Julie E. Fischer

Defining Health Diplomacy: Changing Demands in the Era of Globalization

CONTEXT Accelerated globalization has produced obvious changes in diplomatic purposes and practices. Health issues have become increasingly preeminent in the evolving global diplomacy agenda. More leaders in academia and policy are thinking about how to structure and utilize diplomacy in pursuit of global health goals. METHODS In this article, we describe the context, practice, and components of global health diplomacy, as applied operationally. We examine the foundations of various approaches to global health diplomacy, along with their implications for the policies shaping the international public health and foreign policy environments. Based on these observations, we propose a taxonomy for the subdiscipline. FINDINGS Expanding demands on global health diplomacy require a delicate combination of technical expertise, legal knowledge, and diplomatic skills that have not been systematically cultivated among either foreign service or global health professionals. Nonetheless, high expectations that global health initiatives will achieve development and diplomatic goals beyond the immediate technical objectives may be thwarted by this gap. CONCLUSIONS The deepening links between health and foreign policy require both the diplomatic and global health communities to reexamine the skills, comprehension, and resources necessary to achieve their mutual objectives.

IDSR as a Platform for Implementing IHR in African Countries

Of the 46 countries in the World Health Organization (WHO) African region (AFRO), 43 are implementing Integrated Disease Surveillance and Response (IDSR) guidelines to improve their abilities to detect, confirm, and respond to high-priority communicable and noncommunicable diseases. IDSR provides a framework for strengthening the surveillance, response, and laboratory core capacities required by the revised International Health Regulations [IHR (2005)]. In turn, IHR obligations can serve as a driving force to sustain national commitments to IDSR strategies. The ability to report potential public health events of international concern according to IHR (2005) relies on early warning systems founded in national surveillance capacities. Public health events reported through IDSR to the WHO Emergency Management System in Africa illustrate the growing capacities in African countries to detect, assess, and report infectious and noninfectious threats to public health. The IHR (2005) provide an opportunity to continue strengthening national IDSR systems so they can characterize outbreaks and respond to public health events in the region.

Moving ahead on the global health security agenda

On February 13, 2014, a new Global Health Security (GHS) agenda was launched by more than 20 countries, in collaboration with the World Health Organization (WHO), the Food and Agriculture Organization (FAO), and the World Organisation for Animal Health (OIE). This new effort aims to drive and coordinate action among these partners, as well as the international NGO community and the private sector, in a more dedicated effort to prevent epidemics, detect biological threats early, and respond rapidly. There is hope and expectation that many more countries will join the agenda in the year ahead. All countries are invited. The specific objectives are organized around priority issues: antimicrobial resistance, food safety, laboratory biosafety and biosecurity, outbreaks, timely disease detection and reporting, sample sharing, effective diagnostics, emergency operations centers, rapid response teams, and ability to mobilize medicines and expertise during health emergencies. What is compelling and potentially so valuable about this effort is that it gathers, elevates, and shines a bright light on a series of deeply important issues that do not necessarily receive the attention or the international collaborative effort they require. The agenda broadly encourages self-examination regarding the work that countries do on these issues, and asks countries and nongovernmental organizations to dig deeper and consider new commitments in the years ahead. A review of the issues on this agenda makes clear how serious these challenges are. And a look at who is doing some of the leading work on these issues shows how important it will be to identify international best practices, to form new international collaborations, and to encourage countries from around the world to offer their expertise and resources where they are needed.

Moving Forward to 2014: Global IHR (2005) Implementation

When the Member States of the World Health Assembly agreed to adopt the revised International Health Regulations in 2005 (IHR [2005]), no one thought that the next steps would be easy. The original 194 States Parties committed to improve global health security by strengthening the framework for managing public health emergencies. IHR (2005) represented a response to the challenge posed by emerging infectious diseases, from the insidious spread of HIV/AIDS over decades to the SARS crisis, in an era of commonplace international trade and travel. The revised regulations aimed to improve early detection and response to public health events that might affect populations across borders by increasing the transparency and timeliness of reporting. The agreement replaced historical lists of notifiable diseases with an algorithm for assessing public health threats in context, and it conferred new authorities on the World Health Organization (WHO) to collect information and facilitate rapid evidence-based responses. Countries agreed not only to share information promptly, but to develop and sustain the capabilities needed to detect, assess, report, and respond to any potential public health emergency of international concern. This unprecedented commitment offered a foundation for a truly global disease detection and response network, capable of containing emerging disease threats when and where they occur to reduce the toll on economies and human lives. IHR (2005) entered into force in June 2007, beginning a 5-year period for each nation to evaluate its own current core capacities from the local to the national level and to develop a plan of action for closing any gaps. In June 2012, all States Parties were obligated to report to WHO either that they had achieved the core capacities required to implement the revised IHR fully or that they would require a 2-year extension to implement their action plans. As of late March 2013, 42 countries (out of 194 reporting States Parties) had indicated to WHO that they had achieved all of the core capacities required to implement IHR (2005) fully; 110 countries requested a 2-year extension with an implementation plan. An additional 42 countries neither submitted an extension plan nor indicated that they are in compliance (Figure 1). As each nation assessed and reported its own capacities, the self-imposed stringency of the evaluations most likely varied. However, we can clearly say that approximately 80% of the world’s countries have not met their international legal obligations to implement IHR (2005). These shortfalls reflect the scope of the tasks rather than a lack of commitment on the part of health ministries worldwide. Countries must be prepared to carry out the core functions of public health surveillance and response for infectious and noninfectious hazards (including zoonotic, foodborne, chemical, and radiological/nuclear events as well as communicable disease outbreaks) at the local, intermediate, and national levels and at points of entry. These capabilities depend on an adequately trained and equipped public health workforce, a strong surveillance and response framework, a functional national public health laboratory

