Operationalizing “One Health”: A Policy Perspective— Taking Stock and Shaping an Implementation Roadmap

MEETING OVERVIEW | MAY 4–6, 2010 STONE MOUNTAIN, GEORGIA

National Center for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and Pathology PART I. Executive Summary

The U.S. Centers for Disease Control and Training: Develop and build skills, expertise, Prevention (CDC), at the request of and in close and competencies through a One Health training collaboration with the World Organisation for curriculum, and identify opportunities to integrate Animal Health (OIE), the Food and Agriculture One Health approaches into existing curricula. Organization of the United Nations (FAO) and the World Health Organization (WHO), hosted a One Health Global Network (OHGN): Advocate meeting entitled Operationalizing “One Health”: and garner international support for One Health A Policy Perspective—Taking Stock and Shaping through a network that serves as a vehicle for an Implementation Roadmap in Stone Mountain, further global collaboration on One Health Georgia, USA, May 4-6, 2010. The Stone Mountain programs. meeting was the latest in a series of One Health meetings organized by diverse global institutions Information Clearing House: Promote One Health with the intent of providing a forum for national advocacy through a centralized area where One and international specialists to focus on policies Health success stories and lessons learned are and implementation of a One Health approach to gathered and made available to a wide-ranging improving human and animal health. audience.

The specific goal of the Stone Mountain meeting Needs Assessment: Develop country-level was to identify clear and concrete actions to self-assessment methods that will identify move the concept of One Health from vision to programmatic areas that could benefit from a One implementation. Fifty-four select global leaders Health approach, and specific areas for targeting from government, non-government, academic, improvement. policy and economic sectors reviewed progress to date and identified key policy decisions and Capacity Building: Identify ways to leverage financial commitments necessary to support existing programs and capacity-building efforts to sustainability and expansion. To provide have a major impact at minimal cost. background for participants, the meeting began with a series of presentations about recent Proof of Concept: Demonstrate through a One Health events, followed by short panel retrospective and prospective evidence base that presentations and in-depth discussions where the use of One Health interventions leads to better speakers described their own experience in cross-species health outcomes. advancing the concept of One Health within their sector and/or country. Participants had the Business Plan: Articulate the concept of and opportunity to comment on panel presentations rationale for One Health more clearly and present during group discussion periods and provide their this information to policymakers and donors own perspective through small group sessions and worldwide. activities. Meeting participants defined a 3-5 year vision of One Health encompassing four main Each group was asked to develop One Health areas: culture change, increased visibility, political plans and partnerships that would occur within will/financial support, and optimal coordinated a designated timeframe. These workgroups will efforts. Seven specific activities were identified convene and continue their development to as being critical steps in attaining the defined finalize their actions plans, develop timelines and 3-5 year vision and separate workgroups were carry out activities. formed to address each of these activities. These workgroups include:

2 PART II. Overview of Events Leading Up to the Stone Mountain Meeting

Background remarks, Danielle Grondin of the Public Health Agency of Canada noted that because the According to the World Health Organization political economic agenda is the priority of world (WHO), new infectious diseases have emerged at leaders today, One Health must be translated the rate of one or more per year since the 1970s. into language that is relevant to finance ministers SARS, HIV/AIDS, West Nile virus encephalitis, to facilitate the evolution of this concept from Nipah virus encephalitis, dengue hemorrhagic principle to practice. fever, and other diseases of zoonotic origin are well known examples of this increase in disease threats. In 2008, the Food and Agriculture Stone Mountain Meeting Organization of the United Nations (FAO), the Much progress was made at the Winnipeg meeting World Organisation for Animal Health (OIE), and toward defining approaches for achieving One WHO (the three major international organizations Health objectives; however, a complementary dedicated to issues concerning animal health meeting was necessary in order to define the and human health) collaborated with the United specific action steps needed to further move Nations Children’s Fund (UNICEF), the United the One Health concept forward. Therefore, Nations System for Influenza Coordinator (UNSIC), a Scientific Planning Committee composed and the World Bank to develop a joint strategic of representatives from the U.S. Centers for framework to address risks associated with Disease Control and Prevention (CDC), OIE, emerging and re-emerging infectious diseases. The FAO, WHO, the European Union, and Princeton document in which this framework was originally University was assembled to organize a follow- communicated, Contributing to One World, One up meeting. This subsequent expert consultation Health*—A Strategic Framework for Reducing titled, Operationalizing “One Health”: A Policy Risks of Infectious Diseases at the Animal-Human- Perspective – Taking Stock and Shaping an Ecosystems Interface, set out six specific inter- Implementation Roadmap, was held May 4-6, 2010 linked objectives for countries to consider in in Stone Mountain, Georgia, USA. The Scientific their approach to infectious-disease control at the Planning Committee developed a rich and animal-human-ecosystem interface. interactive agenda and carefully selected leaders from national Ministries of Health and Agriculture, In March 2009, the Public Health Agency of the European Commission, the United Nations, Canada hosted an expert consultation titled and the World Bank; in addition, representatives “One World, One Health: from ideas to action” from other diverse institutions from the academic, in Winnipeg, Manitoba. The purpose of the policy, and economic sectors were invited to consultation was to discuss the Strategic participate and contribute their expertise and Framework and to identify and shape country- experience to the discussion. level recommended actions to globally advance the framework. Participants recommended the development of supra-country approaches that use multidisciplinary/trans-disciplinary methods in addition to trans-boundary/regional approaches to ensure an integrated approach. In her closing

