Creating Impact for One Health and EcoHealth; advancements in implementation, evaluation and governance
September 10-12, 2018 at the University of Bologna, Italy
Creating impact for One Health and Ecohealth Reflections from NEOH Final Action Conference , September 2018
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Below you can find a summary of the 2 day conference with presentation slides linked (Please reference any documents or text used accordingly).
Day 1: Monday 10 September
Prof. Leonardo Nanni Costa from the Department of Agricultural and Food Science (DISTAL), and former Dean of the School of Agriculture and Veterinary Medicine, University of Bologna officially opened the meeting of 110 paerticipants with a warm welcome and an encouragement for the idea of integration and collaboration as a means of finding sustainable and ethical solutions to global health challenges.
In Session One, Maurizio Aragrande (DISTAL and Vice Chair of NEOH), as joint host and organiser, gave a further welcome and to all before Barbara Häsler (Chair of NEOH) introduced the conference theme and background. She spoke briefly about the founding principles of NEOH; that it was designed to be a space for all individuals from different disciplines who had an interest in One Health (OH) to meet and work together to develop a framework for evaluation of OH. This had been achieved through several workshops, short-term scientific meetings (STSMs) and informal communications. This ethos would be continued within the workshop, being open to all and providing an innovative and safe environment to speak freely without political agenda limitations.
The Keynote speaker, Prof. Erik Gómez-Baggethun, from the Norwegian University of Life Sciences presented his thoughts on how to Reconcile different (opposing) demands and use of economic analyses to inform decisions that help us promote health, equity, ecological stewardship, and economic efficiency. He spoke of how classical economic analyses such as Cost Benefit analyses and proportions of GDP, excluded positive and negative externalities, in particular positive effects ecosystem services (ESS). The main challenge is finding agreement on how to capture and express the value for such externalities and how to include these in a “Total Economic Value” framework. Market based valuations and related instruments (e.g. carbon trading system) have several flaws and assume market efficiency and equitable market exchange and access, and has led to criticism from environmental justice groups referring to “environmental racism” based on the notion that “the poor sell cheap”. Prof. Gómez-Baggethun made reference to several ethical examples where markets could be considered as not belonging (“wombs for rent”, US citizenship “for sale”, “commodification” of trophy game species). He referred to the “imperialism of economics” where the only expression of something’s value was monetary, (despite the Oxford Dictionary’s wider definition, which includes the importance and usefulness of things) as being the “tragedy of the well intentioned valuation”. An integrated but pluralistic valuation was called for, with a disaggregated expression of both qualified and quantified values, which would include economic, ecological and socio-cultural values. In the discussion that followed, the issue was raised that economic valuations tended to hold a veto over others and perhaps the environment should hold that position. It was observed that we need to be honest about the limitations of science and other hard disciplines and discuss options beyond. The fact that the political ecology is often removed from the purified economic teaching these days, strengthened the monetary single valuation concept. It was mentioned that communicating integrated evaluations may be challenging as policy makers consider simple, clear messages as “music to the ears”.
After morning coffee, the first part of Session Two (The One Health/ EcoHealth Policy cycle consisted on feedback from each of the NEOH Working Groups on their involvement and contributions to NEOH evaluation framework. These presentations included references to and evaluation) i)the evolution of OH , ii)the use of the evaluation mechanism in policy formulation and evaluation, iii)that the OH-index was not a measure of success but rather of OH-ness, iv) how the case studies demonstrated the operational methodology of the framework for an integrated analysis of OH initiatives, v) the outreach which took place to national and international, private and public stakeholders in the formulation and dissemination phases of NEOH and vi) how a bridge had been built to include biodiversity and ecosystems. To close, Sandra Buttigieg (University of Malta), gave a reflection on her personal transformation through her involvement in NEOH. She gave the take home message that transformation of disciplinary to interdisciplinary working is possible without “turf wars”.
