Successive epidemics of international concern such as SARS, Ebola, Zika have raised the focus on responses to health emergencies, as ‘global health security’. It has also given new attention to the implementation of the International Health Regulations (IHR), including as an agenda item in the World Health Organisation’s 2016 World Health Assembly.
The IHR were adopted globally by member states in the WHO in 2005, including by all 46 countries in its Africa region. They seek to prevent, protect against, control and provide a public health response to the international spread of diseases “…in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” Countries were required by June 2012 to have developed core public health capacities for surveillance, reporting on and response to public health risks and emergencies, including at ports of entry. This includes capacities to provide specialized staff, multi-sectoral teams and laboratories and local investigations to prepare for, prevent and rapidly contain and control cross border public health risks that may be due to infectious diseases, food safety, and to chemical, radiation and zoonotic hazards. Countries unable to meet these core capacities by June 2012 could request for an extension to 2014 and in exceptional circumstances to June 2016. So we are now a month away from the time all countries were expected to have achieved these core capacities.
These capacities are not delinked from the core capacities needed to protect public health within countries, nor from comprehensive primary health care approaches that seek to engage all sectors to promote health and prevent ill health. Within countries, these capacities are not just a matter for the health sector. They call for society, state, private sector and non-state organizations to promote public health. For example, preventing communities living near mines from being poisoned by arsenic or mercury contamination of water, soil, and food calls for intervention from local authorities, planners, mine managers, state sectors responsible for infrastructure, mining, environment, health and labour, workers and communities. This includes workers and families who migrate from other countries to work on mines and who may otherwise return with long term lung, gastrointestinal, neurological or renal problems. While focusing on cross border risks, the presence of uncontrolled environmental risks, or of cholera, typhoid and other epidemics within African countries is not unimportant for the IHR, and certainly not for people in that country. These problems signal weaknesses in public health that may lead to risks spilling across borders. They may also arise from trade or economic determinants that are international in scope.
Hence, as we approach June 2016, while there has been progress in implementing the IHR, it is a matter of concern that there are still deficits in the core capacities. An October 2015 WHO report compiled feedback from 118 of 196 States Parties to the IHR on a self-assessment questionnaire on progress made in developing these core capacities. It showed that progress had been made globally in legislation and policy; coordination and collaboration with other sectors; improved detection, early warning, preparedness and emergency response capacities and in communication with the public and to stakeholders.
For the African region, reporting by March 2015 showed that African countries were also making progress on a number of core capacities. Not surprisingly given the responses and investments after the Ebola epidemic, the most notable improvements were in surveillance and laboratory capacities. Improvements in these areas are seen to be essential for early warning system for detection of any public health events for rapid response and control, to prevent them spilling over borders. There has been investment in surveillance and laboratory capacities in Africa through an Integrated Disease Surveillance Response, and international support for African and sub-regional communicable disease control centers for detection and early warning of infectious disease risks. There has, however, been less progress in preparedness, in capacities at ports of entry, and in capacities to deal with chemical and food safety risks. It suggests that while the region may be better prepared to deal with infectious disease epidemics, this may not be the case for other public health risks.
The progress suggests that the global health security agenda has given great focus to control of infectious diseases and ‘biosecurity’, not least as a response to the international spread of recent epidemics of Ebola virus and Zika virus. Significant new global resources are being mobilised for emergency responses. Assessment tools and reporting systems are being discussed in the WHO, with some proposals for new global mechanisms, global financing facilities and independent assessment by global actors.
However global health security cannot be reduced to emergency responses and infectious disease control, nor can the prevention of cross border disease be delinked from the measures taken from local to national level within countries and between countries in their regions to strengthen the primary health care and public health functioning of health systems. Uganda was able to respond to its 2000 Ebola epidemic within two weeks from first case to confirmation and controls being implemented. This speed of response was as much to do with the strength of systems within districts and the strength of communication between local and national levels of the health systems as the sophistication of its laboratory capacities. The spread of cholera and typhoid epidemics in Africa draws more from inadequate investment in safe water, sanitation and waste management systems and weak public health inspection than from gaps in emergency preparedness. New viral epidemics are emerging as poor communities and animal vectors are being squeezed into closer proximity by mono-cropping and mining activities; and new emergencies such as rising antimicrobial resistance are deeply embedded in how health systems function and interact with the public and with the pharmaceutical industry. Rising levels of chronic conditions in many African countries that foretell a future crisis of escalating unaffordable costs for countries and households are contributed to by cross border trade in harmful processes and products.
The global health security agenda cannot thus be narrowed to one of emergency responses to infectious disease. Instead, global health security also needs to identify and act on the determinants to prevent such emergencies. The IHR as an overarching umbrella for international public health obligations recognises this. So too, in their intent, do the Sustainable Development Goals. While many determinants of global health security lie outside the health sector, and while resources are indeed needed to deal with emergencies and their economic and social impacts, a health sector response to preventing and controlling emergencies needs to link with and support longer term health systems strengthening. This starts locally, within countries and particularly with the comprehensive primary health care and public health approaches that are needed to identify, prevent and manage risk before it grows into an emergency.
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