3 PART III. Welcome and Overview

Opening Remarks Dr. Khabbaz stressed that the large number of attendees at this meeting is evidence in itself of Rima Khabbaz, CDC Deputy Director for the worldwide commitment to One Health. She Infectious Diseases went on to explain that each participant invited to attend the Stone Mountain meeting was identified During her opening remarks, Dr. Khabbaz thanked and selected to ensure a global, multi-disciplinary everyone for their participation, recognizing that representation. Together, the participants everyone was present for the same reason – a represented the inter-sectoral collaboration belief that One Health is the best approach for needed to move forward on One Health initiatives. attaining better health for humans and animals and for improving the environment. Dr. Khabbaz said that CDC was honored to host this meeting and hoped that the agency could Dr. Khabbaz pointed out that One Health is serve as a strong partner in advancing this effort. not a new idea. While historically, physicians She pointed out that One Health is an important and veterinarians had worked closely, the 20th priority for CDC’s infectious disease programs Century brought about a wide separation between overall. Dr. Khabbaz ended by emphasizing the these specialties. Moving from generalists to need for participants to continue working to move specialists further hindered interactions between One Health forward by assessing the current these practices which became even more critical state of the One Health approach; identifying as the century progressed. The tremendous and building upon successes and lessons mid-century advancements in technology and learned; identifying opportunities and barriers industry, increasing ecologic and environmental to implementing One Health; and formulating changes, and new human patterns of travel and strategies to address needs. Participants also were consumption created a highly connected world encouraged to identify concrete action steps for that provided multiple opportunities for the each of these critical components associated with introduction and spread of new and One Health implementation. re-emerging diseases.

In September 2004, health experts from around Purpose and Proposed Scope the world met in New York City to discuss One for One Health Health. The meeting, titled “One World, One Speakers: Alex Thiermann, OIE, Liz Health: Building Interdisciplinary Bridges to Mumford, WHO, Jan Slingenbergh, FAO Health in a Globalized World,” was organized by the Wildlife Conservation Society (WCS)/ During this session, participants were provided Rockefeller University and resulted in 12 with information regarding the concept of One recommendations. Referred to as the Manhattan Health as it was defined for the purposes of Principles, these recommendations called for the strategic meeting. It was stressed that there the establishment of a more holistic approach to is a clear need to operationalize One Health to preventing epidemic and epizootic diseases and move beyond the conceptual. The environment maintaining ecosystem integrity. must be broadened, but should not challenge the mission of each agency individually. Instead, Since the New York meeting, additional global the way in which One Health objectives are strategies, conferences, and consultations have achieved must change. Therefore, the importance further advanced the One Health effort and laid of operationalizing One Health is not in defining a strong foundation for the current meeting. the concept, but rather lies in the activities at the

4 cross-cutting points of each organization. These from past meetings and how they set the stage for organizations must work in terms of collaboration operationalizing the concept of One Health during and integration rather than individually and the Stone Mountain meeting. in silos. The significance of the timing of the Stone It was also observed that the Stone Mountain Mountain meeting was described during the meeting could serve as a well-timed complement overview of the “One World, One Health: from to the FAO-OIE-WHO Joint Technical meeting ideas to action” consultation held in Winnipeg, held in Verona the previous week, where a Manitoba, Canada in 2009. The Winnipeg meeting variety of themes regarding emerging and re- did provide a stepping-stone for the Stone emerging diseases at the human-animal interface Mountain meeting, which promised excellent were explored. These common themes identified results and increased forward momentum, during the Verona meeting could ideally provide a including focused decision making, timeline technical basis for the discussions taking place at development and distribution of activities and the Stone Mountain meeting concerning strategies roles for advancing One Health. for operationalizing the agreed upon concepts and translating strategic alignment into action. Review of agenda and Review of the Series of One participant expectation Health Meetings and the Daniel Normandeau, Meeting Facilitator, ConversArt Significance of the Stone Mountain Meeting When reviewing the agenda, Mr. Normandeau suggested that the group consider the following: Speakers: Alain Vandersmissen, European Commission, Mark Raizenne, yy What must we walk away from this Public Health Agency of Canada, Alex meeting with? Thiermann, OIE, Kate Glynn, OIE yy What should we be creating together in this This session aimed to provide participants with two and a half day period? an understanding of the key historical events leading up to this meeting (the achievements) in yy How would you define success in specific, the context of developing and advancing the One concrete, grounded terms? Health agenda (the work that remains to be done), specifically to move from the theoretical to the Participants then compared notes with their more practical, allowing further implementation at colleagues, shared ideas, and determined what international, regional, national, and local levels. kind of shared or common agenda would emerge A timeline was given to illustrate the history of from this meeting. There were many connections One Health, focusing on the last 6 years and in among the reports, but one strong theme that particular on the role of the recent International emerged was a sense that the “pump is primed” Ministerial Conferences on Avian and Pandemic for operationalizing One Health. It is time to move Influenza. In their remarks, presenters described toward specific, concrete, results-driven, and several of the most recent meetings focusing on observable actions that are not confined to one One Health or the animal-human-ecosystems individual view and can make a significant impact interface and detailed their accomplishments, on health. lessons learned and existing gaps. Presenters discussed the significance of and contributions

