"New Realities for Global Health Security"
Chaired by His Excellency Bertie Ahern
15-16 February 2016
Last year in Wales at the InterAction Council’s 32nd Annual Plenary Meeting, the Council addressed the threat of global pandemics. Diseases do not respect national borders: health security is a global concern that affects all people and all nations. Last year, the Council recommended that states must be better prepared for sudden disease outbreaks, that disease surveillance be increased, health systems strengthened, and responses improved through multilateral cooperation and adequate funding for the World Health Organisation (WHO).
Global health is a question involving security, foreign policy, economic, and development challenges. In short, global health security is a global public good requiring collective action. Continuing its commitment to seek multilateral solutions to imminent global issues the InterAction Council convened a High-Level Expert Group Meeting focusing on “New Realities for Global Health Security” chaired by Mr. Bertie Ahern at the Celtic Manor in Newport, Wales from 15-16 February 2016.
Challenges relating to Global Health Security
There are fifty emerging diseases all over the world, largely related to increased contact between humans and nature. The UN High-Level Panel on the Global Response to Health Crises noted in its recent report following the outbreak of Ebola that “future epidemics could far exceed the scale and devastation of the West Africa Ebola outbreak and the emergence of a highly pathogenic influenza virus, which could rapidly result in millions of deaths and cause major social, economic and political disruption, is not an unlikely scenario."
The probability of such outbreaks is increased by the effects of climate change (for example, affecting the distribution of mosquitoes responsible for the spread of the Zika virus); population increases; changes in food systems; and evolving land use. Increased travel can result in rapid spread of diseases. This occurred with SARS, which infected 8,096 individuals, killed 774 and cost the global economy an estimated US$40 billion in 2002-2003.
The UN High-Level Panel noted further that: "the high risk of major health crises is widely underestimated…and the world’s preparedness and capacity to respond is woefully insufficient." The response to each outbreak differs, but any response relies on a functioning health system, absent in the Ebola affected West African states and thus requiring an international response to bring the epidemic under control. The response also relies on each country implementing the International Health Regulations (IHR), an international treaty binding upon its states parties. Recent pandemics have shown that the IHR have not been fully implemented in many states. Low- and middle-income (LMI) states are lagging behind. In part, the reticence to the IHR is due to states not fully understanding the IHR, not having the capacities to implement them or not finding the benefit in their implementation. There is also a belief amongst some that the IHR are primarily a device to protect high-income states from low- and middle-income states. This is a belief reinforced by many high-income states imposing travel restrictions during the Ebola outbreak in contravention of the IHRs whilst at the same time calling for the implementation of the IHRs by low- and middle-income states. There is thus a need to raise understanding for the importance for all countries to implement and to comply with the IHRs, and to connect implementation with incentives and the broader development agenda. Their full implementation is fundamentally a question about foreign policy, financial policy and ensuring public goods. Heads of state and government must understand the importance of the IHR and actors such as the World Bank should be supportive of IHR implementation.
The recent report “The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises” by the Academy of Medicine’s Commission on a Global Health Risk Framework for the Future assessed the financial requirements for improved health security.
It assesses that there could be US$60 billion per annum in expected losses from pandemics. Against this figure the Commission proposes an investment of US$4.5 billion per annum to include US$3.4 billion to upgrade national preparedness funds at the WHO and the World Bank. This is less than one dollar per person if compared to the world population.
The threat from infectious disease is further exacerbated by antimicrobial resistance; now identified in the UK and the US as a strategic risk to national security, with (if not successfully addressed) an estimated 10 million excess deaths by 2050 and costing the global economy US$100 trillion. In the UK, the Chief Medical Officer has described antimicrobial resistance as a “big of a risk as terrorism.” The risk arises from the overuse of antibiotics by humans and in farming. It can return civilization to the pre-antibiotic era when minor infections led to amputation or death, and will make hazardous now common operations such as joint replacements. This will affect everybody regardless of where they live, their health, economic circumstances, and lifestyle behaviours. It will affect sectors beyond human health, such as animal health, agriculture, food security, and economic development. Antimicrobial resistance is a danger of the utmost urgency and requires immediate global action by fully engaged governments, in particular by ministers responsible for agriculture and food. There are proposals to put antimicrobial resistance on the agenda of the UN General Assembly and even suggestions to work on a framework convention on antimicrobial resistance.
