, since it has implications for both humans and animals. Animals in the United States consume two times the volume
of medically important antibiotics that humans do (O’Neill, 2016). On the human side, AMR is particularly relevant in the context of TB, for which the annual rate of AMR-attributable deaths is projected to be as high as 10 million by 2050 (Spellberg et al., 2013). Given evolving understandings about AMR’s relevance to both the animal industry and human health, Goosby suggested that an integrated approach to AMR data in policy decisions could be useful. Furthermore, consensus is needed on current readiness to implement surveillance capability through the International Health Regulations (IHR). He added that increased transparency would enhance the ability to monitor outbreaks in countries lacking continuously running surveillance systems that uniformly cover the geography (Review on Antimicrobial Resistance, 2015; Solomon and Oliver, 2014; WHO, 2014).
Nonprofit organizations are largely responsible for raising awareness of outbreaks in the locations in which they operate, said Goosby. Much discussion has centered on this dynamic since the Ebola challenges of 2014–2016.1 However, this has not resulted in a pivot toward an effective, sustainable surveillance system, despite the 2005 IHR describing it, Goosby noted (WHO, 2008a). Typically, a virus is not detected at the point when it jumps from an animal reservoir to a human host but rather when an infected individual engages the medical delivery system. This detection can occur long after the virus has had the opportunity to embed and spread within a human population, so resources should be mobilized to enable the surveillance system to operate rapidly in front of a pathogen as it begins to move into humans, he added.
ONE HEALTH PANDEMIC RESPONSE FRAMEWORK
The ethos of the One Health approach is to provide detection, response, and prevention capabilities at the global, national, and local levels, said Goosby. This involves orchestration that is multi-sectoral, transdisciplinary, and collaborative. Transparency and accountability are essential to building system integrity. He noted that it is important to be able to reveal weaknesses and vulnerabilities without criticism or ridicule, instead meeting these with an attempt to better understand and strengthen the response. Given the disparities and inequitable distribution of capabilities throughout the globe, shared responsibility across the international community is the only realistic method of creating a system of preparedness and alerts for emerging threats, said Goosby. He contended that the assumption that individual sovereign nations can be independently responsible for the entire
1 The 2014–2016 Ebola epidemic in West Africa caused more than 11,300 deaths in Guinea, Liberia, and Sierra Leone. More information about this outbreak can be found at https://www.cdc.gov/media/releases/2016/p0707-history-ebola-response.html (accessed March 26, 2021).
complement from outbreak detection to response—without regional or global support—leads to less successful efforts, as multiple examples in the attempt to mount various regional COVID-19 responses have indicated.
Improving Pandemic Detection
Given that a majority of human infectious diseases arise from pathogens shared with wild or domestic animals (Taylor et al., 2001), Goosby pointed out that the risk of disease emergence exists virtually everywhere, not just in low-income countries. A global surveillance system would be able to detect pathogens before they reach domesticated animals—where they have the opportunity to spread to humans. He said he understands that the World Health Organization (WHO) and the UN are discussing the ability to fund and support the level of global orchestration that such surveillance requires. In the United States, the Biden administration is working to convene a specific discussion about threat detection and response from a regional perspective. Goosby added that this is the first time in his career that high-level talks about pathogen detection efforts are taking place, and he was eager to see these pivot into a funded, sustained priority.2
Global Actions in Pandemic Detection
Goosby emphasized that improving pandemic detection demands new global action. The COVID-19 pandemic has revealed the frailty of existing global detection mechanisms. IHR systems were weak due to governments lacking motivation to share public health risks, Goosby noted, and post-COVID-19 efforts can improve upon this by incentivizing the sharing of outbreak data. WHO should reinvigorate IHR—placing greater focus on intersectional equity—and the UN should establish health security infrastructure, said Goosby.3 These steps would create surveillance systems capable of discerning an outbreak, notifying authorities, quantifying the concern, and prompting action from WHO. This would include an announcement, evaluation, and reconsideration of whether the threat does indeed reach emergency level. In an established emergency, resources would be released to converge on the site to enable continuous surveillance that would feed and inform an international understanding of the threat.
2 A recent report of the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response (published after the workshop, in June 2021) addresses the issue of permanent funding for global disease surveillance directly. The report, “A Global Deal for our Pandemic Age,” can be found at https://pandemic-financing.org/report/foreword (accessed August 9, 2021).
3 The definition of intersectionality as it applies to public health can be found at http://www.ncchpp.ca/docs/2015_Ineg_Ineq_Intersectionnalite_En.pdf (accessed July 7, 2021).
Goosby noted that rather than duplicating capability in multiple areas, regions require the ability to move resources to the problem, allowing for rapidly expanding capabilities in the source country.
