BY TOMEKA FRIESON
Breaking news flashes across your phone screen. A new drug-resistant superbug, with symptoms such as fever, extreme fatigue, diarrhea, and searing muscle pain, has taken hold in a small Ethiopian town. So far, only one individual has died, but scientists are working as fast as they can to respond to the sudden and unidentified outbreak. This news is quite concerning, but given your location in the US, you refrain from preoccupying yourself with the details of the case. A month later, breaking news flashes across your phone that this infectious bacteria has managed to spread throughout all of Ethiopia. While scientists are beginning to identify the cause as a pathogen that individuals acquire through constant travel from South Asian to African countries, 200 individuals have died within the month, and hundreds of planes have taken flight from Ethiopia to all regions of the world. The pathogen is on the loose. Within the next month, cases of this drug-resistant superbug have been identified in France, India, Cuba, and now even the US. Death tolls are rising at a frightening rate, and still no solution has been made to combat the contagiousness of—or even the symptoms associated with—this virus. More and more individuals are scared to leave their houses, news outlets are panicking, and governments the world-around are scrambling to find an answer to this epidemic.
Such can be the pathway of an infectious disease, and such is the target of global health security.
The summer of 2018 is expected to come with its plethora of health challenges. Drug-resistant strains of bacteria are becoming more prominent and powerful, a major complacency has set in regarding the AIDS epidemic, and concrete policy regarding reproductive health rights and services remains unestablished.1 What’s more, in recent years, global health challenges have run rampant: 2003 saw the severe acute respiratory syndrome (SARS) virus, costing countries a collective 30 billion dollars in economic output in four months; 2009, the H1N1 flu pandemic, killing 284,000 individuals in its first year; 2014, the largest Ebola outbreak in history, infecting over 28,000 people and killing over 11,000; and 2015, a sudden outbreak of the Zika virus, leading to 61 US deaths.2,3,4 Because of the current trajectory of global health issues, it remains uncertain as to whether future outbreaks can truly be prevented.
According to the US Centers for Disease Control and Prevention, global health security is defined as the preparedness of a country to detect and respond to disease threats, whose prevalence is not only measured by the emanation and propagation of new microbes, but also rising drug resistance; the ability of laboratories to induce and release dangerous microbes, whether intentionally or not; and increased globalization of both travel and commerce.5 On February 13, 2014, then, countries of all regions and economic statuses gathered in Washington, D.C., with the intention of launching the Global Health Security Agenda in order to unite on an issue that is not only relevant in terms of international diplomacy, but also national policy, territorial wellbeing, and personal health.3 While not widely debated amongst intellectuals throughout the ages, this issue, if not soon addressed in a widespread and international manner, could pose serious repercussions for future societies and public health infrastructure. As a result of the national preoccupations of some countries with the notion of an immense infectious disease threat that could effectively eradicate an entire nation, the five-year Global Health Security Agenda (GHSA) was established and signed by over sixty countries with the common goal of limiting the spread of infectious disease outbreaks, optimizing human wellbeing and minimizing loss of life, and reducing the economic burden placed upon countries by sudden outbreaks.3,6
In order to achieve these goals, numerous GHSA-member countries have created roadmaps by which they plan to address the specific issue of global health security in their respective nations. Moreover, every country may choose to specialize in addressing one of the three objectives of global health security: prevention, detection, and response. The prevention component contains four subcategories: antimicrobial resistance, zoonotic disease, biosafety and biosecurity, and immunization. The detection component contains an additional four subcategories: national laboratory system, real-time surveillance, reporting, and workforce development. Further, the final objective, response, contains three subcategories: emergency operations centers, the multisectoral rapid response of law to public health, and medical countermeasures. Regardless of addressing specific facets of the overall objectives of global health security, though, every country must still track their progress over time in effectively reaching and surpassing these goals, the measure of which will be the central subject of this investigative piece.7