The second part of Session Two consisted of feedback from two external discussants (Cristina Romanelli, United Nations Secretariat of the Convention on Biological Diversity (CBD) and Zoran Katrinka, Programme Director for One Health, Unipol Gruppo DDOR, Serbia) on their assessment of NEOH followed by open discussion. Christina Romanelli introduced biodiversity’s complex relationship with health and as such, biodiversity should be built into a OH and integrated approach to health, and the associated evaluation tools of NEOH. She questioned to what degree biodiversity was included in NEOH’s evaluation. Did the framework account for scales (temporal and spatial) and did it bridge the communication gap from project to policy makers? Zoran Katrinka provided an outline of a SWOT analysis of NEOH; S: not only were the tools provided but their use was demonstrated but the knowledge and skills were provided to use them; W: no obvious weaknesses were noted within the time and financial restraints; O: further dissemination through publications, university and school involvement; T: there was a possibility that their use could lead to “mistaking the maps with the territory”. It was also mentioned that the socio-ecological context of health needed greater inclusion but that a larger platform would be needed to address this. Responses and comments from NEOH members and the audience during the open discussion, included that the framework can be applied to various scales and that, in describing the system and its boundaries, the scale at which it operates must be included. It was mentioned that the next stage for NEOH was to make the use of these tools as part of solution finding and as a catalyst for further action, including creating a common descriptive of what OH is, and a common space for OH, EcoHealth and Planetary health to come together, rather than trying to claim separate territory for funding. Dissemination into schools and universities was essential and could start with the concept of needing to understand the individual from the cellular and biochemical level to the level of the individual within a socio-ecological context.
After lunch, Session Three, Where Science meets Policy (Progress towards implementation of One Health/EcoHealth in a collaborative manner), included three presentations followed by a panel discussion. Katey Pelican from the University of Minnesota spoke on University-government partnerships as One Health game changers: Meeting country needs through multisectoral partnerships and collaboration. She spoke of multisectoral systems still lacking adequate preparation to deal with complex threats. Because universities hold a fluid position within societies with trust from community to policy level, Katey Pelikan mentioned that universities can be a catalyst for change, referencing the work done by networks such as OHCEA and SEAOHUN. Part of this was creating a OH workforce i.e. changing the system through changing the people working within it, who would provide multi-sectoral engagement, education and training and institutional strengthening. She introduced the OH-SMART tool as a means of including all sectors including those from social science and business, and how action plans developed from such interaction were self-empowering. Jeff Wilson, of Novometrix Research Inc., Canada spoke on Network Integration for Stakeholder Engagement within the context of OH. He explained that there is an international move towards collaboration and that “a collaborative economy was becoming a global social movement”. However, management of these networks is needed for true integration to occur at the level of leadership and to include a participatory democracy for individuals. A circle of trust develops which leads a feeling of reduced risk followed by more readily data sharing. Afifah Rahman-Shepherd form Chatham House spoke on Perspectives on health evaluation and governance: Insights from review work. She discussed the barriers that exist to sustaining the political attention to the concept of OH. There were still power struggles and tension between human and animal health with individual expectations and organisational agendas as barriers. A lack of centralised leadership and governance was another barrier although it was acknowledged that centralisation may come at the cost of flexibility. These first two points were interlinked in a vicious cycle. AMR was presented as a common long-term opportunity for adopting a OH approach. There was still a perception that evidence was lacking to justify investments in OH.
Several points were raised in the panel discussion that followed. These included the importance of setting common goals and identifying synergies (and making best use of them) when collaborating in a co-ordinated OH initiative. Investing in OH training and especially OH communication would also help overcome barriers. The issue of an environment of trust and optimism was raised which invariably leads to better transformative ideas. The concept of finding an “intuitive flow state” and including the question of “Does it feel right?” when evaluating OH ideas or initiatives was raised. A change in behaviour and approach is needed when moving into interdisciplinary work. Evidence is only a small part of what is required for behaviour change and arguably an individual’s belief (which is often affected by social proof via their peers) is stronger.
