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Implementing a One Health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions

Implementing a One Health approach to emerging infectious disease: reflections on the... Background: ‘One Health’ represents a call for health researchers and practitioners at the human, animal and environmental interfaces to work together to mitigate the risks of emerging and re-emerging infectious diseases (EIDs). A One Health approach emphasizing inter-disciplinary co-operation is increasingly seen as necessary for effective EID control and prevention. There are, however, socio-political, ethical and legal challenges, which must be met by such a One Health approach. Discussion: Based on the philosophical review and critical analysis of scholarship around the theory and practice of One Health it is clear that EID events are not simply about pathogens jumping species barriers; they are comprised of complex and contingent sets of relations that involve socioeconomic and socio-political drivers and consequences with the latter extending beyond the impact of the disease. Therefore, the effectiveness of policies based on One Health depends on their implementation and alignment with or modification of public values. Summary: Despite its strong motivating rationale, implementing a One Health approach in an integrated and considered manner can be challenging, especially in the face of a perceived crisis. The effective control and prevention of EIDs therefore requires: (i) social science research to improve understanding of how EID threats and responses play out; (ii) the development of an analytic framework that catalogues case experiences with EIDs, reflects their dynamic nature and promotes inter-sectoral collaboration and knowledge synthesis; (iii) genuine public engagement processes that promote transparency, education and capture people’s preferences; (iv) a set of practical principles and values that integrate ethics into decision-making procedures, against which policies and public health responses can be assessed; (v) integration of the analytic framework and the statement of principles and values outlined above; and (vi) a focus on genuine reform rather than rhetoric. Keywords: One health, Emerging infectious disease, Zoonoses, Bioethics, Health policy, Health law * Correspondence: chris.degeling@sydney.edu.au Centre for Values, Ethics and the Law in Medicine, K25 Level 1, Medical Foundation Building, University of Sydney, Sydney, NSW 2006, Australia Marie Bashir Institute for Infectious Disease and Biosecurity, University of Sydney, Sydney, Australia Full list of author information is available at the end of the article © 2015 Degeling et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Degeling et al. BMC Public Health (2015) 15:1307 Page 2 of 11 Background crisis. In this paper we examine the socio-political, eth- The recent Ebolavirus (EBOV) outbreak in West Africa ical and legal considerations implied by a One Health and continuing human infections with a novel H7N9 in- approach to EIDs. First we describe how a One Health fluenza A virus in mainland China are salient reminders approach could galvanise and enhance current capacity of how human and nonhuman health are inextricably in EID prevention and control. Making reference to case linked. Nonhuman animals are the source of 70 % of examples, we then identify and characterise socio- emerging and re-emerging infectious disease (EID) political, ethical and legal concerns that have the poten- threats to human health [1], and more than half of all tial to limit the effectiveness of One Health interven- established human pathogens [2]. The threats posed by tions. Finally, we draw on this data to provide guidance EIDs are dynamic. EIDs are caused by pathogens that as to how these concerns and issues might be addressed, can change their behaviour over time – either through and point to remaining challenges to the likely success genetic modification or through changes in the patterns of the One Health approach to EID control and and pathways of transmission [3]. Social, economic and prevention. political systems can either promote or inhibit pathogen transfer, and the incidence and pathogenicity of the dis- Methods ease [4]. While a lack of data makes quantitation diffi- In order to explore the broader implications of a One cult, EIDs and zoonoses account for a significant Health approach we employed philosophical and qualita- proportion of the global disease burden [5]. EIDs and tive methods to map existing and potential scientific, emergence of zoonotic pathogens, including human im- ethical and political responses to EIDs in Australia and munodeficiency virus (HIV), are direct causes of an esti- our region. The overarching philosophical approach is mated 15 million deaths worldwide each year [6]. that of developing sustained arguments that critically A One Health approach is increasingly considered to analyse the existing literature and reconceptualise or re- be the most effective way of managing EID threats [7, 8] fine key concepts. This conceptual information is often because it represents an acknowledgement of certain observed in exemplars and paradigm cases. In particular facts about the nature of disease, which are then de- we focused on materials pertaining to the social, political ployed to structure the response. One Health is and ethical consequences of responses to the risks posed grounded in a recognition that human, animal and en- to human health and wellbeing by Hendra virus [HeV], vironmental health are interdependent [9], that animal Nipah virus [NiV] and Rabies virus [RbV] in Australasia, species provide a shared reservoir for pathogen exchange and compared them with international responses to ca- and spread, and that many EIDs are driven by varied nonical examples of pandemic and food borne zoonoses and dynamic human-animal interactions [9, 10]. The re- – severe acute respiratory syndrome (SARS) [17] and sponse One Health offers is to deconstruct the disciplin- bovine spongiform encephalitis/variant Creutzfeldt Jacob ary silos [11] which have separated biomedical and disease (BSE/vCJD), respectively. A synopsis of the char- social sciences devoted to the study of human disease acteristics and burdens of these diseases and the patho- from those devoted to nonhuman disease and ecological gens that cause them are outlined in Boxes 1 and 2. concerns [12, 13]. Inter-disciplinary research is called for Because our aim was to generate inductive insights and required, as is interventionist practice at local, na- and develop a robust set of arguments – rather than a tional and international levels involving: policymakers, comprehensive catalogue of every case example or publi- planners, regulators, physicians, veterinarians, ecologists, cation – the sample evolved iteratively from searches of public and animal health officials, environmental health textual sources such as publicly available international officers, microbiologists, and other allied natural and so- (e.g. WHO) and government reports; academic data- cial scientists [10, 14]. bases (e.g. PubMed); online/print news services (Factiva); Although principally associated with EID prevention organizational newsfeeds (Centers for Disease Control); and control, One Health is also relevant to prevention and the websites of major One Health collaborations and control of endemic and zoonotic animal diseases, as [18]. Materials in the sample were read and qualitatively well as securing food safety [15, 16]. Considering the reviewed through an iterative process of testing, revising magnitude and complexity of global issues surrounding and refining our definitions, principles and theoretical infectious disease and food security, the One Health ap- generalisations [19, 20] – against the emerging concep- proach has the potential to provide the creative, effective tual map and feedback from the research team. Led by and sustainable solutions required. the first author, this cycle of searching, mapping and Despite its strong motivating rationale, implementing critical analysis continued until a period where new text- a One Health approach can be challenging. Dealing with ual materials were not providing substantive new in- EIDs in an integrated and considered manner can be sights and the team was confident that a position of highly problematic, especially in the face of a perceived conceptual saturation had been achieved. In what Degeling et al. BMC Public Health (2015) 15:1307 Page 3 of 11 follows we draw on these analyses and reflections to de- Table 1 EIDs of immediate importance to Australasia scribe the content, context and nature of the challenges Hendra virus infection is endemic among at least two species of flying fox in Australia and causes rare, but catastrophic, human infection [85]. that need to be faced for the effective implementation of Loss of habitat has led to increasingly intense incursions of flying foxes a One Health approach to EID control and prevention. into populated rural and peri-urban areas and promoted the ‘spill-over’ of Hendra virus into horses and then to people [86]. Hundreds of people have been directly exposed to Hendra virus, with seven confirmed Findings human infections and four deaths since 1994. With over one hundred EID prevention and control strategies require a One Health dead horses and persistent risk, the emergence of Hendra has had approach significant impact on equine and tourist industries in north eastern Australia, diverted major research resources and caused significant One Health is a holistic approach that emphasizes, distress and controversy in the broader community [31, 87]. but is not restricted to, the need to understand and Nipah virus, a close relative of Hendra, is endemic in East Asian flying fox regulate the environmental context (human-animal- populations. In 1999, after a program of deforestation and agricultural ecosystem interface) of disease emergence and development in Eastern Malaysia it spread to pigs then humans and expression [21]. EIDs are characterized by their com- other animals, causing respiratory disease and severe encephalitis [88]. It subsequently was reported in India and Bangladesh. Humans can be plexity and uncertainty as to their causes, conse- infected directly from bats, by ingestion of contaminated food and from quences and likely solutions [22]. In broad terms, other humans. Among 522 confirmed human cases, the overall mortality the occurrence and cross-species transmissibility of was greater than 50 % [89]. Nipah control programs devastated Malaysia’s pig industry and caused high unemployment and dislocation many emerging pathogens, like Ebolavirus (EBOV) of rural populations, at a cost of more than US$1 billion to the national and H7N9, arise from human activities such as economy [90]. Nipah virus has been identified by WHO as a likely cause changes in land use, growth in global trade and of future pandemics. travel and intensification of animal husbandry prac- Rabies virus infects the central nervous systems of people, wildlife