HEALTH SECURITY Badr ZERHDOUD IHEID Executive Course on Global Health Diplomacy Course Manager and Research Assistant Health security Structure of the workshop I) Introduction to the concept health security – Definition – The health security components: the identified threats – Health security: health and national security or human security? II) The instrument in support of health security: the 2005 International Health Regulations III) The Copenhagen consensus (exercice) IV) The case-study Health security « It refers to the activities both proactive and reactive to minimize vulnerability to acute public health events that endanger the collective health of national populations. Global public health security widens this definition to include acute public health events that endanger collective health of populations living across geographical regions and international boundaries. It also covers a wide range of complex and daunting issues, from the international stage to the individual household, including the health consequences of human behaviour, weather-related events and infectious diseases, natural catastrophes and manmade disasters ». 2007 World Health Report Health security components: the threats Human causes of health insecurity • • • • • • Inadequate investment Unexpected policy shifts Consequences to conflicts Microbial evolution Food-borne diseases Bioterrorism Weather-related events and infectious diseases Major epidemics • SARS • Iinfluenza Other public health emergencies • Chemical and radioactive events Human causes of health insecurity (1) Inadequate investment Reduced vigilance, inadequate surveillance and a relaxing adherence to preventive programmes provoked the emergence or re-mergence of: • HIV/AIDS • Dengue (1.2 million cases were reported by WHO in 1998 from 56 countries) • Malaria This phenomena exists mainly in developing nations, with notably in connection with the adjustment policies supervised by the Bretton Woods in the 80’s and 90’s. Human causes of health insecurity (2) • Unexpected policy shift: the case of polio in Northern Nigeria Some unsubstantiated claims on the safetiness of oral polio vaccines (risk of sterilization of young people) in Northern Nigeria led 2 local governments to suspend the polio immunization. The terrifying result is the: • Large outbreak of polio in the North Nigeria causing the paralysis of thousands children • Reinfection of the south of the country • Spread of the outbreak to polio-free countries (Afghanistan, Egypt, India, Niger, Pakistan, Somalia) • The cost is about US $450 million Human causes of health insecurity (3) Conflicts The collateral effects of the conflicts from health dimension are as follows: • The weakening of health systems • Reduced capacities in detecting, preventing and responding to infectious diseases Example: the outbreak of cholera in Democratic Republic of Congo in 1994 In July 1994, between 500 000 and 800 000 people crossed the boarder to escape from the Rwandese genocide and arrived at Goma (Congo). During the first month after their arrival, more than 50 000 refugees died. The spread of transmission was highly related to the contamination with Vibrio cholera of the only avaibale source of water resource, Lake Kivu. Human causes of health insecurity (4) Microbial evolution and antibiotic resistance The continuing and increasing resistance to anti-infective drugs do represent a major threat to health security and is a major factor in the emergence and re-emergence of infectious diseases. Human causes of health insecurity (5) Food-borne diseases Although the safety of food has dramatically improved overall, progress is uneven and food-borne outbreaks remain common in many countries. In addition, some new food-borne diseases have emerged and create considerable concern, such as the recognition of the new variant of Creutzfeldt-Jakob disease associated with bovine spongiform encephalopathy. Human causes of health insecurity (6) Bioterrorism According to the CDC, a bioterrosism attack is the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants. . Kofi Annan, the Former U.N Secretary-General defined it as a major concern 2004 when he indicated that “we need to pay much closer attention to biological security to build an effective global defence against bioterrorism and overwhelming natural outbreaks of deadly infectious disease”. Bioterrorism cases Anthrax: By 2001, a total of 22 persons are thought to have been infected: 11 each with cutaneous and inhalation anthrax. The five patients who died were all infected with inhalation anthrax. The offensive prompted a profound rethinking of threats to national and international security. It showed the potential of bioterrorism to cause not just death and disability, but social and economic disruption on an enormous scale both in the United States and internationally. Smallpox: Such a threat is therefore not new. “Could it not be contrived to send the smallpox among those disaffected tribes of Indians “. Sir Jeremy Amherst, British Commander-in-chief in the American colonies in July 1763, reported about the smallpox-infested