Global Health Risk Framework Governance for Global Health: Workshop Summary (2016) / Chapter Skim
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3 Lessons from Past Outbreaks
3 Lessons from Past Outbreaks
Pages 17-42
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From page 17... ...
• Bidirectional communication at the international, national, and community levels is critical during a health emergency response, and efforts should be made to better engage affected communities and nations to ensure ownership of a response. (Chan, Elias, Liu, Phumaphi, Stocking, Tomori)
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From page 18... ...
b Public health emergency of international concern. In this chapter, various lessons emerging from past global outbreaks of infectious disease are explored through multiple perspectives, from severe acute respiratory syndrome (SARS)
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From page 19... ...
The vision for the revised IHR was "a world on the alert and able to detect and collectively respond to international infectious disease threats within 24 hours, using the most up-to-date means of global communication and collaboration," Heymann said. These revisions were intended to establish a climate in which infectious disease outbreak reporting, while not enforced, was expected and respected.
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From page 20... ...
in 2003. NOTE: AFRO = WHO Regional Office for Africa; AMRO = WHO Regional Office for the Americas; EMRO = WHO Regional Office for the Eastern Mediterranean; EURO = WHO Regional Office for Europe; GPHIN = Global Public Health Intelligence Network; NGO = nongovernmental organization; ProMED = Program for Monitoring Emerging Diseases; SEARO = WHO South-East Asia Regional Office; WHO = World Health Organization; WPRO = WHO Regional Office for the Western Pacific; WR = WHO representative.
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From page 21... ...
FIGURE 3-2 Progression of SARS through reported surveillance events and WHO policy decisions from November 2002 through March 2003. NOTE: GOARN = Global Outbreak Alert and Response Network; GPHIN = Global Public Health Intelligence Network; ProMED = Program for Monitoring Emerging Diseases; SARS = severe acute respiratory syndrome; WHO = World Health Organization.
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From page 22... ...
The resulting 2005 revision of the IHR moved the focus of the regulations from controlling infectious diseases at borders to detecting and containing diseases at their sources by strengthening core capacity and, as Heymann observed, "from passive to proactive, using real-time global surveillance evidence, and from three diseases to all public health threats." Briefly, the IHR 2005 addressed the following objectives: • Strengthening national capacities. Unfortunately, Heymann noted, because national capacities are self-assessed, many countries have missed multiple deadlines and are now asking for extensions until 2016.
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From page 23... ...
that determines when outbreak intervention should occur and which national core capacities need to be strengthened; and • Broad-based, global advocacy for health security. We should be concerned with strengthening those three areas now, rather than worrying about what happens when health emergencies occur, he argued; discussions of global governance for health risks should focus on prevention.
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From page 24... ...
However, the report did identify several areas in which the IHR 2005 had proved successful in 2009: • Strengthened cooperation, communication, and technical support through national focal points; • Increased country capacity for addressing pandemics, including surveillance, risk assessment, and response; • Streamlined decision making; • Attention given to economic and social interests; and • Strong public health rationale and solid scientific information pro vided to justify health measures that affected international trade. In addition to the previously noted failure of many member states to fulfill their capacity obligations under the IHR 2005, another major shortcoming revealed by the 2009 H1N1 pandemic was the absence of any means to enforce the regulations, as Fidler, Heymann, and others had acknowledged.
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From page 25... ...
, the organization was forced to rely on "volunteerism from within," repositioning essential staff to emergency posts, which is not sustainable. Lastly -- as was even more prominent in the West African Ebola epidemic -- separation of authority and autonomy between WHO's regional offices and its headquarters weakened the organization's ability to exert "command and control" during the crisis response, Fineberg observed.
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From page 26... ...
, Liu particularly urged preparation for future Ebola outbreaks in the following areas: • Surveillance, recognizing the potential for widespread infection; • A pool of experienced health care workers; • Vaccines and treatments for Ebola; and • Rapid international response, including an international center of operation. Weaknesses of the Response Liu attached particular significance to two shortcomings of the response to Ebola in West Africa, namely communication with the community in terms of content.
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From page 27... ...
At conferences, meetings, and workshops such as this one, discussion directed toward the technical and political means of responding to infectious disease threats tends to neglect the needs of the affected populations, Liu observed. She warned that the equation of sickness and security could contribute to a climate of fear that impedes action in a health crisis where it is most needed, and called for political will to minimize the gap between sounding the alarm and an effective response.
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From page 28... ...
The panel's recommendations on responding to major disease outbreaks include support for a "unified WHO Centre for Emergency Preparedness and Response," as proposed by the separate Ebola Interim Assessment Panel (discussed later in this chapter) , but with the additional proviso that it be semiautonomous, Piot reported.
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Responding to Major Disease Outbreaks 3. reate a unified WHO Centre for Emergency Preparedness and Re C sponse with clear responsibility, adequate capacity, and strong lines of accountability.
