Bird Flu and Public Health Systems: Lessons of History


This page in:

(image: Wikipedia Commons)


Here we go again!  In the last couple of weeks there has been a lot of media buzz about the outbreak of H7N9, a new deadly bird flu virus in China, centered in Shanghai and surrounding provinces and now reported in Beijing.  This outbreak follows the global panic and economic and travel disruptions caused by the severe acute respiratory syndrome, or SARS, in 2003 and the H5N1 avian influenza outbreak in 2006. 


Compared to previous episodes, according to The Economist, this time the government response in China has been “far swifter and more open.” Does this mean that across the world governments have adopted policies and made the necessary investments to develop and strengthen essential public health infrastructures to respond effectively to this type of public health crisis?


I would say the answer in many countries is “no.”  Disease surveillance systems, public health laboratory networks, and epidemiological intelligence capacity, which are critical for understanding how infectious diseases spread and mounting an effective response, continue to be the most deteriorated, underfunded, and often underdeveloped, components of the health systems.


So what can countries do to be ready to deal with the spread of viruses such as H7N9 and outbreaks of infectious diseases that transcend national borders and swiftly move across continents, making governments, businesses and the population jittery?


Country experiences show that a coordinated effort is needed to identify the strengths and weaknesses in veterinary and public health systems, and develop interventions to sustain good practices and bridge gaps to tackle the animal and human health dimensions of infectious diseases such as bird flu.


Building strong bridges between systems, institutions and professions is critical to promoting effective prevention and response to contagious diseases arising at the animal-human and ecosystems interface. Such an approach is strongly advocated in a recent World Bank Public Health Policy Note, Connecting Sectors and Systems for Health Results, and is key to addressing the “diseases of today and tomorrow,” to paraphrase Dr. Jim Yong Kim.


This implies, as countries such as Argentina and Brazil have done with the support of the Pan American Health Organization and the World Bank, that governments need to prioritize the adoption of policies and target investments to develop and maintain institutional capacity at the national and local levels to perform essential public health functions.


Such functions include: 1)  monitoring, evaluation, and analysis of  population health status; 2) surveillance, research, and control of the risks and threats to public health; 3) health promotion;  4) social participation in health; 5) development of policies and managerial capabilities to support public health efforts; 6) public health regulation and enforcement capacity; 7) evaluation and promotion of equitable access to necessary health services;  8) human resources development and training in public health; and 9) reduction of the impact of emergencies and disasters on health.


The lessons of history clearly demonstrate the importance for countries of having well-developed public health systems (the latter not to be confused, as is often the case, with medical care services delivered in clinics and hospitals run by Ministries of Health or other public entities). 


Just as the spread of “pestilences” in the Latin American and Caribbean colonies during the early 16th century was facilitated by maritime trade and required first quarantine systems, new laws and regulations, sanitation campaigns in the major port cities, and eventually the creation of ministries and departments of health to administer the public health functions to control the spread of diseases that disrupted trade (e.g., yellow fever) and agricultural production (e.g., hookworm disease, malaria), in the 21st century, newly emerged and re-emerging infectious diseases threaten the entire global community and require similar systemic efforts.


I would argue, then, that efforts to address the systemic deficiency of public health systems and to build the institutional capacity for performing essential public functions should be a priority component of any global health initiative for the post-2015 period. After all, the prevention and control of infectious disease epidemics that extract a heavy human, economic and social toll are a "global public good" that merits priority support from national governments and the international community, including the World Bank.



Follow the World Bank health team on twitter: @worldbankhealth






"Crying wolf? Contagion is a real threat!"




Patricio V. Marquez

Lead Health Specialist, Health, Nutrition and Population Global Practice, The World Bank

Join the Conversation

April 17, 2013


very nice expose! The system in any country affects not just the residents of that country, but also everyone else because of trade and travel.

With the ongoing spread of H7N9 avian flu infections, there is much coverage of the capacities in China (when it's not an emergency, nobody seems to care or we are OK with living dangerously). So, on China the following appeared:

" The operational budget for China’s CDC is now about 100
million yuan ($16 million), compared with a few million yuan a
decade ago, according to the center’s Feng. Still, the country
lags behind the U.S. in terms of human resources: Feng’s
national health emergency team has about 30 people, compared
with more than 800 people in similar roles at the U.S. CDC. " (Bloomberg, April 8)

China has 1.4 billion people -- and a team of 30 to deal with national emergency of contagious disease outbreak. The disparity in veterinary capacity is even more stark. This makes no sense since pathogens know no borders.