blankets distributed to the Shawnee and Delaware people Weather-related events and infectious diseases (The Rift Valley fever case) Climate conditions combined to environmental, epidemiolgical and socioeconomic factors contribute to expose populations to more infectious disease. The Rift Valley fever is particularly relevant. The El Nino phenomenon is by a higher rainfall increasing the breeding sites of mosquitoes, in connection with non-vaccinated cattle which transmit the virus from animals to humans. From December to March 1998, a large oubreak of Rift Valley fever occured in Kenya, Somalia and Tanzania Number of cases: 89000 478 unexpected deaths Consequences:increase of blindness, meningo-encephalitis… Major epidemics SARS: It represents the first severe disease of the 21st century with its features of a public health threat: “it spreads from person to person, requires no vector, displays no particular geographical affinity, incubates silently for more than a week, mimics the symptoms of many other diseases, takes its heaviest toll on hospital staff, and kills around 10% of those infected”. Scientists believe that SARS virus first cropped in the Guangdong province, an agriculture area of 80 million inhabitants where local farmers practise traditional farming methods and live in close contact with chicken, ducks, fish and pigs, and which are shown to spread the disease to humans. After China, Vietnam, Singapore, and Canada were affected by the disease. Major epidemics (SARS) According to the World Health Report, the total economic cost of SARS in Asia was US $20 billion in gross national product for 2003 or a more dramatic US $60 billion of gross expenditure and business losses. Thus, SARS is probably the best illustration that pathogens will call for a strengthened global cooperation in order to stop its spreading Major epidemics (Influenza) « Coming on the heels of the SARS outbreak, the prospect of an influenza pandemic sparked immediate alarm around the world and with good reason. Far more contagious, spread by coughing and sneezing and transmitted during an incubation period too short to allow for contact tracing and isolation, pandemic influenza would extend the devastating consequences that had been seen with SARS in Asia and Canada to every corner of the world within a matter of months ». – WHO 2007 World Health Report Other public health emergencies Chemical and radioactive events: some selected major chemical incidents 1976-Seveso (Italy): chemical plant explosion caused by dioxin (226000 people were evacuated) 1984-Bhopal (India):chemical plant leak (methyl-inocyanate) causing more than 2800 deaths, 20000 injured 2001-Toulouse (France): factory explosion (ammonium-nitrate) causing 30 deaths and more than 2500 injured 2006-Abidjan (Côte d’Ivoire):toxic waste (hydrogen, sulphide, sodium hydroxide) causing more than 100000 injured and 10 deaths Health and national security National security was seen as the state’s ability to defend itself against external threats and describes the philosophy of international security predominance based on the rise of State-Nations. Today, globalization as a process of interaction and integration among the people, companies and governments of different nations, driven by international trade and investment and aided by information technology, is disrupting such a conceptual frame. Health and national security The national security approach will now rely on: Health of the population as an issue from a strategic perspective Health in war Infectious diseases (SARS, HIV/AIDS, tuberculosis) The Bioterrorism threat Human Health (1) This conception is people-centered rather that the security state-based. Its main focus is to protect individuals through their well-being and respond to ordinary people's needs in dealing with sources of threats. Human Security v. National Security? Human Development Report: the 1994 Human Development Report of the U.N.D.P is a major contribution for the recognition of human security as a crucial concept. This publication asserted that human security relies on the freedom from hunger and the freedom from want, which involves intrinsically the absence of hunger, illness, war and violence. As it suggested, increasing human security would imply a certain number of actions such as “investing in human development, engaging policy makers to address the emerging peace dividend, giving the United Nations a clear mandate to promote and sustain development, enlarging the concept of development cooperation so that it includes all flows, not just aid, agreeing that 20 percent of national budgets and 20 percent of foreign aid be used for human development, and establishing an Economic Security Council. Conclusion The two components of health security described here are very important insofar as they are the keys of interpretation of global health challenges. Need for a reconciliation of the two since all health-related challenges need a global cooperation of different actors, governments of course but in close connection with organizations, NGOs and alliances. Most of those challenges