Emmelie, Susanne, and Stephen

Evaluating the capacity of multi-scale institutions

to cope with ‘sleeping sickness’ disease spread

Adaptive governanceStockholm Resilience Centre

March 8, 2012

Sleeping sickness - Background• Human African Trypanosomiasis (HAT) occurs in 36 sub-Saharan Africa

countries

• Dependent upon Tsetse fly (Glossina spp) vectors.

• Highest exposure in rural populations dependent on agriculture, fishing, animal husbandry or hunting. Cattle is the key mode of human-animal transmission.

• Occurs in two forms, a cronic form of that accounts for 95% of reported cases of sleeping sickness, and an acute form. Each form has different vectors with different modes of transmission.

• After continued control efforts, the number of cases reported in 2009 has dropped below 10 000 for first time in 50 years. This trend has been maintained in 2010 with 7139 new cases reported.

Source: WHO

Most neglected diseases

Source: Yamey 2002

Social-Ecological Linkages I

• Understanding mechanisms which produce pattern we observe (spread + periodic epidemics)

• Spread is a function of increased transmission rates– Where is the number of Tsetse bites to humans maximised?– Where is the pathogen load in Tsetse flies highest?

• Inherently low transmission rate between reservoirs (livestock, wildlife) and humans. - Transmission rate highest in low-population density areas

(riverine habitat perfect for Tsetse vector)- Dramatic improvements to transmission rates can be achieved

with small management interventions

Social-Ecological Linkages II• As in most diseases, there is a non-linearity associated with the

system which produces jumps from low-level endemism to periodic epidemics.

• Upheaval - Ecological or Social disruptions can bring about increased transmissions – pushing the system above a critical threshold which causes an epidemic.– Social upheaval often causes land-use change (e.g. discontinuation of livestock

grazing creates new vegetation increase habitat for Tsetse) and social movements.

– Good example – After Civil War in Uganda, dramatic increase in outbreak of HAT

Time trends of HAT

Democratic Republic of Congo

Angola

Systems approach

• Link upheaval events to factors affecting transmission –these are one component of specific social-ecological interactions and feedbacks.

• Factors which affect disease spread cut across many areas

• Combating diseases necessitates cross-sectoral cooperation

Source: Berrang-Ford et al. 2005

Spatial and temporal scales

Source: Berrang-Ford et al. 2005

Actors

• WHO

• Pharmaceutical companies

• NGOs

• Research communities

• Endemic countries

• Livestock owners

Level Actor Role

Global WHO Directing and coordinating global health issues. Objective to eliminate HAT as public health problem. Runs a control and surveillance programme of HAT with cross-scale collaborations.

International Aventis, Bayer HealthCare In public-private parthership with WHO aiming to distribute new and less toxic drugs for HAT.

WHO collaboration centers Involved in HAT research projects.

NGO’s Activities mostly in connection to HAT epidemics.

Donor organizations Providing financial support

National National governments Providing security and national health care. Coordination of WHO control and monitoring programmes.

NGO’s Activities mostly in connection to HAT epidemics

Local/Regional Local authorities Health providing services

NGO’s Intervention in prevention and control

Local population, livestock and land owners

Impacting the conditions for disease transmission

Institutions

International Norms on drug development

Pricing policies and other international policies

Constitutions

Rules regulating:

-Pharmaceutical market

-Drug affordability

-Public-private partnershipsNational Social norms on land-use

National policies

Rules regulating:

-Pharmaceutical distribution systems

-Land-use changes

-National health care

-Public-private partnerships Local Social norms on land-use

Knowledge and health seeking behaviour of consumersRules regulating:

-Land-use changes

-Drug affordability

-Access to drugs and vaccines

Institutions

Anatomy of Misfits (Galaz et.al. 2008)

• Question 1 – At what scales does the disease (and factors affecting transmission) operate?

• Question 2 – At what scales do the institutions operate?

• Look at four key factors: Land-use Change, Conflict, Drug availability, & Climate Change

• Look for spatial, temporal, and cascade misfits.

Land-Use Change• Land-use change occurs at different scales – the

most relevant (and the clearest patterns observed) are the national and regional scale.

• Factors that affect land-use change (market demand, climate change, crop-raiding) act across national boundaries.

• Institutional capacity to constrain land-use change acts on national scale and downwards

• There exists a spatial misfit. Governments have little power to affect these international, external, drivers.

Conflict

• Conflict occurs at regional (Uganda) or national scale (Congo)

- Also has trans-boundary effects (refugees).• Institutions (conventions) exist an international scale.

- International lack of willingness to enforce those rules. Not a problem with misfits per se.

• However, institutions and enforcement capacity often react very late to prevent conflict (e.g. Kosovo).

• There exists a temporal misfit. A delay in response time that stems from structural rules of the UN (veto).

Drug Availability

• Key issue: Lack of market demand for neglected disease medicines.

• Norms at the international scale govern drug development – ‘only private sector can make drugs’.

• Affected nations’ ability to access medicines undermined by the combination of these two issues.

• Is this a spatial misfit?

Climate change• Familiar concept. International institutions not

capable of preventing free-riding on the level of the nation state. Spatial misfit

• Temporal misfit. International institutions not adapting sufficiently fast to react to risk of catastrophic climate change.

• Cascade misfits. Climate change affects social-ecological interactions on multiple scales, through cascading effects (e.g. droughts affecting food supply that affects nutrition and lack of disease resistance).

Number of new reported cases T.b. gambiense 2011

Source: WHO 2011

International regimes

• Is the problem an issue of norms?– Dominating norm is that the private sector is in

the best position to develop drugs.– But for the diseases with low profitability, this is a

governance failure.• Rise in public private partnerships & public-

sector led drug development– Changing norms peoples’ mental models

accepting new forms of drug development governance.

ConclusionNot addressed:•Political-institutional dimension not addressed•Social networks or bridging organizations

However:•Through the misfit analysis and international regimes and institutions we get an understanding the benefits of hybrid transnational governance networks and institutions•Useful for a systemic approach towards neglected diseases

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