4

Current One Health Efforts and Opportunities

The first half of the workshop’s second session consisted of two panel discussions focused on current One Health initiatives and gaps to address. The moderators began by directly engaging the panelists with questions. The objectives of the discussions were to (1) assess the current status of developing a One Health workforce to identify gaps between employment needs and education and training programs; (2) explore frameworks to establish cross-sector collaborations and community engagement to strengthen threat surveillance and detection; and (3) discuss challenges of and methods for introducing One Health ideology into existing systems for epidemiological surveillance at the local, national, and international levels.

WHAT IS BEING DONE NOW?

Mark Smolinski, president at Ending Pandemics, moderated the first panel discussion, which focused on current applications of the One Health approach. Esron Karimuribo, professor at Sokoine University, Tanzania, discussed community-based data collection efforts. James Hospedales, executive director at the Caribbean Public Health Agency, noted various environmental impacts on pandemic activity and other health considerations and discussed environmental surveillance. David Rizzo, department chair of plant pathology at the University of California, Davis, outlined multiple ramifications of plant health on global health. David Goldman, chief medical officer of the U.S. Food and Drug Administration’s (FDA’s) Office of Food Policy and Response, addressed the relevance of foodborne illnesses. Carrie S. McNeil, One Health specialist at Ending Pandemics, described simulations in preparedness efforts.

AfyaData Tool and Experience from Tanzania

Smolinski asked about the One Health community-based surveillance approach developed in Thailand, which was replicated in Tanzania with the AfyaData tool, which is an app with web and mobile components intended to facilitate collection of data regarding human and animal health events at the community level and make it available at national and global levels.¹ Karimuribo explained that the approach was community focused from the outset. During the design process, officials working with human and animal populations were brought together with the community to identify surveillance challenges. The AfyaData participatory disease surveillance technology factored in these challenges during development for use at the community level as part of a One Health approach. This community focus incorporates the local environment, including local languages. The AfyaData system was designed for use by both community members and community health workers, so it needed to be multilingual, enabling users to feel comfortable identifying and reporting events regardless of language. The brand name for the technology is rooted in this community focus: “afya” is the Swahili word for “health.” Karimuribo shared a visual representation of AfyaData.² Karimuribo and his colleagues have proposed a vision of a unified, verified signal that is shared by numerous ministries that deal with health, livestock, wildlife, and environment. It would enable these actors to see events unfolding in real time and generate information to inform their responses.

Support from the United States enabled Tanzania to establish a One Health coordination desk at the Office of the Prime Minister, which also houses the Disaster Management Department, Karimuribo explained. These improvements facilitate managing disease outbreaks, mobilizing human and financial resources, and deploying support staff for verification and diagnosis. For instance, the AfyaData tool was used successfully by a community-level One Health reporter in Ulanga, Tanzania, who reported a sudden rise in dog bites. The tool enabled rapid response mobilization, whereby an outbreak of rabies was confirmed and followed by immediate containment measures, including mass dog vaccination and awareness efforts. This exemplifies how AfyaData links data from community events with officials who can initiate responses.

Smolinski noted Karimuribo’s engagement with the Maasai community in Tanzania while designing the AfyaData tool. The proximity of

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¹ An outline comparing the two systems can be found here: https://www.exemplars.health/emerging-topics/epidemic-preparedness-and-response/surveillance-technology-ending-pandemics-case-study (accessed May 30, 2021).

² More information about the Afyadata tool can be found at http://afyadata.sacids.org (accessed April 29, 2021).

the Maasai community’s livestock to wildlife, nature preserves, and parks caused some concern among international partners about the potential for spillover from wildlife into the domestic animal population. Smolinski asked whether engagement with the Maasai community or its use of the data-sharing tool has led to behavioral changes. Karimuribo replied that the community was first engaged during the initial design of the AfyaData system. In asking them about the challenges they faced, it was discovered that the community was concerned about water sources as a potential point of disease transmission between humans and animals. Ngorongoro is a world heritage site with a unique ecosystem that is cohabitated by humans, wild animals, and domestic animals. Using input from the Maasai community, a system was designed to support the control of human and animal diseases. Karimuribo reported that after 10 years in operation, the system has brought about behavioral changes, particularly with respect to how the community responds to the system’s reports. Multiple community-level events involving schoolchildren and abnormal primate behavior have been identified, linked to wildlife, investigated, and contained.

Impacts of Human Destruction of Nature on Global Health

Smolinski asked about the impact of human destruction of nature, such as deforestation, and other ecosystem disturbances on the emergence of new diseases. Hospedales stated that over the past 40 years, most pandemics have emerged out of forests and wetlands encroached upon by human activities, such as agriculture and legal and illegal logging. This ecological pressure and displacement of animals from their habitats can promote pandemics and is linked to larger concerns of climate change and degradation of environments. The One Health initiative could gain traction by connecting to the broader climate consciousness that is growing among governments, businesses, and even celebrities and popular culture, said Hospedales. Deforestation is associated with loss of biodiversity and the release of carbon dioxide into the atmosphere, which in turn creates hospitable conditions for pandemics. Thus, slowing and halting forest destruction could be beneficial in terms of pandemic control. Moreover, areas of forest being destroyed could be targets of increased surveillance efforts, including satellite-based systems³ combined with collecting on-the-ground syndromic data from pharmacies and health centers to produce an early warning system for pandemics. Rather than waiting for the first case of a new pandemic virus to occur, Hospedales asserted, such an early warning system could look at the confluence of circumstances that lead to pandemics.