In January 2016, The Lancet reported on a 25-year study on the global burden of disease: revealing the large number of deaths due to preventable risks. An earlier study published in 1990 had found that malnutrition, unsafe water, and lack of proper sanitation were leading health risks. Today, these are on the verge of being replaced by dietary risks and high blood pressure leading to non-communicable diseases, such as diabetes and heart-disease, which account for nearly 70 per cent of global deaths and 86 per cent of premature deaths in developing countries. Non-communicable diseases have immense financial implications in developing countries. Most of these diseases are not attributable to genetic predisposition, but are rather triggered by the environment. Many of these diseases are attributed to behaviour or other clear risk factors such as the over consumption of alcohol, the use of tobacco, and lifestyle choices such as inactivity and poor diet. There are excellent examples in addressing these behavioural issues through fiscal means, for example by imposing sugar or alcohol taxes. For poor people consuming poor diets may not even be a choice, but a result of what is available to them in food stores and attainable to them financially. Foods high in fat, salt and sugar are cheaper than fresh fruits and vegetables. Perhaps this could be addressed with trade arrangements favouring fresh produce over processed food products.
Industrialisation, exposure to hazardous chemicals, and climate change significantly impact global health. Currently, air pollution kills around 7 million people annually (household air pollution kills around 4.3 million and outdoor air pollution kills 3.7 million, with overlaps), leaving women and children most exposed. The environmental effects on human health are most likely underestimated. Indeed, global environmental changes including climate change, biodiversity loss, and freshwater depletion threaten to reverse the gains in health that have occurred over recent decades.
Underpinning both defence against pandemic infectious diseases and the fight against the increase in non-communicable diseases is an effective health system. Global health security can only be addressed through a long-term commitment to strengthen health systems (including universal health coverage and public health as well as personal and collective health security) rather than designing disease-specific solutions case by case. For real impact on the ground, a broad approach is required. The Commonwealth Secretariat has addressed this by adopting a more comprehensive approach to building and strengthening health systems and building universal healthcare. It focuses on building holistic health systems under the umbrella of knowledge, advocacy, capacity, and governance. Importantly, the Commonwealth approach addresses health services: protection, disease prevention, and health promotion. New work by the WHO equally links health security to universal health coverage. This approach needs to include addressing the shortage of healthcare workers - for example Sierra Leone, which was the most badly affected by Ebola, has only 0.1 doctors per 10,000 persons compared to 24 doctors per 10,000 persons in the US. The solution must include training increased numbers of healthcare workers, policies to encourage them to remain in their own countries and 'task shifting' – letting lesser qualified workers undertake, with appropriate training, tasks previously reserved to more highly qualified workers.
Health is key in the global Sustainable Development Goals (SDG), an unprecedented and ambitious agenda addressing the way all dimensions of life on this planet shape human life. The SDGs differ from the Millennium Development Goals in that the SDGs do not rely on aid, but rather require all states to take concrete measures towards achieving sustainable development. Goal three is to provide “Good Health and Well-Being” for populations. The SDGs are interrelated and interdependent and in addition to goal three many other SDGs have direct or indirect impact on global health: poverty, climate change, access to water, responsible production and consumption, and gender equality.
Health and Conflict
The Ebola outbreak in West Africa occurred in post-conflict states and highlights the need to address health systems during peace processes. However, it also highlights the need to maintain some form of a health system during conflict situations. Healthcare facilities, workers and patients have increasingly become targets for attacks. In the last few months, hospitals run by, for example, Médécins Sans Frontiéres in Yemen, Afghanistan and Syria have been attacked. Deliberate attacks on health facilities represent a flagrant violation of international humanitarian law (IHL). In accordance with IHL all those taking part in the fighting are obliged to protect medical facilities and personnel at all times. Means must be found to reinstate and uphold respect for these rules and enhance protection from accidental, deliberate or negligent attack, identify who is responsible for such attacks, and take action as required by IHL. This is reflected also in the UN Secretary General’s report to the forthcoming Humanitarian Summit. Its Core Responsibility 2 states that "even wars have limits: leaders must recommit to upholding the rules that protect humanity."
Governance for Health
Global health governance is about how to use the world’s assets more fairly and effectively to improve people’s lives. Governance for health implies the impact on health of governance decisions across other sectors: social, economic, environmental, commerce, trade, finance advertising, culture, migration, and communication. Finding, and agreeing on, coherent policy across sectors and societies is one of the most prominent challenges for global health. This requires engagement with actors across the spectre of the international community as well as on national and local levels. The problems at hand cannot be left to health departments alone. They must be supported by heads of state and government.
