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7 Governance Challenges for Zoonotic Disease Surveillance, Reporting, and Response “. . . [I]nnovations in global health governance, rather than merely in- creasing investments or incremental improvements in the old systems, are needed to meet the deadly crisis of the new age. These innovations will need to come in the realm of ideas, as the prevailing principles and norms that guide global health governance are redefined and reinvented for a comprehensively and instantaneously interconnected, complex world. They will be needed in the realm of institutions, where new rules, decision- making procedures, resources, and participants are required if the expecta- tions and behaviour of the world’s countries and citizens are to converge on the reality, rather than just the ideal, of health for all.” —Andrew F. Cooper, John J. Kirton, and Ted Schrecker Governing Global Health (May 00) As previous chapters have demonstrated, there are many challenges in achieving sustainable global capacities for zoonotic disease surveillance and response. One of the more formidable challenges is identifying governance strategies that will result in an effective global, integrated zoonotic disease surveillance and response system. This chapter addresses the challenges in identifying and implementing these strategies: in particular, how societies organize themselves in ways that are effective in preventing, preparing for, and responding to threats to human and animal health. It also discusses some potential options to address these challenges. Governance tasks arise within each country and through the interac- tions countries have with one another. The complexity of multiple gover- nance and scientific contexts at a global level is daunting for human and animal health specialists that are unfamiliar with world politics, intergov- ernmental organizations, and international law, and for policy and legal ex- perts who lack scientific and technical knowledge about zoonotic diseases. Governance challenges can only be effectively met through strong partner- ships among the diverse set of experts needed to craft feasible responses to emerging zoonotic diseases. The drivers underlying the emergence of infectious diseases are in large 0

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES part ecological, political, economic, and social forces operating at local, national, regional, and global levels. In diverse ways, they physically bring humans and animals closer together. However, these forces also create domestic and diplomatic problems for governments when changes in the disease drivers require new approaches—integrated approaches—across multiple relevant sectors. The integration of scientifically informed strate- gies to detect, prevent, and control zoonoses within existing governance structures is proving difficult for states, intergovernmental organizations, and nonstate actors. Several of the committee’s recommendations (see Chapter 8) aim to develop integrated capacities for disease surveillance and response that link human and animal health. These capacities operate from the local to the global level, and need the support of political commitment, normative rules and principles, legal frameworks, and material capacities (e.g., human resources, laboratories) that operate at the same levels. THE RELATIONSHIP BETWEEN HUMAN AND ANIMAL HEALTH CAPABILITIES AND GOVERNANCE “Governance” refers to the structures, rules, and processes that soci- eties use to organize and exercise political power to identify and achieve objectives. When we examine governance, we want to know what political objectives societies pursue, why societies select those objectives, and how societies attempt to reach those objectives. Governance includes, but is not synonymous with, government. Societies use governance mechanisms that are not part of the government, for example, when using the market to govern economic behavior. Conflating governance and government means that “global governance” would be impossible because no world govern- ment exists. Typology of Governance Literature on governance often identifies three governance realms: na- tional, international, and global, which are described in Table 7-1. National Governance National governance refers to the way in which a country organizes political power within its territory and controls interactions among local, subnational, and central governmental authorities. The allocation of ju- risdiction is particularly important for disease surveillance, which is often a state or provincial function rather than the responsibility of the central or federal government. When it is decentralized, achieving harmonized,

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0 GOVERNANCE CHALLENGES TABLE 7-1 A Typology of Governance Governance Scope of Rule Level Actors Involved Sources of Rules Applicability National • Government • Constitutions Generally limited governance • Nongovernmental entities • Legislation to the territorial (e.g., corporations, • Administrative jurisdiction of the producer and consumer regulations state organizations, medical • Law of subnational and veterinary units associations) • Common law • Individuals (e.g., as • Court decisions voters) • “Soft law” norms International • States • Treaties Rules apply in governance • IGOs • Customary relations among international law states either directly • General principles or indirectly through of law recognized IGOs as international law • “Soft law” norms Global • States • Treaties Rules apply and affect governance • IGOs • Customary relations among states • MNCs international law and the activities and • NGOs • General principles behavior of nonstate • Individuals of law recognized actors and individuals as international law • “Soft law” norms • Private governance regimes NOTES: IGOs = intergovernmental organizations, MNCs = multinational corporations, NGOs = nongovernmental organizations. SOURCE: Adapted from Fidler (2002). coordinated policies can be complex. Privatized human health and vet- erinary services also change the context in which a country’s governance takes place, particularly with respect to managing private economic incen- tives that may be in competition with the production of public goods. The demands that global disease threats generate make decentralization and privatization in national human and animal health governance even more challenging. International Governance The second level of governance is international, typically defined as the regulation of political interactions among countries. Unlike national

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES governance, which is hierarchical, politics among nations is anarchical— meaning that sovereign states interact, but do not recognize any common, supreme authority. It is for this reason that regimes arise: to form the “persistent and connected sets of rules (formal or informal), that prescribe behavioral roles, constrain activity, and shape expectations” of sovereign states (Keohane, 1984, p. 781). Through regimes, such as international law and intergovernmental organizations (IGOs), countries govern their relations. Many are able to negotiate to identify common interests, forgo the hierarchy of power that always exists, and cooperate in international governance. In human and animal health, international governance is apparent in the functioning of IGOs, especially the World Health Organization (WHO) and the Food and Agriculture Organization (FAO)—both specialized agen- cies of the United Nations (UN)—and the World Organization for Animal Health (OIE), an independent non-UN organization that is also a reference organization of the World Trade Organization (WTO) (see Box 1-2). Inter- national agreements and programs operated by WHO, FAO, and OIE are mechanisms of international governance because they regulate the interac- tions of states concerning human and animal health, travel by humans, and food-animal trade, among a number of other issues. Global Governance The third governance level is global, which refers to efforts by states and nonstate actors to shape the exercise of political power within and among countries. Global governance differs from international governance because it recognizes that nonstate actors are involved in managing and regulating political activities. In other words, sovereign states are not the only governance actors in world politics. For example, nongovernmental organizations (NGOs) that promote human rights might criticize multina- tional corporations by using international human rights law developed by states and persuade these corporations to adopt codes of conduct to im- prove safety and health standards for workers. These codes are instruments of global governance arranged through global political activities among nonstate actors that do not emanate from national governments or IGOs. Global governance strategies cut across traditional boundaries developed in national and international governance. Governance and Hard and Soft Law These forms of governance produce diverse normative strategies to channel political power and human behavior to work toward identified goals. Legal experts sometimes categorize these strategies as “hard law” or