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³ Hospedales gave the example of Planet: https://www.planet.com (accessed May 30, 2021).

Although plants are an important part of the environment, they are often ignored in discussions of pandemics, said Smolinski. He asked about the relevance of plant pathogens to broader considerations of pandemic control. Rizzo commented on the role of plant health within the One Health framework. Food security and food availability are reliant upon plant health, which can be adversely affected by insects, biotic and abiotic agents, and plant pathogens. Food safety is a major concern linked to One Health, Rizzo explained, because vegetable crops can be contaminated by wild and domesticated animals that harbor human pathogens such as E. coli and Salmonella. Rizzo noted a few examples of the interface between plant and human health. Mycotoxins (toxic secondary metabolites caused by some fungi that infect plants) are capable of causing disease and death in humans and other animals. Plant diseases can also have economic impacts. For instance, coffee is not a staple crop, but coffee farming provides livelihoods for millions of people in low-income countries. The emergence of coffee rust disease in Central America destroyed many coffee crops and caused indirect adverse health effects for residents. Moreover, the impacts of deforestation extend beyond destroying trees to include spreading plant pathogens and insects. Deforestation and the export of commodities harvested from forests have introduced exotic species and pathogens to new environments, contributing to global One Health concerns. These factors are interlinked, with plant health as one nexus of these linkages. Rizzo pointed out that the majority of all food comes from plants, either directly or indirectly, through animal feed. Because plant health is a major component of One Health, he suggested that pathologists should collaborate with plant health researchers to pursue the One Health approach.

Food and the One Health Approach

Smolinski noted that despite the relevance of foodborne illnesses to One Health, they are often omitted from initiatives and instead addressed as a siloed issue. He asked how foodborne illnesses can be incorporated into a broader conception of One Health. Goldman remarked that his experience in the U.S. Department of Agriculture (USDA) food safety and inspection service and his nearly 20 years working on foodborne illness at FDA have given him insight into these issues. The interplay of animals, environment, and human health has long been evident, yet this interplay has only been considered within the context of One Health in recent years. For example, the initiation of PulseNet in the mid-1990s by the U.S. Centers for Disease Control and Prevention (CDC) and other partners involved comparing unique genetic characteristics of food samples, environmental samples, and

human clinical isolates.⁴ These comparisons linked foodborne illness with the exposure that caused the disease. Since then, whole-genome sequencing has become a powerful surveillance tool for comparing the genetic characteristics of food, environment—either the natural environment or the food manufacturing environment—and human illness, he added.

Goldman noted that the National Center for Biotechnology Information at the National Institutes of Health (NIH) has a catalog of more than 500,000 pathogens, including bacterial pathogens that may link human illness with environmental and animal pathogens, which enables federal officials to look daily for links between illness and pathogens, which can be confirmed using epidemiology. This process can enable early identification of an outbreak, affording the opportunity to respond quickly to prevent secondary cases. The interplay of humans, food animals, wild animals, environments, and crops warrants more exploration. Goldman noted that researchers have focused on this interplay of pathogens and the environments and ecologies in which they live, thrive, and become available to cause human infections.

Using Outbreak Simulations to Promote One Health Readiness

Smolinski remarked that Sandia National Laboratories have been instrumental in developing simulation exercises—often referred to as “tabletop exercises”—to improve One Health efforts. He asked how this methodology is used to strengthen national programs and regional collaboration. McNeil said that emergency management actors have long used simulations to improve readiness and strengthen preparedness for various types of outbreaks and emergencies. When assessing One Health readiness, it is clear that ecosystem health, plant health, public health, and animal health are studied in siloed fields; these fields’ bodies of knowledge are siloed accordingly. This disconnection between sectors is detrimental to the early stages of outbreak detection as well as the response stages. Intended to mimic real-life conditions, simulations can be used to identify and address the barriers created by silos.

Sandia National Laboratories has developed role-based multiplayer, multi-scenario exercises with participant-led analysis, said McNeil. These exercises put participants in roles similar to those they would likely play during a real outbreak. In 2015, Sandia, on behalf of Ending Pandemics, coordinated an exercise in South Asia with One Health participants from 13 ministries across eight countries, each with a unique scenario. The focus

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⁴ PulseNet is a national surveillance network for foodborne illnesses that was originally established to collect molecular subtyping data from pulse field gel electrophoresis analysis, accessible at https://www.cdc.gov/pulsenet/index.html (accessed May 30, 2021).

was to test cross-sector, cross-border coordination during an emerging novel coronavirus. Epidemiologists and public health workers focused on public health data, case definitions, and line lists; laboratorians (individuals who work in laboratories) were faced with everyday challenges, such as freezer space and incoming samples. Simulation participants are only provided information that someone in their role would be privy to in real life. For example, public health workers are not given data from the animal health sector, because in a real outbreak, the public health sector would not have access to that information. McNeil explained that by testing these systems through simulations, participants are able to analyze for themselves where information sharing and coordination are taking place, where they are lacking, and where they could be improved upon.