and domestic mammals. The disease is transmitted by bites from infected tices [23–25]. The speed with which our understand- animals and once it becomes symptomatic, it is virtually always fatal. ing of the biology and epidemiology of H7N9 has 55,000 people die and 7.5 million receive post exposure prophylaxis developed demonstrates how much our ability to re- annually, costing $124 billion [91]. Rabies is endemic in much of South East Asia but its range is expanding. Focusing on Australia, the spond to new EID threats has improved over the last continent is free from Rabies, but the current expansion of the disease few decades. Yet despite advances in immunobiology in Indonesia [92] is a genuine threat to northern regions. Although likely and genomics that have contributed to diagnostics, controllable in domestic dog populations [93], if Rabies were to become endemic amongst wild or feral animals in this setting, current modelling therapeutics, and vaccine development, the threat of indicates it would be almost impossible to eradicate [94]. EIDs to human health and community wellbeing persists. Part of the reason why EID threats remain in spite of of choices that will have to be made. This suggests that scientific advances, are that EID events are not simply the One Health approach needs more than inter-sectoral about pathogens jumping species barriers. The threats collaboration and robust health legislation, as the unique posed by EIDs are comprised of complex and contingent nature of EIDs critically limits the effectiveness of scien- sets of relations that involve socioeconomic and socio- tific, top-down and technocratic approaches to govern- political drivers and consequences, with the latter ex- ance [29]. tending beyond the impact of the disease. The social, cultural and economic impacts of zoonoses are signifi- Table 2 Significant historical (i.e. effectively eradicated) EIDs cant. The examples contained in Tables 1 and 2 demon- Severe acute respiratory syndrome (SARS) is a human respiratory infection, caused by a coronavirus isolated from Chinese horseshoe bats [95]. It strate the difficult balance between the human health was first reported in Asia in 2003 and, within a few months, spread to risks and socioeconomic and cultural costs of EID con- thirty seven countries in the Americas, Europe and Asia. It affected more trol [26, 27]. Policy decisions should be based on sound than 8000 people and caused 774 deaths, before being successfully eliminated by concerted international efforts. The outbreak and fear that evidence – but it is often the case in dealing with EIDs another pandemic could occur are estimated to have cost Canadian that the evidence required is absent or fluid. EID events and east Asian economies US$200 billion [27]. are often dynamic situations that are characterised by Bovine spongiform encephalitis/variant Creutzfeldt Jacob disease (BSE/ uncertainty. As events unfold new evidence is created. vCJD) is a rare but fatal human neurodegenerative condition, caused by Consequently decisions made on the basis of present consumption of bovine products contaminated with the prions that cause BSE. Since vCJD was first identified in 1996, 175 cases have been data can be seen as wrong in the future, as more evi- reported in the UK and forty nine elsewhere. The World Bank estimates dence and a better understanding emerges. that the direct costs of vCJD/BSE to date exceed more than US $11 Official reviews of canonical EID events such SARS billion. Infected herds and the control measure imposed to prevent further infections devastated agricultural communities. The impacts of [17] and BSE/vCJD [28] share two key findings: (i) that the emergence of a new zoonotic disease amongst the British public actions to reduce risk should not be predicated on scien- were far broader than agriculture, including the cessation of UK plasma tific certainty; and (ii) that policies to deal with the risks production because of potential iatrogenic infection. With an estimated one in 4000 UK residents carrying vCJD, the burdens will continue well and effects of an EID need to be founded on widely held into this century [96]. values, so that people understand, in advance, the kinds Degeling et al. BMC Public Health (2015) 15:1307 Page 4 of 11 Implementing a One Health approach faces socio-political, emergence and transmission – a case example being the ethical and legal challenges focus on vaccine development and the husbandry prac- The success of One Health depends on more than scien- tices of horse owners in response to the zoonotic risks tific knowledge and technical achievement because some of Hendra virus [31, 36].. of the issues that arise in addressing EID risks are so- The political impetus for action in response to many called ‘wicked problems’ [30]. When a new EID threat EIDs is not necessarily scientific evidence but societal emerges there are rarely ready-made solutions and perceptions. Indeed, in the face of scientific uncertainty health policymakers and practitioners are often forced to and ethical ambiguity, ideological perspectives and make tragic choices that may contravene widely held short-term political considerations often supplant efforts values. Considerations must include the need to protect to devise effective long-term interventions [28, 37]. public health and the wider social, economic and envir- Political imperatives to avoid, or at least minimise, onmental impacts of proposed interventions. Economic public concern whilst dealing with EIDs can also prove and political interests can complicate the decision- challenging. In the case of BSE, powerful interests domi- makers’ motives and decision-maker uncertainty is com- nated early government responses, leading policymakers pounded by policy decisions becoming entangled in pol- to make decisions that avoided public controversy, but itical, ethical and legal considerations [31–33]. As events had major economic consequences. As the crisis un- surrounding the EBOV outbreak in West Africa illus- folded, expertise became politicized leading to conflict trate, the importance placed on a specific EID threat at between agencies and policy inconsistency between any one time also depends on who is setting the agenda health communication strategies and the measures being [34]. Therefore to be successfully implemented, the One taken to minimize the risks to human health [38]. Even Health approach must address a range of socio-political, when the link between BSE and vCJD became clear, ethical and legal challenges that arise as a consequence existing feed bans were poorly enforced and risk com- of the spread of infection within and between species. munication was dominated by fear of public panic [39]; Most of these challenges are not unique to One Health, even as the decision was made to remove all potential but are shared by any approach to addressing EIDs. sources of human infection from the UK food supply, However these challenges frequently go unrecognized. messages were confused and policy implementation im- In the following section we will clarify the nature of peded by poor co-ordination between agencies [28]. these issues so they can be addressed later in the paper. A common but problematic response to EID threats has been to invoke the precautionary principle. Roughly (1)Socio-political challenges speaking, the precautionary principle can be applied in situations where human activities create a scientifically A focus on individualism, perceptions, short term so- plausible, but uncertain, risk of significant harm. In re- lutions, populism and avoiding controversy are features sponse the principle advocates that actions ought to be of political life, which can prove challenging for EID pol- taken to avoid or reduce the harm, and that these ac- icy and work against developing effective strategies for tions need to be proportionate to the seriousness of the addressing EIDs. potential harm. In other word, in the absence of evi- Policy responses to EID events such as Nipah and dence take a conservative approach. Hendra virus infections (outlined in Box 1) tend to focus However applying the precautionary principle to EIDs on necessary and proximal causes (what individuals do in an attempt to protect the public can result in what, in to put themselves at direct risk from an infectious retrospect, amounts to an excessive response. This oc- pathogen) because the science about other aspects of curred with attempts to control Nipah infection, where EIDs is often complex, uncertain and lacking a clear nar- significant damage was inflicted on industry, livelihoods rative. Compounding this, our moral psychologies have and the economy. Similarly, experience with highly evolved to respond to direct harms – not indirect distal pathogenic avian influenza (HPAI) H5N1 in China and causal stories. Many people in liberal democracies be- SE-Asia showed that overzealous policy responses can lieve that they are entitled to rights and freedoms that destroy livelihoods and threaten food supplies [40, 41]. cannot be sacrificed merely for the marginal gains of In Vietnam alone, almost 40 million birds were culled in others. As the discourse surrounding climate change and 2004 in an attempt to eradicate HPAI. Although many other wicked problems illustrates, this promotes techno- birds were owned by large commercial operations, logical solutions because they do not require substantive others were kept by ‘backyard’ farmers and villagers. changes in human behaviours and underlying values sys- Mass culling of poultry appears decisive, but places ex- tems. [35] The net result is that the policy focus for EID cessive burdens on vulnerable populations, is ineffective prevention and control tends to remain on individual in the context of extensive ‘backyard’ poultry farming behaviours rather than the structural drivers of and can, in fact, promote the spread of disease [42]. A Degeling et al. BMC Public Health (2015) 15:1307 Page 5 of 11 similar scenario is currently playing out with Rabies con- citizens to whom it is applied, otherwise it can become trol in Bali. mired in controversy about whose values should prevail Unfortunately, the precautionary principle and analytic [31, 37, 49]. Therefore, one of the first and most import- tools and concepts appealed to in this domain, fail to de- ant tasks of policy work is to establish how the public liver what is required at times of EID outbreaks since interest is best defined. they do not advance public engagement or help resolve disagreements in times of uncertainty [43, 44]. Philo- (3)Legal challenges sophical critiques of the precautionary principle applied to EIDs have also shown its limitations, including that The legal environment in which EID policy is made defining criteria by which to judge a threat as plausible and in which responses to outbreaks occur, presents its and a response proportionate, often will only substitute own set of challenges. The law surrounding EID re- one uncertainty for two others [45]. sponses in most jurisdictions is diffuse, complicated and often subject to