At the opening of the UN General Assembly last September, UN Secretary General Ban Ki-moon asked, “Why is it easier to find the money to destroy people and planet than it is to protect them?” The current level of investment in countering the threats to human lives is inadequate. The challenges presented above are all plagued by a lack of sufficient willpower to place these issues in the heart of political agendas, to fund them adequately, and to hold non-compliant states accountable. These were identified as “gaps”: a political gap, a financial gap, a gap in accountability, and a gap in response and implementation. The scientific community has had to conform to political realities as even a presentation of solid, scientific evidence does not necessarily lead to policy change. The InterAction Council is well posited to make recommendations on how to address these gaps and how to frame these questions in order to bring global health to the forefront of the international political agenda. For example, the InterAction Council should make recommendations to the G7 meeting in Japan, where global health security will be on the agenda and recommend Germany to include this to the agenda of the G20 meetings in 2017.
In Wales, there is an excellent example of addressing global health on a national and regional level based on a sustainable development principle. The Well-being of Future Generations Act in Wales was passed by the Welsh National Assembly in April 2015. It aims to improve the social, economic, environmental and cultural well being of Wales. Its seven goals include a prosperous, resilient, healthier, more equal and globally responsible Wales of cohesive communities and vibrant culture. It requires public bodies mentioned in the Act to prevent problems ahead and engage in long-term planning. The Wales plan is an early example of how the SDGs will be implemented and how to measure a nation’s progress. The plan was welcomed by, for example, the UN stating that “what Wales is doing today we hope the world will be doing tomorrow.” Using the Welsh project as an example, the IAC could consider how to promote the idea and make it a viable option in other regions, countries and communities. Good global health begins at home – and this type of governance for global health can be critical to ensure the health of populations.
The InterAction Council has already worked on human security, and noted last year that individual health security is inextricably linked to collective health security. It was suggested that global health is in fact connected to a broader perspective: that of planetary health, which is defined as “the health of human civilisation and the state of natural systems on which it depends.” It’s a concept that integrates human health and environmental sustainability. To truly address all threats to global health, states and other actors must therefore address it as a question involving not only the health of people but also the state of the planet.
The High-level Expert Group meeting recommended that the InterAction Council consider the following recommendations:
1. Investing in Pandemic Preparedness
- States must invest in preparedness for pandemics and global health emergencies for their own benefit and the benefit of all.
- States must build stronger national health systems, infrastructure, and processes built to a common standard set and regularly assessed, as envisaged by the IHR.
- The WHO should establish a dedicated Centre for Health Emergency Preparedness and Response coordinated with the rest of the UN system, the World Bank and the IMF.
- The reticence to implement the IHR must be addressed through multilateral dialogue and by emphasising the objectives of the IHR, which is global preparedness to cope with health emergencies for all countries.
- Adequate and accelerated funding of research and development in the field of infectious disease prevention and response.
2. Support the recommendation of the National Academy of Medicine that the World Bank and other donors should make support contingent on a country’s participation in an independent assessment of the IHR process.
3. The IMF should also include pandemic preparedness in its economic and policy assessments in its country evaluations.
4. Health systems strengthening will require technical support from WHO and financial support and leadership from the World Bank and other donors to secure support for low and middle income countries and sustaining health system capabilities and infrastructure in fragile and failed states and in war zones to the extent possible.
5. In war zones, the InterAction Council calls on all parties to the conflict to fully respect IHL and refrain from operations near or the targeting of hospitals and schools; and promote the development of technical means to help protect health facilities, and, if attacked, identify the perpetrator.
6. Recognize the impact of conflicts, failed states and displacement on global health and recommend the WHO to revisit its “Health as a Bridge to Peace” initiative.
7. Support the call by the WHO for a meeting with Heads of State on antimicrobial resistance at the UN General Assembly in September 2016.
8. Call on Germany to include global health on the agenda of the G20 meeting in 2017.
9. Welcome the Sustainable Development Goals and call on states to take appropriate measures to work toward the realisation of the SDGs with a cross-sectoral approach.
10. Call on states to integrate the SDGs with the wider concept of planetary health as called for in the “Rockefeller Foundation-Lancet Commission on planetary health and on safeguarding human health in the Anthropocene epoch.”
11. Engage with communities to consider adopting similar national, regional and local approaches as the Well-being of Future Generations Act in Wales.
12. States should address governance of and for health:
- Drawing from the Commonwealth Secretariat toolkit to strengthen health systems in a comprehensive manner, including through implementing universal healthcare
- Governance for health requires support to the ministries of health by other governmental sectors, such as trade, finance, and development.
13. Support current leaders in developing learning networks to share experience and knowhow.