are intrinsically linked to poverty and health for development is a precious tool to address it. 2005 International Health Regulations « The world has changed dramatically since 1951, when WHO issued its first set of legally binding regulations aimed at preventing the international spread of disease. At that time, the disease situation was relatively stable.Concern focused on only six “quarantinable” diseases: cholera, plague, relapsing fever, smallpox, typhus and yellow fever. New diseases were rare, and miracle drugs had revolutionized the care of many well-known infections. People travelled internationally by ship, and news travelled by telegram ». Margaret CHAN, WHO Director General, A safer future, WHO 2007 World Health Report Few basic data elements It is estimated that 2.1 billion airline passengers travelled in 2006 . An outbreak or epidemic in one part of the world is only a few hours. Infectious diseases can not only spread faster, they appear to be emerging more quickly than ever before. Since the 1970s, new diseases have been identified at the unprecedented rate of one or more per year. There are now at least 40 diseases that were unknown a generation ago. More than 1100 epidemic event were verified by WHO the last five years Need for an efficient instrument to combat infectious diseases The revision of the IHR was adopted by the World Health Assembly in May 2005, and came into force on 15th of June 2007. It includes all diseases and health events that may constitute a public health emergency of international concern. 194 States parties to the IHR revised Philosophy of the instrument: To have the necessary global framework to prevent, detect, assess and provide a coordinated response to events that may constitute a public health emergency of international concern (Article 2 IHR). The Regulations now cover public health emergency of international concern whatever their origin or source (Article 1.1), including: (1) naturally occurring infectious diseases, whether of known or unknown etiological origin; (2) the potential international spread of noncommunicable diseases caused by chemical or radiological agents in products moving in international commerce; and (3) suspected intentional or accidental releases of biological, chemical, or radiological substances. - IHR The seven areas of work for IHR (2005) implementation: 1. Foster global partnerships 2. Strengthen national disease prevention, surveillance, control and response systems 3. Strengthen public health security in travel and transport 4. Strengthen WHO global alert and response systems 5. Strengthen the management of specific risks 6. Sustain rights, obligations and procedures 7. Conduct studies and monitor progress IHR 1) Foster global partnerships: Partnership is required between all countries to share technical skills and resources, to support capacity strengthening at all levels, to support each other in times of crisis. Partnership between different sectors (e.g. health, agriculture, travel, trade, education, defence) is also essential to build coherent alert and response systems which cover all public health threats, and, at the time of events, are able to rapidly mobilize the required resources in a flexible and responsive way. IHR 2) Strengthening national disease prevention By strengthening national public health systems, specifically in the area of disease surveillance and response, countries can detect, assess, and respond to public health threats in a timely manner and prevent international spread. IHR 3) Strengthening public health security in health and travel The control of diseases at border crossings remains a fundamental element of the Regulations. A number of IHR (2005) requirements apply to designated airports, ports and ground crossings. They entail close collaboration with other UN organizations (see list) IHR implementation List of international organizations involved in the implementation of the IHR: :: International Atomic Energy Agency :: International Air Transport Association :: International Civil Aviation Organization :: International Labour Organization :: International Maritime Organization :: International Shipping Federation :: Food and Agriculture Organization of the United Nations :: World Organisation for Animal Health (OIE) IHR 4) Strengthen WHO global alert and response systems: Effective global systems for alert and response are critical to provide global risk assessment, support countries that request assistance, mobilize international resources and coordinate international response. Such systems monitor global public health threats, assess risks, and complement national alert and response systems. IHR 5) Strengthen the management of specific risks It includes control programmes for: The improvement of international control efforts to contain, eliminate, or eradicate epidemic-prone diseases the reduction of the public health risks associated with chemical, toxic and environmentally induced events. IHR 6) Sustain rights, obligations and procedures: It is essential that all relevant national and WHO staff be fully aware of, and understand, the