In the exercise conducted in South Asia, Sandia National Laboratories and Ending Pandemics looked at cross-sector collaboration between the animal health and public health sectors and cross-border collaboration among all countries, said McNeil. Participants identified the need for a South Asia One Health disease surveillance network to foster information sharing across borders. Since then, additional remote and in-person simulation exercises have informed the development of the South Asia One Health disease surveillance network. One of these activities was to use simulations to inform disease prioritization for the network. The multirole, multi-scenario approach to conducting exercises used at the regional level has also been applied to national initiatives. Numerous countries have received training in this methodology through Biothreat Readiness Leadership trainings. McNeil explained that Sandia National Laboratories offers the Portal for Readiness Exercises and Planning (PREP), a free, online software platform that tracks information and multiple scenarios related to biothreats.⁵ Biothreat readiness leaders have tested their national One Health strategies with tabletop exercises and also conducted exercises at operational levels, such as in response to outbreaks of Rift Valley fever and brucellosis. She highlighted several opportunities that outbreak simulations can provide: (1) building relationships in advance of an outbreak, a component she identified as critical for successful outbreak response; (2) fostering appreciation for each sector’s strengths and unique challenges; and (3) developing specific plans for how to move forward.

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⁵ More information about PREP can be found at https://gcbs.sandia.gov/tools/prep.html (accessed April 29, 2021). Ending Pandemics hosts its own version of this multiplayer tabletop exercise software, called “START_x,” which can be located at https://endingpandemics.org/startx-exercises (accessed July 28, 2021).

Integrating Environmental Surveillance Within Public Health Systems

Smolinski asked how environmental surveillance can be better integrated into public health. Hospedales acknowledged the importance of this and pointed out that the tendency toward compartmentalization can complicate responses to even simple outbreaks, referring to his experience in CDC’s Epidemiology Intelligence Service investigating shigellosis caused by eggs. In some countries, aspects of environmental surveillance have been internalized effectively. For example, in Trinidad and Tobago, the ministry recently issued a note indicating that numerous monkeys had been found dead in the southern forests. Presumptive causes of death for New World monkeys include lead poisoning and yellow fever. Therefore, this type of event can serve as an early warning for a yellow fever outbreak, which can be addressed with a vaccination campaign. Such a response exemplifies an effective integration of environmental surveillance into public health systems. Furthermore, digital health technology affords innovative possibilities, Hospedales noted. For instance, citizens and health workers can use mobile phones to take measurements for powerful environmental surveillance. The increasing access to digital tools, along with the growing interest in environmental surveillance, can strengthen the integration of environmental surveillance within public health systems.

Applying Plant Pathology to Human and Animal Diseases

Smolinski remarked that plants can serve as a model system to advance knowledge or methods that are directly applicable to human health; he asked Rizzo to expound upon this perspective of plant health. Rizzo said that many of the processes that occur in humans and animals also occur in plants. Although there are clear differences between plants and humans, specific concepts from plant pathogen research can be applied to humans and animals (e.g., aerial pathogen surveillance, innate immunity). Moreover, plant research is not constrained by certain ethical considerations that apply to humans and animals. Finally, he pointed out that plant pathologists work with units of population and community, not individual plants. For example, an individual wheat plant has little value and is not the focus. Thus, plant pathologists can offer modeling and community epidemiology insights and skills.

Using Whole-Genome Sequencing in the One Health Approach

Smolinski noted that whole-genome sequencing has revolutionized disease surveillance. He asked how this technology can be applied broadly to help advance the One Health approach. Goldman remarked that whole-genome sequencing provides the opportunity to make connections at the

molecular genetics level. Traditional epidemiological processes are then used to verify that the connections are in fact related to exposures that caused illness. This combination of processes holds great promise for advancing foodborne illness surveillance, said Goldman. He emphasized that the power of whole-genome sequencing lies in its capacity to reveal connections in real time. Each day, federal and state officials query an expansive database to identify these connections, yielding early warnings about potential outbreaks and facilitating quick and early responses.

Using Simulation Technology During the COVID-19 Pandemic

Smolinski asked how Sandia National Laboratories has applied their simulation technology to the COVID-19 pandemic. McNeil replied that each outbreak or simulation would ideally conclude with an after-action review to evaluate the actions taken and identify opportunities for improvement. Needed changes are then identified and implemented into future plans and training resources. However, in the midst of the COVID-19 outbreak, it has been challenging to create opportunities for such reflection. Because reflection is critical, Ending Pandemics and Sandia have developed a during-action review and tabletop (DART) methodology, said McNeil. This approach incorporates a prospective element, rather than just retrospective reflection, and identifies how future scenarios can be used to address concerns of communities and countries. DART allows participants to consider the information needed today to best prepare for potential events in the near or distant future. As the One Health paradigm applies to the COVID-19 pandemic, the simulation incorporates a One Health perspective.

McNeil remarked that One Health strengths can be called upon in situations that warrant a high level of surge capacity. For example, the animal health and plant health sectors have polymerase chain reaction (PCR) testing capabilities, and animal health workers are trusted community members who contribute in valuable ways to risk communication in the field. The plant health and animal health sectors have numerous capabilities—ranging from logistics to epidemiology to laboratory to emergency management—and this capacity can be leveraged across other sectors. McNeil added that such cross-sector leveraging has been implemented during the COVID-19 pandemic. Thus, an opportunity exists to sustain such activities and develop institutional policies that strengthen and improve resource sharing and surge capacity. She noted that challenges have arisen when animal health workers could not access personal protective equipment due to the increase in demand caused by COVID-19. This challenge presents an opportunity to plan for such occasions by creating stockpiles for them. Other mitigation strategies can be considered, such as obtaining supplies from universities or schools. While it is impossible to accurately predict the worst-case scenario

that will become reality, simulation scenarios can help to identify opportunities to mitigate and prepare for potential situations.

