On June 19th I had the opportunity to participate in a panel at the Global Livestock CRSP End of Program Conference entitled “Risk at the Noxious Nexus: Livestock, Wildlife, People, Disease, and Development.” Dr. Pete Coppolillo of the Wildlife Conservation Society’s Yellowstone Rockies program moderated the panel, which included Dr. Rudovick Kazwala of the Sokoine University of Agriculture, Tanzania, Dr. George Aning, of the University of Ghana, Legon, and myself. As moderator, Pete prepared a conceptual diagram for the talk, based on the four pillars of zoonotic disease control and management: Mandate, Means, Motivation, and Knowledge (MMMK). Quite an acronym. I was asked to talk a little bit about knowledge and some conceptual linkages in zoonotic disease control and management, and in the preparations, put the following notes together. I thought I’d share them here. Note: A Podcast from the panel will be posted on the GL-CRSP website, as soon as I have the time to edit it.
Introductory Remarks. Watching Dr. Kazwala’s slide show really brought an interesting image to mind. I’m sure you’ve found that the past has a way of resurfacing and becoming relevant in new and very different ways as you age. When I was a kid, I was really into old movies. In particular Westerns. I’ll always remember this one scene from a film set in a dusty rural outpost probably near the Badlands in the Dakotas, where a rough looking guy is on a plank board table in a dimly lit room in a clapboard house, held down by another guy with a beard looking quite like Michael Jacobs [Principal Investigator of the Afghan PEACE project for the GL-CRSP with trademark Montana 19th century beard] in a Civil War uniform. He’s swigging a big gulp of whiskey from a dingy bottle when another guy, a medic or a doctor comes to the table with a tough looking saw. They’re going to amputate his leg, and right when the doctor is about to start sawing, the guy on the table looks up and sees this picture on the wall. It’s an anatomically correct poster of a horse, and you see his face get this worried look as he asks the question:
“What kind of doctor are you anyway?”
The doctor looks down at the floor and under his breath replies:
Last fall I was in the field with the HALI project visiting some Maasai households out in the bush near a wildlife management area, also a dusty badlands looking place, watching the HALI team interact with pastoralists. Often, I saw HALI vets and animal technicians interacting with household members, treating broken limbs, answering questions about respiratory issues and stomach problems, and essentially playing the role of the medic in the Western: a multi-faceted medical resource for rural areas. I didn’t witness any amputations, but I was impressed at both the trust and appreciation for the medical attention paid to the HALI team, and also the extreme realization for the challenges of providing medical prevention and treatment options out there. Especially in areas where the health of livestock and households are so intrinsically linked and connected.
I’m not a veterinarian, nor will I pretend to be an expert on zoonotic disease. In fact, I can look around the room today and see quite a few individuals with considerably more experience and knowledge in this area, notably David Bunn and Grace Marquis. I even used one of Graces’ old observational public health studies from Peru as a model for a component of my current study. I’m simply honored to be a participant in this panel, especially in the company of Drs. Kazwala and Aning.
What I can speak about and comment upon, however, is the complexity of zoonotic disease, the complexities in understanding and grappling with the challenges facing zoonotic disease control and management, and the severe difficulties in designing and implementing research targeting zoonotic disease and education.