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0 GOVERNANCE CHALLENGES “soft law” approaches. Typically, hard law is formal, binding law (e.g., a statute in national governance or a treaty in international governance). Soft law, which political scientists include in their definition of “institutions,” consists of nonbinding rules, principles, guidelines, and norms that guide individual behavior (e.g., moral precepts), corporate entities (e.g., codes of conduct), and sovereign states (e.g., political understandings among coun- tries concerning shared problems). Each governance realm contains hard law and soft law. National governments enforce hard law rules through criminal or civil sanctions. However, most hard law in international gov- ernance—the rules of international law—has no centralized enforcement. Consequently, whatever enforcement takes place happens in an ad hoc, de- centralized manner, such as when a country takes countermeasures against another country for violating an international law. Soft law rules are some- times more effective than hard law, even when the threat of enforcement is nonexistent. In addition, soft law allows political actors an option for developing collective responses without the high transaction costs of reach- ing binding agreements. Thus, calling a rule or principle “hard law” or “soft law” does not necessarily indicate which approach is likely to be more effective in any given governance context. Zoonotic Disease Surveillance, Response Capacities, and Governance Conducting zoonotic disease surveillance to detect threats to human and animal health that cross political borders and to intervene against those threats requires governance strategies and mechanisms that encourage countries to share information and collaborate on responses. For disease surveillance and response systems to be effective, countries must implement international and global governance approaches within their territories, from the local to the national level, and beyond to the international com- munity, through both formal legal rules and informal modes of collabora- tion. What this governance enterprise contains, why political actors pursue and sustain the effort, and how strategies, mechanisms, and capabilities are built and sustained are critical questions to address, for the answers will determine whether or not a system can work effectively. Trends in Human and Animal Health and in Governance: Convergence Amidst Fragmentation The drivers of emerging zoonotic diseases are bringing human and animal health ever closer together. This convergence, and the increasingly diverse circumstances in which humans and animals interact across the world, creates the need for more centralized, harmonized, and rationalized governance across the multiple sectors within and among countries. One

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES expression of this new understanding and appreciation is the greater col- laboration among WHO, FAO, and OIE—which is to be applauded and supported. There remains, however, considerable uncertainty about the mechanisms for this collaboration, the definition of responsibility among the three agencies, and their connections to WTO. Convergence in and of itself does not automatically lead to collaboration and integration at na- tional, international, and global governance levels—where unfortunately, fragmentation of sectors remains the dominant theme. Decentralization and privatization in the human and animal health sec- tors are creating additional difficulties for national governance struggling with rising globalized disease threats at the local, subnational, and central government levels. This was highlighted when the Indonesian government refused to provide isolates of highly pathogenic avian influenza (HPAI) H5N1 to WHO without guarantees of a return to the nation of resources, whether it was a portion of the intellectual property or the particular products developed using the strains (Padmawati and Nichter, 2008). This experience raised new questions, such as: “How does one implement a high- priority global health program in a decentralized political state? How does one encourage decentralized problem solving while supporting national disease control programs that demand centralized activities and infrastruc- ture?” (Padmawati and Nichter, 2008, p. 46). The situation has become even more confused, as the traditional posi- tion of WHO as the sole intergovernmental authority for human health has been undermined by the growing involvement of other bodies (e.g., the World Bank and WTO) and the creation of new initiatives (e.g., the Global Fund to Fight AIDS, Tuberculosis, and Malaria). In addition, major powers in the international system, particularly the United States, have taken more active and often unilateral roles in global health, substantially affecting international health governance. Examples include the U.S. Global Leader- ship Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (the reauthorization of the President’s Emergency Plan for AIDS Relief [PEPFAR]), the U.S. President’s Malaria Initiative, the U.S. Agency for International Development’s initiative on Avian and Pandemic Influenza Preparedness and Response, the Group of 8 global health initiatives, and most recently, the Obama administration’s $63 billion Global Health Ini- tiative, which expands support beyond PEPFAR to address maternal and child health, family planning, and neglected tropical diseases (The White House, 2009). The landscape of global health governance has also changed with the explosion of new actors and programs, particularly involving nonstate ac- tors (Garrett, 2007). This explosion includes the activities of philanthropic NGOs (e.g., Bill & Melinda Gates Foundation, Google.org), advocacy

