Quiz

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Origins: International Cooperation for Global Health

Anna Kalbarczyk, MPH

Johns Hopkins University

Summer Rosenstock, PhD, MHS

Johns Hopkins University

Alain Labrique, PhD, MHS, MS

Johns Hopkins University

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Introduction

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Semantics and Some Food for Thought

► What is the distinction between global and international?

► How is international engagement relevant to global disease control?

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The Four Eras of International Cooperation around Global Health

► Linked to our understanding of infectious disease etiology and epidemiology

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Era 1 (1300s–1850s): No Cooperation

► Sick versus healthy

► “Cordon sanitaire”—plague villages

► “Stay away from our community,” “Blame and kill!”

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Era 2 (1851–1892): Cooperation to Keep Disease OUT

► “Pre” germ theory

► Protect Europe from exotic diseases

► Slightly coordinated measures across ports of entry to Europe and US

► International Sanitary Conferences begin

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Era 3 (1892–1946): Early Engagement to Address Diseases Regionally

► Germ theory more widely accepted

► First international treaty on maritime quarantine ► Suez Canal, 1869

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Era 4 (1946–present): International Engagement to Address Diseases Globally

► World Health Organization, UNICEF

► Global program agenda ► Saving Lives at Birth, Gavi, Partnership

for Maternal, Newborn and Child Health (PMNCH)

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Pandemics: Response to Emerging Diseases—1

► Era 1 (1300s-1850s): Plague

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Pandemics: Response to Emerging Diseases—2

► Era 1 (1300s-1850s): Plague

► Era 2 (1851–1892): Cholera

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Pandemics: Response to Emerging Diseases—3

► Era 1 (1300s-1850s): Plague

► Era 2 (1851–1892): Cholera

► Era 3 (1892–1946): Cholera and influenza

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Pandemics: Response to Emerging Diseases—4

► Era 1 (1300s-1850s): Plague

► Era 2 (1851–1892): Cholera

► Era 3 (1892–1946): Cholera and influenza

► Era 4 (1946–present): Smallpox and polio

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Era 1: No Cooperation

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Era 1 (1300s–1850s)

► Disease causation unknown

► No international cooperation

► Early beliefs: supernatural ► For example, plagues, Black Death

► Responses: ► Pogroms, sacrifices to gods ► Limited, uncoordinated quarantine ► Isolation or banishment of sick

Representation of a massacre of the Jews in 1349 Antiquitates Flandriae (Royal Library of Belgium

manuscript 13076/77)

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The Great Plagues

► Sixth century: Justinian Plague ► 10,000 deaths per day in Constantinople ► 10-20 million deaths across Mediterranean ► Response: donations to churches and

monastery enrollments went up ► Fourteenth century (1347 +++ )

► One in three people in western Europe died ► About 25 million deaths across Europe ► Response: panic, terror, massacres

► Seventieth century (1665) ► About 31,000 people in the UK died ► Response: panic, flight

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Fourteenth Century (1347...)

Infected clothes being burned. Illustration from “Romance of Alexander” c 1340

Fourteenth century English engraving (History Today.com)

► Responses: trentine, quarantine, isolation of communities, burning of infected homes, clothes

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Plague: Reflections—1

► In spite of severity, did not provoke cooperation among nations … WHY?

Fifteenth century bible depicting Bubonic Plague (Corbis)

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Plague: Reflections—2

► In spite of severity, did not provoke cooperation among nations … WHY? ► Ignorance of cause ► Ignorance of spread ► Superstition ► Weak Nation-States ► No strong motive for cooperation ► No platform or forum for cooperation

Fifteenth century bible depicting Bubonic Plague (Corbis)

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Era 2: Cooperation to Keep Disease Out

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Era 2—The Great Cholera Epidemics

► The first cholera pandemic: 1817–1824 ► Deaths: unknown (100s of 1000s) ► Origin: Calcutta

► Spread across Asia, through Central and Northern Europe

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The Great Cholera Epidemics—1

10 year period Number of epidemics

1831-40 5

1841-50 3

1851-60 4

1861-70 5

1871-80 4

1881-90 4

1891-1900 3

1901-10 3

1911-20 2

1921-90 0

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The Great Cholera Epidemics—2

“Whenever cholera broke out – which it did four times between 1831 and 1854 – nothing whatsoever was done to contain it, and it rampaged through the industrial cities, leaving tens of thousands dead in its wake.”-- Summers, Judith. Soho—A history of London’s most colourful neighborhood, Bloomsbury, London, 1989.