Smolinski asked whether the simulations use virtual reality training. McNeil responded that the ones she discussed are strategic, operational policy-level simulations that can reveal how well participants are coordinating and working together. Sandia National Laboratories has developed other video-game-based simulations for tactical level trainings, such as carcass disposal and waste management tasks. She noted that simulations using video game technology can improve readiness in underresourced communities that may be unable to send staff for hands-on One Health emergency training. Sandia has also explored virtual reality and augmented reality technologies. While it would be possible to develop simulations using these technologies, they have opted not to do so thus far, said McNeil. In developing the PREP platform, Sandia discovered the benefits of keeping its training modules as simple as possible and requiring minimal bandwidth. She acknowledged promising and interesting opportunities to use virtual reality and augmented reality in training simulations, such as those for biosafety and biosecurity training. However, the current need is best met with simpler, more immediately available technology, she contended.

Protecting Environments Using the One Health Approach

Smolinski asked whether community-based tools or other components of the One Health approach are helping to conserve ecological integrity. Karimuribo noted that AfyaData can be adapted for any scenario. For example, some districts in Tanzania had concerns related to environmental health, so the tool was adapted to support data collection related to these concerns. Given an existing framework and tools, the AfyaData system can facilitate the digitization of information and link responders to data. Hospedales said research investigating integrated coastal and aqua-terrestrial solutions brought about advances for small islands’ management of marine protected areas, engagement with farmers, sustainable use of pesticides, and drainage. He posited that the rapid rate of deforestation and wetland destruction could be addressed, at least in part, by improving surveillance for emergent problems and facilitating increased government scrutiny and corporate accountability. Surveillance could be improved by using satellite imagery and high-resolution drone imagery. To that end, a deal has been brokered with the drone pilots’ association in Trinidad and Tobago to enlist pilots in supporting continuous surveillance of brushfires and assisting with rapid detection and response. This approach may be beneficial in other settings, such as in Africa, Asia, and the Amazon. Hospedales added that public scrutiny of human-caused environmental destruction may also serve as a deterrent to those who may carry out these activities.

Applying Systems Thinking Approaches in Food Systems

Smolinski asked about the forces at play in communities that rely upon seafood and coastal ecosystems. Hospedales replied that the understudied concept of complexity in ecosystems is relevant to this issue. Numerous environmental factors interconnect, with implications that are not widely appreciated. For example, high levels of Sahara dust are transporting aspergillus spores to coral reefs, and sargassum weed has spread to the point of becoming contiguous from West Africa to the Western Atlantic Ocean. These types of large-scale events exemplify interconnected factors that should be studied, said Hospedales. Although researchers may be skilled at reductionist science, they are often less adept at studying how factors are interconnected, he added. Rizzo further elaborated that, similar to the concerning rise of antimicrobial resistance (AMR) among bacterial pathogens, the overuse of fungicides may have effects that can spill over into fungal diseases among humans that can be particularly concerning for those with compromised immune systems. This is yet another example of the interconnections between systems and the need for widespread information sharing and collaboration. McNeil maintained that a systems approach should be applied when considering any food system. In addition to the large-scale interconnected factors, the downstream effects on communities should also be considered, including immediate food security and subsequent health issues and risks.

Integrating One Health with National Security

Smolinski noted that in many countries, much of the national budget is allocated to national defense. He asked about strategies to link the One Health mission to national security, in terms of funding and government buy-in, and opportunities for military branches to partner with One Health programs in activities such as deployment and data sharing. Goldman said that from the food safety perspective, the U.S. Department of Defense (DOD) has been a long-time One Health partner. For example, USDA has a National Advisory Committee on Microbiological Criteria for Foods, and DOD has contributed to the knowledge base on foodborne pathogens since the committee’s inception.⁶ Such efforts contribute to the One Health mission by improving the understanding of connections between foodborne pathogens, exposures, and human illness.

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⁶ The National Advisory Committee on Microbiological Criteria for Foods is currently part of the Food Safety and Inspection Service at the U.S. Department of Agriculture; its executive committee includes liaisons from DOD and other federal agencies. More information can be found at https://www.fsis.usda.gov/policy/advisory-committees/national-advisory-committee-microbiological-criteria-foods-nacmcf (accessed May 30, 2021).

Plant-Based Medicines and One Health

Although not all plant-based medicines have been shown to be effective, much of the world uses these treatments, noted Smolinski. Their use is often culturally determined and is unlikely to be replaced by more expensive drugs. He asked about the role that One Health might play in better understanding the widespread use of these medicines. Acknowledging that he is not a plant-medicine expert, Rizzo noted that traditional medicines extend beyond plants to include fungi, such as mushrooms. Many plants clearly have medicinal properties, as important medicines have been derived from plants for centuries. From the One Health standpoint, the study of plant medicine should be approached with an open mind, he added. Collaboration with anthropologists, sociologists, and practitioners of Western medicine can help encourage stakeholders to maintain an attitude of openness about the effectiveness of traditional medicines.

Karimuribo explained that pastoral communities in Tanzania often value the lives of animals above the lives of humans. In these communities, individuals may accept traditional medicine for their own health needs while seeking commercial veterinary products for their animals. This dynamic creates a unique point of entry in these communities. For example, a mass animal vaccination campaign could be used as an opportunity to address human health awareness issues or conduct short human-health screenings.

