Health security in Asia Pacific requires both national preparedness and a regionally coordinated approach; it is both a technical and a foreign policy issue. While increased regional connectivity provides opportunities for stronger collective action, it also presents new challenges in containing the spread of communicable diseases.
Over the past decade, there have been three major outbreaks of airborne mutated influenza that emerged in the AP region: SARS in 2003, H5N1 in 2004–05, and the current H7N9 emerging from China. Many experts believe that another mutation – perhaps of greater virulence – is inevitable over the coming years as humans and animals interact more as a result of urbanization and pockets of extreme poverty.
Multidrug-resistant tuberculosis (TB) is being closely monitored in Bangladesh, China, India, Indonesia, Myanmar, Pakistan, Papua New Guinea, the Philippines and Viet Nam. Drug-resistant malaria, now emerging in the Greeter Mekong sub-region, threatens to undermine a decade of progress globally, potentially costing billions.1A 2015 Swine Flu outbreak in India has infected 33,000 people, killing over 2000. Although the decade since SARS led people to forget the rapid spread of that deadly epidemic to 37 countries in a matter of months,2 Ebola has powerfully and tragically brought health security to public consciousness. It takes little imagination to foresee the devastating human and economic consequences that a pandemic on that scale might bring to Asia Pacific and its trading partners.
The region, and the world are underprepared. The World Health Organization has admitted to being “ill prepared” to handle the Ebola outbreak, and recently released a comprehensive list of shortcomings as well as suggested reforms they and global policy-makers must realize moving forward.
“We can mount a highly effective response to small and medium-sized outbreaks, but when faced with an emergency of this scale, our current systems — national and international — simply have not coped,”
WHO Director-General Margaret Chan (April 2015).3
While we cannot predict what the next Asia Pacific outbreak will be or where it will emerge, there are some basic truths that we must acknowledge:
We get the response we pay for. It is debatable whether, for example, per capita government spending of US$244 in India (US$69 total) or US$102 in Bangladesh (US$29 total) can ensure the health security of their populations, and consequently of their neighbours. This is particularly true where large numbers of people live in poverty and close proximity. Note Sierra Leone’s total health expenditure per capita at US$96did not support the systems required to contain ebola. The financial legacy of decades of low aspirations for public health will inevitably be reflected in the region’s ability to respond.
There will be orders of magnitude differences in the costs of prevention, versus that of outbreak control. The combined costs of mounting a pandemic response and the economic impacts of an outbreak at scale far outstrip the investment required to improve prevention and preparedness.
Ministries of Health and the World Health Organization are not the only agencies responsible for disease outbreaks. Hard financing realities clearly demonstrate that the central agencies of finance, planning, and national leaders themselves, must become directly involved; and the stakes are high enough to justify it.
The response requires political will at the highest level, and financing.
We should not be waiting until the Asian equivalent of Ebola is on our doorstep
Leaders should be confident they can detect diseases early, and that they have health systems that are robust enough to tackle them once they’ve been detected. At least as importantly, they should be confident their neighbours are prepared, and negotiating hard at head of government level if they lack this assurance.
Whilst many of us may have been reassured by the airport screening stations popping up around the region, huge populations living near porous borders do not have protection. They often have access to few services and little disease surveillance. This leads to intolerable risks for their own communities and seriously threatens the health and economic stability of the entire region.
There are however, models of regional cooperation that have the potential to drastically improve cooperation. Particularly so, amongst key central agencies like ministries of finance, planning and health. A solid example is the recent, historic commitment by the eighteen East Asia Summit leaders to an Asia Pacific free of malaria by 2030. This demonstrates the strength of political will in the region to work together in tackling communicable diseases head-on.
Investments in malaria provide strong benefits for regional health security
Malaria currently strains underfunded public health systems across much of the region, but investing to eliminate the disease can reinvigorate them. A decade of investment, largely from the Global Find to Fight AIDS, TB and Malaria, has already seen cases of malaria more than halved. Some nations, such as China and Sri Lanka, are already very close to eliminating the disease.
By investing to eliminate malaria, these nations have been left with a strong public health presence in every village, including surveillance systems that can pick up communicable disease before it spreads. Ongoing surveillance at borders helps prevent importation of malaria and other diseases, often among poor mobile populations. As the Sri Lanka example proves: The closer nations move to elimination, the stronger the benefits are for the whole health system.
Health surveillance becomes increasingly critical when people frequently move across borders. With rapid economic development and regional economic cooperation expanding, migration is set to increase. Health security relies on the rapid detection and containment of emerging health threats, but also on the critical provision of affordable treatment – without discrimination – to people on the move.
Cross border cooperation around malaria and other health threats are the same. Malaria elimination efforts help build and stress-test health security systems.
To reach and sustain malaria elimination, health systems need to build strong surveillance, laboratory and response systems for malaria outbreaks. strengthening these systems also builds the capacities required for tracking other infectious disease outbreaks and health security threats, such as dengue and epidemic influenza.
Over time; reducing the need to respond to malaria cases and outbreaks frees disease surveillance, response and clinical staff/facilities to be able to deal with other infectious diseases and epidemics. It is an investment with short-term gains and a long-term legacy.
Elimination of drug-resistant malaria will require systems that address the drivers of drug resistance – not only for malaria treatment, but other antimicrobial agents, which presents a serious health security threat. APLMA’s work on malaria elimination has, for example, already brought together drug regulators from the region to discuss stronger cooperation on pharmaceutical regulation.
Improving health security is not only about detecting and managing diseases
As outlined in Global Health Security Agenda (GHSA)5, the nature of health security threats are such that being prepared and acting decisively, in union, are critical to success. East Asia Summit leaders have already taken such a concrete step in the historic 18-country commitment to eliminate malaria from the region by 2030.
Reaching the regional malaria elimination goal will require an urgent and coordinated regional response, predictable financing, and maintaining an adequate health workforce that is skilled and motivated to practice good programme management, good medicine and good surveillance.
Just as investment in malaria elimination has knock-on effects to preparedness for other health security threats, underinvestment in public health kills people and derails economies.6
Like other health security threats, regional malaria elimination requires a ‘whole-of-society’ approach. Informed citizens and empowered communities are among the most effective frontlines of preparedness and response. It also requires a ‘whole-of-government’ approach; leadership from the highest level, financing to see the task through, as well as close cooperation between nations to secure borders.
In following through on their malaria elimination commitment, EAS countries will be investing in stronger health security for Asia Pacific, and for the world.
Dr Benjamin Rolfe
Executive Secretary, APLMA Secretariat
 Lubell Y et al. Artemisinin resistance – modelling the potential human and economic costs. Malaria Journal, 2014; 13:452 (http://www.malariajournal.com/content/13/1/452).
 2013 $ Constant http://apps.who.int/nha/database/Country_Profile/Index/en
This post coincides with a regional meeting in Bangkok (6–8 May) aimed at accelerating collaboration among countries in Asia-Pacific Region to achieve Global Health Security Agenda (GHSA) goals.
The meeting focuses on workforce development, national laboratory system strengthening and antimicrobial resistance prevention. It is hosted by the Thailand Government in collaboration with the United States Centers for Disease Control and Prevention (US CDC), United States Agency for International Development (USAID), the World Health Organization (WHO) and the UN Food and Agriculture Organization (FAO). The views represented here are solely those of the author