Global health, Global change, and

Sustainable Development
The One Health & EcoHealth frameworks

Bassirou Bonfoh
CSRS
 Health is not just a benefit of sustainable
development – it is a prerequisite. For
populations trying to escape the cycle of
poverty, one of the most serious handicaps is
the high vulnerability to disease

Ways to build resilience to health threats and

to integrate efficacious health and sanitation
strategies into participatory planning processes
leading to equity effective interventions
(Pathogen)-Host-Environment Relation
Level of research
(Pathogen)-Host-Environment Relation
PATHOGEN - HOST RELATIONSHIP

OTHER
Residual load * Natural
* Latency * Acquired trough infection
* Persistence, die-off * Acquired trough vaccination
* Infective dose * Of new-born acquired through
PATHOGEN placenta and mother’s milk HOST
* Species, strain
FACTORS * ... FACTORS
FACTORS IMMUNITY
* Age and sex
* Health status
* Nutrition, diet
* Hygiene
* Season
TRANSMISSION ROUTES
Hands, person-
to-person
contact
Utensils No transmission

Insects
pathogen
Excreted

Water
Transmission and symptomless infection
Food

Crops,
fish ponds Cattle,
poultry Transmission and infection manifest sickness
Soil

Sanitation

Hygiene habits
Dietary Habits } Exposure
Global changes
Paths between environement, agriculture and infectious diseases

Displacement of Human impact

Emergence of new
bats into human with novel bat
viral diseases
settlements viruses

Human contacts with natural

Forest hosts (primates rodents ect) Malaria
clearance
Mosquito proliferation Enhanced transmission
and activity of mosquito-borne
infections Dengue

Increased
Crops Reduced
Expanded vulnerability
yield Under
agricultural nutrition
activities and poverty
Reduced Increased risk of
Livestock diarrhoeal and
yield
respiratory diseases
Climate
change Zoonoses: Schistosomiasis
old and new Emergency of new
infectious
diseases
Global changes

Ex. Factors that alter the dynamics of malaria

transmission
Form of change Example of change Altered effect b
Pathogen life-cycle dynamics mosquito
Climate Temperature, humidity, rainfall c longevity, activity and distribution
Pathogen introduction, immunological
status, transmission dynamicaters,
Demographic Migration, birth rate especially if malaria is intermittent
Public health, landscape change, Transmission generally lowered with
Economic behaviour change development
Parthogen and insecticide
Evolutionary resistance Increases transmission
Deforestation, irrigation,
urbanization, density of cattle and Mosquito species dominance, density and
Landscape zoophilia of vectors activity
Treatment, insecticides, health Number of carriers, disease dynamics
Public health education altered
Global changes

Risk = f (hazard + vulnerability +..) +y + y

Consequences
Emerging issues
Consequences
Last decade
• Endemic, NTD….
• Ebola
• Nipah virus
• Influenza A H5N1
• Influenza A H1N1
• SARS
• BSE
• West Nile virus
• …….
• …Pollutions
Consequences
A classification of emerging diseases by disease and
economic burden
Form of emergence and re- Example(s)b Human disease Other coasts
emergence impact (scale 5) (scale 5)
Genuinely new human pathogen HIV/AIDS 5 5
vCJD 1 3
SARS 1 3
Nipah virus infection (Malaysia) 1.5 2
Hendra virus infection 1 2
New strain of known pathogen Spanish influenza 5 5
Known pathogen in new TB, measles, smallpox
5 5
population (indugenous peoples)
Newness uncertain Nipah virus infection (South Asia) 1 1
Newness unlikely African Ebola virus infection 2 2
Guanarito virus infection
(Venezuela) 2 2
Drug resistance Malaria 3 3
TB 3 3
Insecticide resistance Malaria 3 4
Dengue fever 2 2
Kala-azar 2 1
Multi-causal Dengue fever 3 3
Consequences
Weighted risk analysis of climate impacts on
infectious disease risks in Europe
Strength of link with climate change