Crowdsourcing Event Verification

Smolinski asked how Tanzania’s community-based approach addresses rumors that move though the system and whether the AfyaData system is integrated or collaborating with data systems such as Program for Monitoring Emerging Diseases (ProMED)-mail⁷ or EpiCore.⁸ Karimuribo explained that Tanzania’s system has a module called “AfyaWatch,” which is designed to enlist community members in conducting local-level verification of reported events. Individuals who do so are given a credibility score based on the accuracy of their reports. These scores enable local verifications to link with official verification, reducing the need for ministry officials in the livestock and environmental sectors to verify the events. Furthermore, the Tanzanian systems are being linked with global scanning reports, including ProMED-mail and EpiCore. By integrating local data with global

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⁷ ProMED is a source of information for clinicians and laboratorians, providing timely reporting of pathogens and their vectors. More information is available from https://promedmail.org (accessed March 30, 2021).

⁸ Smolinski explained that EpiCore is a crowd-based epidemiology community that volunteers to verify any signal that comes through automated disease surveillance systems. More information is available at https://endingpandemics.org/projects/epicore (accessed March 30, 2021).

data systems within its data science management module, Tanzania can use advanced analytical approaches and artificial intelligence modeling for prediction and intervention.

Integrating the Private Sector into One Health Approaches

Given the private sector’s role in environmental health, Smolinski asked how it can become more engaged with One Health challenges. Goldman said that foodborne illness is a One Health problem; therefore, it should be addressed by a One Health solution. For example, discerning the contamination of produce involves understanding how land adjacent to agricultural fields is used. This requires collaboration between numerous private parties, including produce growers, farmers, ranchers, and possibly state authorities. McNeil said that the private sector is critical at every stage of One Health. Private-sector actors contribute initial detection efforts in the livestock industry and beyond, as well as in response activities, including logistics and response equipment supply. She said inclusion of private-sector actors in simulation exercises is one way to develop coordination and trust with the private sector. In an assessment conducted in the United States, they found that more engagement with the private sector is needed to build trust, forge partnerships, and bolster preparedness.

Hospedales raised the issue of private-sector cooperation with military actors in the arena of health security. In the Caribbean, hurricane response efforts have necessitated civilian–military cooperation. However, other regions, such as Central America, may have tension between military and civilian systems. In these settings, fostering civilian–military cooperation for epidemic detection and response initiatives can be challenging. In the Caribbean, presidents have mandated that many federal agencies—including public health and security agencies—work together. The European Union has funded simulations to test how these actors can best collaborate in response to various public health emergencies. Hospedales added that in past decades, a network of U.S. military labs in Cairo, Kenya, and Asia had access to veterinary and animal sources. Data from these types of networks could be integrated with environmental data to good effect, he noted.

In closing, Smolinski highlighted the role of natural history collections and other biological collections in One Health systems. These collections have helped solve challenges with emerging pathogens in the past. The Smithsonian Museum of Natural History currently features the Outbreak: Epidemics in a Connected World exhibit, which explores epidemics in an emerging and interconnected world with a One Health lens.⁹ The work

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⁹ More information about the Outbreak: Epidemics in a Connected World exhibit can be found at https://naturalhistory.si.edu/exhibits/outbreak-epidemics-connected-world (accessed April 29, 2021).

involved in creating this exhibit demonstrates the valuable research that comes from the Smithsonian Natural History Collection, said Smolinski. He suggested that improving natural collection infrastructure in the Global South could be of benefit to others.¹⁰

OPPORTUNITIES FOR IMPROVEMENT

John Nkengasong, director at the Africa Centres for Disease Control and Prevention, moderated the second panel discussion. Panelists focused on knowledge and dissemination, interfacing mechanisms, policy issues, and strategies to connect the relevance of One Health to sectors beyond the traditional health sectors (e.g., economies, local industries, other stakeholders). John Balbus, senior advisor for public health at the National Institute of Environmental Health Sciences (NIEHS), discussed how data can be used both to improve global health and advance the One Health approach. Christopher Braden, deputy director at the National Center for Emerging and Zoonotic Infectious Diseases, addressed the modernization of surveillance systems and formalization of collaborative partnerships. Carlos Das Neves, president at the International Wildlife Disease Association, highlighted One Health approaches in low-income countries that can serve as exemplary models for higher-income countries. Cristina Romanelli, program officer of biodiversity, climate change, and health at the World Health Organization (WHO), described opportunities for society to shift toward a fairer, healthier, greener civilization in the wake of the COVID-19 pandemic.

Gaps and Challenges in One Health Approaches

Nkengasong asked panelists to speak about challenges facing the United States and other nations, with a focus on identifying areas that are lagging behind in terms of integration into One Health systems. Balbus considered several areas in which challenges have been created by stove-piping—a process in which data are funneled directly to high-ranking authorities. For example, at the 1992 UN Conference on Environment and Development in Rio de Janeiro, Brazil, two conventions were signed pertaining to the domains of biodiversity and climate change.¹¹ In the decades since, efforts to integrate these domains remain limited. Balbus suggested that this

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¹⁰ McNeil noted that a Project Echo series was conducted entitled “Museums and Emerging Pathogens in the Americas.” More information is available from https://hsc.unm.edu/echo/institute-programs/mepa (accessed March 30, 2021).