Session Four after coffee provided time for the NEOH Management Committee meeting, a side meeting for early career investigators to work in the Bologna Declaration, a presentation by BiodivERsA on their 2018 call for proposals on Biodiversity and its influence on Animal Human and Plant health https://www.biodiversa.org/1480 as well as a general networking opportunity.
The day was completed with a conference dinner and launch of the NEOH handbook at the Garganelli restaurant at the Savoia Hotel Regency.
Day 2: Tuesday 11 September
Session Five and Six: One Health and EcoHealth developments in different macroregional contexts, contained presentations with examples from 7 regions of the world.
Europe and the Mediterranean Region: Ann Lindberg, of the National Veterinary Institute, Sweden presented on the OH European Joint Program, which was set up to bring together national public organisations (public health, veterinary and food safety) for policy driven R&D and to create a societal responsibility for prevention, surveillance and preparedness for zoonoses and emerging infectious disease. It currently includes 19 countries and has 39 partner institutions. It provides an opportunity to strengthen an integrated approach to health at a national and regional level and is designed to be policy driven.
Maria Grazia Dente, of the Istituto Superiore di Sanità, Italy presented the case of MediLab Secure network, which has a OH approach to arbovirus infection control in non-European countries in the Mediterranean and Black Sea regions. It covers 19 countries with 55 institutions including laboratories, Public Health departments and Ministries of Health. They create an awareness of the added value of OH and focus on capacity building in diagnosis and integrated surveillance. They identified weaknesses and gaps existed in co-ordination and collaboration with respect to data collection, sharing and analysis between nations and institutions. They aim to create an awareness of the benefits of multisectoral risk assessments (promoting a OH approach) and achieve consensus on national levels of risk and on cross border risk factors.
Asia: Hung Nguyen-Viet, the Regional Representative for E and SE Asia, International Livestock Research Institute (ILRI) and Hanoi University of Public Health identified Asia as an area of rapid population and economic growth with complex and emerging health issues. There are several OH/EcoHealth projects (APEIR, ECOZD, BECA, EcoEID, FBLI) active in the area with varying degrees of integration and some overlap. Their focus is on research, capacity building and operational research for change. The case for the SE Asia OH University network (SEAOHUN) was presented, linking and empowering 67 universities (including 120 schools and faculties) to generate intellectual and social capital across human, animal and environmental health sectors.
Canada: Cécile Aenishaenslin, from the Université de Montréal, Canada presented Canada as the “mother of EcoHealth” with reference to IDRC’s long standing root in EcoHealth and the several other branches such as the Centre for Coastal Health, Veterinarians without borders and CoPEH. There has also been an early adoption of the OH approach, most notable with Canada’s approach to AMR with the Canadian Integrated Program for AMR (CIPARS). Noted challenges were that OH and EcoHealth risked forming new silos and communication channels need to be kept open. The idea of convergence may come at the cost of diversity. There is still a long road before the OH and EcoHealth ideas are more broadly implemented. Although academia and public institutions are open to the ideas, the awareness of OH and EcoHealth by the general public is weak.
USA: Katey Pelican from the University of Minnesota, spoke about the OH aspects of both the Department of Agriculture and CDC. The USDA has a OH Co-ordinating Centre to leverage veterinary surveillance for the mitigation of risk of zoonotic and other complex disease issues. The CDC’s OH office connects human animal and environmental health. The challenges of interdisciplinarity were highlighted as communication, data sharing and lack of joint protocol for investigation and response. The use of a Joint External Evaluation Assessment has been useful to identify strengths and weaknesses using a traffic light grading system and push for greater integration and OH approach. However, it was recognised that the wheels turn slowly at a national level and changes are incremental.
Latin America: Efraín Benavides, of the Universidad de la Salle, Bogotá, Colombia reported that local veterinary profession and education is too focussed on disciplines and clinical practice. Progress has been made though workshops, reports, publications and postgraduate courses to strengthen training in interdisciplinary and systems thinking aspects of OH and EcoHealth. Decisions in control of NTD and the like are stil made within silos, despite recognition of the socio-ecological context of disease such as Chagas, leishmaniosis and rabies. The recent hosting of the EcoHealth conference has helped with exposure but more communication for integration and the adoption of the EcoHealth and OH approach is required.
