On July 24th, Nigeria had been polio free for a full year.  Nigeria, the most populous country in Africa, was one of only three countries where wild polio remained endemic --- Afghanistan and Pakistan being the other two.   And, its new polio free status is a tremendous milestone for the country and for the international effort to eradicate polio.

The Global Polio Eradication Initative was launched in 1988 in response to a World Health Assembly resolution to eradicate polio.  While the resolution was led by member states, the initative is spearheaded by four primary partners --- the World Health Organization, Rotary International, UNICEF, and the CDC.  In recent years, the Bill and Melinda Gates Foundation has also taken on a growing role.  The World Health Assembly continues to issue the resolutions that dictate the scope and strategy of the initiative while the implementation is handled largely by the spearheading members.  

Such a division of labor and contribution is not unusual.  The World Health Organization, like other international organizations have limited budgets comprised of member contributions.  Increasingly, member contributions are earmarked --- meaning that member states select programs to fund, constraining the organization's ability to fund other programs.  As a result, contributions by Rotary International and the Gate Foundation have become essential to meeting the budgetary needs of programs like the Global Polio Eradication Iniative.

Since 1988 more than 2.5 billion children have recieved polio vaccinations and the Initiatve has produced many hopeful milestones.  For example, only one of the three types of wild polio virus remains endemic.  a case of type 2 wild polio was last reported in 1999, and the last reported case of type 3 was in 2012.  Likewise, in 2012, India --- widely regarded as the country facing the greatest obstacles to polio eradication --- was removed from the list of endemic countries.

There have, of course, been setbacks as well.  Conflict, political instability, and damaged health infrastructure led to an outbreak of polio in Syria, which spread to Iraq, in 2013.  Syria had been polio free since the 1990s.  Likewise, polio in Pakistan and Afghanistan have met with resistance and have been the targets of violence.  In Febrauary, four workers in southwest Pakistan were kidnapped and murdered.  Continuing conflict and a growing humanitarian crisis in Yemen has also threatened eradication efforts.  However, in July, all sides agreed to a humanitarian pause, during which 50,000 children were vaccianted for polio and other vaccine preventable diseases. 

Despite these setbacks,  decreasing infections rates and Nigeria's recent success should leave us optimistic.  Although eradication efforts have been slow and difficult, the eventual success will hopefull encourage greater global cooperation and coordination on disease control and global health. 

Sunday, the World Health Organization's Executive Board announced a package of proposed reforms in response to criticism that it was slow in responding to the Ebola outbreak.   The full announcement can be found here. It includes a variety of reasonable additions and changes to WHO management of public health emergencies, such as the creation of a new position focused on coordination outbreak response, and the development of "emergency stand-by capactities".  Among the most notable is the proposed creation of a $100 million contingency fund intended to improve the WHO's ability to respond rapidly and independently to disease outbreaks and other public health emergencies.   

Although the announcement is and interesting read, there are few surprises among the proposed reforms.  However, there were two things that stood out to me.  First, although the contingency fund and other proposals seem reasonable, I question the actual viability of such reforms. These are proposed reforms, suggested by the the Executive Board, but in need of approval by the World Health Assembly (WHA).  Even if approved by the WHA, the implementation of these proposals will be determined by the availability of funds.  The WHO's budget has been in decline for years.  The budget for 2012-2013 was 20% less than the previous budget.  The current budget (which was approved in 2013) is $3.97 billion dollars.  In it, the funds for responding to health crises was reduced by half of its previous level.  

In addition to the decline of the WHO's already small budget --- consider that the budget for Department of State Health Service in Texas  in $3.3 billion --- the WHO also maintains very little discretion over its funds.  In 2013, 30% of the WHO budget was comprised of core contributions from member states.  Core contributions are unearmarked and allocated according to the WHO financing decisions.  The remaining 70% of the budget was comprised of voluntary contributions --- two thirds of which came from member states and the remaining third came from donations provided by foundations, like the Bill and Melinda Gates Foundation, philanthropic groups, and other large organizations.  Because 70% of the budget comes from voluntary contributions, actual funds available do not always meet proposed program budgets.  For example, in 2010, the WHO's proposed budget exceeded total funds by 20%.  In addition, voluntary contributions can be and generally are earmarked by donors for specific projects --- like HIV/AIDS.  This mean that even if the WHA approves the suggested reforms, and these reforms are incorporated into the next budget, and that budget is approved, the implementation of such programs is highly dependent upon funding decisions by individual donors.

The second aspect of the announcement that stood out to me, was the rhetoric about the necessity of strengthening the International Health Regulations (IHR) and health systems in developing countries.  The IHR are binding regulations that structure countries' responses to disease outbreaks.  Specifically, the IHR establish states' responsibility in monitoring, reporting, and responding to health emergencies while also limiting those responses to avoid interference with international trade.  Specifically, the IHR establish core capacities necessary to detect, assess, report and respond to public health crises at the national and international levels.  