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 GOVERNANCE CHALLENGES and service-providing groups (e.g., Médecins sans Frontières,1 Program for Monitoring Emerging Diseases or ProMED-mail), and private, multi- national corporations (e.g., development of corporate-driven food safety standards). Although the increasing involvement of states, IGOs, and nonstate ac- tors has brought new energy, prominence, and funds to global health, the multiplication of actors and initiatives has led to concerns that global health governance is becoming so fragmented that it is dysfunctional, and in need of new “architecture” to align interests, programs, and funding more effec- tively (Fidler, 2007). The complexity of zoonotic diseases, with the multiple sectors and players involved, exacerbates this fragmentation even more. The extent to which international and global health governance are susceptible to centralization, harmonization, and rationalization remains an open ques- tion, especially in light of the world’s transition to a multipolar system (in which multiple states have relatively equal military, cultural, or economic influence)—a context in which multilateralism might become more difficult (National Intelligence Council, 2008). The committee concludes that the convergence apparent in the drivers of emerging zoonotic diseases means that each level of governance has become increasingly important and inter- dependent. At the same time the fragmentation in governance, at these same levels, has complicated the development and implementation of strategies to advance governance within each level and to integrate initiatives across all three levels. GOVERNANCE PROBLEMS FACING INTEGRATED SURVEILLANCE AND RESPONSE SYSTEMS FOR EMERGING ZOONOTIC DISEASES Traditional Governance “Silos” for Human and Animal Health Historically, given their different missions and principal concerns, the approach taken by WHO to develop and adopt the International Health Regulations of 1969 (IHR 1969), which focused on reducing human mor- bidity and mortality, did not affect how OIE, attentive to reducing the impact of animal diseases on trade and economics, functioned in respect to animal diseases and vice versa. By 1969, experts at WHO recognized that the four legacy diseases subject to IHR 1969—cholera, plague, yellow fever, and smallpox—did not reflect the range of microbial threats at that time (Dorolle, 1969). Given the weaknesses of IHR 1969, the best available governance device to address human and animal health threats was inter- national trade law, which allowed countries to restrict trade when animals 1 Also known as Doctors Without Borders.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES or animal products posed a threat to human health (e.g., food safety) or animal health (e.g., contagious diseases threatening food-animal production in the importing country). Historical obligations to notify WHO or OIE of diseases reflected concerns about the potential of infectious agents to spread through inter- national commerce, causing adverse effects on trade. In fact, the primary purpose of international trade law was not primarily to protect human or animal health but rather to liberalize trade to generate economic growth and development and avoid trade sanctions. It is not surprising that tradi- tional approaches to disease notification by OIE and WHO were neither closely intertwined nor crafted to be sensitive to the drivers of emerging zoonotic infectious diseases. As a consequence, they had little in the way of enforcement provisions. Much of the governance innovation taking place today with respect to human and animal health and emerging zoonotic diseases attempts to break out of traditional patterns and ways of thinking about disease surveillance, prevention, and control and their subsequent effect on human and animal health at the local, national, and international levels, and to provide greater imperatives to action. The International Health Regulations 2005 (IHR 2005) is a binding legal instrument that obligates the 194 countries that have signed the treaty to improve their sur- veillance and response capacity, and to report promptly to WHO any dis- ease outbreaks representing an international public health emergency. The purpose is explicitly dual, to protect public health and to limit interference in international traffic and trade. Under IHR 2005 outbreaks of smallpox, wildtype polio, new strains of influenza virus and severe acute respiratory syndrome (SARS) are public health emergencies of international concern. Regime Contributions to Fragmentation and Weakness Concerning Governance of Drivers of Zoonoses The fragmentation and weaknesses of regimes involving the drivers of zoonoses limit the ability of national governments, individually or through collective action with IGOs and nonstate actors, to prevent zoonotic threats. For example, the legal regime for international trade is also separate from environmental protection law and unconnected to issues regarding popula- tion growth. The committee concludes that, given the prevailing fragmented and weak governance, the goal of an integrated human and animal health approach is critically linked to efforts to develop and sustain governance mechanisms to promote integrated disease surveillance and response capa- bilities in countries and is dependent on universal implementation of IHR 00.

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 GOVERNANCE CHALLENGES International Environmental Law: Governance and Environmental Degradation Chapter 3 discussed examples of environmental degradation driving the emergence and spread of zoonoses—deforestation, encroachment on wildlife habitat, and climate change. Each is complex and has problematic governance regimes. Environmental governance at the international level, for example, does not have a central mechanism as international trade law has in WTO. International environmental law and other forms of global environmental governance have been largely ineffective in affecting the driv- ers of climate change, which, in turn, could exacerbate the impact of envi- ronmental degradation on the emergence of zoonotic diseases and become subject to the governance principles for human and animal health. Part of the challenge, particularly at the international and global lev- els, is that environmental problems exhibit different features that require custom policy solutions for each setting, and involve huge economic con- siderations. Although deforestation and climate change are linked ecologi- cally, they are different problems politically, the former being national and internal, while the latter is external and involves all nations. In part, this explains why governance activities regarding the environment are not well connected or integrated for the purpose of protecting human and animal health. Deforestation and Encroachment on Wildlife Habitat Deforestation and other activities related to exploitation of natural resources also facilitate the encroachment of humans on wildlife habitat and in this manner can promote the emergence and spread of zoonotic dis- eases. Under international law, the state in which the forest or the wildlife habitat is located has sovereignty over such resources, and has the right to develop those resources according to its strategies for economic and social development. Without an agreement, other states potentially affected by the exploitation of that resource have no grounds to intervene in the domestic affairs of the “exploiting” state. Although countries have concluded treaties on the type of problems described above (e.g., desertification, protection of endangered animal species), deforestation has only been subject to soft law instruments, such as the Statement of Forest Principles (United Nations, 1992). In this instance, compliance with soft law has not proved compel- ling for countries interested in exploiting their forest resources. The same dynamic generally holds for efforts to protect wildlife habitat from human encroachment. Typically, countries potentially affected by the exploitation of environmental resources in another nation are unwilling to provide suf- ficient resources to offset the costs of not exploiting these resources.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Climate Change Climate change is a fundamentally different issue than deforestation and encroachment on wildlife habitat. A single country can reduce defores- tation or encroachment on wildlife habitat within its territory by pursuing and enforcing conservation policies, but any individual attempt to address climate change is bound to be futile because the threat arises from the ac- tions of many countries. Pollution of the atmosphere, a resource subject to the sovereignty or jurisdiction of no state or group of states, also cannot be addressed by one nation. As the travails of the Kyoto Protocol and the impasse concerning post-Kyoto strategies demonstrate, hard and soft law instruments have not persuaded countries to make common sacrifices to reduce threats related to climate change. The same situation exists with respect to efforts to help developing countries handle the effects of climate change on their economies and societies. The committee concludes that the weakness of regimes concerning environmental degradation, deforestation, and climate change suggests that pursuing governance strategies in these realms is unlikely to contrib- ute much in the near term to preventing and protecting against emerging zoonotic diseases. This reality heightens the importance of having disease surveillance and response capacities in order to detect and intervene in a timely manner against outbreaks. Other Drivers Food Security Chapter 3 also identified food security as a driver contributing to zoo- notic diseases. The global food crisis in 2008 highlighted how vulnerable food security is even though, under human rights law, governments are re- quired to take necessary actions to ensure that every individual has access to adequate food (High-Level Task Force on the Global Food Security Crisis, 2008). The impact of food insecurity, of course, is not just its legal implica- tions, or even the specter of starving people. Malnutrition is a determinant of the resistance of an individual to infectious diseases, and starvation forces people to search for alternative food sources, some of which (e.g., bushmeat) increase the risk of emerging zoonotic diseases. Although counterintuitive, efforts to achieve food security at affordable costs, and thus fulfill the right to health, could lead governments to increase food production at the expense of food safety, animal hygiene, and envi- ronmental protection. Ensuring food security at a reasonable cost, in the context of population growth, requires increasing food resources through

