Emerging Infectious Disease Surveillance in Southeast Asia: Cambodia, Indonesia, and the US Naval Area Medical Research Unit 2
2012; Taylor & Francis; Volume: 8; Issue: 2 Linguagem: Inglês
10.1080/14799855.2012.686338
ISSN1555-2764
Autores Tópico(s)Vibrio bacteria research studies
ResumoAbstract Emerging infectious diseases (EIDs) pose international security threats. What cultural, political, and economic challenges stand in the way of setting up EID Surveillance infrastructure? Are there general principles that might guide engagement with developing countries and support such infrastructure? Using the US Naval Area Medical Research Unit 2 as a common denominator, this study compares barriers to EID surveillance in Cambodia and Indonesia and presents key factors that constrain disease surveillance systems. As extensive interviews revealed, low levels of development in general are the main impediments to building EID surveillance infrastructure and are perhaps beyond the scope of health and scientific agencies at this point. Ultimately, political economy matters and promoting greater understanding of these issues is a critical first step in mitigating negative outcomes. Acknowledgments This article is based on an earlier product of collaboration between the Defense Threat Reduction Agency's Office of Strategic Research and Dialogues and the Naval Postgraduate School with support from the Asia Health Policy Program at Stanford University. The views expressed herein are those of the author and do not necessarily reflect the official policy or position of the Defense Threat Reduction Agency, the Department of Defense, or the US Government. I thank my research assistants: Zachariah James Falconer-Stout, Jim Chhor, Serei Linda Tauch, Khamly Chuop, John La, Angela Archambault, Ita Perwira, and Syefri Luwis. The help and guidance of William O'Donnell, David Hamon, Meg Flanagan, Karen Eggleston, Fayre Makeig, Paul Forster, Amalya Mangiri, Gina Samaan, Sandra Yolles, Hugo Yon, Jim McLaughlin, Amy Freedman, and two anonymous referees, but most of all 49 individuals in Cambodia and Indonesia who cannot be named here for confidentiality reasons, are gratefully acknowledged. Notes 1. This motivation is drawn from Defense Threat Reduction Agency, M. L. Flanagan, C. R. Parrish, S. Cobey, G. E. Glass, R. B. Bush, and T. J. Leighton, "Anticipating the Species Jump: Surveillance for Emerging Viral Threats," Research in Progress, DTRA Advanced Systems and Concepts Office, December 4, 2008. 2. Richard P. Wenzel, "What We Learned from H1N1's First Year," The New York Times, April 13, 2010, p. A25. 3. Although there is active surveillance, in which health care providers report notifiable diseases or syndromic information, it is rare in the developing world. 4. "In the developing countries, the destabilizing effects of endemic diseases are amplified by emerging and epidemic-prone diseases. Outbreaks and epidemics disrupt routine control programs and health services for extended periods. This is mostly due to logistical constraints and minimal resources to ensure containment. The dramatic interruption of trade, travel, and tourism that can follow news of an outbreak or epidemic places a further burden on already fragile economies." Quoted in Mary Kindhauser, ed., Progress Report 2002: Global Defence against the Infectious Disease Threat (Geneva: World Health Organization), p. 15. Available at http://www.who.int/infections-disease-news/cds2002/index.html 5. Mely Calballero-Anthony, Nontraditional Security and Multilateralism in Asia: Reshaping the Contours of Regional Security Architecture? (Muscatine, IA: The Stanley Foundation, 2007), p. 1. 6. A definition of patronage: "An unequal relationship of mutual dependence and reciprocity … depends on differentiation of power, wealth and status in society … creates the position of Patron (who dispenses largesse, resources and protection) and Client (who provides loyalty and support to the patron) … is a voluntary and instrumental relationship … A patron usually has several clients. Depending on their proximity to the Patron, clients may also have their own clients. The result is an informal hierarchy taking the shape of a pyramid with the Patron or 'Big Man' at the apex. Patrons may enter into mutually beneficial alliances. The patronage network refers to patronage 'pyramids' and patron alliances operating in a particular area/community." Quoted in Lillian Cherotich, "The Influence of Patronage Networks on Kenya's Experience of Corruption," paper presented at "The Economics of Corruption" conference, Internet Center for Corruption Research, Passau, Germany, October 9–16, 2010, slides 2 and 3. Available at http://www.icgg.org/downloads/2010/cherotich.pdf 7. WHO, Combating Emerging Infectious Diseases in the South-East Asia Region, SEA-CD-139 (New Delhi: WHO Regional Office for Southeast Asia), pp. 20–33. Available at http://www.searo.who.int/LinkFiles/Avian_Flu_combating_emerging_diseases.pdf 8. As explained on the no longer accessible pagewww.med.navy.mil/sites/nmrc/Pages/namru_2_edr.htm, which referred to Indonesia specifically. 