Regional talent should be pre-identified and prepared to respond to an alarm within hours—assessing, reporting, and initiating an infusion of additional resources to better define and respond to findings, said Goosby. This must be a shared responsibility, which requires a high degree of commitment, Goosby asserted. To date, relying on individual sovereign nations to establish the full continuum of services and capability for surveillance has largely been unsuccessful. Discussions are taking place on incentivizing surveillance, including generating definitions of the specific incentives. The impact of surveillance on health security is often influential in driving developed countries to generate resources for the global detection effort, because governments and appropriators are generally more willing to contribute funding when it is contextualized in terms of security. He noted that many medical professionals view security considerations as outside their comfort zone. However, as public health and medical considerations may not come into play for security decision-making groups, Goosby suggested that medical professionals include security considerations in their discussions. Goosby added that security-focused and public health–focused thinking can enhance one another, but since these are distinct communities, attention should be given to the processes needed to move toward synergy.
Local Actions in Pandemic Detection
The necessary increase in detection capability will need to evolve locally, said Goosby. Monitoring all humans, animals, and environments on a global level would likely be unfeasible, so greater sophistication is required to address various surveillance challenges—for example, strengthening the capacity for earlier detection and developing an alarm system that generates regional alerts to trigger capacity support on a global level. New approaches and novel technology could empower local communities and support traditional surveillance capabilities, especially in hot spots (Allen et al., 2017). Examining COVID-19 trends in big data has enabled greater understanding of the movement and purchasing patterns of people within a given geography in California, leading to predictions of infection and hospitalization surges. The capacity to predict the impact of increased population accumulation—such as during the Christmas holidays—on hospital delivery systems has now become quite accurate. Technology such as tracking the purchasing patterns on cell phones will add another lens to the ability to be more specific in anticipating threats, he added.
Strengthening Pandemic Response
Goosby stated that many countries, including the United States, have limited contact tracing capabilities, as has been evident during outbreaks of COVID-19 and TB (Hale et al., 2021), and some countries have none. Limited contact tracing impedes the ability to limit new infections. Prior to COVID-19, nearly 40 percent of large emerging disease events were linked to lack of public health infrastructure (Bogich et al., 2012). To avoid similar failures in future pandemics, countries should strengthen their health systems to enable a rapid and coherent response, said Goosby. He noted that in California’s Bay Area, high COVID-19 infection rates have hampered contact tracing efforts, which are less effective during large surges of infections. He anticipated that the decreasing infection rate will reinvigorate the utility of contact tracing. In California, this case-finding contact strategy was planned to begin with six counties before moving to a regional level, with surveillance informing each stage of lifting containment measures. Goosby pointed out that this is a shift from the last three infection surges in California, where surveillance did not inform reopening plans. This pattern exemplifies the shared responsibility of a regional response, which should be modeled and implemented at the global level, he added.
Key Response Sectors
Several sectors have key roles in response efforts through continuous and episodic engagement. National governments, which remain the entities responsible for responding to outbreaks, have a line of accountability that can be invoked. Goosby noted that governments are responsible for the population in a way that other sectors are not; thus, they should be accountable for initiating and leading health responses. He continued that local, state, provincial, and national governments are critical partners in orchestrating procurement and distribution systems at scale. Academia can engage schools of medicine, public health, and veterinary medicine to lower barriers in applying the best science, data solutions, policies, and technologies for in-country implementation. Additionally, academia offers specific skill sets needed to collect, aggregate, and analyze data. This analysis can create feedback loops with policy makers, identifying mistakes in implementation and recommending improvements, thus creating self-correcting systems. Goosby emphasized that such partnerships are needed between government and local academia to establish sustainable patterns. He added that all the countries he has worked in have had pockets of capability that should be recognized, expanded, and leveraged, such as those that have driven progress in the past 30 years in responding to HIV and TB epidemics. Pivoting to finding regional talent—as opposed to bringing in an
academic medical center from thousands of miles away—can help to evolve and mature the delivery of care, said Goosby.
The nonprofit sector also plays a role in establishing credibility in recommended services. Local community-based organizations are able to access populations that historically have been difficult to identify and retain for care over time, making these organizations valuable partners in response efforts. The private sector can harness the strengths and networks of business, investors, and enterprise to address identified health priorities in partnership with government. However, Goosby noted that public–private partnerships can be relied on too heavily, and—given that the private sector rarely holds a mandate to sustain a response—it can be difficult for the government to hold the private sector accountable. Thus, while the private sector can bolster response efforts by providing financial resources and capacity for procurement and distribution, Goosby said the appropriateness of roles should be considered in establishing such partnerships.
