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From Afghanistan to Ebola: 8 lessons for Global Governance for Health and a Framework Convention on Global Health

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You may have missed this news from mid-October: Due to the plethora of humanitarian disasters demanding global resources, along with the diminishing international combat presence in Afghanistan, the World Food Programme (WFP) has been forced to cut food rations in Afghanistan, affecting up to 1 million people. With its funding appeal experiencing about a $150 million shortfall, the WFP determined that it had to cut rations from 2,100 to 1,500 calories per person to avoid having to cut off some people from food aid entirely. Incredibly, the United Nation’s Afghanistan humanitarian appeal is among the better funded appeals, at 61% funded as of November 10, compared to 46% for UN humanitarian appeals overall, with some appeals many months old still below 40% — and even below 30%  — funded, including for the Republic of Congo, Somalia, Chad, Burkina Faso, Nigeria, and Iraq.
The major public health story of the past weeks continues to be the Ebola epidemic in Sierra Leone, Liberia, and Guinea, even as U.S. media coverage has been dominated by fears of Ebola in the United States, with states implementing quarantines and other highly restrictive policies — responses likely unconstitutional in their failure to be based in public health need. The crisis in West Africa persists, with very encouraging but also quite fragile indications of progress in Liberia, yet concerns of the epidemic worsening in Sierra Leone, and stable or worsening in Guinea.

Liberia Ebola grave markers LA Times Robyn Dixon Nov 10 2014

Victims of Ebola in Liberia. Honor them. Image courtesy of Robyn Dixon/LA Times.

Together, Ebola in West Africa and hunger in Afghanistan – in particular, as emblematic of a world that seems incapable of providing – or unwilling to provide – the required resources and policy focus on the current multitude of global humanitarian and health-related crises, hold a number of lessons for what needs to be incorporated into a more effective global governance for health. And as we will get to, a Framework Convention on Global Health could be a significant step towards embedding these into global governance structures.
Among the lessons are these eight:

  1. Sustained focus: We need a global governance system that can be give sustained and full attention and the required resources to situations around the world, including humanitarian crises that are all too common and multiple simultaneous disease outbreaks (presently, along with Ebola in West Africa, there is a separate Ebola outbreak in the Democratic Republic of Congo [perhaps coming to an end], the Middle East Respiratory Syndrome, and the Marburg virus in Uganda). Countries require sustained global attention after the immediate disaster is over to support successful rebuilding of communities destroyed (for example, post-typhoon Philippines and post-earthquake Haiti), as well as after conflicts (rather than pulling back on support, as in Liberia and Afghanistan). Whether this means more numerous, focused, and coordinated agencies; expanded leadership and capacity of, and new ways of working within, existing agencies even while reducing bureaucracy; new or improved forums of engagement, or; other approaches, the global health space and the diversity of its demands is too expansive for short attention spans and lurching from crisis to crisis to continue to be the modus operandi.
  2. National leadership: Fostering enhanced national health leadership must be a central aim of reformed global governance for health. Even as sustained global attention to many situations around the world simultaneously is a must, the best way to enable short-term crises to move towards lasting solutions rather than remain perpetual crises is for national figures, organizations, and processes to be at the center of national responses and recoveries. Global presences and processes should enable strong national leadership with empowered civil societies that ensure accountability and that keep local and national authorities as well as the global community well-informed of people’s health realities.

This could take multiple forms. A reformed WHO or other entity might be charged with leadership training, mentoring, and other capacity-building activities (even simple measures like funding for highly skilled interns). Further, a Right to Health Capacity Fund could support civil society capacity, public education on the right to health, and government institutions that can further the right to health, from judiciaries and parliamentary human rights committees to national human rights institutions and, critically, health workers themselves. Global accountability mechanisms will need to manage the difficult balance of holding nominal health leaders and political decision-makers to account without pulling funding or other support that is needed to advance people’s health. Whatever form these take, national and local civil society participation will be critical in determining the balance.

  1. Human bonds: Sustained global focus and priority would benefit from publics that understand the realities of people whose lives may be very different from their own, living in countries with deeply deficient health systems, or lacking clean water and decent sanitation facilities, or experiencing marginalization and discrimination, or suffering from humanitarian crises. People may then be less likely to be hardened to disaster after disaster or the even more collectively lethal common causes of death among poorer populations. And they may be less likely  to support policies like travel bans and quarantines even if they are not scientifically called for and could cause even more suffering abroad.

