As the G20 gather and revisit global pandemics, Ayako Ebata asks why world leaders are not spending more time addressing the concerns of those whose lives are quietly devastated on a daily basis.
Sitting in a pig farmer’s house in the Yangon region of Myanmar, I heard a question I’d heard many times before from backyard farmers: “What will your project provide us with?”
It was my last month of a year in Myanmar, undertaking fieldwork for the social science component of the Myanmar Pig Partnership, a project looking at zoonotic diseases that cause gastrointestinal infections in pigs and people as well as antimicrobial resistance (AMR). I’ve been part of a team investigating the understandings and perceptions of diseases, the socioeconomic costs of pig diseases and the veterinary health care systems that farmers in the Yangon region rely on.
It is not surprising that the pig farmer helping us with our research wanted answers. Zoonoses – diseases that pass from animals to people – can hit pig farmers hard. As a non-medical expert, before taking part in this project zoonotic diseases for me meant the Ebola crisis in West Africa, SARS, avian influenza, and swine flu – dramatic and scary disease outbreaks. These zoonotic diseases draw our attention and encourage policymakers to react and respond with urgency.
Through taking part in this project, however, I have learned that there is much more to zoonotic diseases. The bacterial zoonotic pathogens we are investigating in Myanmar, Salmonella and Streptococcus suis, are endemic among many poor people. Gastrointestinal (stomach and intestine) infections from these pathogens are shown to damage the youngest members of our societies, for example inhibiting vital brain and nerve function development. While global mortality from diarrhoea has declined over the past years, approximately 2 million people remain affected, many of them aged under five.
The effects of such zoonoses are not just about people’s health but also about their livelihoods. Worldwide, two thirds of resource-poor rural households keep livestock. These animals can be a source of household income, nutrient-rich food and assistance in agricultural labour; they provide manure for crop production, a means of saving and a way to gain social status. When animals infected by zoonotic pathogens fall ill or die, it can threaten the future of poor, rural or marginalised people.
In addition, inappropriate treatment of these zoonotic pathogens in animals with antimicrobials and the use of these products to promote growth are leading to AMR. This makes it more difficult and costly to treat the infection both in animals and in people. The dimensions of the problem are not yet well understood in Myanmar, but experience in China, Vietnam and elsewhere suggests that it is the poor who will be hardest hit.
So why has there been such little attention paid to these zoonotic pathogens? Why is it that the world talks about health catastrophes and crises but not about these endemic pathogens that affect millions of people’s everyday lives?
One reason is that the burden of diseases is calculated in such a way that it fails to reflect under-documented, yet damaging and important, diseases. In particular, gastrointestinal infections are difficult to trace back to microorganism infection without laboratory-based diagnosis. As a result, many cases of, for instance, diarrhoea receive no microbiological scrutiny and therefore fail to show up in the statistics.
Another reason is policymakers are influenced by particular understandings of diseases that need to be prioritised. These are often motivated by issues of power and social justice. Too often, those who live with zoonotic diseases on a daily basis are not well represented in the policy-making environment. Consequently, policy actions fail to benefit those most affected.
Strengthening health systems
How can we help design effective interventions? One way forward is to strengthen health systems. This is essential – and must take a One Health perspective, recognising the many interconnections between human and animal health. Drawing on what we’re learning in the Yangon Region, these strengthened systems must include not only veterinary health care providers but also, for example, veterinary antimicrobial providers, the knowledge providers behind them, their qualifications and experiences, social relations and diagnostic capacity.
Strengthening health systems may not be as catchy as discovering vaccines. Yet it is more likely to reach the poor. In fact, a stronger veterinary health system is what many of our farmers interviewed in Myanmar asked for.
In Myanmar, pigs are known to become ill during the rainy season. We started our fieldwork in June 2016. In every village we visited, there were pigs falling ill or dying and you could see the desperation of those who were raising the animals.
“We want sustainable, long-lasting support from qualified veterinarians. Will you please help us achieve this?” many villagers asked.
Villagers and farmers told us about their concerns, ranging from economic loss from diseased animals to insecurity when applying antimicrobials without technical expertise. Quick access to high-quality veterinary care would make a difference to many of them.
The more time we spent in these communities, the more we realised that they have coping strategies even when access to qualified veterinarians is limited. But perhaps we can do better by shifting the focus from catastrophic and frightening zoonotic diseases to those that are endemic yet affect the lives of many poor people. In the end, that’s what those who are affected wish. Why don’t we start listening to what people at the frontline say?