A better informed approach to global health

One important thread of scholarship has used the interdisciplinary nature of One Health to champion health interventions that are grounded in a wide range of knowledge, and do not rely on a set of purely medical assumptions. For instance, Giles-Vernick et al. (Reference Giles-Vernick, Owona-Ntsama, Landier and Eyangoh2015) use a wide range of qualitative evidence to trace the complex connections between local and biomedical understandings of Buruli ulcer in Cameroon. Other similar work has asserted the importance of using a combination of social scientific and technical approaches to build a more comprehensive knowledge base to tackle, for example, anthrax (Coffin et al. Reference Coffin, Monje, Asiimwe-Karimu, Amuguni and Odoch2015), brucellosis (Godfroid et al. Reference Godfroid, Al Dahouk, Pappas, Roth, Matope, Muma, Marcotty, Pfieffer and Skjerve2013) and livestock ticks (Walker, Reference Walker2011). Bardosh et al. (Reference Bardosh, Inthavong, Xayaheuang and Okello2014) make a similar case regarding the control of neglected helminths in Laos – though they also warn of the difficulties of reconciling large scale projects with multiple complex local environments. In a sense, these studies leverage the recent enthusiasm for One Health to advance an argument of much longer standing: interventions that focus technical and medical activities are often insufficiently adapted to the contexts in which they work.

If such scholarship is primarily focussed on either critiquing or improving specific types of health intervention, others raise related issues at a systemic level. For instance, Hinchliffe (Reference Hinchliffe2015) shares the concerns of Bardosh et al. regarding the difficulties global health agendas are likely to have in adapting to different contexts, but goes further, suggesting that the ‘One World – One Health’ formulation itself is particularly prone to collapsing local diversity into unhelpful ‘one-size-fits-all’ global policy making (see similarly, Okello et al. Reference Okello, Bardosh, Smith and Welburn2014) (‘One World – One Health’ is, as Galaz et al. (Reference Galaz, Leach, Scoones and Stein2015, 3) point out, a slogan copyrighted by the World Conservation Society. Although it is largely used synonymously with ‘One Health’, it is sometimes used to emphasize the global nature of the agenda). Relatedly, Okello et al. (Reference Okello, Welburn and Smith2015) point out that the means by which health policy is made in developing countries is often poorly understood, suggesting that a truly comprehensive One Health approach will also need to include knowledge of these processes.

A fairer approach to global health

We turn now to a group of arguments that use the One Health concept not merely to make interventions smarter, but to address a set of political and ethical issues within the global health agenda. A central issue, again raised by Hinchliffe, is One Health's tendency (at least as currently practiced) to concentrate on controlling disease at the point of transmission. As Galaz et al. (Reference Galaz, Leach, Scoones and Stein2015); following Wald, (Reference Wald2007) argue, a considerable proportion of One Health work has emphasized an ‘outbreak narrative’ that focuses on the risks posed by zoonotic infections, and the surveillance tools necessary to detect and contain them. Implicit in this worldview is a threat posed to Western countries from perceived ‘hotspots’ elsewhere. Thus the supposedly universal ‘One World’ perspective can privilege a scientific and Western-centric concern with pathogenic contamination. In this view, the structural drivers of human and animal disease are too often marginalized. Seeking to rebalance the debate, Mutsaers (Reference Mutsaers2015, 130) has suggested that One Health should stress ‘not only…how easily life is threatened, but also…our dependence upon others, of co-existence as a basis for our existence, biologically as well as politically’, a reading of One Health that may be useful in building approaches that emphasize solidarity and partnership over defensive, self-interested biosecurity.

If One Health risks furthering an excessively narrow approach that focuses on defending against particular zoonotic threats, then what are the broader alternatives? One alternate vision is outlined by Wallace et al. (Reference Wallace, Bergmann, Kock, Gilbert, Hogerwerf, Wallace and Holmberg2015) in their call for a ‘structural One Health’ – in this perspective, the traditional division between human and veterinary medicine is merely one of several boundaries that must be dismantled. It is of equal importance, they argue, for health to be understood in terms of political economy, giving primacy to poverty, inequality and the interests of capital as drivers of disease. This is necessary not just to make interventions better, as discussed above, but to redirect attention towards underlying political and economic issues. For instance, there is a call to address the ways in which social deprivation and multiple diseases form mutually reinforcing ‘syndemics’ (see Rock et al. Reference Rock, Buntain, Hatfield and Hallgrímsson2009, following Singer, Reference Singer1994). In this analysis, the task of One Health is to critically discuss socio-economic processes such as livestock intensification, acute inequality and the destruction of various natural habitats that have the potential to destabilize ecosystems and make pathogenic transmission and other sources of disease more likely. In other words, a structural One Health is one that not merely seeks to make, say, global livestock value chains more biosecure, but also asks fundamental questions of the livestock industry itself. This can only be done through broader kinds of research. For instance, Liverani et al. (Reference Liverani, Waage, Barnett, Pfeiffer, Rushton, Rudge, Loevinsohn, Scoones, Smith, Cooper, White, Goh, Horby, Wren, Dundogu, Woods and Coker2013) show how industrialized animal production provides opportunities to protect against many diseases, whilst simultaneously introducing new pathogenic risks. Yet this is merely one of several complex trade-offs involved, as a truly structural One Health must also consider the significance of livestock intensification on food security, healthy diets in humans, climate change, the ‘winners and losers’ in animal production value chains and so on.