High Vibrio spp. (except. V. Lyme

cholerae O1 & O139) borreliosis Weighted high risk
Visceral leishmaniosis
Hepatitis A, Campylobateriosis, Rift Valley Dengue fever
Mediu Leptospirosis Fever, Chikungunya fever,
Weighted medium
m Yersiniosis, Cryptosporidiosis, Giardiasis,
risk
Yellow fever hantavirus, Salmonellosis,
Tualraemia Shigellosis,West Nile fever
Low Anthrax, Cholera (O1 and O139)
botulism Legionellosis Weighted low risk
Listeriosis, Meningococcal infection
Malaria, Q-fever,
Tetanus,
Toxoplasmosis
Low Medium High

Potential severity of consequence to society

Mitigation options
 Ex. Exposure, Symptoms, cost
Early Control of Zoonotic Disease is Both Cost-effective and Prevents Human Disease

Cost of
control
outbreak
Exposure
Exposure in humans
in animals Clinical
Clinical signe signs in
in animals humans

Humans seek
medical care

WHO, 2009
Inadequate link between information
and decision
Reality & Complexity

Why is it complex? , why failures?

• Targeting diseases, multiple pathogens
• Socio-economic disparities
• Resources allocation to research-action
• Access to
• Resilience
• Behaviour change
• Equity-effectiveness
• ….
Reality & Complexity

Disparities (context & factors)

• Gender (sex, women, men…)
• Age (children, elders…)
• Wealth (poor..)
• Geographic (rural, urban, slums..)
• Climate (arid, semi-arid, humid…)
• Culture (minorities, ethnic, religion…)
• Power (civilian, militaries…)
Global Health

Human health and security

Ill-Being Well-Being
Powerlessness Freedom of
choice and action

Bad social Good social

Vunerability Security
relations relations

Lack of Enough
Poor health Good health
material material

Millenium Ecosystem Assessment, 2005

Global Health
Managing uncertainties
Changes

Well-
Well-being

Uncertainties
(likelihoods Actors
Conflicts) capacity
Power

Designing health systems

 Global Health
Global mortality projections
30
Intentional injuries
Other unintentional
25
Road traffic accidents

20 Other NCD
Deaths (millions)

15 Cancers

10 CVD
Mat//peri/nutritional
5
Other infectious
HIV, TB, malaria
0
2004 2015 2030 2004 2015 2030 2004 2015 2030

High-income Middle-income Low-income

countries countries countries
 Global Health
Neglected diseases
Neglected people
Neglected health and social systems
80
“The big three”
70
Burden (million DALYs)

60

50
Neglected Tropical Diseases (NTDs)
40

30

20

10

Hotez et al. (2006) PLoS Medicine

Global Health
Investments in health…
Global Health

The fatal imbalance

Tropical diseases (including malaria) and
tuberculosis account for:
• 12% of the global disease burden
• Only 1.3% of new drugs developed

Tropical diseases:
18 new drugs
(incl. 8 for malaria)
1.3%
21 new drugs
98.7% for neglected diseases
1,535 new drugs Tuberculosis:
for other diseases
3 new drugs
10. September 22
2013
Global Health

Creative
listening

Needs ⇔ demands
Perceptions and behaviors
Mapping of:
Potentials and solutions
Who is at risk?
Who is vulnerable?
Who is resilient?
Access
Tools and approaches for “decay analysis”

From Efficacy to Effectiveness

Efficacy 80%

X Access x 80%

X Targeting Accuracy x 80%

X Provider Compliance x 75%

X Consumer Adherence X 75%

= Effectiveness = 29%
Access
Effectiveness factors
Access
System effectiveness of malaria treatment
Access
1000
simple
malaria System &
fevers Sought Individual
care behaviour Health
Provider system
90% behaviour
Compliance
Sought
care Accessed
Patient Individual
within ACT Adherence & & drug
24 h provider behaviour
within
Correctly Therapeutic
53% diagnosed
24 h
or
Efficacy
ACT
76% prescribed 179 cases
stocked in
79% Adhered to Treatment successfully
94% treated
treatment effective
= 37%
access 65% 98%
17.9%

19 lost 3 lost
47
94 lost
lost 76 lost 94 lost
113 lost 35 lost
425 lost

824 failures - treat effectively

Access 63% reduction in 10 years since 2000
is primarily due to Health System change
And why was it rapidly scalable at national level?