new rights, obligations and procedures laid out in the Regulations. In addition, a number of legal bodies and procedures (e.g. National IHR Focal Points, WHO IHR contact points, international roster of experts, emergency and review committees) must be identified and/or set up and maintained. IHR 7) Conduct studies and monitor progress: Monitoring and evaluating the implementation of the IHR is essential to its success. This will allow proposals for its improvement. Legal basis for adopting IHR Constitution of WHO Article 21 “The Health Assembly shall have authority to adopt regulations concerning: (a) sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease (…); Article 22 “Regulations adopted pursuant to Article 21 shall come into force for all Members after due notice has been given of their adoption by the Health Assembly except for such Members as may notify the DirectorGeneral of rejection or reservations within the period stated in the notice”. Main content (1) Subsidiary role of WHO for other Public Health Emergencies of International concern Article 2 Purpose and scope The purpose and scope of these Regulations are to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. Main content (2) Article 4 Responsible authorities Article 5 Surveillance Article 6 Notification Article 10 Verification Article 12 Determination of a public health emergency of international concern Article 13 Public health response PART III – RECOMMENDATIONS Main content (3) PART V – PUBLIC HEALTH MEASURES PART IX – THE IHR ROSTER OF EXPERTS, THE EMERGENCY COMMITTEE AND THE REVIEW COMMITTEE ANNEX 1 : A. CORE CAPACITY REQUIREMENTS FOR SURVEILLANCE AND RESPONSE ANNEX 2: DECISION INSTRUMENT FOR THE ASSESSMENT AND NOTIFICATION OF EVENTS THAT MAY CONSTITUTE A PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN GOARN The Global Outbreak Alert and Reponse Network (GOARN) is a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. It helps: combating the international spread of outbreaks ensuring that appropriate technical assistance reaches affected states rapidly contributing to long-term epidemic preparedness and capacity building. Partners: scientific institutions in Member States, medical and surveillance initiatives, regional technical networks, networks of laboratories, United Nations organizations (e.g. UNICEF, UNHCR), the Red Cross (International Committee of the Red Cross, International Federation of Red Cross and Red Crescent Societies and national societies) and international humanitarian nongovernmental organizations (e.g. Médecins sans Frontières, International Rescue Conclusion IHR adoption indicates that public health was identified as a central governance challenge nationally and internationally in the 21st century. The Regulations provide a framework that supports not only improved international cooperation on health but also the strengthening of national health systems THANK YOU CASE STUDY For the past few years, there have been isolated reports of a mysterious disease appearing throughout the world. The disease, known as Spontaneous Aging Syndrome (SAS), caused affected persons bodies to degenerate rapidly, as if decades of aging were taking place within the space of a few days. There is no treatment yet for the disease although major pharmaceutical companies in the West are already conducting research into potential vaccines and cures. The disease is believed to be caused by a new mutation of a common sexually transmitted virus. The fact that only a few cases have arisen suggests that it is not easily transmissible. However, scientists are concerned that this will change as the virus continues to mutate. If SAS eventually mutates into a form that is more easily transmitted, millions of people throughout the world could become infected and die. Copenhagen consensus Lack of education, living conditions of children, conflicts, living condition of women, hunger and malnutrition, money laundering, population of migration, vulnerability to natural disasters, land degradation, drugs, unsafe water and lack of sanitation, air pollution, terrorism, financial instability, deforestation, diseases, arms proliferation, climate change, subsidies and trade barriers. CASE STUDY You are a government official of a low-income country with no research or drug manufacturing capacity. You have been called to an urgent meeting by the President, as a case of SAS has now just been detected in your country. To prepare for this meeting, you will now discuss the discussion with your colleagues from relevant ministries (health, trade, environment, justice, finance, planning…) in order to advice the Prime Minister on how to address this issue consistent with ethics and international human rights obligations. An important factor for your group to consider is how the religious and cultural taboos in your country will affect the country’s response efforts, given that the virus has been spreading through sexual transmission. I) What immediate actions do you propose to respond to the current case? II) What long-term plan do you propose for addressing the threat of a larger outbreak?