Global health security is a major biological, political, and social issue that can have serious ramifications in the long-run for any and all parties involved. For one, in our incessantly and continuously globalizing world, travel and trade between and within various countries is constant. We are all connected in this way, yet it is in this same way that the threat of disease is most prominent. With constant travel comes constant contact with others, and with constant contact with others comes consistent exposure to microbes that, if acquired at the opportune place and time, could give rise to an epidemic. This is why global health security is invaluable. Without any specific measures to ensure protection from threats of infectious disease, all countries are vulnerable to the onset of epidemics. Moreover, with unanticipated epidemics come unanticipated financial burdens, arising from healthcare costs, as well as debilitation of the workforce due to sickness.3 Yet, with proper procedures in place, countries can be prepared to respond more actively to any perceived threat of infection. In a study assessing the degree of compliance to the 2005 International Health Regulations issued by the World Health Organization, researchers found that seventy percent of countries failed to comply with guidelines, consequently rendering any method to effectively address the regulation of international health nonexistent.3,8 This lack of an international map of clear gaps to address global health administration and security, combined with different countries’ prioritizations of global health security in their national political agendas, elucidates a stark disparity in international health that could, if unaddressed, proliferate into an outbreak of epidemic proportions.3 In fact, Dr. Jordan W. Tappero, senior advisor to the Centers for Disease Control and Prevention’s Center for Global Health insisted that “in less than 36 hours, an outbreak that begins in a remote village can reach major cities on any continent and become a global crisis.”2 The purpose of this article, therefore, is to examine the progress made by three disparate countries in achieving the goals established in the 2014 Global Health Security Agenda, as well as similar and distinct measures each country is taking to ensure global health security. More specifically, progress of countries in achieving goals of the GHSA will be analyzed with regards to infectious disease, defined by the World Health Organization as any disease spread directly or indirectly from person to person due to the presence of a virus, parasite, bacteria, or fungi.9
In order to best compare the progress made by varying countries in regions around the world, three countries—Ethiopia, Bangladesh, and the United States—were chosen as the countries of investigation and assessment. Using these three countries of differing geographic locations, economic standings, and degrees of progress to achieving their GHSA goals, a diversity of country profiles can be examined. Further, the definitions for economic divisions for each country were defined by the World Bank and describe low-income countries as those with a gross national income (GNI) per capita of $1,005 or less in 2016; middle-income countries as those with a GNI per capita between $1,006 and $12,235; and high-income countries as those with a GNI per capita of $12,236 or more.10
Firstly, Ethiopia, defined as a low-income country, has taken great leaps to achieve its GHSA goals, but still has much work to be done in order to most effectively prevent the initiation and dissemination of an infectious disease.10 With a population of 102.3 million individuals and a fertility rate of 4.5, Ethiopia is a country with many citizens but few financial resources. It is for this reason that tuberculosis, although decreasing in prevalence, still remains the fourth leading cause of Ethiopian deaths and has risen to the third leading cause of premature deaths.11 In terms of Ethiopia’s capacity for addressing its healthcare needs, Ethiopia’s government performed a Joint External Evaluation (JEE) that assessed the strengths and weaknesses of the country’s Public Health Emergency Management (PHEM) system, which was drastically tested during the 2014 Ebola epidemic. Primary findings of this assessment included the need to take action on multisectorial engagement, increased surveillance of the spread of human and animal diseases, and increased laboratory resources. More specifically, the fundamental obstacles necessary to overcome in order for Ethiopia to further advance in its achievement of the GHSA outcomes are the augmented incorporation and cooperation of the various organizations that influence the health security of humans, animals, and food, in order to encourage collaboration on systematic policy; the necessity for greater disease surveillance to more clearly track when and to where diseases within Ethiopia are spreading; and ensuring ample laboratory resources and technicians.12
Like Ethiopia, the government of Bangladesh, a middle-income country of 161.9 million residents and a fertility rate of 1.9, has identified areas that both promote and inhibit GHSA goal progress.13 Some of the main obstacles identified by the JEE, however, were those of a lack of coordination both among and within Bangladeshi ministries, a segregation of the ways by which various JEE factors are addressed, and a lack of documentation as a vector to record Bangladesh’s plans to better global health security.14 While very adequately and efficiently improving the country’s global health security measures, clarity and cooperation of various organizations’ roles, as well as the creation of palpable documentation, would greatly augment Bangladesh’s global health security preparedness.