Could global governance foster such personal effects? Perhaps so. For example, it could channel funding for policymakers to travel to places of ill health, whether in the throes or aftermath of a humanitarian disaster or disease outbreak or simply communities on the short end of immense global and national health inequities. With a growing interest in technology for accountability, governance functions could also support technology to link people across countries and communities. Could traveling electrons and satellite signals create human bonds? And besides direct support, governance might set standards or policies that could catalyze national and local efforts towards these ends.

  1. War and peace: The longer-term origins of the Afghanistan food shortages – decades of war – and the cause of the shattered health infrastructure hindering the Ebola response in Sierra Leone and Liberia – recent civil wars – place the link between war and health in the spotlight. So too does the war in Syria, for its levels of death and its refugee crisis, as well as the direct targeting of health workers and facilities, so far killing more than 500 health workers (see this map). Wars are part of the historical roots of the high murders rates in a number of Central American countries. Then there is the most basic connection between war and health: war kills and maims. And expanding our focus on violence more broadly, we come to the global pandemic of violence against women.

What is the role of global governance for health in this? In some targeted areas it is easier to see its role, such as building on WHO action (see this World Health Assembly resolution, para. 2(8)) to strengthen the norm against and further stigmatize targeting health workers and facilities in conflict, and the norm of protecting and not discriminating against health workers who meet their professional duty of caring for all in a conflict – whatever side their patients are on. Global financing structures could increase funding to local women’s and human rights organizations working to change norms – and laws – on violence against women, including to more effectively enforce laws that are on the books to prosecute perpetrators of violence, and to provide shelter to women who are being abused. A World Health Assembly resolution from May 2014 has further areas of action, such as providing the necessary health services to survivors of violence, enhancing data collection and intersectoral collaboration, and contributing to norm change. The resolution also requires WHO to develop a plan of action to strengthen the health sector’s response to violence against women and children. The global health community could step up support to health workers aiding women who are targeted in conflicts, responding to both their physical and mental health needs, and documenting the crimes to facilitate prosecution.
Looking to war more broadly, a start might be simply to create greater institutional linkages between WHO and other health structures with entities, from intergovernmental to non-governmental, whose main mission is peace. Might it be possible for the global community to do more to support community health leaders in peacebuilding and peacemaking functions? Or target sustained health system reconstruction efforts in post-conflict countries as part of a return to functioning societies, reducing the possibilities of renewed conflict?
At least these areas would be a start. You may have other ideas to contribute.

  1. One Health: One Health is the concept that human health is integrally linked to the health of animals and the environment. Ebola, believed to have transited the continent to West Africa via fruit bats, is a case in point. So is antibiotic resistance, as overuse in livestock (and people) fuels its development and spread. Global governance structures need to incorporate this concept, from their staffing, skill sets, and institutional linkages to their leadership and regulatory authorities. These links and this leadership will need to extend from global to local levels. In the environmental realm, for example, WHO could drive research on the links between how and to what extent climate change is already affecting health, adding to the already very powerful case for strong action (, and driving action on the policy changes required to protect health in this era of climate change.
  2. Comprehensive global health financing: Like the concept of health itself, as embodied in the idea of One Health, health financing will need to be reconceived, from being essentially about the health sector, occasionally incorporating water and sanitation, to embracing a broad range of health needs. These include not only health care and – critically for much of the world where clean running water and adequate sanitation are not taken as given – water and sanitation, but also food and nutrition, environmental health, research and development, health-related humanitarian needs, right to health capacity building, and the public health capacities required to prevent, detect, and respond to infectious disease threats, now often given short thrift.

This will require new comprehensive, well-developed resource needs estimates, including for building capacities to detect and respond to disease outbreaks, estimates that to my knowledge are yet to be developed. Resource needs estimates then need to be translated into the necessary financing, requiring that financing frameworks or structures encompass the full scope of these health necessities – and the political will and legal commitments to ensure these funds through domestic resources, topped off by international assistance and innovative financing.
For the final two lessons, we move from the expanse of health to the traditional realm of global health, health systems and, narrower still, medical technologies. For Ebola reminds us of the centrality of effective medical technologies, vaccines and medicines that can stave off disaster, or save lives if disaster does strike.