Swine flu and vaccines. You know in Star Trek they seem to have these vaccinations for everything in the galaxy, yet space is still considered this dirty disease ridden place, kind of like an airport. Yet when they visit a new alien planet they get a shot and are immune to everything. It’s too bad things can’t be as simple as on TV. Not to discount the idea of the vaccine, but I think all too often it’s considered a silver bullet, and frankly earth is not the Enterprise. Zoonotic disease really catapulted on the scene again this spring with swine flu, and I found it interesting to observe the reactions of the global media. In fact, I kind of always find it interesting to watch the reactions of the global media to what I’ll call “real” news, news that is exciting and fear really sells, just look at box office numbers for horribly written and produced horror films. With swine flu there was of course such a frenzy. Maybe because the pump is so primed thanks to Avain Flu, and other really exciting epidemics like Ebola and SARS, I think we are as a society really afraid of zoontoic disease, perhaps because we can’t see it, and don’t’ understand it, like a monster under the bed as a child. It’s tough to fight something you can’t see and hardly understand. And I think this is truly the challenge in working with zoonoses in the development context. Not that we in developing countries understand it, but we don’t have to, because we as a public have these institutions and individuals who are trained to protect us, along with a government that ensures just that through funding and policies that treat health as a public good, at least when it comes to epidemics. I think it’s widely considered now that Mexico did a tremendous job with swine flu response and control, and suffered the consequences. Culling thousands of animals suspected as infected at huge cost to the government and pork industry. While potentially not as rapid as some would have liked, their response seems to have come in good time considering the infrastructural challenges at hand. Yet they intervened for both the national and global good, and will struggle with the stigma of having contaminated pork for probably years to come, and who knows what the impacts on livelihoods and human capital will be in the infected area.
This is just one of the complexities to the knowledge, management and control of zoonotic disease: transparency. After watching the “global pandemic” the Grim Reaper on the cover of the Economist, the studies on the cost of intervention at that magnitude. I began to wonder that if there was no global media, would the Mexican government have responded as quickly? If there was no limelight, no TV, how many would have died and could it have been another Spanish flu with Mexican pork continuing to be exported to global markets?
Things seem to keep coming back to the issue of power, and as Abdi Jama mentioned after the LINKS/LEWS team presentation, getting the information into the hands and channels that inform the public, that let the public own that knowledge is critical to control, to management, and to public health in general. Publicizing the disease, the threat, is integral. Ownership of the knowledge is really a crucial factor.
Importance of Communication. Listening to a lot of the talks over the past few days I couldn’t help but notice some similarities in solving development problems. The listening and establishment of relationships and trust that leads to the understanding of the problems and definition of a problem model, and then the collaborations on training and capacity building that then enables the research, education and intervention efforts on a wide scale seems pretty standard for a lot of our successful projects: ENAM, PARIMA, AFS, and LEWS/LINKS to name a few. Underlying this success, as Layne Coppock and a few others pointed out, is the time to initiate this process. Time that groups like the can CRSP provide. With zoonotic disease, this time element, the time that can enable the various sectoral collaborators to develop a working relationship to tackle the legal and policy challenges, along with the field-based capacity strengthening and development of appropriate diagnostic tools is especially critical. One thing I’ve learned from HALI is how difficult it can be for a team of veterinarians to shake things up and get things moving along; both in terms of funding and understanding. Communication and marketing I think are critical here, to gather the attention and really spread the message that there is a new and evolving role for veterinary science in development, away from increasing production, to a greater role in overall human health and development. Like Michael and Catherine were talking about in Afghanistan, there is a great demand for trained professionals in the discipline, and the more integrated and multi-disciplined training that can be provided, the more impact may be obtained, for overall ecosystem health by combining outreach with education, information, and communication campaigns. Yesterday during the group discussions, I thought the two modeling groups made a very excellent point: often it is the way ideas and information are packaged that truly impacts the way that information is used, or used at all. The One Health campaign I think has been invaluable in this regard. It has been especially difficult for the HALI team leaders to collaborate with medical professionals, and their relationships with the various government groups, especially Tanzanian National Parks were also a challenge. But I think it is promising that veterinarians are taking the lead here, and I hope that the project has laid the groundwork as one type of model with promise for zoonotic disease management at the landscape level.