Africa: Agnes Yawe, of the One Health Central and Eastern Africa (OHCEA), Uganda spoke of the OHCEA university led network as only one of many OH initiatives which included SACIDS, AUC/AU-IBAR, Afric-One and EAC/GIZ. OHCEA is built on the four pillars of education and capacity building, research nnovations and commercial services, resource mobilisation and partnerships and organisation and network strengthening. The development of a OH workforce is an active part of this with experiential learning, student clubs and in-service capacity building. Take home messages included that visionary OH champions were needed within institutions and that motivation could be maintained by recognising the significance of incremental changes.
Oceania: Mieghan Bruce, from Murdoch University, Australia reported that EcoHealth was represented in the region by the Oceania EcoHealth chapter. Mieghan reminded us that the region included several small island states, but that these, in the EcoHealth context, could be more aptly named as “Big Ocean” states given their dependence on the ocean. She reported than there is enthusiasm for OH especially with regards to infectious disease but that the environment element needs strengthening. The AMR and usage surveillance strategy for 2015-2019 includes a PH approach but still needs to be fully implemented. Fiji showed promise with a control programme for a leptospirosis outbreak, which had wide collaboration including private enterprises. However, sustainability of such collaborations beyond outbreak control remains a challenge. At the level of education and training, OH is retained within the veterinary and public health disciplines only, and from a funding perspective, there remains a separate focus on human or veterinary projects, even within AMR surveillance.
A short discussion followed these presentations, which included the concept “donor colonisation” and the call for more active self-funding within countries, which would require engagement of finance ministries. The OH concept is still struggling to gain significance at government level in some countries. It was mentioned that if Canada was the mother of EcoHealth, then Africa was the birthplace of OH and that many initiatives began and many OH lessons were learnt there, and this should be recognised more. It was recommended that the future focus of OH and EcoHealth should be on basic health services, education and disease prevention.
Before the closing of Session Six, two further presentations were given. John Berezowski from the University of Bern presented The Future of NEOH, outlining thoughts and developments from the NEOH2 working group. NEOH2 stemmed from a desire to continue the strong relationships and the momentum which existed within NEOH. The future of NEOH was to become a European based but global network of likeminded One-EcoHealth individuals, differentiated from other organisations with a focus on activities, which were needed and valued by the OH/EcoHealth communities. The vision statement was presented as “We envision a world where people, animals and the environment are recognized as being interconnected; and transdisciplinary, systems thinking methods, and integrated approaches are universally practiced for understanding, maintaining and improving the health of all.“ For a governance structure, the proposal was to join EcoHealth International and become their European Charter. The name of the new organisation would be Network for EcoHealth and One Health (retaining the NEOH acronym). NEOH members were encouraged to join EcoHealth International as individual members in the meantime.
The final presentation of Session Six was on the NEOH declaration on One Health & EcoHealth, by Giulia Paternoster, University of Zürich, Switzerland, Olga Muñoz, University of Florida, USA and Gabby Laing, House of Lords Intern, United Kingdom. Prior to the conference they had invited participants to take part in a survey to share their visions of One Health and EcoHealth. They presented some of their findings but because the sample size of participants was small they set up an interactive session on Mentimeter, in which attendees were encouraged to take part and complete the survey before the coffee break. The findings of these inputs will form the basis of the Bologna Declaration on One Health and EcoHealth.
Session Seven: Breakout groups for Parallel discussion sessions and workshops took place after lunch with reporting back after afternoon coffee.
The One Health integration for impact group dealt with the benefits and risks of integration including hierarchy, knowledge systems and social issues. They spoke of changing the narrative from “environment” to “ecosystems” to include biodiversity and the nature related links to health. Gender challenges were also raised with special reference to equality in education and also the integration of the gender perspective in funding.
