By NGAIRE WOODS & OK PANNENBORG
The World Health Assembly met last week amid a slew of proposals — most recently from the UN Independent Panel for Pandemic Preparedness and Response — to create stronger, enforceable global rules for tackling future infectious disease outbreaks. A new global pandemic treaty, more robust and independent international institutions, and an international pandemic financing facility are all in the mix. But a bottom-up strategy might work better.
A separate review by the World Health Organization (WHO) earlier this year highlighted four ways to strengthen global health governance. It called for a centralized approach to bolstering countries’ preparedness for health emergencies; a worldwide notification system to ensure robust monitoring of compliance; global capacities such as a genomic sequencing infrastructure; and closer coordination among international institutions, including the WHO, the World Organisation for Animal Health, the Food and Agriculture Organization, and the UN Environment Programme.
These are all worthy objectives. But is a top-down approach the best way to pursue them? To answer that question, global health experts should pay more attention to successful grassroots efforts to combat disease.
Consider the fight against onchocerciasis, or river blindness. In the 1970s, it was led by World Bank President Robert McNamara, Merck CEO Roy Vagelos, and WHO Director-General Halfdan Mahler. But, over time, a bottom-up strategy, whereby almost half a million village community health workers owned the problem, proved more effective. A 1994-95 multi-country study showed that, when communities are responsible for organizing their own distribution of ivermectin (the drug that treats onchocerciasis), coverage is higher than when the health system delivers the drug. Another report by the Carter Center highlights the role that kinship and local networks play in tackling this disease.
Similarly, the Bombay Leprosy Project (BLP) is a long-standing program in Mumbai’s largest slums, such as Dharavi. BLP community volunteers, trained by paramedical workers, conduct door-to-door surveys among the population in order to detect new cases. During the pandemic, it has been one of the most effective channels for delivering personal protective equipment (PPE), healthcare, food and now coronavirus disease (COVID-19) vaccinations to the poorest of the poor in areas where the Maharashtra state and federal governments are essentially absent.
The importance of bottom-up initiatives in responding to the pandemic is not limited to developing countries. The UK government invested heavily in a centralized national test-and-trace service. But evidence suggests that even relatively underfunded local schemes performed better, leading the government to rethink its approach.
Increased efficacy is not the only reason to consider a grassroots strategy. Politically, many countries — perhaps scarred by their experience of trade blockages at the outset of the coronavirus pandemic, the worldwide scramble for PPE supplies, and vaccine nationalism — are currently more focused on national resilience than global commitments. A new emphasis on local resilience may therefore find a much more receptive audience in communities around the world. One of the shortcomings of international health regulations during the ongoing pandemic has been the failure to prepare, provide and coordinate adequate resources at the country level. A bottom-up approach could change this.
Moreover, investments in community-level health surveillance capacity will likely be key to tackling this and future pandemics. Here, the right financial incentives are crucial. Rural smallholders in Africa and Asia will be the first to know when some of their chickens or ducks seem sick — possibly with an avian influenza virus that could trigger a human pandemic. –AN
