Transcript An Ecosystem Approach to Monitoring Infectious Diseases a

An Adaptive Ecosystem Approach
to Monitoring Infectious Diseases
LSHTM June 4, 2004
David Waltner-Toews
Department of Population Medicine,
University of Guelph and
Network for Ecosystem Sustainability
and Health (www.nesh.ca)
Climate Change and Health
D. Charron et al
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Collaborations between University of Guelph, Health Canada, Environment
Canada, other universities and government agencies as appropriate, and
many international partners (see www.eccho.ca)
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Projects
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Climate change and human and animal diseases in Ontario – special report to
Ontario Ministry of Natural Resources
Climate change and waterborne disease in Canada
Climate change and Lyme Disease in Canada
Climate change, West Nile virus and avian influenza in ring-billed gulls
Climate change and foodborne diseases
Note: we are working with partners to develop ecosystem approaches to
deal more holistically and realistically with these issues
Ecosystem Approaches to Health
D. Waltner-Toews et al
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Developing a systemic understanding, for both research and practice, of the
links between the health and disease of populations, environmental
management/change, socio-economic change, and public policy and action.
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Projects
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Animal slaughter practices, environmental degradation and community health in
Kathmandu, Nepal
Community adaptation and resilience in the face of extreme weather events in the
Canadian Prairies (overlap with climate change work)
Sleeping Sickness and landscape changes in East Africa
Agroecosystem health in Kenya and Ontario.
Health, Biodiversity and natural Resource Use in the Peruvian Amazon
Ciguatera fish poisoning in Cuba (overlap with climate change work)
Ecosystem approaches to disease surveillance (projects under development)
Teaching
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Graduate courses in Ecosystems and Health and Epidemiology of Zoonoses
Short courses on Ecosystems and Health on request
New textbook created on ecosystem sustainability and health
Courses through EcoHealth for Health Professionals Group jointly with medical
school at Western
Life is not a dream. Careful!
Careful! Careful!
Federico Garcia Lorca
Starting a Surveillance Program –
We need
• I. A set of human goals – where do we want
to go?
• II. A conceptual model of the world – what
is the context? A way to relate indicators to
policy and action.
• III. A set of indicators – how do we measure
where we want to go?
• IV. Capabilities for measurement, data
collection, and calculating indicators
Maintaining a surveillance
program
• V. Workable methods for reporting and
responding
• VI. A story that takes the data and the
models and makes sense of them
I. What are the goals of the
program?
• To develop a framework for surveillance in
order to
• measure the “true” burden of enteric,
foodborne and zoonotic diseases
• (to develop strategies to control and prevent
them ?)
Whose goals are these?
• Global goals – eg measure rates of disease related to
climate (WHO, IPCC, etc) in order to compare
regions and countries and target recources.
• These will only be achievable if they are consonant
with the goals of other stakeholders, at various
scales, with different agendas, interests, purposes,
stories. What are those other goals? How do they
relate to “our” goals?
• We may need both scientific and lay indicators. It is
the responsibility of researchers to demonstrate how
they are linked (eg syndromic surveillance,
absenteeism from school and disease)
II. A Conceptual Model
The purpose of the model is to tell us
how the various goals relate to each
other and to enable us to devise
optimum strategies.
Hydatid Disease in Kathmandu: what’s the problem?