re-interpretation on the basis of whose (2)Ethical challenges interests are given primacy at the time decisions are made. Moreover, in many countries different approaches The effectiveness of an EID control policy will depend by State/Provincial and local authorities, overlaid by on the context of its implementation and particularly its Federal/National powers, complicate regulation so much alignment with stakeholder and public values [17, 46]. In that ‘hard law’ is often replaced by resort to ‘soft law’ of modern liberal democracies at least some consensus executive and administrative powers and international over what is in the public interest and an understanding instruments, such as the International Health Regula- of the values which support it, is therefore required for tions (IHR) [50]. This may add complexity and confu- the successful implementation of EID responses. Yet this sion to the EID regulatory structures, rather than is precisely what has been lacking in outbreaks where facilitating public health responses to a new threat. Such fracture lines, differences and value conflicts have be- confusion provides a salient reminder that even in ‘glo- come apparent. When the stakes are high, evidence and bal law’ approaches to EIDs, the sovereign state remains the implications of actions are uncertain, the situation is the institution responsible for regulation and control complex and resources may be limited but where deci- [51]. sions need to be made, differences are exposed. Such dif- Public health law responses to EIDs tend to be ori- ferences could be around beliefs about how to deal with ented towards controlling cross-border pathogen trans- ecological and environmental issues, which may conflict fer and community outbreaks rather than the underlying with the importance people attach to public goods, pro- deficiencies and structural conditions from which the tection of individual autonomy and animal welfare [47]. threats emerge. Other laws, such as environmental law, These conditions of crisis and division are conducive to may be more useful in addressing structural conditions undesirable consequences including public fear, mistrust, for emergence. Changes in land use and agricultural in- misinformation and non-compliance with public health tensification in developing societies are major drivers of directives. For example in Canada during the SARS cri- EID. However, the cost of laws that restrict development sis, leaders were unprepared for the range of ethical con- may be greater global health inequities, with consequen- flicts that arose, including those over: individual freedom tial effects for health outcomes. In order to clarify EID- versus the common good; healthcare workers’ safety ver- related legal tensions between economic development sus their duty to care for the sick; and economic costs and health security, a more explicit recognition is versus the need for containment [48]. As indicated in needed of who are the primary beneficiaries and who Box 2, both the outbreak itself and fear that another bears the costs of a One Health approach to EIDs [52]. outbreak could occur had significant economic Legal clarity around the frameworks designed to pro- consequences. tect populations from EIDs is critical to providing an en- Any approach which hopes to successfully respond to abling infrastructure to co-ordinate and support the One EID threats, including a One Health approach, needs to Health-based work of policymakers, development plan- address the ethical concerns articulated above. To this ners, human and animal health-workers and biosecurity end, potentially conflicting values and logic must be ne- agencies. gotiated to realise effective, sustainable and just solu- tions. Prioritisation and resource allocation require Discussion political processes based on fundamental ethical ques- One health and public values: implications for EID control tions about what is valuable, what is to be protected and prevention and, ultimately, what is dispensable. To be effective, The health of humans, animals, and ecosystems are in- public policy must be consistent with the values of terconnected. A One Health approach promises a better Degeling et al. BMC Public Health (2015) 15:1307 Page 6 of 11 understanding of how to prevent and control EIDs at socioeconomic context of affected or at-risk the human-animal-ecosystem interface. However the communities, need to be understood and addressed socio-political, ethical and legal challenges of EIDs illus- by policymaking processes. This should ensure that trated above highlight how responses to infectious dis- manifest injustice, livelihood-based decisions and ease threats are intrinsically value laden. When a new other social and cultural factors do not undermine infectious pathogen such as Hendra or Nipah virus first the effectiveness of favoured control measures. appears, or a known threat such as Rabies or Ebola Without adequate knowledge of specific local encroaches on a new setting, there is limited scientific arrangements, there is a danger that insufficiently evidence or past experience to guide decisions or deter- nuanced or unified approaches to EIDs will actually mine whether a planned response will be proportionate. undermine the heterogeneous relationships and Vastly different interpretations of EID events and their contingent practices that make health possible in likely outcomes might be supported by the available circumstances of structural disadvantage [56, 58]. data. Policymakers and practitioners therefore have little guidance as to what they should do when faced with a The social sciences are analytically broader and more nascent infectious disease threat, only what they can do. policy focussed than the natural sciences. Whereas the As others [52–54] have cogently argued, they must natural sciences tend to frame infectious disease threats therefore ask themselves: whose health is being priori- narrowly as matters of biological integrity and security, tized; which public and which good are we seeking to such that barrier technologies and hygiene practices protect? dominate the logic of interventions [59], social science Notwithstanding recognition of a need for comple- approaches go beyond this. Building social scientific evi- mentary work on values-based questions that inevitably dence for use in conjunction with natural scientific evi- surround EID risks and EID control, the adoption of the dence about EIDs aligns with the growing realization One Health approach, so far, has not included develop- that EID emergence is as much about the social and eco- ment of a comprehensive, ethically-informed policy and nomic configuration of capital flow as it is about the bio- implementation framework; this has limited its practical logical features of host-pathogen interactions. Current utility [9, 55]. Despite rhetorical and some financial sup- approaches to the economic and structural drivers of port for One Health as the guiding ethos by which to ad- EID emergence still presume that state and market neo- dress interconnected human, animal and environmental liberalism is part of the natural order, even as evidence health issues, its impact will be minimal unless implica- is mounting that these systems of development are cen- tions of uncertainty on, and potential conflicts between, tral to the problem [60, 61]. Moreover, the current em- human values and political processes are recognised and phasis on microbiology and focus on newer molecular articulated. Any attempt to address these ethical and techniques to characterise pathogens, is drawing atten- normative dimensions must take into account the dy- tion away from developing better understandings of the namic nature of EID risk management. A policy that environmental, economic and social drivers of EIDs. seems reasonable today may be inappropriate tomorrow, While this is understandable given the desire for vac- in light of new evidence. And when situations are uncer- cines and drugs to solve EIDs, if One Health researchers tain, decision-makers inevitably fall back on their values. and practitioners broaden their approach to causality to Therefore, a solid framework based on shared values is include upstream, social and economic systemic causes, needed to support decision-making surrounding EIDs questions and issues that have been traditionally brack- when “evidence” is – or may be – unreliable, and rapidly eted or thought best avoided will become central to the changing or fluid. cross-sectoral collaboration implied by One Health. What is needed to guide a one health approach to EIDs? (ii)The development of a One Health Analytic To successfully meet the challenges described above, Framework (OHAF) needs to be pursued. Such a particularly the necessity to align EID policy with public framework would catalogue case-based experiences values, a One Health approach needs to engage in the and reflect the particular dynamics of specific EIDs, following. and promote inter-sectoral collaboration and know- ledge synthesis, including integration of information (i) Social science and economic research to help about social, cultural and economic impacts, control catalogue and describe the drivers, mechanisms and measures and uncertainty [62, 63]. The framework social and political configurations through which would serve as a prompt to ensure that minority EIDs become threats to human, animal and perspectives are represented and all relevant ecological health [56, 57]. The complex connections concerns are considered. An OHAF could provide a between individual social needs and the local rubric for comparisons between outbreaks. This Degeling et al. BMC Public Health (2015) 15:1307 Page 7 of 11 would allow the inherent complexities of economic in the UK, Australia, the US and elsewhere [69–72] to and societal responses to EIDs to be compared, to explore similar issues and identify citizens’ preferences. inform policy processes. It is vital for discussions They represent informed public opinion better than about EID prevention and control to have this kind of other social research methods (e.g. surveys or focus sound empirical foundation, because uncertainty and groups) because they give participants factual informa- media coverage have the potential to drive bad policy. tion, bring them into a structured and constructive dia- logue with experts, provide them with time to reflect Development of an OHAF could be facilitated by and deliberate, and allow them to represent their views adopting well established and methodically rigorous directly to policymakers. processes such as Framework Analysis, produced by the National Centre for Social Research (UK) [19], or Multi- (iv)The development of a clear Statement of Principles Criteria Decision Analysis [MCDA] developed within the and Values (SPV) for integration of ethical field of decision science [64]. In the first instance Frame- principles and values into decision-making is needed. work Analysis would allow for systematic incorporation This should be based on empirical data about peo- of the perspectives and contributions