Over the last decade, the world has witnessed unparalleled progress in human health. Indeed, countries such as China, Turkey and Rwanda now boast near-universal healthcare systems, resulting in unprecedented gains. Now, as the accounting window of the Millennium Development Goals (MDGs) draws to a close, is a good time to take stock of progress towards these, and to chart a course beyond. While numerous institutions, notably, the United Nations (UN), and private-public-partnerships (PPPs), academic forums and eminent individuals, spar over priorities for a new round of development initiatives, this CAI discussion paper focuses on two health-specific issues that simultaneously present a new challenge and an unprecedented opportunity for the global community to continue to promote health and development: (re)emerging infectious diseases and antimicrobial resistance.

Despite, or possibly because of, the recent progress towards better global health, disease and its myriad manifestations continues to plague the human race. The two issues in focus here are the accelerating emergence of new infectious diseases, coupled with the (concomitant) rise of antimicrobial resistance. The former, most recently in the form of Middle Eastern Respiratory Syndrome-coronavirus (MERS-CoV), follows in the wake of HIV/AIDS; Severe Acute Respiratory Syndrome (SARS); and avian flu, as well as increasingly lethal influenza viruses, such as H5N1. These are new diseases – or more specifically, disease spectrums, reflected in the fact that each is designated as a ‘syndrome’, as opposed to ‘illnesses’ caused by a single infection. That they can travel, and thus infect and sicken on a global scale, would seem to be a given. However, following Indonesia’s claim of ‘viral sovereignty’, and reflected in the recent naming of the MERS-CoV, which is thought to have crossed the animal (bat) – human barrier in the eastern date palm region of Saudi Arabia,  the country of origin, claim of jurisdiction, and resolution of (inter)national obligations in health remain contested. The latter area of focus in this paper, namely, the rise of antimicrobial resistance, reinforces these complications, as ever-more potent strains of nearly-eradicated diseases, especially tuberculosis, enter circulation, and antibiotic resistant infections threaten the enormous strides made against all manner of bacterial infections as a result of antibiotic medicines developed and widely used over the past century. This tension begs the questions: what are the most dire threats emerging against human health; who is responsible for identifying disease (threats); and who is the liable, able and legitimate responder to eradicate, or at least control, the vital response?

Challenges to global public health management

The challenges are three-fold: first, to identify the crisis; second, to locate points of possible response; third, to deploy a response that is acceptable locally (nationally) and applicable globally.

With regard to emerging diseases, the greatest challenge is the speed both of their evolution and of their discovery. For example, every year a new influenza emerges. Annually, geneticists harvest the first strains and try to manufacture a suitably preventive or ameliorative vaccine. This benefits those who are furthest away from the initial outbreak, and are able to access the resulting medicine. However, as health benefits continue to be extended, people around the globe increasingly know their rights and demand equal access to the benefits of scientific vaccine development. This time-release model is proving increasingly unconscionable: so much so that after the 2005 outbreak of influenza H5N1 in Indonesia, in 2006, the state, citing the above-mentioned ‘viral sovereignty’, refused to share samples of the virus, unless it was guaranteed access to any derived antidote or vaccine. Indonesia’s actions set a precedent derived from the ascension of the demand for the human right to health; decoupled, however, from everyday global management practice. The conflagration could prove dangerous when tested against a rapidly spreading infectious disease. Despite this seeming urgency, the revised International Health Regulations (2005) have yet to resolve the conflict between state and global responsibility for the reporting of and response to that right to health.⁽²⁾

Similar in its spread and unresolved issues of responsibility, is the crisis of antibiotic resistance. Multiple causes of this particular scourge have been long identified. They include over- and incorrect use, in both humans and animals; for example, against viral infections, and preventatively to produce stronger, healthier cattle. The actual efficacy of this is being challenged; a bit late. The overuse of antibiotics in people and animals, often for conditions for which the drugs are ineffective or not needed, is seen as a driving force in the development of resistant bacteria. As these organisms have evolved and developed resistance, the development of new drugs has not kept pace.