Although the IHR are the one of the primary mechanisms through which state cooperate to control infectious disease, state level capacities generally condition the effectiveness of disease control efforts.  The WHO's announcement correctly identifies struggling health systems in developing countries and the lack of core capacities as a major obstacle detecting, assessing, reporting, and responding to outbreaks in a rapid and effective manner.  Domestic level health systems are the first line of defense in disease control.  The IHR require addition capacities, which the WHO strives to help states develop.  Yet, the function and disfunction of the health system as a whole is often neglected in favor of focusing on core capacities.  When discussing global public health, a weak health system in a developing country cannot and should not be ignored.  The Executive Board's statement clearly outlines the necessity of improving core capacities and health systems in general:
                                    
                                      "As events since the start of this century have shown, outbreaks rarely have only local or regional
                                      consequences in our highly interconnected and interdependent world.

                                     The International Health Regulations need more teeth. They provide the principal line of collective defence 
                                     against the threat from emerging and epidemic-prone diseases. The world will never reach true health security 
                                     until more countries, and eventually all countries, have core capacities in place.

                                     We need a far more rigorous methodology for evaluating these capacities than self-assessments in a 
                                     questionnaire. And we need to treat the importance of getting these capacities in place like the emergency that 
                                     it is.
                                  
                                     We need to stop thinking about core capacities as something that should be tacked onto a country's health
                                     systems, like an extra arm."

This is the message that has gotten lost in much of the developed world.  Not only must we be willing to fund the WHO --- and a wide range of its priorities --- in order to improve global health, but we must also view failing health systems in developing countries as more than unfortunate products of circumstance and poverty. We cannot just add additional capacities specifically for monitoring and reporting.  We must view the shortfalls of health systems in developing countries as threats in need and deserving of real attention.

This rhetoric stood out to me because of both its accuracy and its irrelevance.  Developing country level capacities for surveillance, reporting, and response, and building more effective health systems are arguably two of the most important challenges in global health.  The concurrent influences of poverty and poor health --- where poverty threatens health and health undermines prosperity --- make developing countries fertile ground for outbreaks.  In addition to the devastation of these outbreaks to the local population, the inability to control outbreaks increases the likelihood of spread.  

Yet the accuracy of this statement does not prevent it from being largely irrelevant. Among development scholars and practicioners, the need to strengthen local systems is an obvious and constant recommendation.  Yet, despite decades of development efforts and the coming conclusion of the Millennium Development Goals, improving basic health systems and core capacities has been a slow and difficult journey --- in large measure due to the apparent irrelevance of disease and death in developing countries to those in developing countries.  One need only look at the current Ebola crisis to be convinced of both realities.

This part of the announcement stood out to me because it is an acknowledgement of the reality and necessity of strengthening health systems in developing countries, in an announcement of reforms that will likely be disregarded, defunded, and dismissed by those most capable of doing so.  

Since late November, the World Health Organization's Ebola situation reports have included interactive maps.  These maps allow the reader to see where new health clinics are being built, and track the progress of response efforts geographically.  It is particularly interesting to examine the maps across time and not the rate of change for various factors. 

According to the latest situation report, the epidemic is responsible for 6,915 reported deaths.  However, cases and deaths as a result of ebola have been and continue to be under-reported.  Although infection rates continue to fluctuate in Guinea and have increased in Sierra Leone, the number of new cases has declined in Liberia. 

All three intense-transmission countries have increased their capacity to provide medical care for EVD patients, although there remain serious difficiencies in rural areas.  This means that many health facilities in rural areas do not have full isolation and treatment capabilities.  In some cases, community care centers have few resources necessary for treatment of patients.  As a result, patients in some rural areas would need to travel long distance in order to received treatment.  

The good news is that one key goal has been met.  There are currently 225 safe burial teams trained and in place.  Guinea, Sierra Leone, and Liberia now all have capacity to safely bury all reported EVD-related fatal cases (although there remain distributional problems that result in lack of capacity in some districts).  This is a fundamental factor in halting the spread of ebola.

The new objectives for the UN Mission for Ebola Emergemcy Response is to isolate and treat 100% of EVD cases and provide safe burial for 100% of EVD related fatal cases by January 1, 2015.

Finding information about the coordinated response by both international and local actors remains difficult.  Little information about budgets, and the disbursment of monies is difficult to come by.  However, for those of us ghouls how have not only humanitarian, but academic interest in the response efforts, the interaction between state and international actors in responding to the epidemic has provide intriguing.  UN General Secretary Ban Ki-moon made his first visit to the affected region over the weekend.  On Saturday, Ban stated that the UN emergency ebola response mission (UNMEER) should be wound down quickly once the epidemic was halted.  He specifically compared UNMEER to UN peacekeeping and the need to keep UNMEER temporary.  