of different schol- ple’s beliefs, including which public health outcomes arly disciplines and expert stakeholders. Framework and public goods should be prioritized and why; Analysis facilitates movement between different datasets, how to adjudicate conflicting claims and preferences; thematic areas, theoretical resources, and levels of and what levels and types of evidence should be pri- abstraction without loss of conceptual clarity [65]. The vileged in these decisions. Framework method is used to organize and manage re- search and interpretation through the process of To be successful, One Health needs to be about more summarization, which is codified into a robust and flex- than disease prevention and control. The dynamic, un- ible matrix that allows the policymaker/researcher to predictable effects and risks to peoples’ lives of EIDs ne- analyze data both by case and theme. It is commonly cessitate a public health and biosecurity infrastructure used in areas such as health research, policy develop- equipped to address the ethical problems that arise. EID ment and program evaluation. Equally, MCDA methods management must therefore be based on normative offer an alternative and potentially complementary principles as well as local knowledge, operational experi- approach to OHAF development. Comprised of a suite ence and disease-specific scientific and economic evi- of analytic strategies, MCDA have been shown to be dence. This means that governments and policy-makers valuable tools for prioritization and decision-making in need to explain and justify the values that underlie animal and human health [64]. MCDA provides a frame- decision-making and engage the public in discussions work to compare policy alternatives with diverse and about ethical choices, so that when difficult decisions often intangible impacts, which can be particularly use- arise in the face of uncertainty, they will be accepted as ful in determining and justifying the prioritization and fair and essential for the public good [47]. This necessi- mobilization of limited research and public health re- tates that the guiding values and likely ethical choices sources [66, 67]. need to be articulated in a formal statement in advance, as in the heat of emerging health threat, decision makers (iii)Genuine processes of public engagement across the will be under pressure from many sources to ‘do some- developed and developing world are also essential to thing quickly’. a successful One Health approach. These processes are not so much about engaging in deliberative (v)Integration of an OHAF and SPV with the IHR and democracy for policy decision-making, as about de- relevant national health and biosecurity legislation is fining the principles and values that should guide essential so that policymakers and practitioners can decision-making. This means procedural inclusive- dynamically test their decision-making. ness alone is not enough to ensure transparency and reflexivity, to capture people’s preferences and to ef- Our response should of course be based on the best fectively communicate with the public [68]. scientific evidence, but EIDs are not just scientific issues, they also have significant social, ethical and animal The successful implementation of the One Health ap- rights dimensions. Experiences of infectious disease proach to EIDs will depend on public trust and co- threats such as BSE/vCJD and SARS indicate that there operation. Public support for unpalatable measures is have been problems combining evidence and human more likely if citizens understand the issues, and policy values at both local and policy levels [28, 73]. The com- implementation reflects community values and prefer- municability of diseases between species raises social, ences. To this end, citizens’ juries have been employed ethical and legal issues that have not been clearly Degeling et al. BMC Public Health (2015) 15:1307 Page 8 of 11 elucidated or adequately addressed. Our response to the realignment and policy integration of Health nonhuman animal disease is not determined solely by Departments with other government agencies bio-scientific knowledge; the way people and animals live [78, 79]. Unfortunately in this case as others, with and amongst each other is also shaped by social attempts at promoting inter-sectoral approaches norms, economic imperatives and human values. In mat- rarely move beyond rhetoric – even when driven by ters of public health it is no longer sufficient to ask what the best intentions and supported by substantial works and what is the strength of the evidence; we also resources [80–82]. need to ask ethical questions about how we should seek to live, and what is the right thing to do [74–76]. Con- The problem is that arguments that promote the need sensus about the best approaches to EID control and for greater co-operation between sectors tend to focus prevention are not always possible, however an agreed on the likely benefits of collaboration rather than what set of guiding principles and values can be a means to reform would entail – that is, what needs to be done or- ensure dialogue, if not always agreement. ganisationally and politically to achieve the desired out- The development of an OHAF and SPV will also pro- comes [83]. Established ‘sectors’– whether orientated mote clearer communication about public risk. Signifi- towards human or animal health, agriculture or the en- cant EID threats have major implications for distribution vironment – have genealogies, traditions and rationali- of scarce resources, access to and regulation of health ties of “what we are here for” that have been shaped by services and maintenance of social order. As described social, political and administrative processes [11]. As in- above it is also clear that policy and legal responses to stitutions, they are philosophically and structurally re- EID threats are often highly politicised and compro- sistant to change that diverts resources and re-orients mised by failure to communicate clearly with the public. practices away from their own sectoral priorities [83]. In Policymakers responsible for responding to disasters essence, they have their own constituencies to serve. As such as EIDs typically find that there is a dissonance be- a consequence, establishment and implementation of tween transparency that may appear alarmist versus mechanisms that enhance information-sharing, collabor- withholding information to avoid panic. Regardless of ation and inter-sectoral co-operation, such as working advice, people will make their own decisions based on groups and interdepartmental committees, have rarely their interpretation of available information, from formal delivered the outcomes promised in the past. Responses and informal channels. So public communication, before to BSE/vCJD in the UK [28], HPAI in South East Asia and during a public health emergency, is frequently as [11], and recent case studies of One Health programs in important as political decisions and regulatory changes Uganda [84], suggest that more work is needed to co- [39, 77]. This means that, to be effective, a One Health ordinate implementation and overcome sectoral inter- approach – like any EID policy – must deal with scien- ests. The complexity of the problems posed by EIDs tific uncertainty, whilst addressing the socio-political, mean that organising effective control and prevention ethical and legal dimensions of effective health commu- programs will require genuine cross-sectoral integration nication and intervention strategies [3]. By exposing and, potentially, re-sectoring of some institutional and decision-making processes to reveal the scientific and professional responsibilities [62]. And as the recent Ebo- normative uncertainties and ethical complexities, the lavirus disease outbreak illustrates, there must also be introduction of an OHAF and a SPV into One Health sustained social and political willingness to achieve theory and practice may incorporate iterative deliber- control. ation and learning into EID policy processes. If One Health is genuinely the way forward, as we be- lieve it is, then we should do more than talk about its (vi)Finally, One Health must be about genuine reform potential benefits. Without genuine cross-sectoral re- rather than merely rhetoric. A One Health approach form and a radical broadening of the scope of its inquiry rests on the assumption that the cross-sectoral inte- into how specific social, cultural and spatial configura- gration of expertise, research methodologies and tions promote the risks of EID emergence, One Health public health infrastructure will inevitably improve is in danger of becoming merely a rhetorical strategy to capacity for disease-risk prediction and effective avoid conflict between its core disciplines, whereby prac- intervention. However, calls for increased inter- titioners, researchers and policymakers will espouse the sectoral co-operation by public health practitioners, methodological and moral case for interdisciplinary col- clinicians, scientists and policy-makers are not a new laboration yet remain in their silos [11]. Even if these phenomenon. For example in the 1990s advocates of barriers are overcome the One Health approach will only “new public health” called for health authorities to succeed if it explicitly acknowledges local contingent turn their attention to the social, economic and and contextual dimensions of disease risk and disease environmental factors that affect health – requiring expression and the political impacts of scientific Degeling et al. BMC Public Health (2015) 15:1307 Page 9 of 11 uncertainty, while also seeking to accommodate the Sydney, Sydney, Australia. Menzies Centre for Health Policy, University of Sydney, Sydney, Australia. Sydney Law School, University of Sydney, Sydney, values and preferences of ‘at risk’ and affected individ- Australia. Centre for Infectious Disease and Microbiology – Public Health, uals. Further, we suggest that decision making around Westmead Hospital, Sydney, Australia. EIDs requires an ethical framework that reflects the Received: 30 July 2015 Accepted: 16 December 2015 values of affected and ‘at risk’ communities, privileges justice, takes account of human flourishing, protects ani- mal health and welfare and is developed in consultation References with relevant stakeholders and the public. 1. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, et al. Global trends in emerging infectious diseases. Nature. 2008;451(7181):990–3. Conclusions 2. Woolhouse ME, Gowtage-Sequeria S. Host range and emerging and reemerging pathogens. Emerg Infect Dis. 2005;11(12):1842–7. EID risk management is a major global public health 3. Morens DM, Folkers GK, Fauci AS. 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Implementing a One Health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions

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References (111)

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Springer Journals
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Copyright © 2015 by Degeling et al.