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The panel's fifth recommendation, to "institutionalize accountability through an independent commission for disease outbreak prevention and response," was inspired by the extraordinary lack of accountability associated with the response to the Ebola crisis, as well as to past health emergencies, Piot said. Rather than having ad hoc committees review what went wrong after every crisis response, there should be a systematic assessment by representatives of civil society and independent experts, as well as of governments, he advised.
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From page 31... ...
Now that the Ebola crisis has generated new momentum for change, we must use it, he urged, "to improve what has to be improved, and to keep going what can be kept going." UN High-Level Panel on Global Response to Health Crises Joy Phumaphi of the African Leaders Malaria Alliance described work to date by this separate multinational panel,5 which is chaired by the president of Tanzania, Jakaya Mrisho Kikwete. Their objective is to prepare a report, with recommendations, to advise the UN Secretary-General on ways to strengthen national and international systems to prevent, respond to, and recover from health crises.
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From page 32... ...
Their considerations include community health security, engagement, and ownership; the participation of traditional leaders and community health workers and their training, care, and maintenance; the fostering of trust in the system and those responsible for it; and the implications of surveillance at the community level. Phumaphi reflected on observations by Chan and others that leadership at the country level should come from the top, from the head of state or the prime minister's office, and also about the benefits and risks of command-and-control approaches to health governance.
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From page 33... ...
Commenting on these points, Stocking stated that the United Nations, through its General Assembly and Security Council, is the obvious agency to coordinate high-level understanding and monitoring of the state of global health security. The involvement of the UN Security Council was crucial to controlling the West African Ebola epidemic and should be extended, she said, and the report advised that an annual global health security report be prepared for the WHA, perhaps by an independent body that could also examine WHO's progress toward increased health emergency response capacity.
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From page 34... ...
Moreover, she added, member states must build true emergency preparation in the form of core capacity, by partnering with other agencies, the private sector, and with NGOs. Responding to Charles Clift's concern that WHO may not be up to the task of coordinating the global response to health emergencies, Stocking remarked that WHO's primary role is the safeguarding of public health globally.
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From page 35... ...
Stocking argued that, while core capacities matter for surveillance in developing countries, the effectiveness of the outbreak response in these settings depends on the fundamental level of development, especially at the community level. ORGANIZATION AND COORDINATION OF GLOBAL HEALTH ACTORS Multiple areas of discussion arose in response to the information presented through examination of past outbreaks and various lessons that emerged.
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From page 36... ...
Rather than "reinvent the wheel" of global health architecture, he argued for rethinking global action mechanisms to include nonstate actors. Referring to Liu's presentation, López-Acuña characterized the West African Ebola crisis as "a history of late awakenings" involving both GOARN and the humanitarian response system of international global security.
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From page 37... ...
It also may be more effective." He noted that the effective but informally governed Global Polio Eradication Initiative7 simply meets once per week by telephone to plan next steps -- an example that convinced him to change his stance, held since 1996, that the IHR represented "the most important tool for the world." Addressing the Ebola Interim Assessment Panel's recommendation for a WHO-developed "prioritized and costed plan to develop IHR core capacities for all countries," López-Acuña noted that this issue should 7 See http://www.polioeradication.org (accessed April 18, 2016)
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From page 38... ...
Larry Gostin of Georgetown University remarked that Heymann had made a compelling case for creating a "nimble, flexible" workforce for response to infectious disease outbreaks and other health emergencies. Gostin wondered what role GOARN might play in this scenario, and how GOARN could be made more effective with sustainable funding, to which Heymann responded that increasing staff at WHO would not achieve this.
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From page 39... ...
Raising Political Will Keizo Takemi of Tokai University reinforced Liu's message that political will drives the global response to health crises. He noted that, prior to its action on the West African Ebola crisis, the UN Security Council had accepted two resolutions pertaining to HIV/AIDS (which has claimed far more lives than Ebola)
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From page 40... ...
Acknowledging the proliferation of such nonstate actors "with good intention, but very limited capacity and knowhow," Liu suggested a response model based on the International Federation of the Red Cross: a trained pool of people, who could be called on in an emergency and organized through a larger command-and-control structure. Eduardo Gotuzzo of Universidad Peruaña Cayetano Heredia noted that civil society organizations can provide vital help in responding to national health emergencies -- including infectious diseases with potential for international transmission -- but that countries need to coordinate those efforts.
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From page 41... ...
If any organization can overcome barriers to information sharing between states, nonstate actors, and industry, it is WHO, Chan insisted. In the case of polio, she noted, "I twisted a few arms, and we managed to get all the information we need." Informal governance means "helping countries to understand the value they can bring to global health and not insulting them in public" -- and by engaging government leaders without "naming, blaming, and shaming" them, she explained.
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