In addition, the United States, with a population of 322.9 million individuals and a fertility rate of 1.9, is not only a major contributor to the GHSA, but is also the driving force behind its world-wide implementation, initiating partnerships with 31 countries and the Caribbean territories; working collaboratively with 17 nations to produce 5-year roadmaps to assess milestones, gaps, and next steps in achieving GHSA aims; and providing one billion dollars in assistance to the fortification of global health security in low-income countries.15,16,17 While found by the JEE to be very steadily and effectively implementing strategies to address GHSA progress in general, advances can still be made in the collaboration practiced among the federal and state governments in addressing global health security issues, as well as augmenting the quantity of biosafety regulations and well-trained technicians in the laboratory.18
Regardless of the socioeconomic statuses of these three countries, common ground in progressing with the GHSA goals can still be identified. One similarity among these three countries, for instance, is the need for greater cooperation amongst various health and health security sectors, organizations, and/or governmental entities. This recurrent necessity among various countries not only elucidates a core gap in addressing security measures, but also points towards a fundamental way by which global health security can be augmented. Lack of cohesiveness and collaboration within and amongst the organizations addressing the GHSA aims leads to unfulfilled objectives and, if taking place within multiple countries, the stagnation of GHSA progress.
How, then, in societies where every organization is focused on achieving its own goals, can a strategy for global health security prevention be implemented that not only actively involves various organizational sectors, but also effectively and periodically assesses progress toward GHSA goals? In other words, how can we as a global society unite under the banner of global health security to ensure a more globally health-secure world?
The solution to this conundrum seems to rely heavily on national efforts, and the issue for many countries—especially all three of the countries assessed within this investigation—is not an outright lack of effort in addressing GHSA aims, but a lack of institutional cohesiveness that leads to objectives being ineffectively achieved due to too few organizations addressing everything that needs to be done or too many organizations addressing the same sub-aspects of the aims and neglecting to address other equally important goals. The solution to this issue, then, seems to be the presence of a centralized regulator of progress. Such an entity could be, as in the United States’ case with its Office of Global Affairs, a governmental entity that delineates the roles of various sectors in addressing public health issues. However, it is important to note that the lack of cohesiveness exhibited does not necessarily have to be attributed to an outright absence of cooperation. Rather, as is the case with Bangladesh, lack of documentation to evidence the division of tasks or resources could serve just as equally as a barrier to the success of future inter- and intraorganizational collaboration. If health security institutions stand together nationally, however, the positive ramifications will be felt internationally. Because the success of the Global Health Security Agenda is so highly dependent on the success of its moving parts—the countries at hand—a widespread and collective augmentation of cooperation on territorial and national levels could drastically affect the big picture. In the case of the Global Health Security Agenda, the whole is greater than the sum of its parts, so addressing a common and recurrent theme such as lack of organizational collaboration within these smaller parts can only change the GHSA for the better.