This call to focus attention on the structural and social processes that drive disease is closely related to the tradition of livelihoods studies and theory, a perspective in development studies that has long argued for the integrated study of social and environmental processes (originally Sen, Reference Sen1981 and Chambers and Conway, Reference Chambers and Conway1992, see Scoones, Reference Scoones2009 for a more recent critical discussion). Indeed, it should be of little surprise that One Health has provided a welcome means to continue aspects of livelihoods research that have historically emphasized human, animal and interfaces, such as research on pastoralist communities (Greter et al. Reference Greter, Vreni, Crump, Béchir, Alfaroukh, Schelling, Bonfoh and Zinsstag2014). Whilst livelihoods theory has produced much useful and challenging work, scholars working to develop a similar body of One Health evidence will need to confront much of the same difficulties faced by this sub-discipline. Namely, that holistic studies which emphasize connectedness and the multiplicity of interrelated factors can cause complications and confusion when putting research into practice. Furthermore, as Morse et al. (Reference Morse, McNamara and Acholo2009) warn, as valuable as livelihoods (or, by extension One Health) research is, it can be both difficult and expensive to conduct, and produce analyses that are not always readily comparable.

A global health that is adaptable to complexity

As researchers and policy makers are encouraged to take a broader view of the causes of ill-health, increasingly sophisticated analytical frameworks are required. The problem, it is argued, is that an over-reliance on biomedical knowledge leads to a:

Thus, what is required is more than simply making use of a wider range of methods and evidence, but innovations in interpretation and prediction that make use of non-linear forms of analysis. This interest in complexity – an approach that emphasizes the importance of unpredictability and non-linear relationships – closely parallels an emerging debate in development studies, where the critique of existing analysis is very similar:

Indeed, for Ramalingam (Reference Ramalingam2013, 337) interpreting epidemiological data is a key example of linear and non-linear forms of analysis. Taking the example of epidemiological statistics in Niger, he explains how ‘aggregate annual measures of measles cases hide the dynamic complexity of the disease,’ noting that apparently random outbreaks can be related to seasonal migration patterns and the inconsistent deployment of vaccinations. According to Ramalingam:

Given the nature of One Health problems, there is a particular need for research which is open-ended – problems like Avian flu require researchers to explore ‘multidimensional data space over which viral genetics, locales, and the socioecological matrix are related, rather than out of a strict set of a priori (and ultimately arbitrary) categories’ (Wallace et al. Reference Wallace, Bergmann, Kock, Gilbert, Hogerwerf, Wallace and Holmberg2015, 7).

Whilst there are welcome examples of this kind of analysis, those same studies also demonstrate the difficulties involved in using complexity-centric approaches to policy and practice. The relationship between climate change and One Health is a pertinent issue – the climate is after all a paradigmatic example of complexity, with its feedback loops, risk and uncertainty (Shackley and Wynne, Reference Shackley and Wynne1996; Lemos and Rood, Reference Lemos and Rood2010). One common concern is that research that emphasizes the limits to knowledge and the unpredictability of the future will, like the ‘information overload’ sometimes associated with livelihoods research, lead to a form of policy paralysis:

Given the potentially transformative benefits of integrated, dynamic modes of analysis, grappling with complexity will be a key task for One Health advocates in future. The challenge will come in reconciling the inherent difficulty in predicting multifaceted phenomena with the ‘political pressures to be seen to be in control in a world of uncertainty and surprise’ (Eyben, Reference Eyben2013, 3).

Institutionalizing a One Health approach

One Health is not merely an aspirational research agenda – a number of scholars have explored the attempts of existing institutions to formally enact a One Health approach.