5 PART IV. Working Sessions

Eight working sessions were held during this two participants the opportunity to ask questions as and a half day meeting. The sessions focused on well as describe their own experiences. Finally, diverse topics, including the economic benefits the members of each individual group were asked and drivers of a One Health approach; successful to exchange views with fellow group members examples of One Health implementation at and develop possible recommendations/next steps the national level and within other sectors for their topic area that could help operationalize (professional, NGO, international and academia); One Health concepts. creating a shared view of success for One Health and the necessary stakeholders; and identifying The key messages that emerged from each critical enabling initiatives to advance the concept session are summarized in the following of One Health. Most sessions opened with panel section of this report as bulleted text. Although presentations from subject matter experts, who recommendations and next steps are outlined briefly described their own experience (or that in this report, they do not imply consensus or of their institution) regarding the session topic; agreement from the entire group or their affiliated these experiences are summarized in the following institution. Instead, the recommendations are pages of this document as “case reports.” A intended as suggestions that may serve as a group discussion followed, allowing all meeting vehicle for moving One Health forward.

SESSION TWO: Economic Benefits of a One Health Approach: Why Should Anyone Invest?

Examples were presented of when applying a The discussion included comparing and One Health approach generated better economic contrasting developing, in-transition and and health outcomes. developed country aspects.

Panel: Jean Kamanzi, World Bank, Jonathan Rushton, Royal Veterinary College, Esther Schelling, Swiss Tropical and Public Health Institute

Key messages of the panel presentations and associated discussion: yy Recent zoonotic threats, including BSE, SARS, yy An H5N1 pandemic has been estimated to H5N1, and H1N1, all have human health and have a $3 trillion global impact; therefore, economic impact. For example, the estimated there are good returns on investments made direct cost of SARS to Canada and Asian in preventive measures to reduce the risks of countries is $50 billion. H5N1 becoming pandemic (i.e., investments of $2.7 billion on prevention to avoid yy During the H5N1 crisis, the World Bank potential losses of $3 trillion). collected $3.9 billion from donor countries over 4 years. By the end of 2009, $2.7 billion yy Ensuring food safety is critical; for example, had been disbursed for capacity-building, 339,000 people working in the agricultural training, education, and resources. sector in the UK (0.6% of the pop.) can affect the wellbeing of 60 million consumers.

6 yy When avoidable losses are greater than One Health can be viewed through two the cost of the intervention, investment is different levels: worthwhile. »» Initial level: focus on disease at the yy When an outbreak of pandemic disease human-animal-ecosystems interface. occurs, traditionally public health AND »» Secondary level: focus on drivers that rest veterinary services respond as separate outside this domain and may influence the entities – no coordinated response occurs emergence and spread of disease (e.g., between services. land use, deforestation, agriculture systems, and migration) yy Joint Service Provisions is an example of added value through better cooperation yy Improved monitoring provides a more between animal and health sectors. The accurate, real-time estimate of disease burden sharing of infrastructure and equipment and impact. clearly illustrates the cost reduction associated with a collaborative approach. yy Investing in One Health is advantageous, because it ensures: yy For diseases that exclusively affect either animals or humans, a specialized approach »» better preparedness and contingency is advantageous; for zoonotic diseases, a plans; more generalized systems approach is more appropriate. »» more efficient and effective surveillance systems for diseases; yy A definition of One Health that allows »» cost-sharing between sectors according to organizations to work with a common vision their benefits of control; is needed. »» increased health equity (neglected zoonoses primarily affect yy Controlling diseases at the human-animal- socioeconomically disadvantaged groups); ecosystems interface in operational terms and requires gradualism -- a systems approach that reflects gains in both effectiveness and »» improved sharing of logistics and costs for efficiency. Gradualism in the context of service provision.

