His name was Emile.
He was 2 years old and lived in Guéckédou, a city of about 250,000 in southern Guinea, not far from the borders of Sierra Leone and Liberia.
Although we do not know Emile’s last name, he touched off a medical crisis when the illness that killed him in December 2013 was finally identified as Ebola in March 2014.
By then, Ebola had killed several other members of his immediate family and had spread throughout the region, eventually taking the lives of thousands, including a small number of people who’d traveled to Europe and the United States after being exposed to the virus but before showing symptoms.
Emile’s death and what followed demonstrate the growing danger posed by emerging pandemic threats triggered by zoonotic diseases — infectious agents passed from animals to humans. And they underscore the urgent need for more effective measures for responding to and preventing the spread of these pandemics in areas where the threat is most potent.
Backed by USAID funding of up to $50 million over five years, the University of Minnesota and Tufts University have assumed a major role in developing those measures under the “One Health Workforce” initiative. Part of the USAID Emerging Pandemic Threats (EPT) program, the initiative is aimed at developing crossdisciplinary teams of human and animal health professionals in central and eastern Africa and Southeast Asia to handle emerging pandemic threats.
The “One Health” approach emphasizes an interdisciplinary response to the spread of infectious diseases where humans, animals, and the environment intersect, explains David Chapman, Ph.D., the U of M’s One Health Workforce director and a professor in the College of Education and Human Development. Its purpose, he says, is to create “a national and international network of people who know how to respond to a pandemic outbreak.”
The Ebola paradigm
The Ebola virus was identified in 1976 — the same year it claimed its first known victims. Between then and December 2013, while the disease was confined to West Africa, there were about 1,716 confirmed Ebola cases.
As of January 2015, the new outbreak announced by Emile’s death had sickened some 22,000 people.
The large number of victims this time around is directly attributable to the rapid growth of cities like Guéckédou (which now has about a quarter million inhabitants compared with about 80,000 in 1996), coupled with poverty, ignorance of the disease, and the lack of an effective public health infrastructure, especially in Liberia, where the disease hit hardest. Previous outbreaks had occurred in remote and less populated locations.
“The latest appearance of Ebola has galvanized world attention on preparedness for outbreaks of this kind of epidemic,” says Chapman. “This attention is good because such things as pollution, climate change, and the threat of bioterrorism may raise the risk of pandemic diseases.”
RESPONDing to threats
USAID started the EPT program in response to the emergence of avian flu as a source of pandemic threats in the early 2000s. In 2003, the SARS (severe acute respiratory syndrome) virus appeared on the scene and quickly spread around the world.
One of EPT’s initial projects, RESPOND, called on the University of Minnesota and Tufts to provide the technical and medical know-how to help achieve several goals. The most important was to work with 28 schools of public health, veterinary medicine, nursing, and medicine in 10 African and Southeast Asian nations to develop university networks that would lay the foundation for a One Health Workforce.
These networks developed curricula and other training tools, including student field experiences and faculty exchanges, focused on enhancing worldwide responses to zoonotic diseases believed to have the potential to turn into new pandemic threats.
The first five years of the initiative started with a broad focus on capacity-building, says Katey Pelican, D.V.M., Ph.D., an associate professor of veterinary population medicine and a member of the core management team that will help direct the U’s efforts with Chapman and John Deen, D.V.M., Ph.D.
Now, One Health Workforce is expanding that work. Led by the University of Minnesota in partnership with Tufts, the current project will work with the networks to create a new kind of workforce that’s capable of an efficient and effective response to infectious disease threats like Ebola, says Pelican.
“The core to this training is hands-on experience so students have better competence in all areas,” she says. “The beauty of working with univer-sities in these networks is that they graduate a large percentage of medical doctors, nurses, veterinarians, and public health professionals who work in that country, so if you change things there, you can change the entire health care workforce,” she says.