Dog
Infection rate
Feces disposal
Canine behaviour
Access to infected offal
Death
Tapeworm
Causes and
places of death
Hygiene
Human-Dog
Relationships
Cultural and
dietary habits
Occupation
Person with cyst
Ruminant
with cyst
Economics
Human
Animal
Vector/reservoir
Population dynamics
hostS
agentS
Ecology
Taxonomy
Molecular
Interactions
environmentS
Physical
Ecological
Social/Political
Host
Agent
HOST
AGENT
ENVIRONMENT
If we act as if the world were
linear
• We will fail to mobilize people at the
appropriate scales
• We will create problems across scales and
perspectives as quickly as we solve them
• The programs – and the health of the
populations they are concerned with - will
not be sustainable
The real world we live in is
complex:
• Feedback loops and self-organization
• Holonocracy (nested hierarchies) and crossscale interactions
• Multiple perspectives – methodological
pluralism (across disciplines, across
cultures)
Feedback loops
Causes of Infectious Disease Emergence, Institute of Medicine categories, complex version
Demand for
cheap food
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Marketing
+
+
+
Consolidation &
Mass Distribution
+
Fast Food
+
Demand for healthy food
&
Fresh Produce
+
Antimicrobial Resistance
+
+
Ecological Simplification
Chemical
+ microbial
control
Microbial proliferation
+
+
+
+
+
+
Age
Cheap food
Immune Suppression
+
+
Disease
+
+
Fecal Pollution
-
+
Two careers
+
+
+
Active governance
Medical Technology
Travel
+
+
More Rich
and
+
Public Health Infrastructure
More Poor
-
Githima
Lack of AI services
Dairy Production
Electricity committee
Less rainfall
Fuel shortage
Tea production
Poor roads
KTDA centers
Deforestation
Less land
per capita
Agrochemical use
Farm productivity
Coffee factories
Intergenerational
inequity
Coffee production
Komothai Co-op
soil erosion
& infertility
Poor farming
techniques
Insecurity
Labor export
Water not accessible
Hilly terrain
income
Ignorance
High population
Komothai water project
School committee
Poor human health
High birth rate
Poor hygiene
Schools
illiteracy
Poor healthcare system
Changing
Lifestyle
Actors
Needs
Activities
Resource states
Concerns
Sweeper
Help fund
(loans)
Issues and influences - sweeper stakeholders
Lack of efficient
and regular
sweeping exacerbates
garbage
mismanagement
Sweeper Hierarchy
Households
Ward
Committee
Set rules and
regulations for
street sweeping
Inspectors
(men)
Money to
send children
to day care or
school
Captain
(men)
Dispose garbage
into containers
Dispose
fecal matter
in plastic bags
in street
KMC
sweepers
Empty containers
into tractor
(once a week)
Dispose garbage
in street
Lack of opportunity
for education &
employment for
children
Hygiene
training
Tractor
Driver
(men)
Protective
equipment
(gloves, masks,
shoes)
Drain
Unblockers
(men)
Health impacts
of handling
garbage
Illiteracy
helps upper caste
keep domination
over them
Literacy
training
Transport
waste to
Teku landfill
Pick up
piles
Not
enough
time
to
collect
garbage
Unblock
drains
Street
Sweepers
(women)
Need
time to
collect
garbage
Sweep streets
(garbage
into piles)
Awareness
needed at
Household level
Massive amounts
of garbage from
slaughterhouses
Improved
slaughterhouse
garbage management
Citizens ignore
request to not
carelessly throw
garbage everywhere
People throw
garbage out
window as soon
they see tractors
Bell system
(does not work)
Garbage
containers
Expect
Sweepers to
clean waste
Cleanliness
Of
streets
Dispose
vegetable
waste
in street
Street
vendors
Nested Hierarchies
(Holonocracies)
Ucayali District, Peru: Nested hierarchy of the key issues and research variables
Research Variables
Key Issues
International Community
• Access to food aid programs
• Access to health and nutrition
programs
• Internal migration
• Diversity of ecological resources
• Seasonal changes in available
ecological resources
• Ecoli counts
• Access to health services
• Community organization/social capital
• Production levels/diversity
• Income levels/diversity
• Time allocation
• Hygiene practices
• Nutritional status
• Parasite loading
• Diarrhoeal incidence/prevalence
• Anaemia
• Anthropometry
Nation
Region/Landscape
Community
Household
Individual
• Priorities for health aid programs determined
internationally
• Little baseline data and follow-up to evaluate
national interventions
• Centralized health policy
• Unregulated commercial extraction
• Flooding cycles affect livelihood systems
• Sectoral approaches that fail to take into account
linkages between health and the environment
• Poor water quality
• Little social capacity
• Food Insecurity
• Poor hygiene and sanitation
• Diverse seasonal livelihood strategies
• Intra-household food allocation
• Gender dynamics
• Malnutrition
• Gastro-intestinal infections
Foodborne Disease Surveillance: Immediate issues at Multiple Scales
Diagnostic
Infrastructure
REGION/
LANDSCAPE
COMMUNITY
Ability and
willingness to
recognize,
summarize,
and report
FAMILY
Willingness
to report
INDIVIDUAL
Awareness
Surveillance
Requirements
Trained
personnel
Ownership
Engagement in
community
Education
Ownership
Of issue
Prerequisites
Foodborne Disease Surveillance: Sustainability issues at Multiple Scales
REGION/
LANDSCAPE
COMMUNITY
FAMILY
Supportive national
& international
networks
Understanding of links
with community priorities.