  1. Health system strengthening: It’s been said before but perhaps needs to be said again: high quality health systems, able to deliver on disease-specific goals but also to ensure comprehensive and effective rights-based universal health coverage, and to deliver the public health capacities that Ebola highlights needs to be developed urgently, must be a guiding principle of reformed global governance. While there have been some significant efforts towards this end, the tragically few health workers in Sierra Leone and Liberia in particular are emblematic of the overall paucity of this effort so far. Consider this: Sierra Leone and Liberia together have few more than one-twentieth the doctors as the number of practicing doctors in Washington, DC, despite having fifteen times the population. (In 2011, Liberia had 90 doctors; Sierra Leone had 136 physicians as of 2010. Washington, DC has about 4,000 practicing physicians, though not all practice full time in the District. Liberia has a population of about 4.1 million, Sierra Leone has about 5.7 million people, and Washington, DC has about 650,000 residents.) Even with other public health capacities in place, like high-level laboratories and networks of epidemiologists, health worker shortages such as these are bound to hamper an effective response to a public health crisis – much less be able to deliver effective quality services on a day-to-day basis.
  2. Research and development: The lack of vaccines or treatment for Ebola is a useful reminder of the centrality of medical research in fighting disease, and how even with fantastic advances in expensive treatments for cancers and other diseases, and the promise of genomics, medical technologies that target diseases that primarily affect the poor remain urgently needed. And not only for such historic killers as tuberculosis, but also for diseases with outbreak potential. This will require new attention to identify the viruses and bacteria with this potential and investing in drug research and development to bring such vaccines and treatments into existence. And not incidentally, while adding a critical tool with which to fight potential epidemics, this could also save many lives, including the people who die of the smaller scale outbreaks that never make the international headlines.

Health workers in Mali, where a child with Ebola arrived from Guinea, but where working together, global experts and local health authorities appear to have stopped any further spread. Image courtesy of Baba Ahmed/Associated Press.

Determining how to integrate these priorities into reformed global governance for health – while beginning to implement them now – is a pressing task. Disease outbreaks happen on their timetable, not ours. Humanitarian aid shortfalls are a sadly common reality. People are dying because of weak health systems and inadequate health financing today.
One platform for these changes could be the Framework Convention on Global Health (FCGH), a proposed global health treaty that would be based in the right to health and aimed at closing national and global health inequities. It would reform global governance for health, from creating greater accountability from local through global levels to elevating health in other legal regimes, such as trade and investment. With developing comprehensive, quality, rights-based health systems as one of its core elements, it could have gone far towards limiting the scope of the present outbreak.
Along with the health systems focus, already central to the FCGH, the governance reforms proposed above would fit well within other proposed treaty elements. Among them, the broader funding could fit within the national and global health domestic financing framework, the links to animal health could be among the greater sectoral integration of efforts to address the social determinants of health, and the outbreak-conscious R&D could be part of the R&D aspect of the FCGH, which could ultimately be a full protocol. The FCGH, still in its formative stages, could be formulated to incorporate other aspects of the above reforms as well.
Our difficulty in sustained focus on situations that demand it may be one reason that we seem to have trouble learning from past incidents, that the same warnings (an underfunded humanitarian disaster, a disease outbreak) seem to be followed by the same promises (we pledge our support, we will do better next time), but too little changes.
An FCGH could instead embed these lessons and promises into a reformed governance, building them into the sustained structures of global health. It is one more reason to support the FCGH. And it would be one way to ensure that the suffering in West Africa, in Afghanistan, and in so many other places around the world produces not cries that echo in our ears only until they don’t, but instead propels us to act, and to honor – in their pain, and in their deaths – the lives of those whom we, as a global community, failed to sufficiently value in their times of greatest need. And from support for civil society to investments in national health systems, it is one way to enable presently poorer or conflict-ridden countries to themselves have the capacity to address health threats of all sorts, a sure way to turn cries of sorrow into smiles of hope.

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