Costing framework for international health regulations (2005)

Costs can be estimated by identifying functional pathways toward achieving all 8 core capacities and global indicators.

Mapping of Networks to Detect Priority Zoonoses in Jordan

Early detection of emerging disease events is a priority focus area for cooperative bioengagement programs. Communication and coordination among national disease surveillance and response networks are essential for timely detection and control of a public health event. Although systematic information sharing between the human and animal health sectors can help stakeholders detect and respond to zoonotic diseases rapidly, resource constraints, and other barriers often prevent efficient cross-sector reporting. The purpose of this research project was to map the laboratory and surveillance networks currently in place for detecting and reporting priority zoonotic diseases in Jordan in order to identify the nodes of communication, coordination, and decision-making where health and veterinary sectors intersect, and to identify priorities and gaps that limit information sharing for action. We selected three zoonotic diseases as case studies: highly pathogenic avian influenza (HPAI) H5N1, rabies, and brucellosis. Through meetings with government agencies and health officials, and desk research, we mapped each system from the index case through response – including both surveillance and laboratory networks, highlighting both areas of strength and those that would benefit from capacity-building resources. Our major findings indicate informal communication exists across sectors; in the event of emergence of one of the priority zoonoses studied, there is effective coordination across the Ministry of Health and Ministry of Agriculture. However, routine formal coordination is lacking. Overall, there is a strong desire and commitment for multi-sectoral coordination in detection and response to zoonoses across public health and veterinary sectors. Our analysis indicates that the networks developed in response to HPAI can and should be leveraged to develop a comprehensive laboratory and surveillance One Health network.

Global Health Diplomacy Training for Military Medical Researchers

Given the unprecedented growth of global health initiatives in the past decade, informal diplomacy between technical partners plays an increasingly important role in shaping opportunities and outcomes. This article describes a course developed and executed specifically to equip U.S. military health professionals with core skills in practical diplomacy critical to help them successfully plan and implement public health surveillance, research, and capacity building programs with partner nation governments and organizations. We identified core competencies in practical diplomacy for laboratory and public health researchers, catalogued and evaluated existing training programs, and then developed a pilot course in global health diplomacy for military medical researchers. The pilot course was held in June 2012, and focused on analyzing contemporary issues related to global health diplomacy through the framework of actors, drivers, and policies that affect public health research and capacity-building, beginning at the level of global health governance and cooperation and moving progressively to regional (supranational), national, and institutional perspective. This course represents an approach geared toward meeting the needs specific to U.S. military public health personnel and researchers working in international settings.

Linking funds to actions for global health emergencies

The International Health Regulations could help align and trigger World Bank and World Health Organization efforts The failings of the international communitys response to the Ebola virus disease outbreak in West Africa underscore the need for new mechanisms for governance and mobilization of resources for timely, coordinated responses to public health threats (1). Creating a global finance mechanism, ideally tied to existing global health frameworks, is a first step. The World Bank recently announced it would create a Pandemic Emergency Facility (PEF). The next necessary element is a trigger to release those funds to support rapid and effective responses during early phases of a public health event. With the World Health Assembly convening soon, we suggest how the World Health Organizations (WHOs) International Health Regulations (IHR) present such an initiator.

Information-Sharing and Disease Reporting in a New Era of International Frameworks and Communication Technology: Middle East Respiratory Syndrome Coronavirus and Ebola Virus Disease Outbreaks

Emerging infectious disease outbreaks amidst accelerating globalization have pressed policy-makers to reinvent the health systems and communication structures developed to protect people and nations during public health events. For over 150 years, nations have negotiated measures to prevent cross-border disease spread. Approaches that endured through the 20th century focused on notification procedures and information-sharing

Funding Public Health Emergency Preparedness in the United States

The historical precedents that support state and local leadership in preparedness for and response to disasters are in many ways at odds with the technical demands of preparedness and response for incidents affecting public health. New and revised laws and regulations, executive orders, policies, strategies, and plans developed in response to biological threats since 2001 address the role of the federal government in the response to public health emergencies. However, financial mechanisms for disaster response-especially those that wait for gubernatorial request before federal assistance can be provided-do not align with the need to prevent the spread of infectious agents or efficiently reduce the impact on public health. We review key US policies and funding mechanisms relevant to public health emergencies and clarify how policies, regulations, and resources affect coordinated responses.