Subject
Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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1471-2458
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10.1186/s12889-015-2617-1
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26715066
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Abstract

Background: ‘One Health’ represents a call for health researchers and practitioners at the human, animal and environmental interfaces to work together to mitigate the risks of emerging and re-emerging infectious diseases (EIDs). A One Health approach emphasizing inter-disciplinary co-operation is increasingly seen as necessary for effective EID control and prevention. There are, however, socio-political, ethical and legal challenges, which must be met by such a One Health approach. Discussion: Based on the philosophical review and critical analysis of scholarship around the theory and practice of One Health it is clear that EID events are not simply about pathogens jumping species barriers; they are comprised of complex and contingent sets of relations that involve socioeconomic and socio-political drivers and consequences with the latter extending beyond the impact of the disease. Therefore, the effectiveness of policies based on One Health depends on their implementation and alignment with or modification of public values. Summary: Despite its strong motivating rationale, implementing a One Health approach in an integrated and considered manner can be challenging, especially in the face of a perceived crisis. The effective control and prevention of EIDs therefore requires: (i) social science research to improve understanding of how EID threats and responses play out; (ii) the development of an analytic framework that catalogues case experiences with EIDs, reflects their dynamic nature and promotes inter-sectoral collaboration and knowledge synthesis; (iii) genuine public engagement processes that promote transparency, education and capture people’s preferences; (iv) a set of practical principles and values that integrate ethics into decision-making procedures, against which policies and public health responses can be assessed; (v) integration of the analytic framework and the statement of principles and values outlined above; and (vi) a focus on genuine reform rather than rhetoric. Keywords: One health, Emerging infectious disease, Zoonoses, Bioethics, Health policy, Health law * Correspondence: chris.degeling@sydney.edu.au Centre for Values, Ethics and the Law in Medicine, K25 Level 1, Medical Foundation Building, University of Sydney, Sydney, NSW 2006, Australia Marie Bashir Institute for Infectious Disease and Biosecurity, University of Sydney, Sydney, Australia Full list of author information is available at the end of the article © 2015 Degeling et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Degeling et al. BMC Public Health (2015) 15:1307 Page 2 of 11 Background crisis. In this paper we examine the socio-political, eth- The recent Ebolavirus (EBOV) outbreak in West Africa ical and legal considerations implied by a One Health and continuing human infections with a novel H7N9 in- approach to EIDs. First we describe how a One Health fluenza A virus in mainland China are salient reminders approach could galvanise and enhance current capacity of how human and nonhuman health are inextricably in EID prevention and control. Making reference to case linked. Nonhuman animals are the source of 70 % of examples, we then identify and characterise socio- emerging and re-emerging infectious disease (EID) political, ethical and legal concerns that have the poten- threats to human health [1], and more than half of all tial to limit the effectiveness of One Health interven- established human pathogens [2]. The threats posed by tions. Finally, we draw on this data to provide guidance EIDs are dynamic. EIDs are caused by pathogens that as to how these concerns and issues might be addressed, can change their behaviour over time – either through and point to remaining challenges to the likely success genetic modification or through changes in the patterns of the One Health approach to EID control and and pathways of transmission [3]. Social, economic and prevention. political systems can either promote or inhibit pathogen transfer, and the incidence and pathogenicity of the dis- Methods ease [4]. While a lack of data makes quantitation diffi- In order to explore the broader implications of a One cult, EIDs and zoonoses account for a significant Health approach we employed philosophical and qualita- proportion of the global disease burden [5]. EIDs and tive methods to map existing and potential scientific, emergence of zoonotic pathogens, including human im- ethical and political responses to EIDs in Australia and munodeficiency virus (HIV), are direct causes of an esti- our region. The overarching philosophical approach is mated 15 million deaths worldwide each year [6]. that of developing sustained arguments that critically A One Health approach is increasingly considered to analyse the existing literature and reconceptualise or re- be the most effective way of managing EID threats [7, 8] fine key concepts. This conceptual information is often because it represents an acknowledgement of certain observed in exemplars and paradigm cases. In particular facts about the nature of disease, which are then de- we focused on materials pertaining to the social, political ployed to structure the response. One Health is and ethical consequences of responses to the risks posed grounded in a recognition that human, animal and en- to human health and wellbeing by Hendra virus [HeV], vironmental health are interdependent [9], that animal Nipah virus [NiV] and Rabies virus [RbV] in Australasia, species provide a shared reservoir for pathogen exchange and compared them with international responses to ca- and spread, and that many EIDs are driven by varied nonical examples of pandemic and food borne zoonoses and dynamic human-animal interactions [9, 10]. The re- – severe acute respiratory syndrome (SARS) [17] and sponse One Health offers is to deconstruct the disciplin- bovine spongiform encephalitis/variant Creutzfeldt Jacob ary silos [11] which have separated biomedical and disease (BSE/vCJD), respectively. A synopsis of the char- social sciences devoted to the study of human disease acteristics and burdens of these diseases and the patho- from those devoted to nonhuman disease and ecological gens that cause them are outlined in Boxes 1 and 2. concerns [12, 13]. Inter-disciplinary research is called for Because our aim was to generate inductive insights and required, as is interventionist practice at local, na- and develop a robust set of arguments – rather than a tional and international levels involving: policymakers, comprehensive catalogue of every case example or publi- planners, regulators, physicians, veterinarians, ecologists, cation – the sample evolved iteratively from searches of public and animal health officials, environmental health textual sources such as publicly available international officers, microbiologists, and other allied natural and so- (e.g. WHO) and government reports; academic data- cial scientists [10, 14]. bases (e.g. PubMed); online/print news services (Factiva); Although principally associated with EID prevention organizational newsfeeds (Centers for Disease Control); and control, One Health is also relevant to prevention and the websites of major One Health collaborations and control of endemic and zoonotic animal diseases, as [18]. Materials in the sample were read and qualitatively well as securing food safety [15, 16]. Considering the reviewed through an iterative process of testing, revising magnitude and complexity of global issues surrounding and refining our definitions, principles and theoretical infectious disease and food security, the One Health ap- generalisations [19, 20] – against the emerging concep- proach has the potential to provide the creative, effective tual map and feedback from the research team. Led by and sustainable solutions required. the first author, this cycle of searching, mapping and Despite its strong motivating rationale, implementing critical analysis continued until a period where new text- a One Health approach can be challenging. Dealing with ual materials were not providing substantive new in- EIDs in an integrated and considered manner can be sights and the team was confident that a position of highly problematic, especially in the face of a perceived conceptual saturation had been achieved. In what Degeling et al. BMC Public Health (2015) 15:1307 Page 3 of 11 follows we draw on these analyses and reflections to de- Table 1 EIDs of immediate importance to Australasia scribe the content, context and nature of the challenges Hendra virus infection is endemic among at least two species of flying fox in Australia and causes rare, but catastrophic, human infection [85]. that need to be faced for the effective implementation of Loss of habitat has led to increasingly intense incursions of flying foxes a One Health approach to EID control and prevention. into populated rural and peri-urban areas and promoted the ‘spill-over’ of Hendra virus into horses and then to people [86]. Hundreds of people have been directly exposed to Hendra virus, with seven confirmed Findings human infections and four deaths since 1994. With over one hundred EID prevention and control strategies require a One Health dead horses and persistent risk, the emergence of Hendra has had approach significant impact on equine and tourist industries in north eastern Australia, diverted major research resources and caused significant One Health is a holistic approach that emphasizes, distress and controversy in the broader community [31, 87]. but is not restricted to, the need to understand and Nipah virus, a close relative of Hendra, is endemic in East Asian flying fox regulate the environmental context (human-animal- populations. In 1999, after a program of deforestation and agricultural ecosystem interface) of disease emergence and development in Eastern Malaysia it spread to pigs then humans and expression [21]. EIDs are characterized by their com- other animals, causing respiratory disease and severe encephalitis [88]. It subsequently was reported in India and Bangladesh. Humans can be plexity and uncertainty as to their causes, conse- infected directly from bats, by ingestion of contaminated food and from quences and likely solutions [22]. In broad terms, other humans. Among 522 confirmed human cases, the overall mortality the occurrence and cross-species transmissibility of was greater than 50 % [89]. Nipah control programs devastated Malaysia’s pig industry and caused high unemployment and dislocation many emerging pathogens, like