Chien (Reference Chien2013) notes that following the outbreak of avian influenza in 2003, the World Health Organization (WHO), the Food and Agricultural Organization (FAO) and the World Organization for Animal Health (OIE) initially found themselves competing for legitimacy and funding when they drew on competing frames (‘technical/biomedical’, ‘societal intervention’ and ‘ecological conservation’) to prescribe solutions for the outbreak. In recognition that a lack of cooperation was actively hampering the global response, over a 5-year period the agencies moved to collaborate, and in 2008 endorsed the One World – One Health Framework. Chien emphasizes the ‘vagueness’ of the One World – One Health Framework they adopted, suggesting that it is this quality which allowed the three agencies to merge their competing frames, while also reducing conflict, avoiding criticism and creating a global consensus to facilitate coordination.

Smith et al. (Reference Smith, Taylor and Kingsley2015) highlight several challenges to the state enacting a One Health approach to tackle trypanosomiasis in Uganda. In 1992, the Ugandan government passed an Act of Parliament establishing the Coordinating Office for the Control of Trypanosomiasis in Uganda (COCTU), a One Health-style platform tasked with coordinating the response of all involved government departments, donors, researchers and non-governmental organizations active in trypanosomiasis in the country. Yet Smith, Taylor and Kingsley note how at times external actors have circumvented COCTU's authority by attaching an ‘emergency’ framing to their interventions; moreover, how an elimination target set at the global level has undermined the country's agency to determine its own plan for trypanosomiasis, despite conferring no extra funding for control. Both challenges to COCTU's remit speak to the difficulty of exerting authority over external actors and events in the context of aid dependency. A third challenge to COCTU's remit is identified internally; in short, Uganda's policy of decentralization, which has devolved the budget for tsetse and trypanosomiasis control to the districts, has proved detrimental for controlling the disease.

Finally, Mwacalimba and Green (Reference Mwacalimba and Green2015) note that while the One World, One Health concept facilitated intersectoral partnerships for avian influenza preparedness in Zambia, certain ‘policy narratives’ (Scoones and Foster, Reference Scoones, Foster and Scoones2010) found more traction than others, with a narrow focus on infectious disease acting to marginalize trade and development concerns. This limited the effectiveness of a trade ban on poultry, in addition to the longer-term sustainability of any multi-sectoral disease control strategy.

Other research considers the factors that might enhance or inhibit One Health activities across institutional boundaries. Kayunze et al. (Reference Kayunze, Kiwara, Lyamuya, Kambarage, Rushton, Coker and Kock2014) report on the ‘bridges’ (contributing factors) and ‘barriers’ (impeding factors) to inter-sectoral collaboration between human, animal and wildlife experts in Tanzania. The main bridges were instruction by high level leaders, zoonotic diseases of serious impact and funding; the main barriers were lack of knowledge about animal or human health issues, lack of networks for collaboration and lack of plans to collaborate. Other studies have also emphasized that successful collaboration between disciplines and professions accustomed to working in different ways may not be a straightforward task, and will require specific attention in terms of training and partnership building (Anholt et al. Reference Anholt, Stephen and Copes2012). In this vein, Stärk et al. (Reference Stärk, Kuribreña, Dauphin, Vokaty, Ward, Wieland and Lindberg2015) have argued that thus far it has been easier to conduct One Health research than to build sustainable One Health systems. Noting surveillance as a key area of potential collaboration, they demonstrate that aside from a number of promising case examples including the joint FAO-OIE-WHO Global Early Warning System database, too often medical and veterinary data recording remains largely separate. As Zinsstag et al. (Reference Zinsstag, Schelling, Waltner-Toews and Tanner2011) and Stringer (Reference Stringer2014) have argued elsewhere, making such collaborations sustainable will likely depend on making a persuasive economic case (see also Rushton et al. Reference Rushton, Häsler, De Haan and Rushton2012).

One health and new technology

Whilst the preceding section outlines the main lines of debate over what One Health can achieve as a research and policy goal, other scholars have extended the concept in different, unexpected directions. One nascent body of literature highlights how the emergence of new technologies, which at first sight appear to support One Health goals of improved public health and nutrition, might actually call into question some of One Health's basic tenets. For example, Yates-Doerr (Reference Yates-Doerr2015) explores the efforts of scientists to proffer the eating of insects as a solution to global food insecurity and an alternative to more environmentally damaging forms of livestock production. Whilst the scientists have a global ambition of tackling problems, Yates-Doerr finds that there is not One World when it comes to creating products, appetites and markets for edible insects, but many different worlds; and as such insect food solutions must be modified according to the specific locales in which they are to be consumed.

