One Health, one cure

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In 1999, West Nile Virus broke out in New York City. There were 59 identified cases in the greater metropolitan region, including seven deaths. It came somewhat as a surprise.

COVID-19 did not.

In the past decade, a USAID-funded research program discovered more than 100 new coronaviruses in 35 countries and detected more than 500 bat coronavirus variants or strains in China in the past decade. That program was called PREDICT. Multiple studies over the same course of time discussed the high likelihood of SARS-CoV–related viruses emerging in humans, due to certain cellular receptors at play. Even more studies discussed spillover, the pandemic properties of zoonoses, and the interlinkages between human-caused environmental change and the spread of emerging infectious diseases.

Though it took a global pandemic, such terms are now well entrenched in the public lexicon. However, the bigger picture is not: the tightly woven braid of human, animal and ecological health. While all eyes are fixed on a vaccine for COVID-19, there’s little awareness – even among certain fields of medicine and science – that preventing pandemics rather than trying to cure them post-haste lies in approaching them through the aforementioned triangulation of health sectors. This approach is called One Health.

“What happens to people with infectious disease, and what’s going on in the environment and wildlife and livestock… I don’t think that has been well understood or well talked about,” says Peter Daszak, a wildlife disease specialist who heads the New York–based non-profit EcoHealth Alliance. “If you try and just look at one side of it, you miss the big issue, which is the big connective system.”

Three-quarters of all emerging infectious diseases in human populations come from animals, transmitted through bug bites, contaminated food and drinks, and myriad other forms of direct and indirect contact. The more we reduce the size of ecosystems and natural habitats, the more those transmissions are likely to occur. Slowing the rate of environmental degradation is imperative – and for many reasons – but so too is identifying, containing and finding cures for the certain viral threats carried by animals that could harm us. The Global Virome Project has calculated that USD 1.2 billion could find majority of viral threats – and approximately USD 4 billion could find nearly all.

To the various doctors, veterinarians, public health practitioners, virologists, epidemiologists and ecologists who subscribe to the One Health approach, there have been plenty of unsurprising zoonoses in the past several decades: West Nile Virus, Ebola, SARS, Monkeypox and various influenzas to name a few. “These were obviously wake-up calls,” says Steve Osofsky, director of Cornell University’s Wildlife Health Center, who in 2003 founded Animal & Human Health for the Environment And Development (AHEAD) as a cross-sectoral platform after observing the impacts of foot and mouth disease – a viral disease that can infect bovids and other cloven-hoofed animals – on landscapes and human livelihoods. “But there’s something different about a global pandemic. We haven’t had a global wake-up call like this in our lifetime. We’ve got to capitalize on this crisis so we don’t see one like this again.”

“The pandemic has shown us that the veneer of civilization is very thin,” says Laura Kahn, physician and co-founder of the One Health Initiative, who decided to dedicate her career to biodefense research after the Anthrax attacks following 9/11. “Any kind of disruption, and suddenly you see things as mundane as toilet paper become an existential threat.

Wake-up calls of the wild

In April this year, the National Institutes of Health (NIH), which is the U.S.’s foremost medical research agency, leaked documents to Politico that it was cutting some of its funding to EcoHealth Alliance. The Wall Street Journal covered this later in August, but in the perpetual maelstrom of coronavirus news, the whole event went largely unnoticed.

It was, however, a big deal. EcoHealth had been working with the Wuhan Institute of Virology as the only U.S. government–funded organization to work specifically on curbing the spread of coronaviruses in China. While it was ultimately the NIH’s choice to revoke the funding, Daszak believes this choice was not unadulterated and likely rather born of pressure from the Trump administration, using the crisis to deliver on its campaign platform of cutting ties with China.

In May, a group of 77 Nobel Prize laureates asked leaders of the NIH and the Department of Health and Human Services to review the decision, which they did, and indeed agreed to reinstate the funding – but only with impossible preconditions, including EcoHealth retrieving a sample of SARS-CoV-2 from the Wuhan lab. Suffice to say, the funding remains revoked, and EcoHealth has become the target of conspiracists, threatening the lives and security of its scientists.

Yet for Daszak, it has all only deepened his actionable will to uphold the Alliance’s mission of predicting and preventing diseases: “If pandemics emerge in China, we will go to China, and we will work with our Chinese collaborators at the Wuhan Institute of Virology. The NIH can cancel the funding, but there is no law that says we cannot work there. It’s really important that we do that, because that’s where diseases emerge that threaten American lives. It is to the benefit of the American public health and national security, and we will carry on.”

That the government cut funding to an organization on the informational frontline of the current pandemic is perturbing. But the whole mess in itself points to something positive: that a small non-profit applying the One Health approach had received such funding to begin with, and that through international collaboration, it was on the cusp of identifying this pandemic before it broke out.