Session Recommendations: yy Traction is needed at the policy level. yy The benefits of One Health should be presented via a strategy of cost/benefit yy A convincing case needs to be presented to analysis, and interventions should be ministries (Health, Agriculture, Finance) to developed. control and manage lingering diseases (e.g., rabies and brucellosis) when the threat is not yy Ministries should work together to distribute as obvious. As each new threat emerges, the burden; costs/benefits of disease-causing prior threat is easily forgotten. activities are not born by the same sectors. Rolling up costs for integrated systems saves yy Sustainable funding should be created; for money across sectors. instance, a minimal tax could be applied to products of animal origin. yy Veterinary and human health infrastructure and capacity should be strengthened to

7 enable the exchange of information between yy Language should be developed to effectively the two sectors - sharing knowledge and communicate One Health to stakeholders resources, including joint labs, shared and bring relevancy to the concept -- One processes and sample-sharing in the field has Health can provide the right language for quantifiable economic benefits. stakeholders to understand and make it relevant to their systems. yy Investments in general platforms, rather than specific ones, should be made. yy The benefit of building resilient systems that can handle uncertainty must be established. yy The private sector should be considered a partner in sharing the costs proportionate to yy Food security and public health issues the benefits when distributing responsibility should be addressed together, improving for emerging pathogens. streamlining and efficiency.

yy Trade and travel should be used as economic drivers; change is likely to occur when economic interests are affected.

SESSION THREE: Successful Approaches or Systems for Implementing One Health—National Examples

Examples of how policy decisions have been policy development, program implementation, made and how financial investment has been financial investment, or sustainability in a variety encouraged at the national and sub-regional of settings were also discussed, as well as level were presented for discussion. Barriers strategies to overcome these barriers. (consistently present) that hamper or prevent Panel: Carol Rubin, CDC, Albert Ko, Oswaldo Cruz Foundation

Key messages of the panel presentations and associated discussion: yy Establish evidence based results to gain defined responsibilities and coordinated national support plans and guidelines for each of the respective partners at the local and national yy Be creative and use various types of media level (i.e., public journals) in order to gain high- exposure and support yy Incorporate community and non- traditional partners (i.e., civil defense, yy Build upon existing multi-disciplinary/ residents associations, public sanitation intersectoral structures that can be leveraged companies, media) to increase capacity, while establishing

8 Case Study: Pandemic H1N1 response as an example of One Health achieving some success: United States Background A One Health Opportunity yy In the United States, CDC functions yy The communication bridges built during somewhat like a Ministry of Health and, HPAI H5N1 response planning allowed USDA serves roles often assigned to a CDC and USDA to coordinate science- Ministry of Agriculture. CDC and USDA based messaging BEFORE H1N1 was often collaborate but have different diagnosed in US pigs. mandates and responsibilities that historically have led to the Agencies yy USDA conducted research that clearly functioning independently. showed that, as with other SIV, H1N1recovered pigs could safely go yy Response to High Pathogenic to slaughter. Avian Influenza (H5N1) built new communication bridges between CDC and yy CDC, USDA and pork producers met to USDA, and pilot surveillance programs for design a united One Health response. SIV in pigs was being planned. yy Conference calls were organized with yy However, the discovery of pandemic relevant stakeholders and USDA, together H1N1 in people but not in animals with CDC, delivered unified messaging created a new tension between the about pork safety. Agencies. For example, some countries issued bans on receiving US pork based Result on human H1N1 case counts published on public health websites. The yy When the first US swine herd was economic impact was significant, diagnosed as pandemic H1N1 positive but not science-based. in Indiana, the story did not impact pork sales domestically or internationally. yy In addition, Swine Influenza Virus (SIV) Recovered pigs went to slaughter and surveillance systems planned by CDC ended up in the grocery store. and USDA were abandoned during the outbreak. In order to avoid being the first positive herd, US producers did not submit samples for SIV analysis.

9 Session Recommendations: yy Non-traditional partnerships should yy Attention must be directed toward a range be formed. of issues rather than continuing the singular disease focused approach. yy Trust and confidence must be built. yy Incentives to bring multi-disciplinary yy Performance indicators should actors to the table (e.g., reward structures) be established. should be identified to motivate and leverage funding. yy Although virus sharing and banking has increased, it must continue to improve into yy Novel and innovative approaches to multi- the future. disciplinary training and career development (e.g., incorporating human public health in yy Consistent messaging across sectors must be veterinary medicine curriculum and zoonotic established; when the public blames industry public health in medical curriculum) are for disease, tension increases. necessary to develop a bottom up horizontal approach which crosses over diverse sectors yy Joint-decision making and communication and create a cadre of One Health partners should continually and consistently occur; across sectors. building relationships to overcome turf/ control issues and developing a shared vision yy Veterinarians should continue to be are critical to the success of any action to incorporated in the Field Epidemiology improve health. Traning Program (FETP), national rapid response teams, and related programs, yy Prevention should be addressed, rather than ensuring they receive the same training as just the problem. other health professionals and can enhance the types of public health responses made yy Lack of urban planning in developing to outbreaks. countries is a big concern and should receive greater representation.

yy Peri-urban settings, including peri- urban agriculture, must be addressed; as populations move toward urban centers, so do livestock and agriculture systems.