¹¹ The two conventions signed were the Convention on Biological Diversity (see https://www.cbd.int/doc/legal/cbd-en.pdf) and the United Nations Framework Convention on Climate Change (see https://unfccc.int/files/essential_background/background_publications_htmlpdf/application/pdf/conveng.pdf) (both accessed July 7, 2021).

insufficient integration is rooted in the signing of separate conventions, as opposed to a joint convention on biodiversity and climate change. Similarly, vertical agendas within the federal government isolate various domains, such as the Global Health Security Agenda¹² and RBM Partnership to End Malaria.¹³ These and other major programs have been initiated to address existing problems, yet environmental health and One Health programs instituted by CDC and other agencies are not often integrated into them. This lack of integration is evidenced by certain executive orders, in which colleagues may call for reviews of the Global Health Security Agenda or mention the impact of climate change, but these concerns are not brought to the fore and the environmental perspective is not fully integrated into the programs. Balbus emphasized that One Health extends beyond pandemics, zoonotic spillover, and animal health. Gaps are evident in oceanic and microbial studies and the One Health–related interconnection of plants, animals, ecosystems, and microbes. These interconnections represent primary mechanisms through which climate change and environmental change will affect the health of all life on Earth.

Braden discussed central issues related to early detection and response and ongoing surveillance challenges. Researchers often struggle to bring together data sources—such as laboratory and epidemiological data—so broadening data collection at the tactical level presents challenges. However, advancements in the conceptualization of data and surveillance are constrained by antiquated systems, he noted. These systems need modernization with updated data architectures and sources, paired with updated technical aspects, such as cloud technology, data pipelines, and integration tools that allow data to be layered in terms of animal, human, and environmental health. New tools are available that may aid in the transition toward more modern data systems. Additionally, better cooperation among agencies would contribute to verifying and investigating reported signals. Conducting investigations within silos can be challenging, and working collaboratively across silos can be even more daunting, but cross-disciplinary approaches are needed at the international, national, state, and local levels, said Braden. For instance, when a domestic foodborne outbreak is detected in the United States, experts in human, environmental, and animal health should collaborate in the investigations.

Das Neves suggested that strengthening One Health systems could begin with developing greater interconnectivity and broadening the focus on health systems to extend to financial, political, and social systems.

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¹² More information about Global Health Security Agenda is available from https://ghsagenda.org (accessed April 30, 2021).

¹³ More information about the RBM Partnership to End Malaria is available from https://endmalaria.org (accessed April 30, 2021).

Countries have been fairly effective at managing AMR and recognizing the need for greater connectivity and transformation in those efforts; however, this recognition has yet to extend to other areas. Politicians, industry, pharmaceutical companies, and other private and public stakeholders from high-income nations have partnered on initiatives in low- and middle-income countries, while efforts in their home countries are less comprehensive. The missing factors in achieving collaboration may include awareness, interaction, interest, funding, and political will. Das Neves noted that Nigeria and Rwanda have national One Health strategic plans, but many higher-income countries do not. Lastly, referencing the Venn diagram often used to represent One Health, he remarked that much attention is given to the overlap of the human, animal, and environmental health circles, but nurturing each of those individual areas often receives inadequate consideration.

Romanelli spoke of the broad, interdisciplinary, global view she has developed through her work on sustainable development, global health policy, biological diversity, and environmental science. She emphasized that a more inclusive and coordinated One Health framework is needed. One Health offers an integrated approach to developing purposeful and coordinated responses to some of the greatest global health, environmental, socioeconomic, and political challenges through the lens of systems thinking. However, it also provides an opportunity for diverse stakeholders to work together across sectors and disciplines to take a preventive role in addressing the root causes of ill health. This approach has the power to tackle interconnected challenges, while also strengthening monitoring, preparedness, and response to future health threats. By building the capacity for prevention, One Health can also help to address the social, environmental, and economic determinants of ill health with equity as a driving force in the context of global environmental change. The COVID-19 pandemic has brought to the fore the interconnectedness between the human, animal, and natural worlds. According to Romanelli, the international community has largely failed to adopt a systems approach to planetary health. While time is limited, progress remains possible. She acknowledged that One Health is not the only interdisciplinary and cross-sectoral approach using a systemic lens—conservation medicine, EcoHealth, and planetary health seek to bring about action in a similar manner. Still, One Health provides a valuable opportunity to governments, the scientific community, the public and private sectors, and local communities to develop robust evidence-based strategies for future action.

Romanelli noted that the COVID-19 pandemic has brought society to a crossroads: decisions about how to rebuild may either perpetuate the damaging economic development patterns and practices of recent decades or bring about progress toward a healthier, fairer, greener civilization. She

highlighted WHO’s efforts toward the latter, including a comprehensive manifesto launched in July 2020 to chart the path toward a healthy, green, and just recovery from the pandemic.¹⁴ The manifesto calls on the international community to prioritize health recovery and center the issues of biodiversity and climate protection to prepare for and reduce vulnerability to future health emergencies. The manifesto sets forth six prescriptions for a healthy, green recovery that span 80 targeted action areas: (1) protecting and conserving nature, which is the source of human health; (2) investing in essential services, from water and sanitation to clean energy in health care facilities; (3) ensuring a quick, healthy energy transition; (4) promoting healthy, sustainable food systems; (5) building healthy, livable cities; and (6) stopping the use of taxpayer money to fund pollution. Romanelli emphasized that the prescription to protect and preserve nature is the starting point of the other five. Recognizing and protecting nature as the source of human health has largely been absent from the One Health narrative, she noted. As part of its commitment to One Health over the past several decades, WHO has identified the need to adopt a broader perspective that expands beyond the full range of infectious and noncommunicable diseases to encompass the ecological and environmental dimensions. Romanelli noted that developing and implementing One Health programs in past decades has inadequately addressed environmental concerns at national and global levels.