The Vectors, VB pathogens and VB zoonotic diseases from a OH perspective group reflected that in this topic, the environment played a crucial role. Because surveillance varied between countries, NEOH2 could play a leadership role by mapping and connecting the existing surveillance stakeholders. It could be an intercountry forum for collaborative surveillance and prevention, providing a neutral forum to prevent conflicts of interest.
The Evaluating the added value of OH surveillance of AMR group, raised 3 main topics namely, compatibility of surveillance across programs, what research was needed and sharing of data and information. Compatibility challenges persist across programs when it comes to integration and validation standards (between human and veterinary labs), technical issues and attempts to include the environmental component of surveillance. More outcome research was needed but this was challenged by persistently siloed disciplines. An adaptive and shared leadership was necessary and a forum for data sharing was called for.
The Procedure to approach interdisciplinary issues in OH initiatives group spoke of the needs for interdisciplinary work which included a common language, mutual trust and respect, a common goal, shared leadership and learning, institution support and buy in and appropriate fund allocation within the interdisciplinary context. The procedure was used within the group and utilised a matrix to identify the skills and expertise required within a system to work together for complex and interdisciplinary challenges.
The Introduction to OH methods group presented on the importance of qualitative methods to understand and work within the socio-ecological constratc of the human-animal-environment interface. They used the topic of Obesity of dogs and owners (one of the NEOH case studies) to demonstrate the dynamic and systems approach which was taken.
The OH implementation in the global South group presented on improving food safety, food security and nutrition in livestock based communities who were usually marginalised populations of small-scale farmers. The lack of formal veterinary and public health services was highlighted and the significance of the need for community based capacity building was made, with respect to building on local indigenous knowledge. The need for strengthening the collaboration between researchers, academia, ministries and civil society was highlighted.
Before closing the conference, reflections were invited from NEOH members, Kitty Maassen (Netherlands) and Richard Kock (UK). Kitty Maassen mentioned that the presentations from the NEOH working groups in Session Two were maybe too concise for those less familiar with NEOH’s tools but reminded participants that Wednesday’s workshop would provide more details of this. Some of the main points made during the conference were the need for common language, understanding each other’s viewpoints, challenges of actual implementation and the involvement of the government, the need for greater inclusion of environmental aspects and public health professionals in NEOH, and the use of systems thinking in the holistic approach to health. On the Science Policy discussions, it was encouraging to learn about the university networks in Asia and Africa, but again there seemed to be a challenge to involve government and there was a reminder that business and private sector should be included in collaborative outreach. The number of different OH Eco-health initiatives across the globe was impressive as was the range of focus areas among them. As a few take home thoughts, NEOH’s tools should be used beyond evaluation but also in setting up new, and improving existing collaborations and initiatives. In addition, creating opportunities to build understanding and trust were essential. There is a Dutch expression “It arrives by foot and it leaves by horse” which reflects the way trust develops with interaction and time.
Richard Kock reflected on the Science and Policy session, how lots of great science is going on but not enough people are taking it on, it needs to remain digestable; there remains a communication issue to the governments but also the general public. Absence of evidence is often used by government and policy makers for inappropriate action. With complexity of current health issues, there is not enough time to generate evidence and therefore the precautionary principle must be pushed whilst evidence is gathered. OH in practice works best when there is government involvement as shown by the OH European Joint Program. Africa has been the crucible of many things including OH, it is where the survival approach is required. The African way is being converted from a sustainable resilient system to one of consumerism and carbon producers. Going forward, NEOH and Europe needs to be humble and listen to the “developing” countries, which can teach us a lot in the OH approach. Compliments were expressed to John Berezowski and taking NEOH forward. The quote of Arthur Koestler (“Every creative act involves a new innocence or perception, liberated from the cataract of accepted belief”) was presented with reference to the future plans of NEOH and the overall OH EcoHealth community. Overall, the presentations were great but the breakout group sessions are a critical part of the discussion process, to encourage expression of participants’’ individual ideas and to engage in active debate.
Barbara Häsler closed the conference by thanking the organising committee and all participants and expressed the vision of keeping the NEOH spirit alive in the next phase, one that is welcoming and inclusive.