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Musings on the future direction of One Health, William Hunting and tuberculosis, while listening to blackbirds sing
  1. E. Paul J. Gibbs
  1. College of Veterinary Medicine, University of Florida, Gainesville, Florida 32610, USA
  1. E-mail: pgibbs{at}ufl.edu

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Had the term ‘One Health’ been in use 130 years ago, it is highly likely that this journal’s first editor, William Hunting, would have used it in the first edition of The Veterinary Record.

The issue, published in July 1888, includes a report of a meeting of the Scottish Metropolitan Veterinary Medical Society at which there had been a lengthy discussion about the prevalence and implications of bovine tuberculosis (TB) in the 300 or so dairies in Edinburgh and its suburbs.

It had only been a few years earlier, in 1882, that Robert Koch had reported his discovery that tuberculosis was caused by a bacillus;1 yet the discussion clearly indicated the concern of the society’s members over the transmission of bovine TB to children drinking the milk from the dairies. Given that both the medical and veterinary professions previously believed that heredity and environment were the major factors causing tuberculosis, Koch’s discovery represented a paradigm shift in understanding the causation of the disease and those present at the Scottish meeting believed that the government had the power under the Contagious Diseases (Animals) Acts to intervene and control bovine TB to prevent its transmission to people. However, it would take another 70 years or so before the risk of bovine TB spreading from infected cattle to people was finally solved.

In 2005, in response to a spate of emerging diseases at the turn of the 21st century, and in the tradition of William Hunting, Martin Alder and Graham Easton, editors of Vet Record and The BMJ, had the foresight to recognise the importance of drawing attention to the concept of One Medicine (in its transition to One Health), a tradition that has been continued in this celebratory edition by Adele Waters and Fiona Godlee current editors of Vet Record and The BMJ.

When I was invited by Vet Record in 2014 to review the short but rapid growth and evolution of One Health, spanning the decade from 2004 to 2014,2 I concluded by questioning whether One Health would prove to be a short-lived response to a spate of emerging diseases that apparently threatened to engulf the world, or a paradigm shift that would lead to a wider and deeper commitment to interdisciplinary action addressing the protection and needs of society in the 21st century.

I saw the continued success and effectiveness of One Health as dependent upon:

  • Sufficient cohesion within the interdisciplinary approach for One Health to be sustainable;

  • Evidence that investment of time and money in One Health provides ‘value for money’; and

  • Effective communication by the advocates of One Health such that society understands the concept, appreciates its importance and provides support.

What you need to know

  • One Health is defined as the integrative effort of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and the environment. Together, the three make up the One Health triad, and the health of each is inextricably connected to the others in the triad. One Health Commission www.onehealthcommission.org

  • One Health differs from One Medicine in addressing the health of the environment as well as human and animal health.

  • In 2004, concerns over the emergence of several zoonotic virus diseases of pandemic potential with wildlife reservoirs provided the genesis for One Health.

  • As One Health has evolved, its embrace has expanded beyond infectious disease to include all aspects of health.

  • One Health is prominent in several global commitments and political declarations, such as the Sustainable Development Goals of the United Nations.

  • The principles of One Health underpin the curricula of many veterinary schools providing a trained workforce to address the next phase of One Health within the nascent concept of Planetary Health.

In 2005 The BMJ and Vet Record collaborated, publishing joint issues recognising the importance of the strong links between human and animal health

Now, four years later, by revisiting these concerns can we have confidence that One Health has created a paradigm shift and was not simply a short-lived response to emerging diseases? I think that the answer is ‘yes’, but with caveats.

The progress of One Health since 2014

Cohesion

In 2014, there were lingering concerns that the medical profession had not enthusiastically embraced One Health. The control of the extensive and tragic epidemic of Ebola in West Africa in 2014, which involved individuals from many different scientific and medical disciplines, highlighted the importance of the One Health approach to tackling emerging disease threats. To the global medical profession, it was further evidence that One Health was important.

Attention Ebola: the Ebola epidemic in West Africa in 2014 highlighted the importance of adopting a One Health approach to tackle emerging disease threats

The support of The BMJ as expressed in this issue of Vet Record, and a recent statement by Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health in the USA, are further indications that the leadership of the medical profession now fully supports One Health.

Value for money

In my review in 2014, I emphasised that it was important that large scale projects, funded under the umbrella of a One Health promise, such as the control of zoonotic influenza, be closely evaluated so that the value-added approach of One Health (both economic and social) to the control and prevention of disease and environmental degradation could be validated. Others have also raised this concern.3 One Health rose to prominence through its application to the control and prevention of emerging diseases, so I considered that without evidence of a return on investment, One Health faced an uncertain future.