The health diplomacy and advocacy sector can contribute to engaging constructively with ministries of health and other parties to identify health priorities, critical implementation issues, and barriers to success. Goosby remarked that it can elevate the role of global health awareness in diplomatic discourse between countries. In the United States, work is under way to understand how to use a health diplomacy platform more effectively to discuss expanding national-level capabilities in determining international-level programming priorities. Many European countries also consider this an area that needs to be leveraged more aggressively, said Goosby.
Universal Health Care Coverage and Pandemic Prevention
The prevention element of pandemic preparedness is difficult to anticipate, Goosby noted. The surveillance system is critical in enabling the ability to mount a counter-response. Discussions of pandemic prevention inevitably lead to the role of community health workers and primary care in supporting local surveillance efforts and containment strategies. While it is logical to contend with one disease via specific health disciplines that may be excellent, though siloed, Goosby maintained that prevention efforts cannot stop there. An integrated, sustainable portfolio of services is beneficial, as many individuals with infectious diseases, such as HIV, TB, or COVID-19, also have other diseases and comorbidities. Clinics that perform disease-specific services require people with multiple health issues to move from one site to another to receive care for their different conditions and needs (e.g., family planning, HIV, TB, hypertension, diabetes, coronary artery disease). However, most programs focusing on a single disease have not yet matured to meet the full spectrum of needs. The universal health coverage (UHC) movement, the One Health
concept, and the global health community at large are converging upon the recognition—underscored by the COVID-19 pandemic—that finding ways to meet the diverse needs of people who are already in existing care delivery systems, while also being positioned to expand in response to new threats, represents a major challenge. UHC ensures accessible, equitable, affordable care, particularly for specific underserved communities, and enables coordination of programs and stakeholders, said Goosby. Therefore, UHC is a critical component of pandemic prevention (Binagwaho and Mathewos, 2020).
The COVID-19 pandemic, like any global crisis, serves as a reminder that the problems of some humans are the problems of all humans, said Goosby (Reid et al., 2021). In a globalized world, no one country alone can effectively respond to human, animal, plant, and ecosystem health threats. To prevent and respond to future pandemic threats, Goosby surmised, coordinated, multi-sectoral strategies are needed that are inclusive, participatory, and based on principles of shared responsibility. For most countries, acting alone to achieve needed actions is not realistic, which speaks to the role WHO and the UN play in orchestrating the identification of unmet needs and invoking shared responsibilities to fill those needs as a global community. This includes the shared global responsibility to understand morbidity, inequities, disparities, and impact as an outbreak moves through the population. Efficiency in understanding and communicating morbidity and inequities establishes credibility with populations, even more so when differences in outbreak dynamics are reflected in allocation decisions. Establishing these connections is challenging, he added, especially on the international scale. A conduit is needed that can present, solidify, and document data regarding needs while simultaneously creating a line of accountability. Goosby said that he anticipates that the One Health platform will become increasingly important in this effort.
Barton Behravesh asked Goosby how he might approach engaging students in One Health. He replied that, from his position at an academic medical center, he recognizes that medical students, residents, and fellows are the future of One Health, and thus efforts to promote this global thinking among students could help the platform gain traction. While students may intuitively recognize the need for this pivot, introducing these ideas
during medical rounds can socialize this type of thinking. Goosby noted he believes the current period is one of bridging medical cultures and perspectives to create synergies. He added that academic medical centers need to open their divisions and acknowledge the role that research institutes and centers can play in augmenting more traditional departments of medicine. Based on his conversations, Goosby said, many deans and chancellors also see this as a necessary step moving forward.
Building Consensus for a Global Health System
A participant asked about the extent to which disparity of opinion regarding the global health system harms One Health efforts. Goosby responded that discussion of resource expansion is difficult because government budgets are already strained. Adding new priorities requires reorganizing current priorities. However, Goosby noted how helping governments to understand how One Health dovetails with security may help to shift discussion of government appropriations and increase willingness to acknowledge the existing resource deficit when looking at both areas simultaneously. For professionals who are not considering issues of health, the security component can catalyze new understandings of health threats. He encouraged medical professionals to develop an understanding of security language and threat perception, as synergy in those areas can lead to funding for an essential new system.
Tracking Movement and Purchasing Patterns
Another participant asked Goosby to elaborate on how cell phones, movement, and purchasing patterns can be used for detection and surveillance and what implementation would look like. Goosby noted that in San Francisco, purchases taking place after Thanksgiving were tracked. This information was not specific to individuals but instead was used to evaluate overall buying patterns, such as from online retailers or in stores. Such patterns reflect how much interaction people are having. As interaction increased, the number of new infections likewise increased within 2–3 weeks. Goosby stated that at the local level, patterns of increased interaction were used as a surrogate marker of increased spread, indicating the need to prepare for a surge. Similarly, cell phone location patterns can provide data to estimate infection rates, which can be added to the compilation of information used for decisions about, for example, lifting restrictions as well as evaluating public compliance with restrictions and determining the appropriate timing for lifting restrictions. He added that surveillance on face mask use has been conducted via images on closed circuit televisions.