Ebolavirus (EBOV) of rural populations, at a cost of more than US$1 billion to the national and H7N9, arise from human activities such as economy [90]. Nipah virus has been identified by WHO as a likely cause changes in land use, growth in global trade and of future pandemics. travel and intensification of animal husbandry prac- Rabies virus infects the central nervous systems of people, wildlife and domestic mammals. The disease is transmitted by bites from infected tices [23–25]. The speed with which our understand- animals and once it becomes symptomatic, it is virtually always fatal. ing of the biology and epidemiology of H7N9 has 55,000 people die and 7.5 million receive post exposure prophylaxis developed demonstrates how much our ability to re- annually, costing $124 billion [91]. Rabies is endemic in much of South East Asia but its range is expanding. Focusing on Australia, the spond to new EID threats has improved over the last continent is free from Rabies, but the current expansion of the disease few decades. Yet despite advances in immunobiology in Indonesia [92] is a genuine threat to northern regions. Although likely and genomics that have contributed to diagnostics, controllable in domestic dog populations [93], if Rabies were to become endemic amongst wild or feral animals in this setting, current modelling therapeutics, and vaccine development, the threat of indicates it would be almost impossible to eradicate [94]. EIDs to human health and community wellbeing persists. Part of the reason why EID threats remain in spite of of choices that will have to be made. This suggests that scientific advances, are that EID events are not simply the One Health approach needs more than inter-sectoral about pathogens jumping species barriers. The threats collaboration and robust health legislation, as the unique posed by EIDs are comprised of complex and contingent nature of EIDs critically limits the effectiveness of scien- sets of relations that involve socioeconomic and socio- tific, top-down and technocratic approaches to govern- political drivers and consequences, with the latter ex- ance [29]. tending beyond the impact of the disease. The social, cultural and economic impacts of zoonoses are signifi- Table 2 Significant historical (i.e. effectively eradicated) EIDs cant. The examples contained in Tables 1 and 2 demon- Severe acute respiratory syndrome (SARS) is a human respiratory infection, caused by a coronavirus isolated from Chinese horseshoe bats [95]. It strate the difficult balance between the human health was first reported in Asia in 2003 and, within a few months, spread to risks and socioeconomic and cultural costs of EID con- thirty seven countries in the Americas, Europe and Asia. It affected more trol [26, 27]. Policy decisions should be based on sound than 8000 people and caused 774 deaths, before being successfully eliminated by concerted international efforts. The outbreak and fear that evidence – but it is often the case in dealing with EIDs another pandemic could occur are estimated to have cost Canadian that the evidence required is absent or fluid. EID events and east Asian economies US$200 billion [27]. are often dynamic situations that are characterised by Bovine spongiform encephalitis/variant Creutzfeldt Jacob disease (BSE/ uncertainty. As events unfold new evidence is created. vCJD) is a rare but fatal human neurodegenerative condition, caused by Consequently decisions made on the basis of present consumption of bovine products contaminated with the prions that cause BSE. Since vCJD was first identified in 1996, 175 cases have been data can be seen as wrong in the future, as more evi- reported in the UK and forty nine elsewhere. The World Bank estimates dence and a better understanding emerges. that the direct costs of vCJD/BSE to date exceed more than US $11 Official reviews of canonical EID events such SARS billion. Infected herds and the control measure imposed to prevent further infections devastated agricultural communities. The impacts of [17] and BSE/vCJD [28] share two key findings: (i) that the emergence of a new zoonotic disease amongst the British public actions to reduce risk should not be predicated on scien- were far broader than agriculture, including the cessation of UK plasma tific certainty; and (ii) that policies to deal with the risks production because of potential iatrogenic infection. With an estimated one in 4000 UK residents carrying vCJD, the burdens will continue well and effects of an EID need to be founded on widely held into this century [96]. values, so that people understand, in advance, the kinds Degeling et al. BMC Public Health (2015) 15:1307 Page 4 of 11 Implementing a One Health approach faces socio-political, emergence and transmission – a case example being the ethical and legal challenges focus on vaccine development and the husbandry prac- The success of One Health depends on more than scien- tices of horse owners in response to the zoonotic risks tific knowledge and technical achievement because some of Hendra virus [31, 36].. of the issues that arise in addressing EID risks are so- The political impetus for action in response to many called ‘wicked problems’ [30]. When a new EID threat EIDs is not necessarily scientific evidence but societal emerges there are rarely ready-made solutions and perceptions. Indeed, in the face of scientific uncertainty health policymakers and practitioners are often forced to and ethical ambiguity, ideological perspectives and make tragic choices that may contravene widely held short-term political considerations often supplant efforts values. Considerations must include the need to protect to devise effective long-term interventions [28, 37]. public health and the wider social, economic and envir- Political imperatives to avoid, or at least minimise, onmental impacts of proposed interventions. Economic public concern whilst dealing with EIDs can also prove and political interests can complicate the decision- challenging. In the case of BSE, powerful interests domi- makers’ motives and decision-maker uncertainty is com- nated early government responses, leading policymakers pounded by policy decisions becoming entangled in pol- to make decisions that avoided public controversy, but itical, ethical and legal considerations [31–33]. As events had major economic consequences. As the crisis un- surrounding the EBOV outbreak in West Africa illus- folded, expertise became politicized leading to conflict trate, the importance placed on a specific EID threat at between agencies and policy inconsistency between any one time also depends on who is setting the agenda health communication strategies and the measures being [34]. Therefore to be successfully implemented, the One taken to minimize the risks to human health [38]. Even Health approach must address a range of socio-political, when the link between BSE and vCJD became clear, ethical and legal challenges that arise as a consequence existing feed bans were poorly enforced and risk com- of the spread of infection within and between species. munication was dominated by fear of public panic [39]; Most of these challenges are not unique to One Health, even as the decision was made to remove all potential but are shared by any approach to addressing EIDs. sources of human infection from the UK food supply, However these challenges frequently go unrecognized. messages were confused and policy implementation im- In the following section we will clarify the nature of peded by poor co-ordination between agencies [28]. these issues so they can be addressed later in the paper. A common but problematic response to EID threats has been to invoke the precautionary principle. Roughly (1)Socio-political challenges speaking, the precautionary principle can be applied in situations where human activities create a scientifically A focus on individualism, perceptions, short term so- plausible, but uncertain, risk of significant harm. In re- lutions, populism and avoiding controversy are features sponse the principle advocates that actions ought to be of political life, which can prove challenging for EID pol- taken to avoid or reduce the harm, and that these ac- icy and work against developing effective strategies for tions need to be proportionate to the seriousness of the addressing EIDs. potential harm. In other word, in the absence of evi- Policy responses to EID events such as Nipah and dence take a conservative approach. Hendra virus infections (outlined in Box 1) tend to focus However applying the precautionary principle to EIDs on necessary and proximal causes (what individuals do in an attempt to protect the public can result in what, in to put themselves at direct risk from an infectious retrospect, amounts to an excessive response. This oc- pathogen) because the science about other aspects of curred with attempts to control Nipah infection, where EIDs is often complex, uncertain and lacking a clear nar- significant damage was inflicted on industry, livelihoods rative. Compounding this, our moral psychologies have and the economy. Similarly, experience with highly evolved to respond to direct harms – not indirect distal pathogenic avian influenza (HPAI) H5N1 in China and causal stories. Many people in liberal democracies be- SE-Asia showed that overzealous policy responses can lieve that they are entitled to rights and freedoms that destroy livelihoods and threaten food supplies [40, 41]. cannot be sacrificed merely for the marginal gains of In Vietnam alone, almost 40 million birds were culled in others. As the discourse surrounding climate change and 2004 in an attempt to eradicate HPAI. Although many other wicked problems illustrates, this promotes techno- birds were owned by large commercial operations, logical solutions because they do not require substantive others were kept by ‘backyard’ farmers and villagers. changes in human behaviours and underlying values sys- Mass culling of poultry appears decisive, but places ex- tems. [35] The net result is that the policy focus for EID cessive burdens on vulnerable populations, is ineffective prevention and control tends to remain on individual in the context of extensive ‘backyard’ poultry farming behaviours rather than the structural drivers of and can, in fact, promote the spread of disease [42]. A Degeling et al. BMC Public Health (2015) 15:1307 Page 5 of 11 similar scenario is currently playing out with Rabies con- citizens to whom it is applied, otherwise it can become trol in Bali. mired in controversy about whose values should prevail Unfortunately, the precautionary principle and analytic [31, 37, 49]. Therefore, one of the first and most import- tools and concepts appealed to in this domain, fail to de- ant tasks of policy work is to establish how the public liver what is