Also, the economic losses in just one week are reported $1.6 billion, due to people's fearful reactions (losses are not due to the disease itself, which has killed 16 people so far).

A transformational regional/global approach to contagion is warranted.

April 17, 2013

As a new round of bird flu hits China, livestock scientist advises to ‘panic slowly’
By Matthew Davis

The initial news reports were slim on details but the reaction was swift. There were at least three people dead in China after apparently contracting influenza from birds. Prices of soybean—a major ingredient in livestock feed—immediately took a dive.

Then the death toll rose to five, virus samples were detected in pigeons, and in Shanghai authorities began slaughtering poultry flocks. Within a few days the death count was up to seven, then nine. And people started to wonder about a connection to all those pig carcasses floating down Shanghai waterways.

Such is the confusing swirl of information emanating from the latest incident in which a worrisome disease has passed from animal to human, a phenomena—and a quite common one at that—known as zoonoses. In this instance, it’s an influenza virus called H7N9 that appears to have originated in wild or domestic bird populations, but much about its source remains murky.

For Delia Grace, a veterinary epidemiologist at the International Livestock Research Institute (ILRI) who spends most of her waking hours studying zoonotic events around the world, there are two essential facts to keep in mind as the situation in China evolves. And they embody how difficult it can be to craft a proper response.

One: the vast majority of zoonoses outbreaks do not escalate to crisis proportions. But, two: every now and then, as happened with Spanish flu in 1918 and AIDS in more recent times, an animal disease jumps to human hosts and causes a ‘civilization altering event’.

Grace suggests the appropriate reaction is to ‘panic slowly’. In other words, be prepared to move quickly if things get worse, but don’t over-react to the early reports. Also, keep in mind that, just based on what gets reported, a new disease emerges somewhere in the world about every four months.

For example, Grace noted that epidemiologists in the United Kingdom, Germany, and the Middle East are probably more concerned right now about a new and deadly corona virus that as of late March had killed 11 of the 17 people known to have been infected. There is evidence that at least one of the infections may have originated in racing camels.

Grace advises decision-makers in the public and private sector to channel the impulse to take action toward addressing conditions that are intensifying zoonotic threats.

We know that in certain parts of the world, livestock intensification is being pushed well beyond the limits of anything we have done in agriculture in the past’, she said. ‘There are hundreds of thousands of animals packed together and little transparency about how they are being managed. And that’s making disease experts pretty nervous.’

But Grace cautions against focusing solely on the risks posed by certain livestock practices and ignoring the fact that livestock are a major source of food and income for 1 billion of the world’s poorest people. She worries that misguided reactions to emerging zoonotic diseases can end up doing significant harm to their lives and livelihoods.

For example, in 2009, the Egyptian government ordered the mass slaughter of pigs tended by Coptic Christians on the mistaken belief that the pigs were linked to the H1N1 flu pandemic. Also, the possible link in Asia between a different, and also deadly, form of avian influenza called H5N1 and ‘backyard’ poultry farming has prompted a shift to more industrial-scale production. Yet, as Grace points out, given the problems plaguing industrial operations in the region, this shift could actually increase the risk of zoonotic diseases while imperiling the food security of livestock keepers.

‘The proper reaction to the risks posed by emerging zoonotic diseases is not to indiscriminately slaughter animals. That could threaten the health of far more people by depriving them of their primary source of protein and other nutrients’, Grace said.

What we need to do is look at the many ways livestock production has gone wrong—lack of diversity in animals, using drugs to mask signs of diseases, dirty conditions—and put them to right.

Matthew Davis is a Washington DC-based science writer and policy analyst; he also serves as a senior consulting writer for Burness Communications.