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 GOVERNANCE CHALLENGES increased production, harvesting of wildlife, or imports—each of which has implications for emergence and movement of new zoonotic diseases. With- out economies of scale in agricultural production, countries are vulnerable to becoming more dependent on imported food and at risk of volatile world food prices, as happened in 2008. Population Growth and Population Movements Although states, IGOs, and NGOs have long attempted to craft regimes to control population growth and movement, these efforts have largely failed. The metrics of global population increases, especially in the devel- oping world, illustrate the failure of schemes to limit world population growth. Internal migration from rural to urban areas or populating previ- ously uninhabited areas to exploit natural resources are predominantly, if not exclusively, matters for national governance because of the international legal principles of sovereignty and nonintervention in domestic affairs of other states. Cross-border movements of populations affect international and global governance, but existing principles and mechanisms merely at- tempt to manage the consequences of population growth (e.g., poverty) rather than addressing the underlying causes of migration. GOVERNANCE INNOVATIONS SUPPORTING INTEGRATED DISEASE SURVEILLANCE AND RESPONSE IN HUMAN AND ANIMAL HEALTH Four objectives for foreign policy and diplomacy were described as conceptually important innovations for surveillance and response capaci- ties in Chapter 1. What has not been seen until recently are disease sur- veillance and response capacities relevant to all four of these objectives of foreign policy simultaneously. Governments, IGOs, and NGOs now talk of threats—such as SARS, HPAI H5N1, pandemic influenza due to any influ- enza virus (e.g., the new triple reassortment influenza A(H1N1) 2009 virus strain sweeping the world), HIV/AIDS, and bio- and agro-terrorism—to national and international security; national economic welfare and power; development objectives (e.g., as threats to the health-related Millennium Development Goals); and human rights and human dignity. The factors that motivate political interest in these realms connect to objectives that gov- ernments pursue in their foreign policies and diplomatic agendas. Without these changes, the potential of convincing governments to expend political, economic, and diplomatic capital to improve these capacities for human and animal health is limited.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Committee Analysis of the House of Lords Select Committee’s Recommendation IHR 2005 already permits WHO to investigate potential zoonotic threats by authorizing WHO to collect information from any source on disease events of whatever origin that might threaten human and animal health. This strategy captures emerging or reemerging zoonotic disease threats. During the committee’s background research, WHO officials de- scribed two examples—one involving Rift Valley fever and one concerning Crimean-Congo hemorrhagic fever—in which WHO used IHR 2005 to alert health officials of potential zoonotic threats. In fact, human health officials promoted the governance approach in IHR 2005 by arguing that it would allow WHO to catch new zoonotic diseases earlier and more often than previously. WHO’s response to SARS functioned as a “roll out” of the approach, which was formally adopted in IHR 2005. As a result it requires notifications of any case of SARS or human influenza caused by a new subtype, which reflects concern with zoonotic diseases (IHR 2005, Annex 2). The decision instrument that guides state parties to IHR 2005 in determining whether a disease event may constitute a public health emergency of international concern is also sufficiently robust to catch zoonotic disease emergence or reemergence (IHR 2005, Annex 2). Given the implicit mandates within IHR 2005 regarding zoonotic dis- eases, the treaty may not need to be amended to explicitly include zoonotic diseases within its disease surveillance approach. Rather, the more salient concern appears to be fine-tuning disease surveillance to detect animal dis- eases earlier so experts have more time to prevent diseases from threaten- ing other animals and, potentially, humans. Under this reasoning, the OIE treaties, not IHR 2005, would require amendment. However, the highest policymaking body in OIE has authorized the organization to collect, analyze, and seek verification of nongovernmen- tal sources of information within WAHIS and as part of its participation in GLEWS. The OIE data in Table 7-4 indicate that when verification of unofficial information was sought between 2002 and 2007, OIE members provided official or unofficial responses to verification requests more often than they failed to respond (providing responses to nearly 74 percent of verification requests made by OIE to its member states). Thus, the HLSC belief that OIE does not or cannot use nongovernmental sources of infor- mation is incorrect. The committee concludes that the performance of OIE member states to provide official notification of disease events and to respond to OIE verification requests is suboptimal for achieving an effective global system of emerging infectious disease surveillance and response. OIE efforts to