Antibiotic use in human medicine and animal husbandry drives antimicrobial resistance. The exact extent that use in veterinary medicine and agriculture (including fish farming) contributes is currently unclear, although its contribution is beyond dispute and joint action around animal and human antibiotic use is needed. This is because resistant bacteria can transfer down the food chain but also, and more insidiously, because resistance genes that escape to mobile DNA in the gut flora of another animal species can find their way to bacteria that colonise and infect human beings.⁽³⁾

This development is also attributable to failure of systems to promote and produce newer generations of antibiotics to keep pace with the evolution of resistant microbes.⁽⁴⁾ As such, there are no effective medications to fight multi-drug resistant or extremely drug-resistant (MDR and XDR) tuberculosis, or HIV that has mutated beyond the reach of most third-line anti-retrovirals. More worryingly, there are also no new antibiotics for the various bacterial infections that cause pneumonia or sepsis, among others; the likes of which spread easily, especially in hospitals, between immune-compromised, ill patients and otherwise healthy staff – and those with whom they come into contact outside the hospital setting. As stated by Dr Janet Woodcock, director of the Center for Drug Evaluation and Research at the Food and Drug Administration (FDA), “We are facing a huge crisis worldwide not having an antibiotics pipeline. It is bad now, and the infectious disease docs are frantic. But what is worse is the thought of where we will be 5 to 10 years from now.”⁽⁵⁾

This situation might prove to be a great global leveller, as neither the developed nor the developing world has access to these necessary, but non-existent, medicines.⁽⁶⁾

Fewer new antibiotics are now advancing through the development pipeline or becoming available. Revitalisation of this pipeline is essential if we are to keep ahead of antimicrobial resistance. Collaboration between the commercial sector, academia, clinical medicine, and national institutions is essential to achieve this aim, but the pharmaceutical industry inevitably remains the main driving force. The challenges here are considerable, yet it is in the interest of wider society to ensure that the incentives for drug development are organised to maximise the flow of new agents.⁽⁷⁾

Would the ‘world’ really allow the gains of the past century to be wiped away? As the rates of tuberculosis rise and travel by foot, car, train and plane to all ends of the earth, much like those of polio, as antibiotic resistance runs rampant in even state-of-the-art hospitals, the trend will be hard to reverse. But what is the alternative?

Meeting challenges

There has to be an alternative. Denial, as seen most spectacularly in the rising tide of HIV/AIDS, but also by way of interventions aimed at radically reducing the incidence of maternal and childhood ill health under the MDGs, is neither effective nor necessary.

With particular regard to the emergence of new infectious diseases, a number of systems are being put in place, under the World Health Organisation (WHO), to track disease outbreaks and coordinate national, international and global responses. Conceived under the WHO’s International Health Regulations (IHR) 2005, these include the creation of National Focal Points (NFP) that are in operation 24 hours a day in all member countries, as well as the Holy See, which joined voluntarily. These NFPs work in conjunction with the Events Information Site (EIS) of the WHO, the Alert and Response Operations (ARO) and the Global Outbreak and Alert Network (GOARN), to verify information and coordinate responses to any Public Health Emergency of International Concern (PHEIC).⁽⁸⁾

As internationalisation increasingly displays national and global intersections, the threats posed by emerging diseases and microbial resistance, as issues of global concern, are tantamount to public health concerns. No one country can respond to either of the (set of) health threats alone. Some means to modify independence for better international public health management include, for example, that:

The United Stated (US) Health and Human Services Department  announced an agreement under which it will pay US$ 40 million to a major drug maker, GlaxoSmithKline, to help it develop medications to combat antibiotic resistance and biological agents that terrorists might use. Under the plan, the federal government could give the drug company as much as US$ 200 million over the next five years.⁽⁹⁾

According to the Trade-Related Aspects of Intellectual Property Rights (TRIPS) regulations, such a donation of public funds would enable the (US) government to access any resulting product, and subsequently patent and produce it in the public domain, for global use.