Target

Source: Data from Tanzania DHS 2010

Socio-economic considerations in global health
Prominent challenges
• Infectious diseases and pandemic
• Non communicable diseases
• Food safety
• Cultural radicalisation of societies (communication)
• Conflicts & governance
• Environmentally compatible energy sources
• Consequences of climate change
• Security and defence
• Cultural impact of stem cell applications
• Nanotechnology & human health
• Cyber security for advanced IT
Socio-economic considerations in global health

Trade-offs
• Difficult decisions on how to use, reject new
opportunities of modern science and
technologies
• Transformational advantages and risks
• Responsibilities of government in complex
demands of different segments (i.e balancing
critical commercial interest & economic
prosperity with cultural sensitiveness)
• Communication between S&T and policy
Socio-economic considerations in global health

Surveillance, prevention, mitigation &

communication
• Scientific credible understanding linked to
realistic policy decision from government and
societal leaders in addressing urgent and long
term challenges
• Communication and debates on advantages
and risks of credible options (scientists,
policy makers, private sector, community
stakeholders…)
And so what?

Ecosystem and societies

• Ecosystem & societies
– Complexity
– Uncertainty
– Transaction cost (financial, social, environment)
– Behaviour, bilieves, tabous, religion
– Epistemology
– Transmission, causality (data quality…)
– ….
New approaches, methods, tools
And so what?

Areas of consensus & actionable next

steps
• Research:
– How diseases originate and transmit?
– How preventive and clinical approaches are
accepted or rejected based on socio-economics?
• Interventions:
– Equity effectiveness
And so what?

Integrated development research

approach
• Bridging epistemological gaps between natural
sciences and humanities
• Connecting outcomes of research on natural
resource management, health, sanitation,
livelihoods and governance
• Tackling the complexity of social development
• Mutual learning for change and undestanding
• Inducing commonalities and methodological
connections between scientifc disciplines and
between cultural paradigms
Approaches to tackle complexities in health
Research questions for development
1. Are existing methodologies and approaches helpful in identifying and examining
health inequities, and if so, how?
2. How is evidence generated, and how is it used in policy debates and decision-
making?
3. What are the strengths and weaknesses of new experimental approaches to
public health innovations?
4. What has worked well, and why?
5. Where were goals not achieved, and why?
6. What additional insights can be gained by connecting different methodologies
and underlying epistemologies in order to address the complexity of health
inequities?
7. How can methodologies be improved in order to deepen and broaden our
research, teaching, and interventions on health inequities by combining the
perspectives of public health, social sciences and development?

Obrist & Jeffery, 2012

 Approaches to tackle complexities in health

Oa Ob Oc Od Object/objectives

A B C D A B C D

Disciplines set boundaries on the Approaches an issue from

parameters of interest; dictate the range of perspectives of different disciplines, but
methodological approaches. They provide each discipline works in a self-
clearly defined starting points, but also pre- contained manner with little cross-
determine the outcomes of the research fertilisation or synergy in the outcomes
Bruce et al. 2004; “Disciplines have a way of imprisoning their
creations”
B

Object/objectives
A O C

A B C D
D
Coordinated and integration-oriented
collaboration between researchers „The world has problems,
from different disciplines universities have departments“
10.09.2013 35
Darbelly 2005 Interdisciplinarité et transdisciplinarité en analyse des discours Brewer 1999, «The challenges of interdisciplinarity», Policy Sciences
 Approaches to tackle complexities in health

NCCR North-South

10.09.2013 36
NCCR North-South, 2000
Approaches to tackle complexities in health

Changes @ Human-Animal-Ecosystem
interface
• Growth and movement of human and livestock populations
• Rapid urbanisation (pollution, sanitation…)
• Expansion of the trade of animals and animals products
• Increased sophistication of farming technologies and
practices
• Closer and more frequent interactions between livestock
and wildlife
• Increased changes in ecosystem (mining, deforestation, …)
• Changes in vector and reservcoir ecology
• Land-use changes, including forest encroachement
• Changes in patterns of hunting and consumption of wildlife
Ecohealth approach
Ecohealth areas
• Linking human health and well-being to changing rural agro-ecosystems
– Nutrition, diet, food security, soil fertility
– Health and agro-system
– Environment and health impact
• NR, Ecosystems, pollution and health
– Mining
– Fish consumption
• Poverty, ecosystems and vector born diseases
– Malaria and other parasitic diseases
– Social approach
• Community health
– Urban ecosystem
– Water, waste, children health
• New approaches
– Better together “Network at the frontiers”
– Ecohealth research in practice
 Ecohealth
approach