Patricio V Marquez
April 18, 2013

Bloomberg News H7N9 has just produced a graphic for those closely following news of the H7N9 outbreak in China. To see it:

Daryl Loo
April 18, 2013

Great article Patricio! And an extremely timely reminder as the outbreak has the potential to get worse. Another possible gap in the system is funding for patients of infectious diseases. We're already starting to see reports on how some H7N9 patients/suspected patients are being saddled with huge hospital bills. Another vulnerable group are the poultry farmers who've had to cull their entire flocks. Would love to hear your thoughts on this.
Bests, Daryl

Patricio V Marquez
April 19, 2013

The evidence provided by recent assessments highlight the significant expansion of health insurance coverage in China over the last decade. As a result, China has now one of the world's largest health insurance systems, including government-run basic health insurance and commercial health insurance. In spite of this progress, some assessments indicate that even for households with coverage, there are considerable out-of-pocket medical expenses, particularly for households with inpatient treatments and/or chronic diseases that require continuous care outside a health facility.

Such observations clearly suggest that infectious disease epidemics have a potential to inflict a heavy toll on individual and families due to gaps in health insurance coverage, and this in turn reinforces the need for further improving the health insurance system to strengthen financial protection (a key social goal in a health system) to minimize the impoverishment effects of disease.

On compensation, there is a long history of compensation for animal disease control (documented since 1866). This measure encourage early reporting of disease outbreak and culling orders, and reimbursement for legitimate private property destroyed by the State for the public good is justified. Direct losses are the ones compensated in whole or in part, for example, birds destroyed, or disinfection/disposal where practical.

The main criteria that has been followed by international organizations and governments is to compensate the appropriate beneficiaries an appropriate amount, with only a short interval between reporting, culling and payment. To do so effectively, considerable advance preparation is required, including: (i) Legislation that spells out the rights and responsibilities of individuals and various State actors in animal disease control; (ii) A broader disease control strategy in place; (iii) Prior agreement among stakeholders on the who, when, how and how much of compensation; and (iv) Resources for implementation that are immediately available for response.

In some countries indirect losses off farm (e.g., lost input sales, lost tourism) are or can be insured against where risks are well-known.

April 19, 2013

There are some more neat graphics and analyses here:

Virology Down Under

Marcelino Reidenbach
April 20, 2013

the Egyptian government ordered the mass slaughter of pigs tended by Coptic Christians on the mistaken belief that the pigs were linked to the H1N1 flu pandemic. Also, the possible link in Asia between a different, and also deadly, form of avian influenza called H5N1 and ‘backyard’ poultry farming has prompted a shift to more industrial-scale production. Yet, as Grace points out, given the problems plaguing industrial operations in the region, this shift could actually increase the risk of zoonotic diseases while imperiling the food security of livestock keepers.

Patricio V Marquez
April 22, 2013

Thanks for your comments as they highlight a major risk factor for the spread of zoonotic diseases. A paper by Graham et al published in 2008 concluded the following in relation to your observation:

"Understanding interactions between animals and humans is critical in preventing outbreaks of zoonotic disease. This is particularly important for avian influenza. Food animal production has been transformed since the 1918 influenza pandemic. Poultry and swine production have changed from smallscale methods to industrial-scale operations. There is substantial evidence of pathogen movement between and among these industrial facilities, release to the external environment, and exposure to farm workers, which challenges
the assumption that modern poultry production is more biosecure and biocontained as compared with backyard or small holder operations in preventing introduction and release of pathogens.

An analysis of data from the Thai government investigation in 2004 indicates that the odds of H5N1 outbreaks and infections were significantly higher in large-scale commercial poultry operations
as compared with backyard flocks. These data suggest that successful strategies to prevent or mitigate the emergence of pandemic avian influenza must consider risk factors specific to modern industrialized food animal production."

Given the above, Graham et al (2008), suggested that:

"renewed attention to the animal-human interface should focus on high-risk populations, especially farm workers. A similar conclusion
was reached by Saenz et al (2006)in an analysis of the risks of influenza outbreaks and transmission to human populations in the context of large-scale commercial poultry and swine production. Monitoring this population may improve detection of early events in emergence of avian influenza. In addition, careful evaluation of operations at all poultry facilities—large and small—should be undertaken to reduce opportunities for the transmission of disease among avian and other species. Moreover, if appropriate protections such as vaccination are identified, the agricultural workforce constitutes a high-risk population for whom protection from zoonotic disease is important not only for their health but for the health of their communities and the population at large. Finally, improved oversight and management of animal wastes—including transport and sale as well as use in aquaculture—should be included in strategies to reduce risks of pandemic HPAI."

To read the above paper:

Tanmay Roy
January 21, 2014

H5N1 also causes huge loss to the farmers of some developing Asian countries like Bangladesh and India during 2005. Thanks for the great article!