9. Navy Medicine, TIMELINE: History of Naval Medical Research. Available at http://www.med.navy.mil/sites/nmrc/documents/Timeline.pdf 10. Details of NAMRU-2 Jakarta were located at http://www.nhrc.navy.mil/geis/sites/namru2.htm (no longer operational), and history from Navy Medicine, TIMELINE. 11. Pillip S. Brachman, Heather C. O'Maonaigh, and Richard N. Miller, eds., Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review. (Washington, DC: National Academies Press, 2001). Available at http://download.nap.edu 12. Decentralization is defined as "the dispersion or distribution of functions and powers; specifically: the delegation of power from a central authority to regional and local authorities." Available at http://www.merriam-webster.com 13. Brachman et al., Perspectives, p. 51. 14. Lt. Gen. James B. Peake, J. Stephen Morrison, Michele M. Ledgerwood, and Seth E. Gannon, The Defense Department's Enduring Contributions to Global Health: The Future of the US Army and Navy Overseas Medical Research Laboratories (Washington, DC: CSIS, 2011), p. 21. Available at http://csis.org 15. Hadi Siswoyo, Meda Permana, Ria Larasati, Jeffryman Farid, Asep Suryadi, and Endang Sedyaningsih, "EWORS: Using a Syndromic-Based Surveillance Tool for Disease Outbreak Detection in Indonesia," BMC Proceedings Vol. 2, Suppl. 3, (2008), p. S3. Available at http://www.biomedcentral.com 16. Celia Lowe, "Preparing Indonesia: H5N1 Influenza through the Lens of Global Health," Indonesia, Vol. 90 (October 2010), p. 154. 17. Lowe, "Preparing Indonesia," p. 154. 18. IOM, Infectious Disease Movement in a Borderless World: Workshop Summary (Washington, DC: National Academies Press, 2010), p. 181. 19. Paul Forster, The Political Economy of Avian Influenza in Indonesia, STEPS Working Paper 17, Social, Technological, and Environmental Pathways to Sustainability Centre (Brighton, UK: University of Sussex, 2009), back cover. Available at http://www.steps-centre.org/wp-content/uploads/Indonesia.pdf 20. Dennis Normile, "Dispute Clouds the Future of US Naval Lab in Indonesia," Science Vol. 320, No. 5876 (2008), p. 598. 21. Stefan Elbe, "Haggling over Viruses: The Downside Risks of Securitizing Infectious Disease," Health Policy and Planning Vol. 25 (2010), p. 484. 22. Thomas Wierzba, "NAMRU-2 Cambodia Expands Research Efforts," Naval Medical Research and Development News Vol. 1, No. 2 (August 2009), p. 4. Available at http://www.med.navy.mil 23. Navy Medicine, NAMRU-2 Det Phnom Penh, Cambodia. Available at http://www.med.navy.mil 24. Foreign aid pledges for 2010 to Cambodia totaled nearly US$1 billion in 2009, while the national budget for 2009 was US$1.88 billion, including foreign financing. 25. Sophal Ear and Sigfrido Burgos, "Livelihoods and Highly Pathogenic Avian Influenza in Cambodia," World's Poultry Science Journal, Vol. 65, No. 4 (2009), pp. 633–640. 26. As the OIE itself notes: "Whenever an important epidemiological event occurs in a Member, the Member must inform the OIE by sending an Immediate Notification (terrestrial and aquatic animals) which includes the reason for the notification, the name of the disease, the affected species, the geographical area affected, the control measures applied and any laboratory tests carried out or in progress. Diseases notifiable to the OIE used to be classified into two lists, List A and List B. In May 2004, OIE Members approved the creation of a single list of diseases notifiable to the OIE. Modifications to the List can be made annually, subject to the approval of the World Assembly of Delegates during its General Session. The modified List does not come into force until the following January, so as to ensure that the list of diseases remains the same for any given calendar year. Proposed changes to the List are based on a decision tree contained in an OIE international standard. A new list has been approved in May 2009 by the Assembly and came into force in 2010." OIE, The World Animal Health Information System." Available at http://www.oie.int 27. It should be noted that in 2002, OIE began a program of nonofficial and rumor reporting for animal health and public health. However, OIE still requires verification of rumors collected from unofficial data to broaden syndromic surveillance (which includes media reports). 