Influencing the International Animal Trade
Given that many vertebrate species are traded internationally, a participant asked how to prevent the spread of infectious diseases without negatively impacting a trade that is central to cultural traditions, livelihoods, and economic activities around the world. Goosby replied that understanding and delivering pertinent science to decision makers and the populations holding such cultural beliefs should be conducted transparently, aggressively, and continuously. Targeting local leaders to be part of the process means that they can become spokespeople for connecting the risk of infection with certain practices. An iterative, community-oriented approach can be useful because governments do not naturally gravitate to these types of efforts; however, HIV outbreaks have demonstrated the value of initiating dialogue with communities to identify and retain patients, which can reduce the number of deaths over time. He added that when faced with difficult outcomes, people will eventually become convinced that changes are needed if the potential consequences are brought to their attention. Encouraging ministries of health and governments to perform this type of surveillance can move the agenda forward, he added. However, the overwhelming majority of current global health data efforts involve collecting and aggregating data that are never actually analyzed.
Increasing Public Awareness of One Health
Barton Behravesh asked how to bring the concept of One Health to the awareness of the general public. Goosby noted that efforts such as The Lancet’s One Health Commission have been helpful in bringing literature to specific, targeted communities (Amuasi et al., 2020a). Regarding a strategy for reaching the general population, the interconnected systems of the planet should be presented more comprehensively. For instance, the educational system is segmented and stratified, while the interconnectedness of the planet is a theme that should be reflected in every discipline. Professionals who develop curricula can find ways to relate it to areas of study ranging from science to social studies to literature. Noting the use of a Muppet character who has HIV on the U.S. children’s television series Sesame Street, Goosby said that educating the general public about health can begin in early childhood.4 Communications professionals can use media to socialize concepts for general audiences. He remarked that institutions could increase visibility of this topic by hiring advertising firms skilled in making messages memorable, but few efforts are currently under way to increase general awareness.
4 More information about HIV education on Sesame Street can be found at https://www.unicef.org/media/media_16631.html (accessed March 28, 2021).
Encouraging Sharing of Outbreak Data
A participant asked about efforts to incentivize sharing outbreak data on a global scale during pandemics. Goosby noted that this is a new topic for discussion, with few if any efforts yet under way. Countries that are competing at every level for resources to address legitimate unmet needs should be a part of the process of determining country-specific incentives, he added, and nations that cannot afford the investment will need assistance. This process should be conducted with—not for—countries to establish national-level ownership. Barton Behravesh asked how the United States can leverage its global leadership role to encourage open and honest disclosure of outbreaks in other countries. Goosby replied that WHO, the UN, and some foundations are in a position to influence reaction to outbreaks. Currently, a punitive blame reflex remains, as evidenced in the reaction to COVID-19, in which political blame-placing began almost immediately, Goosby lamented. He believed that this reaction undermined efforts to analyze whether opportunities had existed to identify the outbreak earlier, to the detriment of understanding where alert systems were effective or inadequate.
Goosby said that to progress toward a comprehensive surveillance system, surveillance gaps should be aggressively mapped. If WHO is empowered to take on this effort, it will require assistance from major donors; such efforts should focus on understanding how new threats move through the population, whether these could reach the global population, and how to contain them. Blaming is counterproductive to these efforts, he added. Sufficient transparency is needed to be able to detect and alert the world of threats early enough to contain them. This transparency relies on building trust among countries that they will not be criticized or punished for revealing their vulnerabilities. This type of shift is achievable given the political will to do so, he said.
Current Status of One Health Implementation
Barton Behravesh remarked that the One Health movement has been ongoing for almost 20 years, but implementation remains a major challenge. The features that are fundamental to operationalizing One Health (i.e., multifactorial, collaborative, transdisciplinary, accountable, and shared responsibility) can be difficult for middle- and low-income countries to establish, because they require commitment from diverse sectors. She asked about examples of locations where progress is being made. Additionally, she queried which challenges are the greatest in broad, proactive implementation of One Health. Goosby responded that the greatest challenge to achieving an acceptable response is countries’ unwillingness
to expand their capabilities. This specifically relates to governments and the ministries of health—which are at the core of the response—and civil society, which can implement steps toward One Health and teach others to do so. Building capability should involve engaging these sectors from the start, said Goosby. He highlighted Rwanda as an example of a country that has established self-determination in these efforts. Rather than allowing multinational nongovernmental organizations to implement programs, Rwanda created its own platforms for addressing HIV and TB outbreaks and used these as a foundation for a COVID-19 response. Goosby stated that Rwanda takes the role of “doer,” which positions it ahead of other nations in the region in effectively responding to outbreaks.