10 SESSION FOUR: Successful Approaches or Systems for Implementing One Health—Examples From Other Sectors (Professional, NGO, International, and Academia)

Examples of behaviors that can prevent progress, Examples of behavioral changes leading to how they were identified as the root factor, and sustainable change were also discussed. how political will was engaged to implement One Health were presented and discussed.

Panel: John Mackenzie, Curtin University of Technology, Laura Kahn, Princeton University, Manish Kakkar, Public Health Foundation of India, Roland Suluku, Animal Health Clubs (Sierra Leone)

Key messages of the panel presentations and associated discussion:

yy Lack of communication and collaboration educational efforts, then continued at the between medical and veterinary authorities, graduate level to reinforce what is learned at particularly during a disease outbreak, is the undergraduate level. very problematic. yy Stepping back from a medicalized paradigm yy A major challenge to implementing One of public health and involving more Health is that most physicians are sub- disciplines is important (e.g., social science specialists, meaning their practices are so professionals and economists). specialized that they may not recognize the relevance of collaboration with other yy Inter-sectoral collaboration is an elusive professionals such as veterinarians. paradigm, especially at ground-level implementation. yy The mission of medical schools is to train physicians to focus on individual yy One Health must be defined in terms of health. This is expensive and does not major stakeholders involved. prevent diseases – it treats disease at the tertiary level. yy One Health is not just about zoonotic diseases. Most disease processes are shared yy Physicians often do not see the connection cross-species, and therefore One Health between animal and human health when encompasses more than just emerging there is no direct patient care. infectious diseases.

yy Efforts to educate inter-disciplinary practices are easier at the undergraduate level, before specialization becomes the focus of

11 Case Study: Animal Health Clubs in Sierra Leone Background yy The clubs aim to influence higher level structures from local authorities to the yy In Sierra Leone, 95% of the country’s national government. animal population was destroyed during an 11-year civil war. yy AHCs have a consortium of various schools in the university working yy The country is experiencing an “Expert with rural development, including the Crisis,” or a crucial lack of human Schools of Agriculture (Animal Health resources, with only 70 medical and Nutrition, Home Sciences and doctors, three veterinarians (all Agronomy), Environmental Sciences, scheduled to retire in 2-6 yrs), and 21 Education (Drama and Songs), livestock officers. Technology, Horticulture, and Forestry. A One Health Opportunity Result yy Animal Health Clubs (AHCs) are a multi- yy AHCs’ achievements include: sectoral collaboration that strives to teach communities in Sierra Leone about »» Growing membership from 1 to healthy living. 25 schools. yy The clubs began by educating students »» Bringing the university closer to from primary school through university the community. on rabies and using them as a way »» Collaborating with municipal to disseminate prevention information authorities. through their communities and »» Providing a neutral forum for multi- among peers. sectoral/multi-disciplinary stakeholder meetings locally and nationally. yy AHCs have broadened to promote awareness on prevention and control of »» Improving awareness and contributing other endemic and emerging zoonoses to the gradual adoption of the One through community level approaches. Health message.

12 Session Recommendations yy Successful collaboration is needed between yy Health-science schools (e.g., medicine, human and animal health communities. veterinary medicine, public health, and nursing) should be situated geographically yy The broad types of transmission mechanisms closer together in order to improve that may not be apparent initially must be collaboration among the sectors. taken into consideration. yy Veterinary and medical students should yy Public health should be reintegrated with participate in joint investigations of individual health. zoonotic diseases.

yy There should be provision for flexibility in yy Pilot models of inter-sectoral collaboration possible approaches and entry points for should be established for students and others inter-sectoral collaboration. There may not to enable them to learn best practices. be a “one size fits all” approach. yy At the global level, One Health should yy An integrated core sector that includes integrate developed and developing world humans, animals, and wildlife should perspectives and recognize that their be identified. priorities may be different.

yy All stakeholders involved in animal, human, yy The medical community should be engaged and ecosystem health issues should engage by contacting and working with professional in dialogue and collaboration beginning in societies (e.g., The American Medical the early stages of any new initiative. Association and the American Veterinary Medical Association). yy Transparency and communication through rapid and shared surveillance are needed yy Because children are disproportionately for the prompt detection of novel affected by zoonoses, pediatric organizations emergent agents. and societies should be included in collaborative efforts.