Complexities: What is emergence? What are the threats? Pete has talked a bit about the changing nature of zoonotic disease in an era of rapid globalization and increasing physical linkages across landscapes. And I think it’s important to note that often these changes brought about by modernization create opportunities not just for new emerging diseases, but also for the resurrection of older diseases, historically not recognized as a threat. One of the pathogens we’re investigating with the HALI project is Cryptosporidium, a protozoal pathogen that is a major cause of morbidity and mortality in livestock and sometimes fatal in human cases as well. Cryptosporidium has been around the block you could say, and has always impacted rural areas and areas where animals and humans share water sources and are in close proximity, but the infrastructural changes of urbanization, and piped water resources have really allowed it to flourish in remarkable ways. The outbreak in Milwaukee US is an excellent example, where Crypto infiltrated the piped water network and caused a mass of infections, actually killing and hospitalizing scores of individuals, especially the immunosuppressed. The point I suppose is that this idea of surveillance is especially difficult given the multiple transmission pathways, and sometimes at even the animal level. There has been a lot of discussion about the potential to use the animal as sentinel, that if one can maintain an outbreak at the animal level, then the risk of transmission to humans can be surmounted. But the challenge of both identifying and then containing this zoonosis, especially in rural areas that already suffer from a deficit of veterinary and medical services is really just enormous. The HALI project has been sampling adult livestock for Crypto, along with water supplies in the Ruaha ecosystem, and while identifying it in water, did not have much success in finding the pathogen in livestock. But then we started sampling the neonatal livestock, well over 25% of the calf herds were infected with Crypto, and over 60% of the calf herds with Giardia. So surveillance must be targeted at just the right level to be effective, both within and across species, in livestock and in wildlife, and as Pete mentioned, the challenges of disease surveillance in wildlife are especially daunting.
Interventions and Rabies. I had the opportunity to work in Tanzania with the District Veterinary office and the WCS on a rabies education event in one of the villages near the WMA. We walked around the village prior to the start of the event, with the district veterinary officer, and it was pretty apparent there was very little activity between that office and the village, either for livestock or for the intended purpose, rabies vaccinations. At the end of the day, everyone seemed very excited about the rabies event. They all in this case, seemed very informed as well. And it was clear that education was not the missing link but simply the lack of resources to do vaccinations of village dogs. This resource constraint is compounded with the lack of capacity to deliver the vaccine in terms of trained human resources, something the veterinary officer readily admitted. Yet this is an issue that is fairly easily surmounted, by the injection of monetary resources and human energy, something that Dr. Kazwala and the HALI team intend to do this September.
Knowledge: What are the conceptual linkages? Do we know what the challenges are? I’m not sure we will ever fully know what challenges are in the realm of zoonotic disease. The tricky thing in zoonoses is that it also involves the category of emerging diseases, diseases that may not be truly recognized or understood by science, by the health communities, and that may place society and communities, including the global community in a very vulnerable state. I would also like to emphasize again the heavy burden born by the rural and urban poor who are usually at the front lines of the emerging disease threat especially in areas of land use change and intensifying use of limited resources. I think a prime example here is HIV, another disease that impacted the rural areas for who knows how long before turning up in Los Angeles and across the US. No one was prepared for HIV, it simply occurred, became endemic, and we are still reeling from the challenge that it instills in society, and in our communities, not just I the developing world, but also in the US, where there will always be considerable work to maintain the social structures behavioral practices that minimize infection and transmission. But knowledge advancements are integral to the process of controlling and managing those zoonotic diseases that are both neglected and emerging, and the development of integrated systems, like those presented by Dr. Kazwala, those that coordinate between animal and human health sectors, are essential in protecting against the ill consequences of zoonotic disease over time. I just think there must be strong emphasis, perhaps a boots on the ground approach, with trained community health workers and paravets working at the village level and continually reporting back to district offices with greater communication capacity. LEWS/LINKS concept of an early warning system for disease could be a really effective tool here, especially to facilitate the information exchange from household to national levels, where intervention decisions can be made. But again, with interventions, there needs to be resources to compensate producers for animals lost and to encourage reporting without fear of negative consequences.