“Creating an effective One Health Workforce is not a departure for our University, which is a recognized leader in research that cuts across boundaries,” says Brooks Jackson, M.D., M.B.A., dean of the U’s Medical School and vice president of health sciences. “It draws upon our existing resources and extends in a new direction the work we’re already doing.”
One world threats
Contact with infected body fluids is the primary way the Ebola virus is transmitted, but prominent Ebola researchers, including Michael Osterholm, Ph.D., M.P.H., director of the U’s Center for Infectious Disease Research and Policy, suggest that limited respiratory transmission already occurs, and additional airborne transmission in future cases cannot be ruled out. SARS is an example of a zoonotic disease that evolved and now can be passed from person to person without physical contact. So is the Spanish flu that emerged in 1918 and in the following two years killed some 50 million victims around the world before burning out.
Zoonotic illnesses are nothing new. Indeed, many of the most common and dangerous diseases affecting humans — measles, smallpox, influenza, and tuberculosis among them — originated in animals. Most of these illnesses are the result of human domestication of animals, a process that began on a large scale with the development of agriculture at the end of the Ice Age.
Some of the newer, most worrisome of these zoonotic pathogens, however, can be traced to more recent times in which human populations, driven by poverty, hunger, or dispossession of land, have pushed farther into habitats where human presence had been rare if not almost entirely unknown. HIV and Ebola both seem to be the products of this more recent dynamic.
“Over the last 50 years, 75 percent of the new diseases that have emerged in human populations have had their origins in wildlife,” observes Saul Tzipori, D.V.M., Ph.D., chair of the Department of Infectious Disease and Global Health at Tufts University and head of Tufts’ One Health Workforce team. “This includes HIV, MERS [Middle East respiratory syndrome, first identified in Saudi Arabia in 2012], Ebola, and SARS.” As a result, the global health community has become increasingly concerned about pandemics, he says.
These diseases are emerging in certain hotspots around the world — all of them in the tropics or subtropics and mostly in developing countries lacking well-organized infrastructures. The most critical of these regions are located in sub-Saharan Africa and Southeast Asia, sites of the One Health university networks.
The new normal
With the population of the developing world set to explode (Africa is projected to be the most heavily populated continent by the end of the 21st century), public health experts believe the world has entered a “new normal.” Under this paradigm, zoonotic diseases can quickly reach a pandemic scale.
“We know that the circumference of the world hasn’t changed,” says Osterholm. “On the other hand, the world is much larger and smaller at the same time. It’s larger in terms of population — the most rapid growth in population is in urban areas of the developing world. It’s smaller in that modern transportation has made oceans, mountain ranges, and international borders irrelevant to the spread of infectious agents.
“If you wanted to create the perfect mixing bowl for enhancing infectious diseases, it would be these megacities,” he continues. “Not only are people living in close, squalid quarters, we also have to feed these new urban populations.”
In the Shanghai metro, or “peri-urban,” area alone, Osterholm says, 750 million chickens are hatched every month just to feed the city’s inhabitants. “Each chick represents an incubator for viruses, including avian flu viruses.”
Meanwhile, as the world’s population grows, the globe, in other ways, keeps getting smaller. Today pathogens can jump from continent to continent, turning into new pandemics in a matter of weeks or months, instead of years or even decades as in the past.
“We have removed all boundaries to the movement of infectious agents,” Osterholm says. “We are moving everything from plants to mosquitoes to fish to microscopic agents. The same is true with infectious diseases.” At any time, he says, some 40,000 large oceangoing vessels transport cargo from country to country. Humans are circling the globe as well; in the past year alone, approximately 1.7 billion people crossed an international border.
“We have immense challenges before us,” says Osterholm. “I liken it to the difference of a swimmer in a calm lake who can cover 12 miles in six hours. Put that same swimmer in a river heading upstream against a 4 mph current… After three hours that same swimmer ends up six miles downstream of where he started.”
In today’s “new normal,” he says, “We are not swimming in a calm lake.”