The One Health approach put its first dot on the map in Germany in the 19th century, where the term “zoonosis” was coined by physician and pathologist Rudolf Virchow, who began bidding for human and animal health to be addressed in relation to one another. “Between human and animal medicine there is no dividing line – nor should there be,” he wrote in 1858. The idea bounced in small ways through Europe and Canada for the next century, until in the late 1960s, prolific veterinarian and epidemiologist Calvin Schwabe at the University of California, Davis pushed for the two fields of health to collaborate in a substantial capacity, and his coined One Medicine approach began to gain research and economic traction in both the U.S. and in Europe.

In late August 1999 in New York, things began to change. Crows started dropping dead around the metropolitan area, and a few elderly people fell deathly ill from an unidentified cause. Health officials assessed their symptoms – symptoms not dissimilar to the flu-like symptoms of COVID-19 – and said it was likely the mosquito-borne Saint Louis encephalitis (SLE) virus. However, the Bronx Zoo’s head pathologist Tracey McNamara was suspicious of the crows, and when the virus began to hit bird species under her own watch, killing a couple of Chilean flamingoes, a cormorant and an Asian pheasant, she began doing necropsies on the birds and found horrific cases of carditis and hemorrhagic encephalitis – symptoms that shouldn’t have been occurring from SLE. She began fearing for the lives of the zoo workers, including herself.

“So, she called the Center for Disease Control (CDC) and said, ‘I don’t think we’re dealing with SLE, I think we’re dealing with something new, and I have some specimens here I’d like to send you,’ ” recalls Kahn. “And the CDC said, ‘You’re a veterinarian, we only deal with human health. We suggest you call the ag lab,’ and hung up on her.” Undeterred, McNamara sent the bird tissues to the U.S. Department of Agriculture National Veterinary Services Lab in Iowa, whose tests found the birds negative for SLE, but positive for a virus in the same viral family. Eventually, the tissues landed at the U.S. Army Medical Research Institute of Infectious Diseases (USAMRID), which discovered they had been infected with West Nile, which had never before been seen in the Western Hemisphere. It was a wake-up call among some scientists who recognized the gravity of the CDC’s inadequacies – it didn’t have the right testing materials to identify a virus that hadn’t already infected U.S. populations. If a foreign epidemic or viral agent of bioterrorism landed on U.S. soil, the CDC wouldn’t be able to figure out what it was.

From there, it was off to the races. Health professionals who had been individually studying the linkages between animal, human and ecosystem health began joining forces. At a 2001 conference in Pilanesberg, South Africa, the Wildlife Disease Association and the Society for Tropical Veterinary Medicine adopted the ‘Pilanesberg Resolution,’ as initiated by Osofsky and colleagues – a series of recommendations for addressing health challenges at the interface between domestic and wild animals, bringing in the relationships between health and environmental stewardship.

In 2004, the Wildlife Conservation Society organized a conference in New York called ‘One World, One Health,’ advocating for a holistic approach to epidemic disease prevention by looking at the interface between wildlife diseases, ecosystem health and human medicine. The resultant 12 ‘Manhattan Principles on One World, One Health’ became a bedrock document for recommendations to policymakers and institutional leaders about the One Health approach. “We didn’t realize at the time that it would become a movement,” recalls Osofsky, who led the drafting of the principles.

Kahn co-founded the One Health Initiative in 2006, and global organizations such as WHO, FAO and the World Bank began to use the Initiative as a consultant platform for collaboration. A few years later, when The Wildlife Trust and the Consortium for Conservation Medicine merged to become EcoHealth Alliance, it was sought out for the same purposes.

Numerous terms for the same approach have been tossed around and, to some extent, are still used interchangeably: one medicine, conservation medicine, ecological medicine, ecosystem health, planetary health, one health – but the one that has stuck the most is the latter.

“If you Googled One Health before 2004, you wouldn’t come up with much,” says Osofsky. “Now you could probably find hundreds of One Health programs and initiatives in academia and the nonprofit sector.  A lot of dominoes have tipped.”

For what it’s worth

The One Health approach was first driven largely by experts in veterinary medicine. “This is right to their core line of work,” says Daszak. “They’re trained in individual and herd health, so there’s sort of an intuitive understanding of what that is.” The specialization demanded of medical practitioners saw them largely miss the One Health forest for the trees of cardiology, radiology, pediatrics and so on. But this began to shift in the mid-2000s, and in 2006 USAID awarded its first large grant to wildlife health experts to work on a major zoonotic disease, allowing the Wildlife Conservation Society and partners to create the Global Avian Influenza Network for Surveillance (GAINS) program. Subsequently, the American Veterinary Medical Association (AVMA) established a One Health Initiative Task Force, and the American Medical Association (AMA) passed the One Health resolution to bolster partnership between the two fields of health – and availability of funding.