While Ban argued that if ebola was not controlled within a year then the mission may be considered a failure, the politics behind the message is also interesting. Why begin discussing winding down the international mission while the rate of new infections continues to fluctuate? The statement may be an indication of the broader politics of global infectious disease responses --- sovereignty concerns in intense-transmission states, funding concerns by donors, reluctance to take responsibility and funding shortfalls in IOs.  

Morbidity and Mortality Weekly Report for December 5 has an interesting field note this week on the transmission of chikungunya in the continental US.  Chikungunya is an illness caused by the chikungunya virus, which is transmitted through mosquitos.  Until June, all known cases of chikungunya in the US had been acquired by tourists to the Caribbean and South America.  In June of this year, the first locally transimitted case was confirmed in Florida.  Accoring to the MMWR note, there have been 11 locally acquired cases since June.   

The number of cases of chikungunya in the US has increased dramatically over the last two years.  The disease occurs regularly in Africa, Asia and the Indian subcontinent.  In recent decades travel and the spread of the mosquito vectors for chikungunya has increased the virus' range to include much or Europe.  Despite ongoing control efforts, it has also been identified in several countries in the Caribbean and South America, and now in the US.  Its spread, however, is difficult to track, particularly in South America.  Chikungunya causes symptoms similar to dengue, another mosquito transmitted virus, which is common in Central and South America.  Yet, unlike dengue --- for which primates are the only hosts --- cattle, rodents, birds and primates can all be reservoirs for chikungunya.  

As a result, controlling chikungunya is more complex than controlling diseases such as dengue.  While it is possible to increase the control of infected humans and livestock (although these measures are in no way foolproof), control of other hosts is difficult.  In addition, over the last several decades, vector control efforts have proven ineffective.  Thus, the most effective response remains prevention --- avoiding being bitten by infected mosquitos.  

Yet, with new, locally acquired cases emerging in the US, hikungunya, it will be interesting to see if the international response changes.  Given that winter generally slows mosquito activity in much of the US, and chikungunya generally doesn't kill patients, my guess is that the response will remain largely fragmented and domestic.  If, however, Puerto Rico becomes the 51st state, the response to chikungunya by US officials might change dramatically.   Puerto Rico has experienced a growing number of locally acquired cases in the last year after chikungunya was imported via tourism and vector movement. If Puerto Rico becomes a US state, US health officials would likely have increased interest in an heightened international response to better control the movement of vectors and infected hosts.

Full text available here: 
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6348a4.htm?s_cid=mm6348a4_w

The Daily Show had a nice interview with Sophia Delaunay, the Executive Director of Doctors Without Borders.  

Stewart started with a job at the media --- isn't the outbreak of ebola over now that no Americans have been affected in the last few weeks?  Of course, Delaunay responded the way any international observer of global health specialist would "I wish that were the case."  The interview not only highlights the ongoing crisis, but Delaunay also provides excellent explanations for why the support has been inefficient.  Not only has aid been slow to arrive, by the time it arrives, needs have changed. 

I recently participated in a panel about Ebola arranged by the MPA students.  They wanted me to talk about the role of federalism in responding to Ebola in the US.  I spoke a little bit about the role of federalism and how the CDC fits into the broader health system.  But I then launched into a discussion about the need for international response --- arguing that the best way to protect US citizens and health care workers was to be proactive in dealing with health threats around the world.  Delaunay makes the point equally well.  Viruses do not respect borders.  

One of the primary difficulties in responding to Ebola has been the availablity of funds.  Many observers, individuals and states alike, have argued that the funds for responding to the crisis should come from existing budgets --- hospital budgets, WHO budgets, and other agency budgets.  The problem is that these budgets are planned in advance and are generally fully allocated to specific programs, leaving few funds available for unanticipated crises.  Moreover, much of the budgeting and allocation process leaves little flexibility for responding to rapidly changing circumstances.  For example, the minutes from an International Incident Management System meeting in Liberia illustrated an ongoing disagreement between Liberian officials and donors.  Two European and one Asian donor had allocated funds to build medical units in Monrovia.  Yet Liberian leaders argued that such units should be built in rural areas because the need in Monrovia had declined.  In fact, hospitals in Monrovia had free beds, whereas in rural areas people were still being turned away due to limited capacity.  The donors were reluctant to change their plans because they had promised their domestic populations that the funds would build units in Monrovia.

The politics of where and how resources get allocated are an essential part of the success of international responses and play a role in who lives and who dies.  Where the political calculations outweigh the calls from folks like Delaunay, consequences are grave.