Successful One Health Implementation Efforts

Nkengasong asked for examples of successful implementation of the One Health approach. Das Neves highlighted the PREDICT program, as well as similar efforts established by the European Union. Additionally, several African and Southeast Asian nations have built effective systems with little to no pre-existing architecture. The creation of a new system may help motivate stakeholders and encourage collaboration, he added. Although higher-income countries may already have existing functional systems in place that can address specific issues, they are also prone to siloing. Thus, he suggested that the strongest examples of One Health program implementation at present come from countries that have struggled with disease, environmental conditions, economic problems, and insecure food systems. Rwanda exemplifies the One Health progress that can be achieved in countries facing these intersectional challenges. In comparison, developed nations often lag behind due to political or economic factors or the silos long

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¹⁴ More information about the WHO Manifesto for a healthy recovery from COVID-19 is available from https://www.who.int/news-room/feature-stories/detail/who-manifesto-for-a-healthy-recovery-from-covid-19 (accessed March 31, 2021).

established in One Health–related sectors. Stakeholders who have worked in siloed fields for decades may be more resistant to collaborative, cross-sector activities than those in countries with newer systems. Das Neves suggested that nations in Europe and North America should also study the accomplishments of countries in Africa to inform their own efforts.

Balbus posited that a predictor for the success of a One Health system may be its sentinel species. Systems using sentinel animal species, such as chickens in agricultural systems, for early detection and surveillance have incorporated fundamental One Health approaches. When the sentinel species is human—including severe acute respiratory syndrome coronavirus 2 and Ebola—the origins of an outbreak often lie in wild rather than agricultural systems. Balbus described the human interface with wild systems as a frontier for the One Health approach. New sensor and technological solutions that can be deployed remotely and on the ground could expand surveillance into this frontier.

Braden noted that One Health approaches have been most successful in places where animal environments and human health are naturally tied together, even to the point of creating unique silos; these types of scenarios lend themselves to an interdigitated approach. For example, rabies control requires dog vaccination programs. Regardless of the label attached to these efforts, they are inherently One Health approaches. The same is true of food safety and vector-borne diseases because effective vector control requires ecological considerations. He added that AMR is a long-standing area of focus for multiple sectors. In recent years, the availability of new funding streams has fueled progress in addressing this issue, with leaders actively engaged in ensuring that a One Health approach was adopted. However, the U.S. national action plan does not address the environmental component. For instance, commonly used pesticides are often antifungals that are important in human medicine, and aspergillus may be gaining resistance to the antifungals used in agriculture. These examples underscore the value of the types of cross-sectoral observations made possible by the One Health approach, said Braden.

Romanelli acknowledged the successes cited by the panel, but she cautioned that now is not the time for celebration or complacency. Excellent work has been achieved, such as the PREDICT program, but much work remains at the local, national, and global scales. At the global level, the tripartite alliance among WHO, the Food and Agriculture Organization of the United Nations (FAO), and the World Organisation for Animal Health (OIE) has revealed areas of failure and weakness.¹⁵ Established to address the gaps in One Health approaches, this alliance found that the ecological

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¹⁵ More information about the tripartite alliance can be found at https://who.int/foodsafety/areas_work/zoonose/concept-note/en (accessed April 29, 2021).

and environmental dimensions of One Health have largely been ignored, while the human–animal interface has received far greater attention, said Romanelli.

Das Neves added that societal involvement has been valuable in settings where One Health approaches have been successful. Achieving buy-in from veterinarians, doctors, and even politicians is relatively straightforward, but getting buy-in from communities and society can be more challenging, he noted. For example, local businesspeople may need to change their business models, big industry will need to adopt environmental perspectives, and children require education before bad habits are formed. The most successful One Health programs are those that engage all stakeholders with roles to play in One Health solutions, said Das Neves.

Institutionalizing and Formalizing Collaborative Agreements for One Health Approaches

Nkengasong noted that many One Health initiatives have been informal arrangements among committed individuals in separate organizations or departments. He asked how such initiatives can be formalized to foster ongoing collaboration that can be maintained through changes in personnel. In the United States, these initiatives often result from one-on-one relationships, but they need to be institutionalized, said Braden, along with the collaboration and integration they involve. This institutionalization can be challenging, because it requires support from leadership and the creation of charters, cooperative agreements, and memorandums to formalize working relationships. He remarked that no single agreement will adequately establish the needed degree of collaboration, so multiple agreements are often implemented. For example, one formal cooperative relationship was established to facilitate data sharing between FDA, USDA, and CDC. Another formal cooperative relationship aims to promote collaboration in conducting outbreak investigations by establishing standard operating procedures, identifying the roles of each agency, and stating the expectations for outbreak preparedness and response. Other agreements have been created related to the use of molecular data in whole genome sequencing to ensure that all appropriate agencies are involved. In addition to the numerous aspects of cooperation that must be formalized at various levels of the participating institutions, cooperation also needs to be formalized at the international, national, and state or provincial levels, Braden added. The establishment of One Health offices can foster coordination within and among these various groups and levels of organization.