required at times of EID outbreaks since interest is best defined. they do not advance public engagement or help resolve disagreements in times of uncertainty [43, 44]. Philo- (3)Legal challenges sophical critiques of the precautionary principle applied to EIDs have also shown its limitations, including that The legal environment in which EID policy is made defining criteria by which to judge a threat as plausible and in which responses to outbreaks occur, presents its and a response proportionate, often will only substitute own set of challenges. The law surrounding EID re- one uncertainty for two others [45]. sponses in most jurisdictions is diffuse, complicated and often subject to re-interpretation on the basis of whose (2)Ethical challenges interests are given primacy at the time decisions are made. Moreover, in many countries different approaches The effectiveness of an EID control policy will depend by State/Provincial and local authorities, overlaid by on the context of its implementation and particularly its Federal/National powers, complicate regulation so much alignment with stakeholder and public values [17, 46]. In that ‘hard law’ is often replaced by resort to ‘soft law’ of modern liberal democracies at least some consensus executive and administrative powers and international over what is in the public interest and an understanding instruments, such as the International Health Regula- of the values which support it, is therefore required for tions (IHR) [50]. This may add complexity and confu- the successful implementation of EID responses. Yet this sion to the EID regulatory structures, rather than is precisely what has been lacking in outbreaks where facilitating public health responses to a new threat. Such fracture lines, differences and value conflicts have be- confusion provides a salient reminder that even in ‘glo- come apparent. When the stakes are high, evidence and bal law’ approaches to EIDs, the sovereign state remains the implications of actions are uncertain, the situation is the institution responsible for regulation and control complex and resources may be limited but where deci- [51]. sions need to be made, differences are exposed. Such dif- Public health law responses to EIDs tend to be ori- ferences could be around beliefs about how to deal with ented towards controlling cross-border pathogen trans- ecological and environmental issues, which may conflict fer and community outbreaks rather than the underlying with the importance people attach to public goods, pro- deficiencies and structural conditions from which the tection of individual autonomy and animal welfare [47]. threats emerge. Other laws, such as environmental law, These conditions of crisis and division are conducive to may be more useful in addressing structural conditions undesirable consequences including public fear, mistrust, for emergence. Changes in land use and agricultural in- misinformation and non-compliance with public health tensification in developing societies are major drivers of directives. For example in Canada during the SARS cri- EID. However, the cost of laws that restrict development sis, leaders were unprepared for the range of ethical con- may be greater global health inequities, with consequen- flicts that arose, including those over: individual freedom tial effects for health outcomes. In order to clarify EID- versus the common good; healthcare workers’ safety ver- related legal tensions between economic development sus their duty to care for the sick; and economic costs and health security, a more explicit recognition is versus the need for containment [48]. As indicated in needed of who are the primary beneficiaries and who Box 2, both the outbreak itself and fear that another bears the costs of a One Health approach to EIDs [52]. outbreak could occur had significant economic Legal clarity around the frameworks designed to pro- consequences. tect populations from EIDs is critical to providing an en- Any approach which hopes to successfully respond to abling infrastructure to co-ordinate and support the One EID threats, including a One Health approach, needs to Health-based work of policymakers, development plan- address the ethical concerns articulated above. To this ners, human and animal health-workers and biosecurity end, potentially conflicting values and logic must be ne- agencies. gotiated to realise effective, sustainable and just solu- tions. Prioritisation and resource allocation require Discussion political processes based on fundamental ethical ques- One health and public values: implications for EID control tions about what is valuable, what is to be protected and prevention and, ultimately, what is dispensable. To be effective, The health of humans, animals, and ecosystems are in- public policy must be consistent with the values of terconnected. A One Health approach promises a better Degeling et al. BMC Public Health (2015) 15:1307 Page 6 of 11 understanding of how to prevent and control EIDs at socioeconomic context of affected or at-risk the human-animal-ecosystem interface. However the communities, need to be understood and addressed socio-political, ethical and legal challenges of EIDs illus- by policymaking processes. This should ensure that trated above highlight how responses to infectious dis- manifest injustice, livelihood-based decisions and ease threats are intrinsically value laden. When a new other social and cultural factors do not undermine infectious pathogen such as Hendra or Nipah virus first the effectiveness of favoured control measures. appears, or a known threat such as Rabies or Ebola Without adequate knowledge of specific local encroaches on a new setting, there is limited scientific arrangements, there is a danger that insufficiently evidence or past experience to guide decisions or deter- nuanced or unified approaches to EIDs will actually mine whether a planned response will be proportionate. undermine the heterogeneous relationships and Vastly different interpretations of EID events and their contingent practices that make health possible in likely outcomes might be supported by the available circumstances of structural disadvantage [56, 58]. data. Policymakers and practitioners therefore have little guidance as to what they should do when faced with a The social sciences are analytically broader and more nascent infectious disease threat, only what they can do. policy focussed than the natural sciences. Whereas the As others [52–54] have cogently argued, they must natural sciences tend to frame infectious disease threats therefore ask themselves: whose health is being priori- narrowly as matters of biological integrity and security, tized; which public and which good are we seeking to such that barrier technologies and hygiene practices protect? dominate the logic of interventions [59], social science Notwithstanding recognition of a need for comple- approaches go beyond this. Building social scientific evi- mentary work on values-based questions that inevitably dence for use in conjunction with natural scientific evi- surround EID risks and EID control, the adoption of the dence about EIDs aligns with the growing realization One Health approach, so far, has not included develop- that EID emergence is as much about the social and eco- ment of a comprehensive, ethically-informed policy and nomic configuration of capital flow as it is about the bio- implementation framework; this has limited its practical logical features of host-pathogen interactions. Current utility [9, 55]. Despite rhetorical and some financial sup- approaches to the economic and structural drivers of port for One Health as the guiding ethos by which to ad- EID emergence still presume that state and market neo- dress interconnected human, animal and environmental liberalism is part of the natural order, even as evidence health issues, its impact will be minimal unless implica- is mounting that these systems of development are cen- tions of uncertainty on, and potential conflicts between, tral to the problem [60, 61]. Moreover, the current em- human values and political processes are recognised and phasis on microbiology and focus on newer molecular articulated. Any attempt to address these ethical and techniques to characterise pathogens, is drawing atten- normative dimensions must take into account the dy- tion away from developing better understandings of the namic nature of EID risk management. A policy that environmental, economic and social drivers of EIDs. seems reasonable today may be inappropriate tomorrow, While this is understandable given the desire for vac- in light of new evidence. And when situations are uncer- cines and drugs to solve EIDs, if One Health researchers tain, decision-makers inevitably fall back on their values. and practitioners broaden their approach to causality to Therefore, a solid framework based on shared values is include upstream, social and economic systemic causes, needed to support decision-making surrounding EIDs questions and issues that have been traditionally brack- when “evidence” is – or may be – unreliable, and rapidly eted or thought best avoided will become central to the changing or fluid. cross-sectoral collaboration implied by One Health. What is needed to guide a one health approach to EIDs? (ii)The development of a One Health Analytic To successfully meet the challenges described above, Framework (OHAF) needs to be pursued. Such a particularly the necessity to align EID policy with public framework would catalogue case-based experiences values, a One Health approach needs to engage in the and reflect the particular dynamics of specific EIDs, following. and promote inter-sectoral collaboration and know- ledge synthesis, including integration of information (i) Social science and economic research to help about social, cultural and economic impacts, control catalogue and describe the drivers, mechanisms and measures and uncertainty [62, 63]. The framework social and political configurations through which would serve as a prompt to ensure that minority EIDs become threats to human, animal and perspectives are represented and all relevant ecological health [56, 57]. The complex connections concerns are considered. An OHAF could provide a between individual social needs and the local rubric for comparisons between outbreaks. This Degeling et al. BMC Public Health (2015) 15:1307 Page 7 of 11 would allow the inherent complexities of economic in the UK, Australia, the US and elsewhere [69–72] to and societal responses to EIDs to be compared, to explore similar issues and identify citizens’ preferences. inform policy processes. It is vital for discussions They represent informed public opinion better than about EID prevention and control to have this kind of other social research methods (e.g. surveys