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The Great Cholera Epidemics—3

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Etiology

► Poor understanding of etiology, but clear that its source is “over there” ► 1851: French government convenes

the First International Sanitary Conference (of 14) ● Problem: different quarantine

regulations among countries in Europe

● Solution: standardize!

Source: Laura Ball, UCLA

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Sidebar: Cholera Isn’t Over …

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Cholera: Reflections

► Finally, cooperative international action for disease control ► WHY?

● Ignorance of cause (somewhat) but, ability to keep it out of a country

● Stronger Nation-States ● Motive for cooperation: trade ● Platform created for cooperation

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Era 3: Early Engagement to Address Diseases Regionally

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The Modern Cholera Epidemics—1

► Slow transition from miasma theory to germ theory

► Control of transmission was demonstrated by sanitation and water treatment

► Skepticism persisted, but science progressed!

Source: (quote in middle): Howard-Jones, N. The scientific background of the Int’l Sanitary Conferences (1851-1938), WHO Press 1975; (map on right) .F. Cheffins, Lith, Southhampton Buildings, London, England, 1854 in Snow, John. On the Mode of Communication of Cholera, 2nd Ed, John Churchill, New Burlington Street, London, England, 1855.

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The Modern Cholera Epidemics—2

► Quarantine and screening efforts bolstered by civil construction and sanitation improvements at home and abroad

► Principles of Semelweiss and Pasteur disseminated widely

► Local and regional actions could impact the spread and impact of disease

Source: C.F. Cheffins, Lith, Southhampton Buildings, London, England, 1854 in Snow, John. On the Mode of Communication of Cholera, 2nd Ed, John Churchill, New Burlington Street, London, England, 1855.

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What about the 1918 Influenza Epidemic?—1

► 70-100 million deaths worldwide

► One-third of all Americans (over 675,000 deaths)

► Poor understanding of etiology ► Bacterial suspect

► Good understanding of epidemiology

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What about the 1918 Influenza Epidemic?—2

► Exiting World War 1 ► Statistics obscured by war-related

deaths

► “War mobilization” mentality

► Data ‘concealed’ to maintain morale ► Neutral Spain—reports allowed, i.e.,

“Spanish Flu” name origin

► War-related human movement

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Poor Implementation of Quarantine

► Poor implementation of quarantine ► New Zealand (~8500 deaths, 0.75% MR) ► Tonga: 8% of the population dead ► Nauru: 16% dead ► Fiji: 5% dead

► But … ► American Samoa: 0 deaths ► New Caledonia: 0 deaths ► Japan: 257,000 deaths (0.425% MR)

► How?

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Era 4: International Engagement to Address Diseases Globally

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Smallpox

► 300-500 million deaths in twentieth century

► Vaccine developed in 1798

► Eradicated in 1980

► 10-15 million cases globally per year

► 2 million deaths

► 30 endemic countries

Nineteenth century lithograph by Gaston Melingue of Jenner vaccinating James Phipps

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Video: Smallpox Eradication

► Please pause the presentation and watch the video on the lecture home page. When you finish watching the video, resume the presentation.

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Smallpox Timeline

► Timeline ► 1959—WHO accepts USSR’s proposal ► 1967—Eradication campaign begins ► 1975—Last case in India ► 1977—Last case in Somalia ► 1980—Eradicated!

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Smallpox: Reflections

► At long last, coordinated GLOBAL efforts to eradicate a disease! Why? ► Post WW-II euphoria? ► Global platform and shared values ► Scientific knowledge base expanded ► Technology available (bifurcated needle) ► Freeze-dried, stable vaccine ► Very clear symptoms and case definition

► Question: could we do this today? Why or why not?

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What about Polio?