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 GOVERNANCE CHALLENGES increase incentives for better compliance and responses need stronger policy or legal measures. The HLSC report never mentions IHR 2005’s obligations on state par- ties to develop and maintain minimum core disease surveillance capabilities. IHR 2005 recognizes that disease surveillance capacities are fundamental public goods for which national governments are, and always will be, primarily responsible. A strategy for animal diseases comprehensively in- formed by IHR 2005 would have to include requirements on OIE members to develop and maintain minimum core disease surveillance capabilities— requirements that OIE agreements do not impose. This change would fur- ther underscore how radical a strategy of substantive harmonization on the basis of IHR 2005 would be for the OIE governance system. The HLSC analysis also did not consider whether IHR 2005 offers a template for improving response capacities in animal health. As described above, IHR 2005 moves response governance closer to becoming an inte- gral part of disease surveillance for two reasons: (1) the regulations only empower WHO to declare a public health emergency of international con- cern and authorize WHO to issue temporary recommendations to guide countries’ responses to such emergencies; and (2) it mandates that state parties develop and maintain minimum core response capabilities from the local to the national levels. OIE itself has not developed strong national animal health response capabilities because it relies on OIE members to develop and maintain them. FAO might possess more response capabilities at the country level, but FAO capabilities are currently inflated because of HPAI H5N1 and might not be sustainable in the long run. Dividing responsibilities between OIE (early warning) and FAO (early response) to animal outbreaks would require amendments and policy changes across two IGOs. The committee concludes that implications of including minimum core disease surveillance and response capacities for animal health at national levels are enormous. In many countries, and particularly in the poorest ones, the disease surveillance and response capabilities of public and private veterinary services are limited and fragmented. Strengthening these capa- bilities within and across countries, while integrating them with capacity building for human and animal health, would require major amendments, resources, and attitude changes at the national governance level. The committee also acknowledged that under a broad-based substan- tive harmonization strategy, the task of amending OIE treaties to reflect IHR 2005’s rules would be an even more significant undertaking than implied by the HLSC analysis. Whether such a transformation of OIE governance would be feasible is difficult to assess, but the committee was aware that the revision process that produced IHR 2005 lasted 10 years (1995–2005), and perhaps would not have been finished by then without

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES the shock of SARS in 2003. Amending the OIE treaties to produce substan- tive harmonization with IHR 2005 would not be a quick and controversy- free diplomatic endeavor. However, it would be feasible with sufficient pressure and resources. MOVING TOWARD A GLOBAL, INTEGRATED DISEASE SURVEILLANCE AND RESPONSE SYSTEM: FUTURE GOVERNANCE STRATEGIES The threat that zoonotic diseases currently pose, and will continue to pose for the foreseeable future, counsels against complacency and in favor of strengthening national, international, and global governance strategies concerning disease surveillance and response capabilities—even though progress has been made in governance contexts in and between human and animal health. The strategies that countries, IGOs, and NGOs should pur- sue is difficult to determine. The answer must balance what reforms might be feasible with what disease surveillance and response capabilities are required of stakeholders. The committee identified three principal reform options that can be explored: (1) structural centralization, (2) structural coordination, and (3) intensified implementation. Structural Centralization: One Regime for Integrated Human and Animal Health Unifying disease surveillance and response efforts for zoonotic threats under a single institution and set of rules would be the most radical reform option. Rather than trying to ensure coordination among WHO, FAO, and OIE, structural centralization would empower one of the existing intergov- ernmental entities to exercise primary responsibility for disease surveillance and early response. This approach would provide a streamlined architecture for global health governance on zoonoses. If established and supported by all three organizations, it would be the most expedient option. However, such a structural centralization has several disadvantages. First, WHO, FAO, and OIE are unlikely to support this approach; second, the transaction costs of negotiating a single regime would be significant; and third, the time needed for complicated negotiations among the three organi- zations would be counterproductive given the pressing needs the zoonotic threat creates. Finally, structural centralization in itself would be insufficient because such centralization does not produce the functional capabilities that are needed for surveillance and response for zoonotic diseases. In addi- tion, streamlined architecture might not produce more effective governance because the new regime would disrupt patterns of collaboration currently

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 GOVERNANCE CHALLENGES developing and could have difficulty with tapping into the major existing bodies of knowledge and experience of WHO, FAO, and OIE. Structured Coordination: Maintaining Core Competencies of Existing Agencies While Establishing Transparent Coordinating Mechanisms Under this second option, WHO, FAO, and OIE would maintain their own respective mandates, but a permanent coordination mechanism would be established with the authority and provide a means of bringing the tech- nical agencies together in order to act quickly, develop common standards and, in the case of a potential emerging zoonotic disease outbreak, prepare a joint response strategy. This would make permanent the current arrange- ment under the United Nations System Influenza Coordinator’s (UNSIC’s) office, except that it would not be disease specific. The rationale is that it would be based on the very successful intervention of UNSIC, which, the committee believes, has made a major difference in the overall coherence and efficiency of the HPAI campaign. The coordinating mechanism could be entrusted to UNSIC, making its mandate broader to include all zoo- notic infectious diseases and making it permanent (it is currently expected to end in December 2010), or entrusted to another high-level UN agency, independent of WHO, FAO, and OIE. The establishment of a permanent coordination mechanism would still carry some transaction costs for the three technical agencies, but these costs would be much less than in the case of the structural centralization integration option. It would also use the available resources of the technical agencies. Intensified Implementation: Integrated Human and Animal Health Capabilities A third option, but not mutually exclusive with the second option, would involve intensifying efforts to implement and integrate WHO and FAO/OIE activities that seek to strengthen local, subnational, and national disease surveillance and response capabilities. The inadequacies and weak- nesses of human and animal health systems in many countries is recognized to be a serious impediment to effective planning to prevent, protect against, and control zoonotic diseases (Vallat and Mallet, 2006). Rather than focus- ing on the structural or substantive aspects of international and global gov- ernance, reform could concentrate on implementing and coordinating the obligations and initiatives contained in the IHR 2005 and FAO/OIE strate- gic plans related to national disease surveillance and response capabilities. In animal health, intensified implementation would require greater commitment, including financial resources, to advance the strategy of im- proving disease surveillance and response capacities within countries as