Why ? determinants
Who is @risk?
What? Consequences
How to improve and
mitigate?

Hung Nguyen Viet

 Analysis of interrelations between environmental sanitation systems, health status and well-being

Ecohealth approach
Health status
(Water and Sanitation)
Exposure to pathogens (viruses, bacteria, protozoa,
helminths)
Health related and help seeking behavior

QMRA

EPI
Health risks-impacts,
Affected population
Dynamic interactions
Physical environment Social, cultural and
between systems and economic environment
interventions
Food chain Structure of society
Excreta, Wastewater, Water Empowerment
Nutrients: N, P Economic status
Chemical pollutants

SSA
MFA

Ecological risks and use of Vulnerability, resilience and

resources equity patterns

Critical control points: comprehensive biomedical, epidemiological, ecological, social,

cultural and economic assessment

Interventions (biomedical, systems, engineering, behavioral or in combination):

Efficacy, effectiveness and equity studies measured in relation to risks
Ecohealth approach

Ecohealth principles
• Systems thinking (linking people to
ecosystem as a puzzle)
complexity, dimensions (ecological,
socio-cultural, economic, governance…)
Challenges: setting study boundaries,
refine design, conduct analysis
Ecohealth approach

Ecohealth principles
• Transdisciplinary research (social-
(social-
ecological systems)
– Contextualisation, non-academic
perspectives and knowledge)
– Challenges: time, undestanding problem,
trust, respect, no priorities, discussion,
negotiation, consensus building,
– Example: Malawi, improved soil quality,
yield, dietary habits, child health (local
knowledge and capacity integration)
– Tools: Social Analysis Systems, Outcome
Mapping,
Ecohealth approach

Ecohealth principles
• Participation (research for
development)
action enhancement, innovation,
Challenges: involvement, ethical,
strategies,
Tools: PRA
Ecohealth approach

Ecohealth principles
• Sustainability (human health and well-
well-being now and for
future generation, ethical, positive and lasting changes)
Action:
Action: use of research for achieving non linear change
(slippage back into previous, negatve patterns, leaps
forward, new problems

Challenges:
Challenges: anticipate dynamics and outcomes and learn
from them, Sustainability is a lofty goal, unforeseen events

– Improving livelihoods and economic conditions with

inadequate attention to environment and social inequities
can imperil health and become unsustainable over time.

Tools:
Tools: trade-
trade-offs, Flexible and adaptive governance
mechanisms
Ecohealth approach

Ecohealth principles
• Gender and Social Equity (unequal and
unfair conditions of women and
disadvantaged groups in society, ethical
dimensions toward reducing inequities)
Challenges: differences, social, economic,
class, age, gender groups, distribution of
power, income, goods, services, education,
habitats
Tools: few methods and tools, awareness,
Ecohealth approach

Ecohealth principles
• Knowledge to action (KN translation,
tailoring, pathway to action,
innovation, actions, changes
Challenges: responsibilities in knowing
the tension between research endeavour
and action,
Tools: Outcome mapping (positive,
negative outcomes,
Ecohealth example: worming & deworming

Neglected tropical diseases

• Social-ecological systems

10. September 2013 47

Ecohealth example: worming & deworming

Neglected tropical diseases

“Preventive chemotherapy”

10. September 2013 48

Ecohealth example: worming & deworming

After deworming

… rapid reworming
10. September 2013 49
Ecohealth example: worming & deworming

Sanitation

10. September 2013 50

Ecohealth example: worming & deworming
Ecohealth example: worming & deworming

Learning from history

Hookworm “eradication” in the

southern United States

“20% thymol and epsom salts

[treatment] combined with 80%
sanitation [prevention]”