13 SESSION FIVE: Creating a Shared View of Success for One Health

Panelists shared their own ideas of success for One Health in terms of outcomes and benefits in order to create a collective view for the group. Panel: Lonnie King, The Ohio State University, Jian Du, China Ministry of Agriculture, John McDermott, International Livestock Research Institute

Key messages of the panel presentations and associated discussion: yy “Where you stand depends on where you »» Change-Management lens: a generational sit” -- success is defined by the lens through change, one which overcomes old which one looks. The following are a series mindsets, must take place in 3-5 year of possible lenses through which to look at segments and be associated with One Health. specific outcomes; a communication »» Cultural/Organizational lens: the “this strategy is critical. is how things are done around here” culture is broken down, and mutual and yy From an agriculture research and reciprocating respect, trust, and interaction development perspective, One Health can across disciplines are instilled as the norm. contribute outcomes and benefits in the following ways: »» Non-technical lens: workers/leaders possess the necessary skills to ensure »» by addressing the needs of marginalized success by having the ability to work and vulnerable people; across boundaries over which they do not »» by addressing the needs of the rapidly have authority. changing developing world; and »» Technical lens: training programs are in »» by ensuring phased planning and place to prepare a cadre of One Health risk mitigation. professionals and teams locally, nationally, and globally. yy One Health can make a major contribution in »» Economic lens: a metrics is formulated the agriculture sector in developing nations, with economic parameters that reinforce where 70%-80% of households are involved and support One Health and prove in agriculture production (compared with 2% reductions in deaths and costs from in the developed world). diseases, as well as demonstrate gains in productivity.

14 Case Study: Rodesiense in Uganda

Background A One Health Opportunity yy Rhodesiense is a zoonotic sleeping yy Significant cattle restocking took place sickness that is not easy to diagnose early north of the areas where sleeping and is difficult to treat in late stages. sickness typically occurs, resulting in the transport of cattle from infected areas into yy Rhodesiense is largely an infection uninfected areas. of cattle that carry the trypanosome infection, which can be transmitted yy A major outbreak occurred in the local to people. cattle market, and nearby residents became infected. yy Cattle infected with these trypanosomes are asymptomatic; this can complicate yy A study was conducted to assess the diagnosis, because healthy cattle can be a veterinary, human, and ecosystem aspects reservoir for tsetse transmission to people. of the disease to better understand its origin in the area. yy Many people in Uganda live long distances from health-care clinics, making Result access to human interventions difficult. yy Several pilot studies have demonstrated yy The drugs used to treat Rhodesiense are that improving animal health can reduce highly toxic; about 10% of patients who the threshold of transmission, because take these drugs die from illness in humans merely represents the toxicity overdose. “tip of the iceberg.”

yy Because of the high prevalence of HIV/ yy An animal intervention not only allows AIDS in the area, rates of Rhodesiense the disease to be controlled, but is also are under-reported. In many cases, beneficial to agriculture in terms of health-care providers erroneously assume increased productivity. that symptoms of chronic disease are associated with HIV/AIDS.

15 Session Recommendations yy Powerful guiding principles should yy One Health should be expanded to be developed to direct processes with encompass the area of preparedness. sponsoring coalitions. yy The One Health concept should be yy New approaches for anchoring new considered in terms of a global start-up behavior in the organizational culture should company. As such, a business strategy to be developed. establish the concept should be developed.

yy Champions who have access to yy The mentality reflected in the phrase “It is media internationally should be the way things are done around here” must identified and recognized as conduits be transformed and transcended. for global communication. yy Efforts should focus on developing countries, yy Visions should be defined and where opportunities exist for making the communicated, and others empowered largest changes quickest. Steps can be to take action. skipped, evolutionary leaps forward can be made, and real gains can be shown. yy The short-term wins must be planned today to disempower cynicism in the future.

yy Efforts must be made to plan ahead, understand those impacted, and plan win/win consequences and incentives to overcome resistance.

16 SESSION SIX: Developing a View of Success for One Health in the Next 3–5 Years

Facilitator: Daniel Normandeau, ConversArt

The group recognized that comprehensive yy Culture change—appreciation for the operationalization of One Health involves making importance of the connection between changes on a long-term time scale. In small humans, animals, and ecosystems; groups, participants were asked to discuss a vision of what One Health should look like globally in yy Increased visibility—evidence-based the next 3-5 years. It was stressed that each view recognition of the value added by should be tangible, results-oriented, outcome- operationalizing the One Health approach driven, and practical. During the plenary session, in preventing, detecting, and controlling four key common themes emerged from the small diseases that impact both humans groups as they presented their 3-5 year vision for and animals; One Health. yy Political will and financial support— to support interdisciplinary collaborative programs;

yy Optimal efforts and Improved coordination—inter-sectoral collaboration in surveillance, communications, outbreak response, and sample sharing.

