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Global health shifts to local experts with global partners

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Science  25 May 2018:
Vol. 360, Issue 6391, pp. 868-869
DOI: 10.1126/science.360.6391.868

Hong Kong passengers don masks during the 2003 SARS outbreak.


A decade and a half ago, severe acute respiratory syndrome (SARS) took hold in the coastal Chinese province once known as Canton. Within months, the respiratory virus had spread across four continents. The U.S. Centers for Disease Control and Prevention issued its first travel warning. In time, 774 people had died and 8,098 were sickened by the outbreak.

The response of governments and global public health organizations to the world's first known instance of a typical pneumonia has informed responses to more recent global health epidemics, including the Ebola outbreak in West Africa from 2014 to 2016 and the Zika virus in Brazil in 2015.

At the center of the U.S. response to the outbreaks was Jimmy Kolker, now a visiting scholar at the American Association for the Advancement of Science's Center for Science Diplomacy. At the time, he was the assistant secretary for global affairs at the U.S. Health and Human Services Department, a position to which he brought experience as the former ambassador to Burkina Faso from 1999 to 2002 and later to Uganda from 2002 to 2005.

Kolker traced the evolution of global health on 4 May as part of the AAAS-Hitachi Lecture on Science and Society, at AAAS's Washington, D.C., headquarters. The annual lecture series is a decade-long collaboration between AAAS and Hitachi Ltd., the global technology and innovation company.

As the U.S. ambassador to Uganda seeking to implement the President's Emergency Plan for AIDS Relief, Kolker said diplomacy was “a crucial but ill-defined” requirement. Applying policies based on science and evidence in Uganda required weighing uncertainties with limited data, a topic Kolker explored in an essay recently published in Science & Diplomacy.

Global health crises require international health institutions, governments, scientists, and diplomats to work together. Yet, this growing but still tiny field of health diplomacy increasingly needs scientists skilled in translating research into actionable policy options—skills AAAS has long worked to hone through multiple science policy, engagement, and diplomacy programs designed to help scientists effectively place research findings into context to ensure that science informs policy. “The data rarely speaks for itself,” Kolker said.

The interplay of science and diplomacy takes on many forms. The SARS epidemic in 2003, for instance, underscored the necessity of open public and international communications, a practice the Chinese government initially discounted. After SARS, the CDC embedded disease surveillance and detection experts with Chinese counterparts.

“The system that was set up, the protocols that were put in place meant that when the next potential pandemic, H7N9, broke out, the Chinese response was timely and enabled governments and experts around the world to bring to bear the knowledge needed to control the outbreak,” Kolker said.

At the outset of the Zika outbreak in Brazil, the government hesitated to share samples necessary to develop blood bank screening, diagnostics, and vaccines. A U.S. team from the CDC, the National Institutes of Health, and other agencies responded to the Brazilian government's request for an experts' meeting. Kolker, who led the group, said the meeting “changed the dynamic” and produced a plan that gave political approval for Brazil's top health institutions to deal directly with American counterparts to streamline cooperation on Zika research, countermeasures, and field studies.

The unexpected 2014 Ebola outbreak in West Africa highlighted the benefit of an earlier collaboration between the CDC and Ugandan scientists dating from what was then the world's largest Ebola outbreak in 2000. The CDC helped Uganda develop its own world-class Ebola laboratory and response center at the Uganda Virus Research Institute. During the West African outbreak that killed thousands, a single case of Ebola in Uganda was quickly diagnosed, and contacts were traced and isolated.

“There was one death in Uganda,” said Kolker. “The methods were in place to deal with the outbreak. We didn't hear about it because Uganda had world-class capacity and did not require outside or emergency help.”

Emerging economies, as the Ugandan outcome demonstrates, are not looking for “donors to provide aid;” instead, Kolker said, they want to work as partners with experts to help build First World capacity in their own health systems and institutions.

Against this backdrop, U.S. funding for international health security is being squeezed, Kolker added, including programs designed to assist emerging economies to meet World Health Organization standards to prevent and respond to global health emergencies.

The White House proposed deep cuts to global health programs in its fiscal 2019 budget proposal, including programs that address HIV/AIDS, malaria, immunizations, and parasitic diseases, said David Parkes, program associate of AAAS's R&D Budget and Policy Program. The president's budget plan would cut these CDC programs alone by a total of $80 million, taking funding levels 16.3% below enacted fiscal 2018 levels.

The fiscal 2019 budget proposal also called for a 36% reduction below enacted fiscal 2018 levels for the U.S. Agency for International Development. It would cut 17% from a CDC infectious disease program that develops tools to stop diseases spread between animals and people, reported the Global Health Technologies Coalition, a group dedicated to advancing deadly disease treatments and diagnostic tools.

Budget constraints and global political trends heighten the need for organizations like AAAS, academic institutions, philanthropies, and the private sector to forge partnerships with emerging economies, Kolker said. Technical partnerships are needed to further expand health care infrastructure and medical expertise. Several AAAS science diplomacy training and public engagement programs contribute to meeting this goal but will be hard put to fill gaps if government commitment is reduced, Kolker added.

In discussing his experience with epidemics, Kolker explained how multidisciplinary and multinational approaches are especially beneficial as researchers in emerging economies increasingly want to select the health experts they partner with and the research they want to pursue. Such collaborations have led research teams to no longer focus exclusively on infectious diseases. Increasingly, they also study chronic diseases such as diabetes, heart disease, and cancer that present growing health burdens in their countries.

“Our health research system has led U.S. institutions to use African institutions as research platforms. This underestimates the ability of Third World institutions to actually identify their own priorities,” said Kolker. “In the 21st century, the new paradigm is that lower- and middle-income countries actually want partnerships with the world's best experts to bring their own capacity to First World standards.”

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