Charles Stiles

10. September 2013 52

Ecohealth example: worming & deworming

Integrated control: China

10. September 2013 53

One Health approach

Human, Animal and Environmental Health

• 60-70% of human pathogens are animal orgin
(pastoralism)
• 75% of emerging animal diseases are
zoonoses
• Most new human diseases are:
– From animal reservoirs
– Pollution
– Life-style and behaviour
One Health approach
Definition
• One Health
– Action-Research that adds values to
human and animal health and allow
resource savings
– Outcome that is not achievable without
the cooperation between disciplines and
sectors (Zinsstag et al)
– Partnership principles
Pastoral code Culture Vulnerability Health system
Climate Gender Pop @ risk Services
Pasture Behaviour Health risk Policy
Animal Perception Nutrition Economic
Products …. …. ….
….

Rentrée Solennelle EISMV, 2012

One Health approach

Collaboration, communication, added-

added-value

Neccessary condition:
Collaboration

Environment
People to relate
Animal Human

Sufficient condition:
Creation of added value Ex. BTB network
One Health approach
One Health Principles
1. Communication
2. Collaboration
3. Value-added/ ethics
4. Conflict resolution
5. Systems analysis/ thinking
6. Creating an enabling environment and
advocating change (Risk, Attitudes, Norms,
abilities, Self-regulation RANAS
7. Teamwork
8. Leadership and management
One Health approach
Key tools
• Inter & transdiciplinarity:
research
• Inter-sectoral intervention
• Multidirectionnel health
component
• Multidimentionnel (global,
regional, national, local…)
• Long term process
One Health approach
Context & processes
• User driven approach (intervention)
• Limited resources (cost-effectiveness)
• Vulnerable, neglected, marginlised population
(pastoralist)
• Difficult access zones (arid, semiarid,
conflictual…)
• Endemic neglected disease
• Long term process
• Mutual learning process
• Social equity
One Health example: mobile pastoralists
Joint human and animal vaccinations improve access to
health care for pastoralists (equity, transdisciplinary)

• Costing study: public health sector could save up to

15% of infrastructure, cold chain and staff costs
• Private veterinarians’ interest in capitalising on
transportation infrastructure
One Health example: mobile pastoralists
Participatory stakeholder seminars to define priorities of the populations and the
authorities jointly provide shortcuts to policy

in line with the Alma Ata Declaration on primary health care (1978)
and with the World Organization of Animal Health (OIE) on community based surveillance.

Decision makers Scientists Concernced population

Towards socially robust knowledge (Scholz)
10.09.2013 62
One Health example: mobile pastoralists

Synoptic view of benefits and costs of animal brucellosis mass

vaccination in Mongolia (intersectoral)
30000000

25000000

20000000
US$

15000000

10000000

5000000

0
Intervention Total Public Private Household Agricultural Total
cost Health health health income Benefits Societal
Benefits benefits benefits loss Benefits

Sector
One Health example: mobile pastoralists

Towards adapted DOTS for TB control in Pastoral

communities (equity in health intervention)

Total cost: 2’600 US$ 495 US$ covered by the DOTS

 Convergence

One Health & Ecohealth to

Health in Social-Ecological Systems
Convergence: health in social-ecological systems

OH EH limitations
• High political debate far from the local
setting
• Discourse on a conceptual & theoretical
framework
• Limited evidence on proof of concepts and
scientific foundation on case studies
• Causality without deep analysis
• Pieces of evidence, specific context base
• Limited added value evidence
Convergence: health in social-ecological systems

Debate on OH & EH
• Discipline ?
• Institution?
• Funding ?
• Leadership??
• Scale of application & monitoring?
• Capacity building in One Health
– Next generation of researchers and practitionners
Convergence: health in social-ecological systems

Exercise IGS Summer School 2013

1. Define your context, identify major changes,
identify well-being related problems,
develop 1-3 research questions;
2. Set up how your discipline is central, define
the general approach and construct a
conceptual frame with the support of other
disciplines;
3. How do you apply major principles of both
concepts