Investigating another emerging technology, Lezaun and Porter (Reference Lezaun and Porter2015) use the example of transgenic animals to question the One Health assumption that pathogen circulation is inevitable and that it is therefore ill advised to circumscribe health policy to the well-being of humans alone (FAO et al. 2008). Anticipating a potential future in which transgenic species could be rolled out en masse, the authors note the fundamental difference in strategy ascribed to the two camps: if One Health represents a strategy of containment (i.e. accepting that pathogens will always exist), transgenic animals represent one of competition (i.e. that some might be engineered out of existence):

One Health and expanding the remit of global health

As we have shown, some One Heath advocates challenge global health actors to take a broader view of the causes of disease, and to consider different starting points for interventions. A possible further step in this line of thought is that the well-being of animals and the environment have an intrinsic value that is not tethered to their impact on humans. Therefore, so the argument goes, these non-human forms of life are themselves worthy of protection. Such topics have often raised complex and contentious ethical issue, for instance over trade-offs between animal welfare and food security (Marie, Reference Marie2006). Whilst such questions are currently on the fringes of One Heath debates, if One Health concepts are to contribute to these longstanding questions, their main contribution may be to emphasize global interconnectedness:

Finally, several authors have argued that the One Health agenda should include a number of hitherto marginal topics. For instances, Mills and Hall (Reference Mills and Hall2014) argue that whilst companion animals for people are sometimes dismissed as ‘a luxury or unnecessary indulgence’, a formidable body of research now attests to the therapeutic and developmental significance of the human-animal bond. Similarly, Sandøe et al. (Reference Sandøe, Palmer, Corr, Astrup and Bjørnvad2014) explore the relationship between the obesity of pets and their owners, noting that the pathogenic lifestyles that drive ill health cross, in a sense, the species boundary. Extending the notion that human and domestic animal health can be addressed together, other authors have, for instance, demonstrated the importance of accommodating pets in natural disaster evacuations (Stauffer and Conti, Reference Stauffer and Conti2014) or noted the human behaviours that make dog attacks on people more likely (Mannion and Shepherd, Reference Mannion and Shepherd2014). If one considers the core project of One Health to be advocating for better defences against zoonotic diseases or reforming global health, such issues may seem somewhat peripheral. But they nonetheless highlight the sheer breadth of ways in which human and animal well-being intersect, and perhaps more opportunistically, the value of attaching various projects to an agenda with some momentum.

Concluding remarks

At its simplest, One Health is both an assertion of the undeniable benefits of collaboration, and a useful overarching concept for asserting the value of a range of issues that might otherwise be marginalized and fragmented. For parasitologists, this offers a renewed opportunity for specialists in, for instance, zoonotic parasites and wildlife parasitology, to shape wider debates over research and interventions. This is a practical and intellectual project of great value, and has understandably generated interest and enthusiasm from a wide range of scholars and professionals. The challenge for the future is to ensure that this broad base of support does not collapse and splinter under its own weight. As we have shown, there is considerable debate over what exactly One Health is for. After all, One Health offers an implicit critique of current practice, and from their various vantage points, actors have different ideas on where the most pressing need for change lies.

Fortunately, many of the different visions of One Health are complementary – or at least, not mutually exclusive. It need not be a contradiction to carefully plan interventions that make use of a full range of disciplinary and professional knowledge whilst also asking broader, structural questions about global health priority setting. The success of both projects will likely turn on the quality of collaborations involved. Similarly, complexity theory offers a potentially powerful framework for describing multifaceted, unpredictable systems – yet it challenges established ways of working in a manner that make both natural and social scientists uneasy. The task now is to do more than simply call for better exchanges of knowledge, but to understand what kinds of policies, funding and institutions might enable such interdisciplinarity to flourish. A clearer understanding of the historical antecedents of One Health would be of great help, as would contemporary comparative studies that reflect frankly on the challenges of pursuing One Health, as well as simply championing the concept.

Ultimately, the wide-ranging, even unruly nature of the One Health debate is a sign of the promise of the concept. If the topics and the participants in the conversation become pared down to a narrow, homogenous group, Galaz et al. (2015, 21) will surely be right that ‘One Health runs the danger of getting siloed and institutionalized with new forms of funding and power…becoming subject to precisely the problem it has sought to challenge’. Instead, researchers and practitioners must continue to find better ways to engage with one another, even if doing so raises unsettling, challenging questions about our own methods and perspectives. After all, the clear lesson of this emerging literature is that One Health cannot be achieved simply as an apolitical, technical project. If it to succeed, researchers and practitioners alike must engage with the political, social and economic questions that are at the heart of One Health.