Das Neves suggested leveraging political and financial power to contribute to the success of One Health agendas. In the past, individuals resisting the One Health approach have claimed that it demands a large

investment with an uncertain deliverable. This argument has lost its credibility, said Das Neves. The COVID-19 pandemic has demonstrated that no matter how uncertain the deliverable of a One Health program is, the cost of inaction is far too high to put off investment, Das Neves further remarked. He expressed hope that this lesson will be applied as the pandemic subsides. In addition to international efforts from agencies such as WHO and FAO, organizing action can happen at the domestic level in the areas of education and business. Das Neves called for a coordinated, joint strategy extending beyond the connection of social science, economic sciences, and health science to perform at the local and national levels. This includes educating the private sector on the One Health strategy. Once the pandemic has been stabilized, the focus on One Health may decrease as international actors turn to address other challenges. This prospect highlights the importance of local actions, Das Neves emphasized.

Romanelli highlighted several components she considers to be essential to One Health strategies. Political will and coordinated action are instrumental for engaging all levels of governance, from local to global. At the global level, WHO provides strategic vision and oversight, but the front lines of natural resource management are at the local level. Local leaders, such as spiritual leaders and traditional medicine practitioners, should be actively engaged because they are trusted within their communities. In addition to education, developing a common narrative and vision can connect all sectors across levels of governance. Even with integrated approaches, however, new silos can be created due to the absence of a common narrative and vision, said Romanelli.

Balbus emphasized the importance of political will and leadership. Beyond merely supporting One Health, leaders must articulate its importance to bring about change in practice, Balbus said. He underscored the role of incentives within federal systems. Global health programs tend to have large budgets, which can disincentivize collaboration with other partners if agencies are wary of potentially relinquishing some of their control over overall budgets. Building in financial incentives to encourage collaboration will warrant considering the overall financial structure of systems and the flows of money within and across them. Lastly, he discussed the demonstration of value added by One Health approaches. The public health, medical, and biomedicine industries are data oriented, such that dialogues with these sectors can be framed with data to avoid giving rise to skepticism that can thwart potential collaboration. For instance, stakeholders in these industries may be skeptical of the effectiveness of interventions that focus on wildlife, ecosystems, and land management rather than on drugs or vaccines. Those working to advance the One Health approach can increase its appeal by building metrics and evaluation methods that demonstrate added value, as well as providing examples of

successful One Health efforts. Balbus highlighted the need for more demonstrations of One Health approaches dealing with complex manipulations of the environment and the protection of health, such as urban wildlife interfaces, environmental chemicals and toxins, and the genetic modification of mosquitoes. Romanelli echoed the observation that the public health sector is data oriented, adding that a wealth of data is not being effectively disseminated due to gaps in cross-discipline communication (see Box 4-1). She urged advocates of the One Health approach to leverage this body of evidence in a coordinated way.

Fostering Local Efforts with Global Collaboration

Nkengasong noted that One Health programs are often highly localized in design and implementation. He asked how global policy can preserve the targeted approach while fostering necessary international cooperation. Braden remarked that animal health, human health, and ecological health are local, and interventions that work at the local level should be preserved and developed. However, developing local programs is insufficient:

coordination is still needed at the state, regional, national, and international levels to affect how private-sector businesses operate. Beyond regulation, higher-level partnerships are valuable in engaging with private-sector actors. Although the private sector is ultimately motivated by financial profitability, common ground can often be found among policy makers and the private sector.

Das Neves stated that local relevance is foundational for One Health approaches; however, these cannot be duplicated from one setting to another. A greater degree of interconnection and information sharing would increase the impact of local-level solutions. For example, if one government is conducting effective surveillance in the bat population for emerging diseases, but a neighboring city 10 kilometers away is not performing any, then it reduces the overall effectiveness of bat surveillance efforts in the area. He suggested that a regional approach may be both impactful and feasible, citing the Africa Centres for Disease Control and Prevention (CDC) as an exemplar that was developed to centralize and coordinate activities within the African region. By working transnationally, regional organizations can ensure that individual, local programs are compatible with one another and that data and experiences are shared across local settings.

Romanelli emphasized the importance of connecting local, regional, national, and global efforts. United messaging and the creation of common narratives and shared vision can aid this process. As context is always a factor, solutions will need to be tailored to local settings. Moreover, sharing valuable experiences can benefit others in reaching common goals. She likened this understanding to that of the Sustainable Development Goals. It is widely understood that these will not be implemented at the local level with uniformity, yet they serve as a set of shared goals that all nations are striving to achieve. Romanelli added that working across the spheres of policy making helps to ensure alignment and coherence of policy at all levels.

Balbus pointed out that NIEHS has been building its citizen science and community-engaged research efforts for many years; they may provide helpful models for connecting local and global action.¹⁶ These types of research can support local groups in collecting data, developing research agendas, and creating sustained partnerships. They can also serve as a powerful mechanism for connecting local efforts to broader regional, federal, and international infrastructure and funding. He noted that NIEHS has a collaborating center with WHO and 20 years of experience with sustained partnerships between core centers and community groups. These relationships have had powerful results, reflecting another way in which capacity building and equity can be incorporated into science research and public health work.

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¹⁶ One example that Balbus cited is the Belmont Forum. More information can be found at https://www.belmontforum.org/about/#About (accessed May 30, 2021).

Session Wrap-Up

In closing, Nkengasong invited the panelists to offer a single word that encapsulates the ideas shared during the discussion. Balbus selected “mainstreaming,” noting that this is the combination of integration and coordination. Das Neves chose “commitment.” Romanelli highlighted “collaborative leadership.” Braden stated that “integration and mainstreaming” are integral to the concept of One Health and the progress that needs be achieved at all levels, in all sectors, and across all disciplines.