28. To understand the political economy of outbreak declaration in animals, examining the human health equivalent and the incentives/disincentives involved is useful: "Since 1951 states have been required by the International Sanitary Regulations (renamed the International Health Regulations in 1969) to notify the WHO within 24 hours of cases of designated diseases (including, as of 1981, those on airplanes and ships) and to obtain laboratory diagnoses. States are also required to inform the WHO and travellers of measures they intend to enact and to submit weekly reports on the development of outbreaks. In practice, however, many states have not reported outbreaks, and when the WHO has announced such occurrences, it is often some time after the fact. This rather weak system, hardly the fault of the WHO secretariat or its committees, reflected the lack of concern about the transmission of diseases among industrial countries and an unwillingness to suffer the consequences of reporting among many developing countries." Mark W. Zacher, "Global Epidemiological Surveillance: International Cooperation to Monitor Infectious Diseases," in I. Kaul, I. Grunberg, and M. A. Stern, eds., Global Public Goods: International Cooperation in the 21st Century (New York: Oxford University Press, 1999), p. 272. Available at http://www.undp.org/globalpublicgoods/TheBook/thebook.html 29. Louise Gresham, Assad Ramlawi, Julie Briski, Mariah Richardson, and Terence Taylor, "Trust across Borders: Responding to 2009 H1N1 Influenza in the Middle East," Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Vol. 7, No. 4 (2009), p. 403. 30. Gresham et al., "Trust across Borders." 31. Bernard Vallat, Veterinary Medicinal Products and Vaccines: Indispensable Tools for Any Effective Animal Health and Welfare Policy, Editorial from the Director General, January 20, 2010. Available at http://www.oie.int 32. This bureaucratic culture was also observed in Mexican government laboratories when an A/H1N1 hit as has been observed. Sophal Ear, "Towards Effective Emerging Infectious Disease Surveillance: H1N1 in the United States 1976 and Mexico 2009," Stanford Center for International Development Working Paper 454 (Stanford, CA: Stanford Center for International Development, 2012). 33. "According to [the WHO], staff in over 90 percent of developing country laboratories are not familiar with quality assurance principles, and more than 60 percent of laboratory equipment is outdated or not functioning … In addition, poor roads and communications make it difficult for health care workers to alert higher authorities about outbreaks or quickly transport specimens to laboratories. The absence of a clear response discourages lower level officials from investing effort in surveillance, and leads to many cases of disease going unrecorded and unreported. These weaknesses limit the effectiveness of international disease control programs. They also impair routine surveillance for other diseases and efforts to investigate and respond to outbreaks, newly emerging diseases, and growth in antimicrobial resistance." GAO, Global Health: Challenges in Improving Infectious Disease Surveillance Systems, Report to Congressional Requesters, GAO–01–722 (Washington, DC: United States General Accounting Office, August 2001), p. 3. 34. "In China, the retired military physician Dr. Yanyong Jiang's questioning of official statements on severe acute respiratory syndrome (SARS) that downplayed the severity of the outbreak resulted in the removal of China's health minister and the Beijing mayor." Kai-Lit Phua and Lai Kah Lee, "Meeting the Challenge of Epidemic Infectious Disease Outbreaks: An Agenda for Research," Journal of Public Health Policy Vol. 26, No. 1 (2005), p. 128. Available at http://www.jstor.org 35. Modernization can lead to self-expression values. "These values bring increasing emphasis on the civil and political liberties that constitute democracy, which provide broader latitude for people to purse freedom of expression and self-realization." Ronald Inglehart and Christian Welzel, Modernization, Cultural Change, and Democracy: The Human Development Sequence, (New York: Cambridge University Press, 2005), pp. 3–4. Nevertheless, this theory is not suggesting that by modernizing, underdeveloped countries will lose cultural traditions. This theory suggests that self-expression values will shape institutions as modernization occurs. 