Feasible strategies for
response
Response Feedback
loops
In both directions
Research practice linkages
Research into Eco-social
systemic links
Continuing
Education
Professional
recognition
Organizational pathways
for engagement
Relevance
INDIVIDUAL
Faith that responses
will help
Maintenance
Requirements
Empowerment
Prerequisites
Multiple Perspectives
Multiple Perspectives & Scales in
Surveillance
• Direct costs of production (economies of scale)
versus indirect (feedback) costs (environment,
social, labour)
• Food as commodity (regional) versus food as
community (local) vs food as nourishment
(individual)
• These all have implications for whether a disease
is seen as a necessary, controllable “cost”
(assuming the system as usual) or an avoidable
tragedy (assuming system change)
III. Surveillance: Indicator “Type”
(perspective) issues – diagnostic
implications
• Infection and/or disease
• Symptoms (self perceived) and/or signs
(externally measured)
• Specific and/or syndromic
• Natural reservoirs and/or people;
• Risks and/or events: if we want to prevent or
control then even if our primary outcome is an
event (disease cases) we need to know the
systemic context to respond.
Surveillance: Scale Issues- reporting
& communications implications
• How to link or synthesize at each scale (eg counts,
rates). How do self reported symptoms related to
signs?
• How to link across scales (eg certain rates may
trigger or reflect structural changes – emergent
properties)
• How to anticipate/identify cross-scale interactions.
Local hand-washing and cooking has water and
energy use implications; regional economic
policies can change local behaviours & disease
patterns.
Indicators: Systemic Questions
• Who owns the indicators? Need external
and internally important ones (signs vs
symptoms)
• What are they for? Which (whose?) goals
do they relate to? Over what time frame?
• What is the reporting feedback?
• Who responds? Does reporting have
tangible results for those reporting?.
IV. Data Collection
• Scale-dependent diagnostic and
measurement capabilities are key for any
systemic response.
• Can be qualitative measures (streets look
cleaner, people feel better) at smaller scales,
but mid to higher level scales require both
qualitative (eg maps) and quantitative
(rates)
V. How can we operationalize
this?
• Integrate socio-cultural and biophysical
perspectives.
• Integrate practice (surveillance) with
research (understanding surveillance).
• Horizontal and vertical linkages across
various programs are essential. Stand-alone
surveillance programs are not sustainable.
Researchers’ Responsibilities
Ecosystem
Description
Tools:
Socio-cultural
system description
Tools:
Systems models
Narratives
Historical analysis & synthesis
Stakeholder, Policy, Governance analysis
Ethnographic Studies
Scientific studies (Lab and field)
Participatory appraisals, SSM, AEAM
System Description
& Dynamics
External Perspective
ACTION
What are the issues?
Key indicators:
Redefine, Adapt
Mapping Issues
on to System
Tools: PAR, SSM, REFLECT, AEAM
Governance:
Negotiation,
Goals
Monitoring
Management
Stakeholders’ Responsibilities
An Adaptive Methodology for Ecosystem Sustainability and Health
D.Waltner-Toews, J. Kay, T. Murray 2001
Presenting Situation:
the Entry Point
Presenting Issues:
complaints and/or
research / agency
agenda
The Given History:
ecological, physical,
social, economic,
political, governance …
Collaborative Learning and Action
Monitoring and Evaluation:
Indicators: What? Whose?
Are we getting better?
Implementation: turning the
vision into action
Design of an adaptive approach
for implementation of the vision
and collaborative learning
Seeking solutions:
cross talk, negotiating tradeoffs, creating a vision,
a collective future narrative
Analysis of:
Stakeholders: the
research team,
community, others.
Whose issues are they?
Issues: ecological,
social, and health
Policy, Politics,
Governance:
Who decides?
People and Their Stories
Multiple socio-ecological stories, pictures,
and system descriptions
Systems Descriptions and Narratives:
Developing a Systemic Understanding
Systems Analysis:
Qualitative: rich pictures, conceptual
models, systems diagrams, different
perspectives across scales
Quantitative: simulations, GIS, mathematical models
Systems Synthesis:
Qualitative: narratives, feasible stories;
tradeoffs, opportunities and constraints
Quantitative: scenarios, tradeoffs,
costs and benefits
Conclusions
• This will only be sustainable if we can
collectively create a story in which every
policy is a hypothesis and every program is
a test of that hypothesis.
• Ultimate goal – self-organization in ecosocial systems to minimize disease
emergence
A Journal and a Book