17 SESSION SEVEN: Implementing a One Health Approach

Facilitator: Daniel Normandeau, ConversArt

During Session Seven, participants were tasked with identifying “critical enabling initiatives” that are feasible for completion over the next 18 months and will ensure the integration of One Health approaches into policy development and help guide implementation. Each group came up with several such initiatives, reflected in the following list.

yy Creating a foundational structure yy Developing a communication plan initiative/legitimacy yy Making investment cases yy Conducting a gap analysis of value added yy Ensuring political engagement at cross- yy Branding and messaging jurisdictional levels

yy Establishing a global One Health alliance/ yy Changing existing authorities and delegations network/partnership in order to facilitate a community approach

yy Creating a One Health business plan yy Leveraging institutional arrangements

yy Conducting proof-of-concept projects yy Involving private-sector enablers that influence behaviors yy Holding annual or bi-annual international One Health meetings yy Identifying national focal points for wildlife and disease reporting yy Involving UNEP, the inter-governmental agency dealing with drivers of yy Establishing a working group to develop key emerging diseases One Health deliverables

yy Obtaining data on One Health experiences yy Creating a clearinghouse website worldwide to raise awareness and understanding yy Engaging in knowledge management, information sharing, and dissemination yy Conducting training and human development

yy Engaging a financial and business consulting group

18 Of these nominated critical initiatives, seven key activities were selected as fundamental to moving forward the One Health agenda and obtaining goals associated with the 3-5 year vision. Seven work groups were then formed to collaboratively develop and implement the key activities, which follow.

1. Training: Develop and build skills, 5. Capacity Building: Identify ways to expertise, and competencies through a One leverage existing programs and capacity- Health training curriculum and identify building efforts in order to have a major opportunities to integrate One Health impact at very little cost. approaches into existing curricula. 6. Proof of Concept: Demonstrate through a 2. One Health Global Network (OHGN): retrospective and prospective evidence base Advocate and garner international support that the use of One Health interventions for One Health through a network that serves leads to better cross-species health outcomes. as a vehicle for further global collaboration on One Health programs and projects. 7. Business Plan: Articulate the subject area of One Health more clearly and present it to 3. Information Clearing House: Promote policy-makers and donors at the global level. One Health advocacy through a centralized area where One Health success stories are gathered and made available to a wide- ranging audience.

4. Needs Assessment: Develop country level self-assessment methods to identify programmatic areas that could benefit from a One Health approach and areas for targeting improvement.

Each group was asked to develop One Health plans and partnerships that would occur within a designated timeframe; plans included specific activities, budgets, deliverables, and constraints. The groups presented the results from their discussions and fielded questions from the larger group, who provided their opinions and suggestions to help strengthen the ideas of each work group. These work groups will convene and continue their development process via teleconference to finalize their action plans and carry out activities.

19 PART V. Workgroup Summary

WORK GROUP 1: Training the avian influenza response, communication will be based mainly on an electronic system, with Goals/Objectives: To develop and build skills, occasional in-person meetings when possible. expertise, and competencies through a One Health training curriculum for various target audiences A Virtual Coordination Team can be permanently (e.g., students and politicians) to prepare One active electronically to serve as a neutral group, Health leaders and workers for planning and or advisory board, which will represent all One implementing One Health activities. Health professional sectors (up to 10 persons) acting in their expert capacity. Training will be provided at the following levels: orientation, operational, proficient, practitioner, WORK GROUP 3: Information and leader. Using a pre-designed metric to develop the scope of the project, the training Clearing House group will select an initial target audience (e.g., Goals/Objectives: To promote One Health the trainees); define where this training will be advocacy and enable trans-disciplinary and trans- delivered; determine the critical needs/outcomes boundary connectivity through the creation of a (e.g., locate the next generation of leaders in the centralized area where One Health success stories area and identify the skills needed); and define are gathered and made available to a wide-ranging the depth of knowledge and the length of time audience. This clearinghouse will serve as a required, depending on training level. repository for information regarding past and on- going One Health programs, results, partners, and WORK GROUP 2: One Health other pertinent information. Global Network (OHGN) This group will help establish or identify a portal Goals/Objectives: To advocate and garner for One Health information to provide broader international support for One Health through One Health connectivity. As a neutral portal a network that serves as a vehicle for further website, existing websites will have the ability to global collaboration on One Health programs and link to the site to share their One Health related projects and provides an efficient method for the programs and information. UNICEF offered to collection and dissemination of information. support the creation of a neutral web space (i.e., a website that does not contain UNICEF branding). The OHGN will be a virtual umbrella, coordinating To leverage the overlap in responsibilities between One Health leadership and advocacy. This the Information Clearing House Group and network will be composed of global professionals the Global Network Group, the OHGN could representing a wide range of stakeholders potentially serve as the website’s managing body. from various public and private institutions; to maintain credibility, members will not be asked to WORK GROUP 4: Country Level participate in a personal capacity. Criteria for the selection of members will be based on expertise Needs Assessment and experience in One Health, networking and Goals/Objectives: To develop country-level self- coordination skills, availability, and willingness to assessment methods to identify programmatic participate. Efforts will initially focus on getting areas that could benefit from a One Health the network functioning; members will be added approach and areas for targeting improvement. as the network gathers momentum. Similar to These assessments would focus on the level of