36. Mely Caballero-Anthony, "Combating Infectious Diseases in East Asia: Securitization and Global Public Goods for Health and Human Security," Journal of International Affairs, Vol. 59, No. 2 (2006), p. 123. 37. David King, Catherine Peckham, Jeffrey Waage, Joe Brownlie, and Mark E. J. Woolhouse, "Infectious Diseases: Preparing for the Future," Science Vol. 313, No. 5792 (2006), p. 1393. 38. E-mail message to author, August 31, 2010. 39. Zacher, "Global Epidemiological Surveillance," p. 271. 40. Wenzel, "What We Learned from H1N1's First Year." 41. In 2002, WHO and the NTI created an Emergency Outbreak Response Fund "to strengthen the global response to infectious disease outbreaks, whether naturally occurring or from the release of biological weapons. The … Fund will ensure that response teams can be on the ground within 24 hours of a detected outbreak – wherever it occurs around the globe." WHO, "WHO-NTI Establish a Global Emergency Outbreak Response Fund," Media Center, December 2, 2002. Available at http://www.who.int This WHO-NTI fund was established with a renewable US$500,000 grant for responses to outbreaks and has been replenished annually. This money was not for economic losses incurred from reporting outbreaks; it was a foundational sum designated by WHO for immediate mobilization and response, while longer-term funding was solicited from the member countries of the World Health Assembly. The resources required to make a dent in US$8.8 billion lost to A/H1N1 are orders of magnitude greater than US$500,000. 42. PDSR "is based on a qualitative approach to epidemiology known as participatory epidemiology, which has the objective of developing and supporting a community-based response to detecting and preventing the disease by using local knowledge of where and when outbreaks are occurring, and enlisting the local population in control efforts. It has much in common with established techniques of participatory rural appraisal but has evolved significantly in Indonesia. The first phase of the PDSR project emphasized the detection and control of H5N1 by separate surveillance and response teams primarily in 'backyard' settings at the household level. Now, a broader village-level approach encompasses all poultry farmers, traders and community leaders; a greater stress is put on empowering communities to understand the origin, prevention and control of all poultry diseases; and better links are sought with veterinary services, where capacity is being developed through PDSR." Zacher, "Global Epidemiological Surveillance," p. 34. See also J. C. Mariner and P. L. Roeder, "Use of Participatory Epidemiology in Studies of the Persistence of Lineage-2 Rinderpest Virus in East Africa," Veterinary Record Vol. 152 (2003), pp. 641–647. 43. Benjamin Hickler, "Bridging the Gap between HPAI 'awareness' and practice in Cambodia," Recommendations from an Anthropological Participatory Assessment, July 24 to August 31, 2007, Emergency Centre for Transboundary Animal Disease (ECTAD), FAO Regional office for Asia and Pacific, Cambodia. Available at http://www.fao.org/docs/eims/upload//241483/ai301e00.pdf 44. Hendri Restuadhi, Bird Flu: Chicken Consumption, Rearing Practices and Perception of Poultry Diseases" (Jakarta, Indonesia: FAO of the United Nations, December 2008), p. 31. 45. G. Samaan, M. Patel, B. Olowokure, M. Roces, H., Oshitani, and the WHO Outbreak Response Team, "Rumor Surveillance and Avian Influenza H5N1," Emerging Infectious Diseases Vol. 11, No. 3 (March 2005), p. 464. 46. This analysis would not have been possible without the heroic efforts of my research assistant, Zachariah James Falconer-Stout. 47. The Cambodia interviews took place in Phnom Penh during the course of three visits in January, August, and December 2009 and were conducted in English and Khmer. The interviews in Indonesia took place during the course of 12 days in Jakarta during January 2010 and were conducted in English and Bahasa Indonesia with the help of two research assistants. More than 200 pages of notes were collected and subjected to content analysis and tagging of key concepts, which enabled frequency analysis to obtain a ranking of top issues raised. Content analysis is used in the social sciences for studying the content of communication by analyzing recorded transcripts of interviews with participants. 48. Sophal Ear, "The Political Economy of Highly Pathogenic Avian Influenza in Cambodia," International Journal of Poultry Science Vol. 10, No. 1 (2011), pp. 71–75. 