One Health: the Balance between Animal and Human Health

Animals and humans interact in many more ways than we think about in domestic suburbia.  Sure, we know that animal farmers are constantly in contact with their produce, and we are happy to pet our domestic cats and dogs.  Sure we recognize that some wild animals get rabies or, here in the desert of New Mexico, occasionally someone comes down with plague because of flea bites from infected indigenous rodents (our first case of this year was just last week).  And we’ve all heard of bird flu.

Yet there are many more ways that animals and humans interact that can compromise the health of individuals or populations.  In an excellent summary article, “Links among Human Health, Animal Health, and Ecosystem Health” Peter Rabinowitz and Lisa Conti from the Yale School of Medicine discuss how small-scale animal agriculture, human migration patterns and travel, animal worker practices, housing and land use development, changes in indigenous wildlife species, toxic hazards like the mercury poisoning in Minimata, Japan, and climate change impact animal and human health synergistically.

In 2007 the American College of Preventive Medicine (ACPM) Policy Committee, of which I was a member and former Chair, passed a resolution introduced by the late Ron Davis urging the American Medical Association to “support an initiative designed to promote collaboration between human and veterinary medicine…encourage joint efforts in clinical care through the assessment, treatment, and prevention of cross-species disease transmission…AMA support cross-species disease surveillance and control efforts in public health…support joint efforts in the development and evaluation of new diagnostic methods, medicines, and vaccines for the prevention and control of diseases across species…[and] engage in a dialogue with the American Veterinary Medical Association to discuss strategies for enhancing collaboration between the medical and veterinary medical professions in medical education, clinical care, public health, and biomedical research.”

The AMA passed this resolution and has been a leader in encouraging the consideration of these issues.  The American College of Preventive Medicine has recently participated in a One Health capitol hill briefing and renewed its endorsement of the One Health initiative.  However, the greatest push to understand and deal with animal-human medical interactions has come from the veterinary community.  The medical community has been relatively quiescent on the issue unless an epidemic occurs.  When one looks at the One Health Commission there are only two MD individual members of the Board of Directors, and only one MD on the Council of Advisers.  (There are twelve on the honorary advisory board of the One Health Initiative.)

Who are the MD leaders concerned about this issue?  Mostly they are epidemiologists, infectious disease specialists, or ag-related occupational medicine specialists.  Two out of three of these specialists are under the medical specialty of preventive medicine.  There aren’t very many of us trained in preventive medicine.  The Institute of Medicine in 2007 estimated there are about 10,000 in the US and that we’d need another 10,000 over the next few years.  To quote from a report from ACPM:

• Between 1999 and 2006, the number of residents enrolled in preventive medicine training programs declined nearly 20%, and in 2007-08 less than half of the approved number of residency positions were filled.
• The number of preventive medicine residency programs decreased from 90 in 1999 to 71 in 2008-2009.

These trends have not abated.  The demand for such residencies has not decreased – it has always been high according to preventive medicine residency directors.  The problem is funding – preventive medicine is the one specialty not consistently mostly supported by the federal government.  Hence for those residency programs in existence, most can only find funding to fill half of their slots (and many approved residencies’ doors aren’t even open).

For human medicine to be fully engaged in the One Health initiative we need more human medicine physicians to be engaged in preventive medicine, which means more federal funding for residencies.  But as with prevention in general, western society tends to provide less than what is needed in the balance with treatment.

 

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A picture of Middle East difficulty

Why haven’t the Israelis and Palestinians made peace yet? A window into the difficulty can be seen in two articles in the Wall Street Journal today (August 20, 2013).

The first article details why the Saudis and UAE are siding with the Egyptian military: they see their nations’ interests as being free of the type of Islamism being espoused by the Islamic brotherhood. [Ignore the irony here for a moment – think Wahhabism.] As the WSJ states, “the Saudis and UAE want to deal a blow to the Muslim Brotherhood and undercut the influence of the regional rivals that back them: Turkey and Qatar.” Saudis and UAE have pledged $12 billion in aid to Egypt, more than counterbalancing any cutoff the US might make of our $1.5 billion.

In a parallel article “EU is to Debate Aid to Cairo” EU members are wringing their hands about what to do. They are increasingly reducing arms exports to Egypt and debating other aid that they would reduce. To give some sense of the relative lack of leverage this means, “Germany had approved weapons sales valued at [$17.6 million] in the first half of 2013…” Again, a drop in bucket.

But more importantly, the approach to dealing with the issue is what is striking. The Saudis and UAE’ers, who live in the region and understand the cultures and mentalities of the players better than Westerners do, are saying a strong hand is necessary inside of Egypt before democracy can be respected. The Westerners, who have our consistent ambivalent “let’s make nice and compromise for the good of everyone” approach and have not been particularly successful in our approaches to foreign cultures (think Africa, Asia, the Middle East) over the centuries, believe the specter of democracy is more important, even if a type of theocracy results.

Israel, the only nation that straddles the Middle Eastern and Western cultures, wants a stable Sinai peninsula and western border with Egypt. It senses that a stable government is vital, and that isn’t likely to happen until General Sisi can install law and order: “‘Only after stability is restored, only after law and order is enforced, only then can you start to talk about launching a process that leads to more democratic processes,’ sad the senior Israeli official.” Though at the same time Israel is wary of an Islamic backlash throughout the region.

So the Obama administration dickers (that has been its approach in most foreign policy for 5 years now) without a clear strategy. And, as a senior Arab official says in the first WSJ article, “‘I don’t think that Washington is really in the conversation’ on Egypt in a significant way.” Seems to be true on Syria as well.

Why is Kerry pushing the Israeli-Palestinian line right now? Perhaps it has to do with the same naïveté driving our wrong-headed approach to Egypt and Syria?

Addendum on August 21: See the article by Walter Russell Mead that is more articulate about this problem in the American Interest just brought to my attention, “Bambi Meets Godzilla in the Middle East.”