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES proposed by FAO and OIE in their joint strategy on Ensuring Good Gover- nance to Address Emerging and Re-Emerging Animal Disease Threats (OIE and FAO, 2007). It would also require a further definition of the respective tasks of OIE and FAO, which could entail a clearer focus of OIE on set- ting standards as well as a commitment from FAO to support its member countries in the implementation of these standards. For human health, IHR 2005 would provide the strategy for intensified implementation, especially helping developing countries comply with their obligations to develop and maintain core disease surveillance and response capabilities. Nonetheless, the intensified implementation strategy faces daunting challenges. Concerns already exist about whether WHO members will adequately implement IHR 2005. Although the committee considers this implementation essential for an integrated surveillance and response system for zoonotic emerging infectious diseases, and WHO is undertaking imple- mentation activities, there is not yet a clear and adequately funded strategy for achieving IHR 2005 compliance. WHO does not have the necessary internal capacity to fully focus on IHR 2005 implementation challenges. Sufficient, sustainable financing to implement and improve disease surveil- lance and response capacity in low-resource countries, discussed in Chapter 6, is a particular strategic challenge. OIE’s and FAO’s Ensuring Good Governance strategy (2007) also confronts implementation problems that arise from, among other things, the scale of the capacity-building task and the lack of sufficient human and financial resources. As noted earlier, OIE has no internal capabilities to task with capacity building within OIE member states, and most of FAO’s capa- bilities are focused on the HPAI H5N1 threat and will rise and fall with the perceived magnitude of the threat. More permanent financing mechanisms, as recommended in Chapter 6, are essential to implement this option. A strategy of intensified implementation that is executed inadequately could raise other dangers for human and animal health governance. The controversy sparked by Indonesia’s decision not to share samples of HPAI H5N1 viruses with WHO for disease surveillance purposes illustrates these dangers. Indonesia questioned the legitimacy of sharing virus samples for global disease surveillance when it, like other developing countries, received little if anything in return. Indonesia has been specifically concerned about its lack of equitable access to influenza vaccines and drugs, which represent an important response against this disease threat. The committee concludes that the HPAI HN campaign, as discussed in Chapter , has shown the strong value and feasibility of enhanced coordination among WHO, FAO, and OIE, as provided by UNSIC. UNSIC’s establishment significantly enhanced the coherence and efficiency of the campaign, and its credibility vis-à-vis the donors.

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 GOVERNANCE CHALLENGES International Trade Agreements Supporting Liberalization of Trade in Agricultural Goods and Food Products Chapter 3 identified trade as a driver influencing zoonotic disease emergence and reemergence. Trade agreements have facilitated the growth of global trade in agricultural and food products. Governance mechanisms that increase trade, such as the General Agreement on Tariffs and Trade (GATT) under WTO, have proved successful. The current WTO round of trade negotiations—called the Doha Devel- opment Round and ostensibly focused on helping developing countries— has been suspended largely because of disagreements on how to liberalize trade in agricultural products and reduce agricultural subsidies, particularly the significant production subsidies that the European Union and the United States provide to their respective domestic agricultural sectors. Despite this setback in multilateral trade talks, global trade in agricultural products is likely to continue to expand for three reasons. First, WTO agreements fa- cilitate the existing levels of agricultural trade and make any retrenchment difficult to accomplish. Second, progress in the Doha Round will have to be based on agreements to liberalize agricultural trade and to reduce the market-distorting impact of agricultural subsidies. Third, regional and bi- lateral trade agreements are proliferating and often include commitments to liberalize trade in agriculture products. These regional and bilateral agree- ments might expand trade in agricultural products despite the difficulties presented in the Doha talks. Rules on Trade-Restricting Measures to Protect Human or Animal Health Trade agreements have provided one way of handling problems related to human and animal diseases. In 2002, WHO and WTO jointly published “WTO Agreements and Public Health: A Joint Study by the WHO and WTO Secretariat,” which describes the increasingly coordinated activities on the technical and policy levels for the organizations with acknowledge- ment of the common ground between trade and health. There was also acknowledgement that their respective policymakers could benefit from closer cooperation to ensure coherence between their different areas of responsibilities. The WTO agreements explicitly allow governments to take measures to restrict trade when pursuing national health and other policy objec- tives in order to protect health. The publication discusses the rationale and benefits of IHR 2005 as well as the risk-based preventive approach in FAO/WHO Codex Alimentarius (Codex) because the WTO Agreement on