49. UNDP, Sustainability and Equity: A Better Future for All, Human Development Report (New York: Palgrave MacMillan, 2011), p. 144. Available at http://hdr.undp.org 50. UNDP, Sustainability and Equity. 51. This problem eclipses even the common theft of reagents from public labs for use in private labs (owned by staff and management in public labs), which hobbles public health surveillance efforts. 52. Personal interview, Phnom Penh, Cambodia, August 8, 2009. 53. Personal interview, Phnom Penh, Cambodia, August 8, 2009. 54. Personal interview, Phnom Penh, Cambodia, August 8, 2009. 55. Personal interview, Phnom Penh, Cambodia, August 8, 2009. 56. Julia Wallace and Phom Bopha, "Tension over End of Civil Service Bonus Scheme," The Cambodia Daily Vol. 44, No. 51 (2010), pp. 1–2. 57. I am quoted at the end of the story as saying the following about salary supplements: "Were they perfect? No. Did they incentivize? Yes. Did they make a life-or-death difference in someone's livelihood? Probably not. Will things work better as a result of their elimination? Probably not." Wallace and Bopha, "Tension over End of Civil Service Bonus Scheme," p. 2. 58. Personal Interview, Jakarta, Indonesia, January 4, 2010. A pilot system, called Early Warning and Reporting System (EWARS), with limited support by WHO and the CDC, should not be confused with EWORS. 59. Personal Interview, Jakarta, Indonesia, January 7, 2010. 60. "US NAMRU2: Is It a Treat or a Threat for Indonesia?" Cinkiezholic's World (Wordpress blog), June 23, 2009. Available at http://cinkiez.wordpress.com/tag/us-namru-2 61. Personal Interview, Jakarta, Indonesia, January 7, 2010. 62. It could also be that the drive for and incentive to publish (built into evaluations of personnel working for labs like NAMRU-2) have changed over time. Three decades ago, the pressure might not have been as severe as today. 63. Personal Interview, Beijing, China, July 15, 2010. 64. Personal Interview, Jakarta, Indonesia, January 4, 2010. 65. Adianto Simamora, "Let Me Prove It All in My Work: Endang," The Jakarta Post, October 29, 2009. Available at http://www.thejakartapost.com 66. For example, if NAMRU-2 scientists are evaluated on the basis of research produced and this priority conflicts with meeting host nation needs, then reconciling these priorities might be a step toward improving relations. Alternatively, more senior (retired) scientists – if willing to serve as some apparently were decades earlier – could also be tapped. 67. Even during the 2004 tsunami that affected Aceh, Indonesia, and many other countries, there was great sensitivity to having American military personnel on the ground in the humanitarian mission that followed. In Cambodia, examples abound. The most recent cancellation by the Cambodian authorities was of a US$28.8 million Land Management and Administration Project by the World Bank because of "too many conditions," according to Cambodia's Prime Minister (as quoted in James O'Toole and Kophak Shakrya Chakrya, "World Bank Blunder," Phnom Penh Post, March 9, 2011). 68. Early findings from the author's follow-on study of Mexico's experience with A/H1N1 confirmed Merianos's finding there – animal disease surveillance, driven by trade concerns with the United States – appears in better shape than human disease surveillance. 69. E-mail message to author, April 11, 2010. 70. "Obama Visit 'Opens Doors for RI,'" The Jakarta Post, February 8, 2010. 71. "[NAMRU] was closed down after Jakarta and Washington failed to agree on its operational procedure, including on diplomatic immunity sought by Washington for US staff working at the lab." Lilian Budianto, "RI Aims at Resolution of Military Ban in US Partnership: Ministry," The Jakarta Post, March 5, 2010. Available at http://www.thejakartapost.com 72. Delthia Ricks, "Flu Wars," Discover Magazine, January 28, 2009, pp. 40–45, 74. Available at http://discovermagazine.com/2009/dec/28-intellectual-property-fight-that-could-kill-millions 73. "Obama Visit 'Opens Doors for RI.'" 74. For example, one advanced laboratory in Indonesia is in such dire need of money that its scientists (interviewed in Jakarta on January 12, 2010) work on a month-to-month basis. 75. A Ministry of Health official in Cambodia knew about viral sovereignty and even characterized the issue as one of benefit sharing, but unless Cambodians become involved in testing (as happened in the case of AIDS antiretrovirals for prophylaxis use, when the Cambodian Prime Minister stopped trials), viral sovereignty does not appear to be of immediate concern in Cambodia.
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