In addition to this similarity in the work needed to be done to better address the GHSA aims of various countries, differences of objectives also exist that emphasize the fundamental disparaging factors of each country. The United States’ issue, for instance, lies not in its ability to access resources or technology to augment laboratorial work, but rather how and the extent to which Americans regulate laboratory work. The laboratorial creation of biological microbes, whether intentionally or not, is considered a significant part of what encompasses a global health security threat. When a country, then, has the potential to create biological weapons and, in the past, has done so, an international body of regulators needs to carefully scrutinize the microbe engineering initiatives of that country. To best address this obstacle, a review of the United States’ inventory of potentially hazardous chemicals may be necessary. In doing this, the government and scientists may better understand how varying chemicals, in concert, could produce harmful effects. Combined with the possible distribution of an informational memorandum on the dangers of microbe creation, the US may more effectively limit this threat and increase global health security. In the case of Ethiopia, however, the issue at hand is much more fundamental. In order to accurately gauge the progress of global health security measures, it is essential to establish a robust bio-surveillance network to gauge the current spread of infectious disease within a country, an action that Ethiopia lacks. This lack of disease tracking could be due to a variety of factors, be they too many people migrating to too many places within the country to accurately record data; too few human, financial, or other resources to afford the recording of data; or simply lack of governmental cooperation to organize the recording of data. As a consequence, differing solutions could be proposed. Ethiopia, for instance, could institute disease data recorders within each city to record the presence and spread of infection at various times. While this could be an ideal response to the lack of disease tracking, a key hindrance may be the lack of human resources necessary to carry out this action. Without adequate resources, disease tracking may be particularly difficult to implement, no matter the cause.
Given these obstacles to the attainment of GHSA goals, then, what factors would help a country reach maximum effectiveness in achieving its aims?
As the US Centers for Disease Control and Prevention points out, the implementation and observation of global health security measures relies heavily on four facets: a well-trained public health workforce, an effective way by which disease dissemination within a country can be measured, the utilization of quality tools and technicians in laboratory settings, as well as an efficient emergency preparedness system to address the possibility of any sudden and unexpected outbreak.19 As a consequence of simply augmenting every country’s capacity to most effectively and efficiently achieve these four aspects of global health security, global leaders could immediately ensure a more health-secure world for future generations. However, the steps necessary to bring various countries to this level vary from one to another. While countries such as the US have practically already achieved these four aspects and could solely manage to improve internally in terms of the specifics of the varying facets, countries such as Bangladesh lack the documentation to put their spoken action into policy and establish a concrete basis for future development. However, some countries like Ethiopia lack fundamental resources to even address the problems at hand, let alone increase or reallocate resources to account for an augmentation in these four aspects. For cases such as these, it may be necessary to establish a global health security fund from which countries could borrow to aid in the more immediate implementation of the GHSA outcomes to achieve the 5-year agenda within the designated time frame. The goal is to stop an outbreak at its source. However, this goal can scarcely be achieved without the cooperation of health, defense, animal, agriculture, and developmental sectors within and among various societies.16
Although the history of global health is a long and complex one, the recent emergence of global health security as a primary issue to address in the coming years exhibits our commitment as a global society to addressing current roadblocks that may inhibit future prosperity. The core theme of global health security is interconnectedness. Without this, any efforts a country makes internally to address global health may not be beneficial to the whole. Moreover, though, without interconnectivity, policies such as that of the GHSA—comprehensive, collaborative, and clairvoyant plans of action to address global health threats within the coming years—may not have been possible. If we as a global community desire to address and prevent the onset of future and possibly fatal epidemics, we must take the current necessary steps in order to do so. Be they prevention, treatment, or response, related to bio-surveillance, biochemistry, or biogeography, one threat truly can have implications the world-around, and assessing how countries are beginning to crack the code of ways to achieve global health security provides invaluable insight into ways in which we can collectively work to ensure a more health-secure world.
Tomeka Frieson is a first-year in Berkeley College with the prospective major of the History of Science, Medicine, and Public Health. She can be contacted at firstname.lastname@example.org.
- Nathe, M. (2017). Seven Global Health Issues to Watch in 2017. Humanosphere. Retrieved from http://www.humanosphere.org/global-health/2017/01/7-global-health-issues-to-watch-in-2017/.
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- Joint External Evaluation of IHR Core Capacities of the Federal Democratic Republic of Ethiopia: Mission Report: March 2016. (2016). [PDF]. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/254276/1/WHO-HSE-GCR-2016.24-eng.pdf?ua=1.
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- Joint External Evaluation of IHR Core Capacities of the People’s Republic of Bangladesh: Mission Report: May 2016. (2016). [PDF]. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/254275/1/WHO-HSE-GCR-2016.23-eng.pdf?ua=1.
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