20 threats/risk of new disease emergence and the WORK GROUP 6: Proof Of fragility or weakness of existing systems within individual countries to encourage policymakers Concept to incorporate a One Health approach while Goals/Objectives: To demonstrate through a developing nation-wide activities and setting retrospective and prospective evidence base that priorities. the use of One Health interventions leads to better cross-species health outcomes than comparable An expert working group will develop a health-care systems that do not utilize One process, including pre-assessment methods and Health concepts. tools, through which a country could request participation in a needs-assessment to determine This group will conduct a series of studies, both where and how One Health approaches could retrospective and prospective, that will provide a lead to real benefits in their unique context. holistic examination of One Health and its various Initially, a pilot program will be established applications over time (i.e., in the past, present, to inform assessment development and test and future). These studies will look closely at implementation. External facilitators (initially, high-risk communities and provide evidence- members of the expert working group) will based information describing why One Health help countries identify members for their in- approaches are more effective, efficient, and country team, or steering committee (e.g., beneficial to improving animal and human health. professionals in government, from NGOs, and in An example of one such study is a prospective the private sector) to be involved in long-term demonstration project that uses baseline data and implementation. After the completion of the metrics to reveal whether disease was reduced pilot program in several countries, results will be through One Health efforts, thereby validating the evaluated and the assessments revised to develop proof of concept. the standardized tools. Countries will submit a formal assessment request and have complete ownership over all the results so the process will WORK GROUP 7: Business Plan not be seen as obligatory. Goals/Objectives: To articulate the subject area of One Health more clearly and present it to WORK GROUP 5: policymakers and donors at the global level. Capacity Building This group will define the overall importance Goals/Objectives: To raise awareness and expand of One Health and create a strategy investment engagement in the One Health concept by document, or socio-economic framework, that identifying ways to leverage existing programs and clearly defines the general concepts of One Health capacity-building efforts, which ideally will result by addressing the proof of concept and the socio- in substantial health impact at very little cost. economic impact. A communication strategy will also be developed to identify the various stages at This five-part approach includes developing which material should be presented to donors and a cross-sectoral capacity building plan with policymakers to ensure adequate understanding of individual countries, coordinating OIE/IHR focal the One Health Concept and to garner support. points that already exist, enhancing training activities, engaging academia in the promotion of One Health, and ensuring One Health is a major component of the zoonotic disease portion of the Asia-Pacific Strategy for Emerging Diseases (2011-2014).

21 PART VI. Conclusion Closing Remarks have learned to collaborate and improvise have prevailed.” Dr. Khan added that this quote Rear Admiral Ali S. Khan, Assistant speaks directly to the activities being undertaken Surgeon General and Acting Deputy by meeting participants and to the One Health Director of NCEZID, CDC concept overall.

In his closing remarks, Ali Khan expressed This meeting resulted in the identification amazement at how well participants dealt with the of many short-term projects that will require dynamic tension in the room between defining follow-up. Dr.Khan emphasized that this is an all that falls under the umbrella of One Health ongoing process and reminded participants that and identifying the specific actions needed to these projects, if realized, will lead to actual operationalize the multi-disciplinary concept. implementation and field action of One Health. He also remarked on how the group took He recognized that this group was empowered inspiration from the larger vision to develop and has empowered individuals in terms of key actions. next steps for One Health in the United States, specifically with regard to a Presidential Directive It is apparent some actions will require a and the possibility of Congressional action considerable amount of time; cultural change, leveraging additional resources for domestic and in particular, does not happen overnight. Dr. international use. Dr. Khan ended his presentation Khan quoted from David Quammen’s book, The with a quote from Dr. Martin Luther King that he Reluctant Mr. Darwin: An Intimate Portrait of felt described the group’s efforts during the two Charles Darwin and the Making of His Theory and a half day meeting: “Your labors in pursuit of of Evolution, where Darwin states, “In the long uplifting humanity have dignity and importance history of mankind, and humankind, those who and are due excellence.”

22 Appendix:

The Operationalizing “One Health”: A Policy James Zingeser, Epidemiologist, FAO Perspective—Taking Stock and Shaping an Implementation Roadmap meeting Elizabeth Mumford, Project Lead for the Global was organized by: Influenza Program, WHO

Carol Rubin, Associate Director for Zoonoses and Simone Magnino, Scientist, Department of Food One Health and Director of the One Health Office, Safety, Zoonoses and Foodborne Diseases, WHO CDC/NCEZID Laura Khan, Research Scholar, Program on Alex Theirmann, Advisor and President of the Science and Global Security, Woodrow Wilson Terrestrial Animal Health Code, OIE School of Public and International Affairs, Princeton University Kate Glynn, Veterinary Epidemiologist, Scientific and Technical Department, OIE Alain Vandersmissen, Coordinator, Influenza, “One Health”, Emerging Diseases of the Jan Slingenbergh, Senior Officer of the Directorate General External Relations, European Infectious Diseases Group/EMPRES, FAO Commission (EC)

i World Health Organization. World Health Report 2007. A safer future: global health security in the 21st Century. 23 For more information please contact: Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: [email protected] Web: www.atsdr.cdc.gov Publication date: February 2011