While no one would question the perceived merit and advantages of a One Health approach, it has to be acknowledged that it is difficult to prove the added value of One Health in monetary terms. For One Health activities sponsored by agencies (such as the World Health Organization [WHO], the Food and Agricultural Organization [FAO], the European Commission, USAID, Department for International Development [DIFID] and the Gates’ Foundation) to have a long-term impact, they require continued and substantial funding, but continued funding is dependent upon the paymasters within these organisations being convinced that investment in One Health represents ‘value for money’. Although the World Bank has expressed confidence in the value of One Health and recently provided an operational framework for One Health,4 even today there are few studies addressing the cost-to-benefit ratio of investments in One Health. Recognising the need, a Horizon 2020 project, coordinated through the UK’s Royal Veterinary College (RVC), was funded by the European Commission in 2014 to provide a structure to evaluate effectiveness and the efficient allocation of resources (http://neoh.onehealthglobal.net). The results of this study will be presented at a network meeting in Bologna, Italy, in September later this year.

But many One Health activities are small in scale, although no less important, and achieve their goals through enthusiasm, without any requirement for direct funding (for examples see www.onehealthcommission.org). One Health should be viewed as an ethos, not a discipline as proposed by Reeve-Johnson;5 thus all who practice medicine, and many who are in allied sciences, can, if they follow the primary tenet of ‘One Health’, namely the promotion of health through interdisciplinary collaboration, consider themselves ‘One Health practitioners’. Modern medicine is a web of inter- and sub-disciplinary collaboration. Within this web, the simple act of seeking advice beyond one’s own profession should be seen as constituting and promoting the ethos of One Health. Much of the promotion of One Health, particularly in the clinical setting, can occur without the exchange of money or the need for formal agreements, and therefore is free of the burden of bureaucracy associated with large-scale One Health projects. To foster collaboration in practice, education and policy, the UK One Health Coordination Group through Vet Futures is promoting One Health by linking organisations, such as the BVA, British Veterinary Nursing Association, NHS, British Medical Association, Royal College of Nursing, the National Trust and the Wildlife Trusts.6,7

Effective communication

The advocates and practitioners of One Health represent a community that communicates well. There are frequent conferences on a One Health theme; for example, the One Health Congress that has just concluded in Saskatoon, Canada (https://onehealthplatform.com/international-one-health-congress), numerous websites and blogs, and two journals dedicated to One Health.8,9

However, beyond the One Health community, the One Health message is not being heard so loudly. This year is the centenary of the pandemic of Spanish influenza which killed an estimated 50 million people at a time when the world’s population was less than two billion. One fifth of the world’s population was affected. At the turn of this century with the emergence of H5N1 highly pathogenic avian influenza and the knowledge that the virus could cause human infection and death, the spectre of a similar pandemic to that of the Spanish influenza loomed. One Health came to prominence as the underpinning philosophy for its control by the international agencies of the WHO and FAO.

Despite the coverage that the global press gives to influenza, the application of One Health to averting another pandemic similar to that of the Spanish influenza is not widely known to the general public. To my knowledge there are no surveys investigating the public awareness of One Health beyond those directly involved. Walk into a British pub and ask who has heard of One Health and you will be lucky to have anyone answer. Ask who has heard of climate change, even if few can identify concrete evidence of its effect, and you will get a chorus.

In 1888 concerns over the transmission of bovine tuberculosis to children drinking the milk from dairy cows were reported in the first issue of Vet Record

But there are some promising signs that One Health is getting more attention. Since 2016, we celebrate One Health Day in November. At a recent veterinary conference in Norway, I was pleased to watch a welcome video from the prime minister, Erna Solberg, in which she mentioned the importance of One Health. Granted the speech was probably written from notes supplied to her office by the conference organisers, but it is significant that a prime minister should feel comfortable speaking to the topic.

So what might be the explanation for this lack of awareness by the general public? There are numerous websites championing One Health, but rarely does one see the term mentioned or discussed in the general media. Perhaps the broad and often diffuse nature of One Health, where there are few available metrics (in contrast to the measurable rise in CO2 concentrations and temperature associated with climate change) make it difficult to engage the general public in the importance of the topic. While it is reassuring that decision makers are becoming aware of One Health, more effective communication beyond the One Health community is clearly necessary. One Health needs to be nurtured from above and below.

While I still have concerns, as expressed above, the growth and acceptance of the concept of One Health convince me that the era of One Medicine has given way to the era of One Health; a paradigm shift has indeed occurred.