Do we know what we are managing for? What is this “for”? Is it management that limits zoonotic disease transmission? Is it management to protect against global pandemics? Is it management that is truly integrated to tackle the issues of neglected zoonotic diseases? I think an interesting feature of the past couple of days has been this insistence on community and grass roots level focus in development. I have heard several presenters talk about how their projects decided to focus at this level because they really did not have the capability to engage and interact for impact at higher levels. Perhaps this is an issue with funding, with the position of outside researchers and power relationships in developing countries, and with what I would consider the limitations of research to enact higher-level policy change in the short term. It really is no different with zoonotic disease. Frankly, there is considerable and rapid progress that can be achieved with limited resources at the village and community levels, and at the district level, and perhaps the Economic Rates of Return (ERRs) here are much greater for a project, especially a CRSP project than at other levels. And managing zoonoses, despite the complexities, can achieve results in the short term, across multiple levels. I think we need only look to David Bunn and the Avian Flu School for evidence of success here.
But back to the question of “Do we know what we are managing for?” Yes, I think we do. The problem is that we need to manage for different things at different levels. We need to manage for animal health at the individual animal and herd levels. We need to manage for human health at the individual and household level. And to achieve health, we need to manage for a host of other considerations, related to infrastructure, water quality, water quantity, and resource management, education, and capacity building (and now I sound like a grant proposal) but I think in the past several days, lots of us have sounded like proposals.
Revisiting Conflict: Battling Evolution. I’m still struggling with the complexities of zoonotic disease, and conceptually, these complexities I think will only expand the more we learn about the interactions and dynamics. My study for example looked at one species, and within it, found that there are very different dynamics in terms of infection. As microbes continue to evolve, to adapt to human methods of control, the challenge will continue. It is not the type of battle that is won, but rather like was noted during the conflict presentations, a battle that is imperative to fight despite the potential futility, and knowing the enemy is critical. In this case we may actually be battling evolution. I didn’t really intend to frame this as a war. I think we all realize that wars are rarely successful, instead, they tend to release a series of unpredictable and unintended consequences that actually make prevention and control more difficult and compromise the original goals and objectives. Just look at the War on Drugs. Perhaps a race is a better analogy. A race against evolution.
Question for the panel: Surveillance. One of the questions that I’ve been struggling with in relation to zoonotic disease and development is the issue of “control” and surveillance. There is a lot of focus on surveillance, and maybe to buck the trend, though I’m not moderator, I’d like to ask the panel a question myself: What good is surveillance in areas where there is minimal capacity to respond and act? I guess what I’m getting at is, if there are resources invested in surveillance in areas where an outbreak occurs, [and that outbreak is donor dependent, and donor intervention seems driven in zoonotic disease by fear, the fear of an outbreak spreading beyond the poor to developed countries] and there is no capacity to respond, then why invest in surveillance? Could these resources be better allocated to other things to improve livelihoods and to work at interrelated issues that enhance and accentuate the risk factors of disease transmission? Issues like water quality and sanitation? Issues like those brought up in the conflict panel, which quite frankly resonated as a panel about power and power struggles between haves and have-nots?
Questions from the audience. If it’s OK, I’d like to hear some responses from the audience on what they think about zoonotic disease, and what are the important ways to address the challenges. I’m particularly interested in what the donor community is thinking. Again, zoonoses are nothing new. They just seem to be increasingly popular as Pete said in this new era of climate change, globalization and media frenzy.
Note: Jimmy Smith of the World Bank asked a pertinent question during the panel: Should zoonotic disease surveillance, control and managment efforts be focused on “hot spots,” geographic areas featuring a series of risk factors ripe for the emergence of new zoonoses? Or should efforts be more “impact” oriented, targeting areas where these zoonoses occur? [The map at the top of the post is a map of these very hot spots, identified in a recent paper in Nature]. The World Bank has invested considerable resoures focusing on a “hot spot” oriented approach to date. After conisderable discussion, it was generally agreed that the so-called impact areas also areas of “hot spot” potential, and so the “hot spot” approach is a much more cost effective and efficient method for prevention and response.