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES the Application of Sanitary and Phytosanitary Measures (SPS Agreement) formally recognizes the food safety standards, guidelines, and recommen- dations established by the Codex Commission. “The link between the standard-setting work of the Codex and the scientific input from the WHO is important in that it lends some dynamics to the trade rules” (WTO and WHO, 2002, p. 143). The report also acknowledges the formal mechanisms and activities used for coordinated communication and mutual participa- tion between and among WTO, WHO, FAO, and OIE—such as WTO’s reliance on WHO’s scientific expertise to resolve trade disputes arising from health concerns, the mutual observer status and active participation to provide advice on the SPS Agreement, Technical Barriers to Trade Agree- ment, Trade-Related Aspects of Intellectual Property Rights Agreement, and World Health Assembly meetings; and their mutual participation in regional and national meetings related to capacity building for disease sur- veillance to detect and control diseases that could pose a threat to health, especially via trade activities. For example, WTO members can violate GATT if a trade-restricting measure is necessary to protect human, animal, or plant life or health (GATT, Article XX(b)). Under the SPS Agreement, WTO members have the right to restrict trade to protect life or health of humans, animals, or plants under certain conditions (e.g., in the context of food safety for human health) and subject to specific obligations (e.g., the measure must be based on a risk assessment and be supported by adequate scientific evidence). Concerning food safety, the SPS Agreement provides that WTO mem- bers that apply standards established by the Codex Commission are deemed to comply with the SPS Agreement (SPS Agreement, Art. 3.2). The same “safe harbor” applies if WTO members base trade-restricting animal health measures on OIE standards. In this way, the SPS Agreement gives legal significance to Codex and OIE standards that they do not have within WHO, FAO, or OIE. Outside the SPS Agreement, Codex, FAO, and OIE standards are nonbinding recommendations. Pegging compliance with the SPS Agreement on conformity with Codex and OIE standards raises the legal importance of these standards in ways Codex and OIE did not achieve in their own realms. Thus, GATT and the SPS Agreement increase the legitimacy of trade- restricting health measures when they are harmonized according to inter- national standards. The SPS Agreement allows WTO members to apply standards that are more protective than international standards, as long as the WTO members comply with their other obligations (e.g., conducting a risk assessment, providing sufficient scientific evidence) (SPS Agreement, Art. 3.3). Countries have violated obligations to report human and animal disease outbreaks because they fear trade sanctions or travel restrictions, and their resulting negative economic consequences. Furthermore, countries

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 GOVERNANCE CHALLENGES have often applied trade and travel sanctions in irrational ways, causing unjustified harm to exporting countries. Even though the SPS Agreement re- quires a risk assessment (Art. 5.1) and a scientific basis for trade-restricting health measures (Art. 2.3), a country experiencing an outbreak can still be damaged by illegitimate trade sanctions and effectively have no re- course. Even the WTO dispute settlement body provides no mechanism for compensating an exporting member for losses caused by unjustified trade-restricting measures because of a perceived health threat (Van den Bossche, 2008). Problems and Potential: WTO’s Recognition of Codex and OIE Standards Attempts to cover up outbreaks for fear of economic sanctions are in- creasingly impractical, as discussed earlier in the chapter. WTO members’ rights to restrict trade for health purposes at levels more protective than international standards allows developed countries, and even private associ- ations of importers (e.g., GlobalG.A.P.2), to impose more stringent require- ments for agriculture and food imports. Although higher standards might create incentives to produce higher value products and generate increased employment, these standards impose costs on exporters in developing coun- tries that are increasingly difficult to meet (Bobo, 2007). Compliance with international standards may still not provide increased market access when developed country or private-sector standards become more stringent. The potential in WTO’s recognition of international standards as a “safe harbor” arises because this approach increases the incentives of ex- porting nations and exporters to upgrade their SPS strategies and capabili- ties at home and in export sectors. Such upgrades could help the effort to protect against zoonotic diseases by providing incentives to produce food and agricultural products according to the highest internationally accepted standards. OIE has leveraged the SPS Agreement’s use of its standards to work more with its members on improving their ability to meet OIE standards. The WTO Secretariat has increased assistance to developing countries to help their exporting enterprises meet international standards. Without the lure of export markets, efforts to have countries improve their production processes in this manner would be less effective. 2 GlobalG.A.P. (formerly known as EUREPGAP) “is a private sector body that sets voluntary standards for the certification of agricultural products around the globe. The aim is to estab- lish one standard for Good Agricultural Practice (G.A.P.) with different product applications capable of fitting to the whole of agriculture” (GlobalG.A.P., 2009).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES WTO Rules and Integrated Surveillance and Response Capacities for zoonotic Diseases Controversies with GATT and the SPS Agreement have focused on whether their rules leave WTO members with sufficient policy space to protect human, animal, or plant life or health from import-borne diseases in the context of expanding and intensifying trade in agricultural and food products. Although important, these controversies do not illuminate how countries, multinational corporations, IGOs, and NGOs should strengthen surveillance and response capacities for zoonotic diseases from local to global levels. National and global action against emerging zoonotic threats could be strengthened by engaging in WTO-based activities that seek to balance human and animal trade and health interests. WTO members could operate these WTO rules more effectively if national, international, and global surveillance and response capacities for human and animal diseases were integrated and robust. However, achieving that objective is not the function of GATT, the SPS Agreement, any other WTO agreement, or any regional or bilateral trade agreement for that matter. Other Regulatory or Policy Options to Address Zoonoses Also discussed in Chapter 3, wildlife trade is too often ignored as a significant driver for zoonotic disease emergence and spread. The cultural food preferences and practices of people, as well as increased interest in exotic pet ownership, reinforce its relevance and often create lucrative incentives for increased trading of wildlife. Thus, legal and illegal wildlife trade activities deserve more concerted attention in disease surveillance, prevention, response, and control. Strengthening governance mechanisms on drivers of zoonotic disease emergence and spread would help reduce threats to human and animal health at all geographic levels. Addressing the issue in existing or new international treaties, or in domestic policies, that may directly address health or wildlife trade, or whose activities may have unintended consequences to them, are options to consider. CONCLUSION The current environment to integrate and improve surveillance and re- sponse capabilities for diseases of zoonotic origin is fraught with structural problems in the form of governance “silos” for human health and animal health as well as fragmentation and weaknesses in regimes that address the drivers of zoonotic disease emergence and spread. Despite these structural problems, conceptual, strategic, and operational governance innovations have improved disease surveillance and response capabilities nationally