One Health and the wider challenge of promoting a healthy planet

There are many definitions of One Health, each finely tuned to the mission of the group or institution, but, without exception, all mention the environment; it is this concern for the environment that differentiates One Health from One Medicine. However, until recently, there has been less attention to this third component of the triad (Fig 1).10

Fig 1

The One Health triad. Reprinted from International Journal of Parasitology vol 43, R.C. Andrew Thompson, Parasite zoonoses and wildlife: One health, spillover and human activity, p 1079–88, Copyright (2013), with permission from Elsevier

Understanding the role of the environment is crucial in the control of disease. Returning to the topic of TB, as reported in the first edition of Vet Record in 1888, it was the environment – the crowded housing of cattle in cities in Victorian Britain – that promoted the spread of bovine TB. Although the infectious agent remains the same, the control of TB in cattle in the UK in 2018 presents an entirely different challenge with the involvement of the badger and one, in contrast to the situation in 1888, that is no longer a public health issue, but an agricultural and wildlife issue with its attendant politics.

Yet, One Health advocates see the application of One Health far beyond simply understanding the environment as a prerequisite for the control of infectious disease; they see One Health as important to the health of the planet. There is now a strong groundswell for greater stewardship of the planet. Copies of Silent Spring are being dusted off and read again.11 The pollution of our seas with plastics, the loss of species diversity, the rise of antimicrobial resistance, the falling populations of migratory birds arriving in the UK each summer and the widespread use of insecticides, are just a few reasons why society is justifiably concerned.

While there are disparate causes and some problems that appear to be almost intractable to intervention, it is in the sphere of environmental stewardship that One Health should expand in the next decade. The veterinary profession introduced the concept of One Health, and it has the expertise to lead and promote interdisciplinary activities to address these issues. Worldwide, the principles of One Health already underpin the college education of veterinary students, providing a pipeline of trained individuals ready to take on the challenge.

In response to the concern over the environment, a number of similar terms have been coined to focus attention on environmental issues, most notably Ecohealth and Planetary Health. In 2012, Jakob Zinstagg12 summarised a discussion held at the fourth biennial EcoHealth conference on the convergence of Ecohealth and One Health. The report pointed out the shared values and approaches of the two concepts, and convergence in the areas of zoonoses, disease emergence and pandemic threats. Zinstagg argued that advocates of Ecohealth and One Health each have strengths to offer the other and by working together, greater impact may be achieved in global health and sustainability. In 2018, I think the convergence is complete and the two communities of Ecohealth and One Health are one when it comes to addressing environmental issues.

Plastic ocean: pollution of our seas with plastics has gained international media attention coverage in recent years, raising the profile of Planetary Health

The nascent concept of Planetary Health is an initiative supported by the Rockefeller Foundation, and is rooted in understanding the interdependencies of human and natural systems with the intent to create policy change that better balances human advancement with environmental and biodiversity sustainability (www.rockefellerfoundation.org/our-work/initiatives/planetary-health).

The concept of Planetary Health traces its roots to an editorial published in Science by Martin Rees,13 a former president of the UK’s Royal Society. The concept is being advanced by The Planetary Health Alliance which currently is a consortium of over 95 universities, non-governmental organisations, government entities, research institutes, and other partners around the world committed to advancing Planetary Health. In 2014, in support of the concept, The Economist issued a special report on Planetary Health and since 2017 The Lancet publishes a monthly Planetary Health journal. It is disappointing that there appears to be little mention of One Health in any of the literature supporting the initiative, so it remains uncertain how the proponents see the interface between One Health and Planetary Health. However, The Lancet Planetary Health does publish papers on One Health. Yet, I see One Health being wider in scope than Planetary Health as the latter does not have a focus on animal health.

As summarised by Essak,10 One Health is prominent in several global commitments and political declarations, such as the Sustainable Development Goals, the International Health Regulations, the Global Health Security Agenda, the UN Paris Agreement on Climate Change, and the UN Political Declaration on Antimicrobial Resistance and underpins the tripartite alliance of the WHO, the FAO, and the World Organisation for Animal Health (OIE). With such wide acceptance, I consider it unfortunate that the proponents of Planetary Health did not direct their drive to further development of One Health.

Listening to the blackbirds sing

My professional life has been spent working to control emerging diseases and, not surprisingly, I have always had an appreciation of the wider environment. Accepting the variability of weather, I have nevertheless assumed the natural environment to be constant. However, now the evidence is compelling that such complacency is misplaced. I have been writing this commentary from a cottage in mid-Wales to the pleasing daily accompaniment of blackbirds singing outside. But even here, in an area of the world dominated by sheep and one that appears to change very little from year-to-year, there are signs of planetary stress. The spring that supplies our water now fails in summer and while the blackbirds continue to sing, the populations of resident and migratory birds have distinctly fallen.

In the first decade of the One Health era, the concept provided the initiative, coordination, and drive to control and prevent disease in animals and people; now in the second decade, One Health needs to recognise the broader issue of Planetary Health and respond with leadership and expertise. Within that leadership, the veterinary profession can, and should, play an important role.

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Footnotes

  • Author’s note: The title is in acknowledgement of Lewis Thomas’s ‘Late Night Thoughts on Listening to Mahler’s Ninth Symphony’ Penguin Books, 1980

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