Second, signs point to a broader united global effort getting underway. “In Europe, several big producers, including GlaxoSmithKline and AstraZeneca, recently became part of a joint government and industry initiative to develop antibiotics that kill resistant strains of bacteria. As part of the project, companies are pooling their resources and research data.”⁽¹⁰⁾ Furthermore, the US Congress passed legislation in 2012 to enable the FDA to review and, if deemed safe, approve new antibiotics more quickly than previously: a measure with potentially enormous influence on the WHO’s approval process. The latter, in turn, has repercussions for expediting global access to vital medication.

Concluding remarks

The challenges of emerging infectious diseases and microbial resistance are ever-present and here to stay. As such, living with their reality and forging a united, global response in order to eradicate and control their outbreak and the havoc that they wreak, should be global priorities.

Overall, there should be increased education and awareness about antimicrobial resistance among the public, as well as health care professionals, in order to promote ‘antimicrobial stewardship’, which, like a beneficial rendering of ‘viral sovereignty’, could promote national and international responsibility with regard to the research on and the development of both pathogens and the means to prevent and combat their spread.

This should be coupled with increased surveillance of emerging diseases and antimicrobial resistance; for instance, in the food chain, current systems and those that are being built up are a positive start. Critical will be the ‘teeth’ with which reporting and responding are guaranteed.

Finally, emerging disease threats and the threat of microbial resistance pose a challenge to the global health community; but given the deployment of technology and the daring to cooperate against the danger of failing to do so, the challenge is surmountable.

Written by Dr Annamarie Bindenagel Šehović ⁽¹⁾

NOTES:

(1) Annamarie Bindenagel Šehović is a Consultant with CAI as well as a  health analyst at DEval in Bonn, Germany; associated researcher and lecturer at the Willy-Brandt-School of Public Policy, and an associated researcher at the GR:EEN FP 7 of the EU, on health and human security. She has extensive expertise in HIV/AIDS, human security and policy analysis. Contact Annamarie through Consultancy Africa Intelligence's Public Health Unit (public. health@consultancyafrica.com). Edited by Liezl Stretton.
(2) Fidler, D.P., 2010. “Viral sovereignty, global governance, and the IHR 2005: The H5N1 virus sharing controversy and its implication for global health governance”, in Infectious Disease Movement in a Borderless World: Workshop Summary. National Academies Press: Washington D.C., http://www.ncbi.nlm.nih.gov.
(3) Davies, S.C., et al., 2013. Annual report of the Chief Medical Officer: Infection and the rise of antimicrobial resistance. The Lancet, 381(9878), pp. 1606-1609.
(4) Given the successes against meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, there is a need to refocus on broader range infections, particularly those due to gram-negative bacteria, which are increasingly multi-resistant. See Davies, S.C., et al., 2013. Annual report of the Chief Medical Officer: Infection and the rise of antimicrobial resistance. The Lancet, 381(9878), pp. 1606-1609.
(5) Meier, B., ‘Pressure grows to create drugs for ‘superbugs’’, The New York Times,2 June 2013, http://www.nytimes.com.
(6) Davies, S.C., et al., 2013. Annual report of the Chief Medical Officer: Infection and the rise of antimicrobial resistance. The Lancet, 381(9878), pp. 1606-1609.
(7) Ibid.
(8) Chu, M.C., Rodier, G. and Heymann, D., 2010. “Address public health emergencies of international concern”, in National Research Council. Infectious Disease Movement in a Borderless World: Workshop Summary,National Academies Press: Washington D.C.,  http://www.ncbi.nlm.nih.gov.
(9) Meier, B., ‘Pressure grows to create drugs for ‘superbugs’’, The New York Times,2 June 2013, http://www.nytimes.com.
(10) Ibid.