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 GOVERNANCE CHALLENGES and globally. However, the progress enabled by these innovations has not been sufficient to produce the necessary integrated disease surveillance and response capabilities for zoonotic diseases. The committee’s analysis suggested this objective will only be achieved through a set of national, international, and global efforts focused on the threat of zoonotic diseases. In the increasingly complicated, challeng- ing, and dangerous interconnections between human and animal health, we have no single simple intervention to end the threat. The committee believed, however, that stakeholders could craft a set of integrated, coor- dinated actions and activities that will measurably improve governance of zoonotic disease threats. The beginnings of this effort are discernable, especially in the increasing collaboration the HPAI H5N1 crisis has created among WHO, FAO, OIE, and other UN agencies and organizations, and the impact this collaboration has at national levels of governance. Aspects of this are also apparent in other governance contexts, such as the manner in which WTO recognizes OIE and Codex standards and the ability of IHR 2005’s disease surveillance strategy to catch zoonotic disease emergence or reemergence. Although governance challenges can look foreboding, never before has there been so much policy and diplomatic activity focused on zoonotic dis- ease threats. The opportunity to harness the momentum generated by SARS and HPAI H5N1 to create a more permanent governance structure—that is flexible and robust enough to handle zoonotic disease emergence and spread rapidly, efficiently, and effectively—has never been greater. REFERENCES Bobo, J. A. 2007. The role of international agreements in achieving food security: How many lawyers does it take to feed a village? Vand J Transnat’l L 40:937–948. Cooper, A., J. Kirton, and T. Schrecker. 2007. Governing global health: Challenge, response, innovation. Aldershot, UK: Ashgate Press. Dorolle, P. 1969. Old plagues in the jet age: International aspects of present and future control of communicable diseases. WHO Chron 23(3):103–111. Fidler, D. P. 2002. Global health governance: Overview of the role of international law in protecting and promoting global public health. Key Issues in Global Health Governance Discussion Paper no. 3. Fidler, D. P. 2007. Architecture amidst anarchy: Global health’s quest for overnance. Global Health Governance 1(1):1–17. http://diplomacy.shu.edu/academics/global_health/journal/ PDF/Fidler-article.pdf (accessed July 20, 2009). Garrett, L. 2007. The challenge of global health. Foreign Aff (January/February). http://www. foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health. html (accessed July 20, 2009). GlobalG.A.P. 2009. What is GLOBALGAP? http://www.globalgap.org/cms/front_content. php?idcat=2 (accessed July 20, 2009).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES High-Level Task Force on the Global Food Security Crisis. 2008. Comprehensive frame- work for action. New York: United Nations. http://www.un.org/issues/food/taskforce/ Documentation/CFA%20Web.pdf (accessed July 20, 2009). House of Lords, Select Committee on Intergovernmental Organisations. 2008. Diseases know no frontiers: How effective are intergovernmental organisations in controlling their spread? First report of the Session 2007–2008. London, UK: The Stationery Office Limited. Jebara, K. B., and A. Shimshony. 2006. International monitoring and surveillance of animal diseases using official and unofficial sources. Vet Ital 42(4):431–441. Katz, R. 2009. Use of revised International Health Regulations during influenza A (H1N1) epidemic. Emerg Infect Dis 15(8):1165–1170. Keohane, R. O. 1984. After hegemony: Cooperation and discord in the world political economy. Princeton, NJ: Princeton University Press. National Intelligence Council. 2008. Global trends 0: A transformed world. Washington, DC: National Intelligence Council. OIE and FAO (World Organization for Animal Health and Food and Agriculture Organiza- tion of the United Nations). 2007. Ensuring good governance to address emerging and re-emerging animal disease threats—Supporting the veterinary services of developing countries to comply with OIE international standards on quality. Paris, France: OIE. http://www.oie.int/downld/Good_Governance07/Good_vet_governance.pdf (accessed July 20, 2009). O’Neill, B. 2004. Disease report and trade responsibilities of OIE member countries. Speech presented at the 72nd OIE General Session, Paris, France, May 23–28. http://www.oie. int/downld/SG/2004/Speech_oneill.pdf (accessed July 20, 2009). Padmawati, S., and M. Nichter. 2008. Community responses to avian flu in Central Java, Indonesia. Anthropology & Medicine 15(1):31–51. The White House. 2009. Statement by the President on global health initiative. Office of the Press Secretary, May 5. Thierman, A. 2008. International Animal Health Regulations and the World Animal Health Information System (WAHIS). Presentation, Institute of Medicine Forum on Microbial Threats Workshop on Globalization, Movement of Pathogens (and their hosts) and the Revised International Health Regulations, Washington, DC, December 16–17. United Nations. 1992. Non-legally binding authoritative statement of principles for a global consensus on the management, conservation, and sustainable development of all types of forests. A/CONF.151/26 (Vol. III). New York: United Nations. http://www.un.org/ documents/ga/conf151/aconf15126-3annex3.htm (accessed July 20, 2009). Vallat, B., and E. Mallet. 2006. Ensuring good governance to address emerging and re- emerging animal disease threats: Supporting the veterinary services of developing coun- tries to meet OIE international standards on quality. Rev Sci Tech 25(1):389–401. Van den Bossche, P. 2008. The law and policy of the World Trade Organization, 2nd ed. Cambridge, UK: Cambridge University Press. WHO (World Health Organization). 2001. Global health security: Epidemic alert and re- sponse. WHA54.14. Geneva, Switzerland: WHO. WHO. 2009. WHO epidemic threat detection  Jan 00– Dec 00 (n=0) (on file with committee). WTO and WHO (World Trade Organization and World Health Organization). 2002. WTO agreements and public health: A joint study by WHO and the WTO secretariat. Geneva, Switzerland: WTO.