The main program that emerged was PREDICT, the epidemiological research project mentioned at the start of this article funded by USAID. It received about USD 200 million over the course of a decade before coming to a close in September of this year (it was extended for six months in response to COVID-19).

“It wasn’t until the past decade that any funders were appreciating and investing in the One Health approach to any significant extent,” says epidemiologist Jonna Mazet, who served as global director of PREDICT and is the founding executive director of the One Health Institute at UC Davis.

Through new projects, USAID is now approaching investment of USD 1 billion for One Health. Other government bodies, such as the Department of Defense and the NIH, and private institutions, such as the Bill and Melinda Gates Foundation, also contribute funding for research. But in the grand scheme of the U.S. medical-industrial complex, disease prevention of any kind is still a marginalized field. The U.S.’s human healthcare spending amounts to about USD 4 trillion annually – a higher percentage of GDP (18 percent) than any other country – a substantial portion of which goes to tertiary care through Medicare and Medicaid. This further means that what funding is out there is targeted far more for human health than for infectious disease prevention grounded in animal or ecological health work.

“USAID wanted to move from a medicine and response and reactionary approach, and take a risk and see if One Health would lower deaths, response times and outbreaks around the world,” says Mazet, whose first work was protecting sea otters in California dying of the same pathogens as friends and colleagues dying of HIV/AIDS. “[USAID] is still coming from a human approach, but they are willing to take risks to improve outcomes and prevent tragedies.”

“One of the problems in science is that we’ve really gone reductionist in infectious disease, so that if you’re working on the cleavage site of a SARS spike protein, it’s much easier to get funded through the NIH for that than it is to work on the ecology of coronaviruses in civets, which of course is a key part of the problem,” says Daszak.

It however remains the case that animal health is still the dominant side of the triangle. Involvement from the ecological side has always been minimal, and faded further into the background when the human health community stepped up its involvement. The balance isn’t yet there.

Throughout the course, there has been global groundswell. China had begun improving emerging disease lab infrastructure in the early 2000s and later began working to attract top scientists to their tables with higher salaries and state-of-the-art technologies. The E.U. launched the One Health European Joint Programme in 2018, formed by 37 government bodies and research institutes from around the continent. Other smaller consortia, particularly from Great Britain, France, Spain, Scandinavia and the Netherlands also work in tandem. Australia, in more recent years, has launched a handful of regional initiatives.

But in terms of funding and manpower, “the U.S. is leading the world on this stuff despite the current rhetoric from the administration,” says Daszak. PREDICT has come to a close, but now there are two new programs in its stead: the One Health Workforce Next Generation Project (USD 85 million) and STOP Spillover (USD 100 million). “But we’re still not doing it right. We still have a huge growth curve to go through.”

One Health, part two

Even without an end to COVID-19 in sight, more people are waking up to the fact that a ‘new normal’ doesn’t just involve face masks and social distancing. If the natural world keeps being destroyed at the present rate and governments don’t take drastic action, the future is likely to hold another global pandemic, and then another and another, in far quicker succession than has been seen in the past.

“Pandemics show us that we do need government sometimes, and we need to be better at de-ivory-towering science,” says Daszak.

But the proper governance needed to fully implement the One Health approach doesn’t yet exist. For the U.S. specifically, Daszak points to two significant changes that have come under the Trump administration that pose risks for the nation’s health safety: withdrawing from the World Health Organization, which will become formally effective in July 2021, and the 2018 disbanding of the Global Health Security and Biodefense unit – also known as the “pandemic preparedness team” – which had been put in place under the National Security Council by the Obama Administration.

Kahn believes the country needs an entire department devoted to the cause: “We need a Department of Health Security with a One Health umbrella where you put all the relevant departments to focus on disease prevention, control and mitigation.”

In terms of global governance, there’s consensus that some sort of body needs to be established for international cooperation on preventing zoonotic disease pandemics. The obvious placement for an agency of this kind would be under U.N. auspices, although this could be slow-going. An effort kick-started by the G7 could move more quickly, says Osofsky.

In the meantime, he also says the focus should be on managing wildlife trade and markets to curb risks. “The lowest hanging fruit is mitigating threats emanating from wildlife markets and wildlife consumption in places where people don’t actually need those products for their sustenance and survival,” he says. “There are of course many parts of the world where people need to eat wildlife to survive, but that is a longer-term issue related to poverty, food systems and food security. We can and should immediately focus on wealthier areas, where wildlife is still consumed but not essential – the true risks of that behavior are now being borne by all of us. That’s where we need to be focusing right now because that’s where risks can start to be mitigated.”

Of course, if all this comes together in a tight new braid of expedited risk mitigation, well-funded research, and more robust national and international governance, the success will be invisible. The prevention will be the cure, as unsung and silent as all the identified coronaviruses that didn’t emerge as global pandemics.