► 1985: PAHO launches initiative to eradicate polio in the Americas by 1990

► 1988: WHA resolution to eradicate polio by 2000

► 1991: last indigenous case of polio in the Americas

► 1994: Americas certified polio free

► 2001: Western Pacific certified polio free

► 2002: EURO Region certified polio free

► 2015: polio present in only two countries

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What about Polio Makes It Eradicable?

► Only affects humans

► No animal reservoir

► Virus very fragile in environment

► Vaccine is safe, effective

► Vaccine is inexpensive

► Immunity is lifelong

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Progress in the Eradication of Polio

Source: Deutsche Welle, Gudrun Heise. (2015). Polio eradicated in all but two countries. http://p.dw.com/p/1GvJD

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So, What’s Missing?

► International cooperation?

► Leadership (global/ national)?

► Effective technology?

► Good surveillance?

► Management/planning?

► Dedicated and competent staff?

► Adequate funding?

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The Last Days of Polio

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Legal Frameworks, Common Agenda, and a Possible 5th Era

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Codifying the 4th Era of International Cooperation for Global Health: the “New” International Sanitary Regulations—IHR 1969, 2005—1

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Codifying the 4th Era of International Cooperation for Global Health: the “New” International Sanitary Regulations—IHR 1969, 2005—2

► International binding legal instrument

► Defines capacity required to respond to local and global public health crises

► Defines country reporting responsibilities

► Defines disease surveillance competencies

► Defines WHO’s responsibility for global health security

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A 5th Era on the Horizon ?

► The rise of transnational agencies, consortia, and partnerships

► Foundations and funds with budgets that far exceed national or even WHO

► Ability to mobilize and promote their own global health agenda

► Discuss: Benefits? Risks?

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Emergent Platforms for Global Health Mobilization

► Motivate global collaboration ► Promote shared values ► Maintain core priorities and accountability

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Current Challenges for Global Health Programs

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Video: Air Traffic

► Please pause the presentation and watch the video on the lecture home page. When you finish watching the video, resume the presentation.

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Video: Mobility of the Human Population

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Epidemiologic Transition: From Infectious Diseases to Non- Communicable Diseases

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The NCD Tsunami

► By 2025, about $7 trillion in losses ► Leading cause of deaths globally (60%) ► 82% in LMICs ► Risk factors:

► High blood pressure ► Smoking ► Alcohol ► Air pollution ► High BMI ► Physical inactivity ► Salt/sugar intake

Source: Lancet. (2012).

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Epidemiologic Transition: Challenges for Global Disease Control Programs

► Single-cause vs. multidimensional etiology

► Agent vs. behavioral

► Rapid results vs. gradual population shifts

► Single sector vs. multisectoral program

► Discuss: What would some major challenges be for a global program to combat obesity-related cardiovascular diseases? ► What are opportunities for international engagement for:

a) Tobacco b) Alcohol c) Diet d) Physical inactivity

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Epidemiologic Transition: Challenges for Global Disease Control Programs

► Challenging, but not impossible

► Less appreciation for collective risk

► Difficult to foster altruism, less emotive than infectious diseases

► Effects not immediate

► Lack of “supply-driven” technology

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Emerging Challenges—How Can We Mitigate These?

► Human conflict

► Drug resistance

► Emerging infectious disease epidemics/pandemics

► Donor fatigue and public fatigue

► Global anti-science movement

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The Next Epidemic—Lessons from Ebola

The next epidemic—lessons from Ebola

► “There is a significant chance that an epidemic of a substantially more infectious disease will occur … in the next 20 years.” – Bill Gates

► A warning and response system for outbreaks ► Resources

► Human ► Logistic ► Information ► Financial

► Medical and public health tools ► Research

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Excerpt

The next epidemic—lessons from Ebola

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Points to Remember

► The four phases of international engagement in global disease control 1. None 2. Keep disease “out” 3. Limited cooperation to manage disease at the source 4. Global coordination to manage and eliminate disease

► Examples of successful global disease control efforts

► The epidemiologic transition

► Threats and emerging challenges to international engagement

► Key thematic approaches to disease control