or focus sound empirical foundation, because uncertainty and groups) because they give participants factual informa- media coverage have the potential to drive bad policy. tion, bring them into a structured and constructive dia- logue with experts, provide them with time to reflect Development of an OHAF could be facilitated by and deliberate, and allow them to represent their views adopting well established and methodically rigorous directly to policymakers. processes such as Framework Analysis, produced by the National Centre for Social Research (UK) [19], or Multi- (iv)The development of a clear Statement of Principles Criteria Decision Analysis [MCDA] developed within the and Values (SPV) for integration of ethical field of decision science [64]. In the first instance Frame- principles and values into decision-making is needed. work Analysis would allow for systematic incorporation This should be based on empirical data about peo- of the perspectives and contributions of different schol- ple’s beliefs, including which public health outcomes arly disciplines and expert stakeholders. Framework and public goods should be prioritized and why; Analysis facilitates movement between different datasets, how to adjudicate conflicting claims and preferences; thematic areas, theoretical resources, and levels of and what levels and types of evidence should be pri- abstraction without loss of conceptual clarity [65]. The vileged in these decisions. Framework method is used to organize and manage re- search and interpretation through the process of To be successful, One Health needs to be about more summarization, which is codified into a robust and flex- than disease prevention and control. The dynamic, un- ible matrix that allows the policymaker/researcher to predictable effects and risks to peoples’ lives of EIDs ne- analyze data both by case and theme. It is commonly cessitate a public health and biosecurity infrastructure used in areas such as health research, policy develop- equipped to address the ethical problems that arise. EID ment and program evaluation. Equally, MCDA methods management must therefore be based on normative offer an alternative and potentially complementary principles as well as local knowledge, operational experi- approach to OHAF development. Comprised of a suite ence and disease-specific scientific and economic evi- of analytic strategies, MCDA have been shown to be dence. This means that governments and policy-makers valuable tools for prioritization and decision-making in need to explain and justify the values that underlie animal and human health [64]. MCDA provides a frame- decision-making and engage the public in discussions work to compare policy alternatives with diverse and about ethical choices, so that when difficult decisions often intangible impacts, which can be particularly use- arise in the face of uncertainty, they will be accepted as ful in determining and justifying the prioritization and fair and essential for the public good [47]. This necessi- mobilization of limited research and public health re- tates that the guiding values and likely ethical choices sources [66, 67]. need to be articulated in a formal statement in advance, as in the heat of emerging health threat, decision makers (iii)Genuine processes of public engagement across the will be under pressure from many sources to ‘do some- developed and developing world are also essential to thing quickly’. a successful One Health approach. These processes are not so much about engaging in deliberative (v)Integration of an OHAF and SPV with the IHR and democracy for policy decision-making, as about de- relevant national health and biosecurity legislation is fining the principles and values that should guide essential so that policymakers and practitioners can decision-making. This means procedural inclusive- dynamically test their decision-making. ness alone is not enough to ensure transparency and reflexivity, to capture people’s preferences and to ef- Our response should of course be based on the best fectively communicate with the public [68]. scientific evidence, but EIDs are not just scientific issues, they also have significant social, ethical and animal The successful implementation of the One Health ap- rights dimensions. Experiences of infectious disease proach to EIDs will depend on public trust and co- threats such as BSE/vCJD and SARS indicate that there operation. Public support for unpalatable measures is have been problems combining evidence and human more likely if citizens understand the issues, and policy values at both local and policy levels [28, 73]. The com- implementation reflects community values and prefer- municability of diseases between species raises social, ences. To this end, citizens’ juries have been employed ethical and legal issues that have not been clearly Degeling et al. BMC Public Health (2015) 15:1307 Page 8 of 11 elucidated or adequately addressed. Our response to the realignment and policy integration of Health nonhuman animal disease is not determined solely by Departments with other government agencies bio-scientific knowledge; the way people and animals live [78, 79]. Unfortunately in this case as others, with and amongst each other is also shaped by social attempts at promoting inter-sectoral approaches norms, economic imperatives and human values. In mat- rarely move beyond rhetoric – even when driven by ters of public health it is no longer sufficient to ask what the best intentions and supported by substantial works and what is the strength of the evidence; we also resources [80–82]. need to ask ethical questions about how we should seek to live, and what is the right thing to do [74–76]. Con- The problem is that arguments that promote the need sensus about the best approaches to EID control and for greater co-operation between sectors tend to focus prevention are not always possible, however an agreed on the likely benefits of collaboration rather than what set of guiding principles and values can be a means to reform would entail – that is, what needs to be done or- ensure dialogue, if not always agreement. ganisationally and politically to achieve the desired out- The development of an OHAF and SPV will also pro- comes [83]. Established ‘sectors’– whether orientated mote clearer communication about public risk. Signifi- towards human or animal health, agriculture or the en- cant EID threats have major implications for distribution vironment – have genealogies, traditions and rationali- of scarce resources, access to and regulation of health ties of “what we are here for” that have been shaped by services and maintenance of social order. As described social, political and administrative processes [11]. As in- above it is also clear that policy and legal responses to stitutions, they are philosophically and structurally re- EID threats are often highly politicised and compro- sistant to change that diverts resources and re-orients mised by failure to communicate clearly with the public. practices away from their own sectoral priorities [83]. In Policymakers responsible for responding to disasters essence, they have their own constituencies to serve. As such as EIDs typically find that there is a dissonance be- a consequence, establishment and implementation of tween transparency that may appear alarmist versus mechanisms that enhance information-sharing, collabor- withholding information to avoid panic. Regardless of ation and inter-sectoral co-operation, such as working advice, people will make their own decisions based on groups and interdepartmental committees, have rarely their interpretation of available information, from formal delivered the outcomes promised in the past. Responses and informal channels. So public communication, before to BSE/vCJD in the UK [28], HPAI in South East Asia and during a public health emergency, is frequently as [11], and recent case studies of One Health programs in important as political decisions and regulatory changes Uganda [84], suggest that more work is needed to co- [39, 77]. This means that, to be effective, a One Health ordinate implementation and overcome sectoral inter- approach – like any EID policy – must deal with scien- ests. The complexity of the problems posed by EIDs tific uncertainty, whilst addressing the socio-political, mean that organising effective control and prevention ethical and legal dimensions of effective health commu- programs will require genuine cross-sectoral integration nication and intervention strategies [3]. By exposing and, potentially, re-sectoring of some institutional and decision-making processes to reveal the scientific and professional responsibilities [62]. And as the recent Ebo- normative uncertainties and ethical complexities, the lavirus disease outbreak illustrates, there must also be introduction of an OHAF and a SPV into One Health sustained social and political willingness to achieve theory and practice may incorporate iterative deliber- control. ation and learning into EID policy processes. If One Health is genuinely the way forward, as we be- lieve it is, then we should do more than talk about its (vi)Finally, One Health must be about genuine reform potential benefits. Without genuine cross-sectoral re- rather than merely rhetoric. A One Health approach form and a radical broadening of the scope of its inquiry rests on the assumption that the cross-sectoral inte- into how specific social, cultural and spatial configura- gration of expertise, research methodologies and tions promote the risks of EID emergence, One Health public health infrastructure will inevitably improve is in danger of becoming merely a rhetorical strategy to capacity for disease-risk prediction and effective avoid conflict between its core disciplines, whereby prac- intervention. However, calls for increased inter- titioners, researchers and policymakers will espouse the sectoral co-operation by public health practitioners, methodological and moral case for interdisciplinary col- clinicians, scientists and policy-makers are not a new laboration yet remain in their silos [11]. Even if these phenomenon. For example in the 1990s advocates of barriers are overcome the One Health approach will only “new public health” called for health authorities to succeed if it explicitly acknowledges local contingent turn their attention to the social, economic and and contextual dimensions of disease risk and disease environmental factors that affect health – requiring expression and the political impacts of scientific Degeling et al. BMC Public Health (2015) 15:1307 Page 9 of 11 uncertainty, while also seeking to accommodate the Sydney, Sydney, Australia. Menzies Centre for Health Policy, University of Sydney, Sydney, Australia. 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