Zoonotic Emerging Infectious Diseasein Selected Countries in Southeast Asia:Insights from Ecohealth

1 23EcoHealth Conservation Medicine: Human Health:Ecosystem Sustainability Official journal of International Association for Ecology and Health ISSN 1612-9202 Volume 8 Number 1 EcoHealth

1 23

EcoHealth

Conservation Medicine: Human

Health:Ecosystem Sustainability Official

journal of International Association for

Ecology and Health

ISSN 1612-9202

Volume 8

Number 1

EcoHealth (2011) 8:55-62

DOI 10.1007/s10393-010-0357-3

Zoonotic Emerging Infectious Disease

in Selected Countries in Southeast Asia: Insights from Ecohealth

Delia Grace, Jeffrey Gilbert, M. Lucila Lapar, Fred Unger, Sonia Fèvre, Hung Nguyen-Viet & Esther Schelling

1 23

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Zoonotic Emerging Infectious Disease in Selected Countries

in Southeast Asia: Insights from Ecohealth

Delia Grace,1Jeffrey Gilbert,1M Lucila Lapar,1Fred Unger,1Sonia Fe`vre,2Hung Nguyen-Viet,3,4,5

and Esther Schelling3

1 International Livestock Research Institute (ILRI), 30709, Nairobi, Kenya

2 Veterinarians Without Borders/Ve´te´rinaires Aans Frontie`res—Canada, Singapore, Singapore

3 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland

4 Department of Water and Sanitation in Developing Countries, Eawag/Sandec (Swiss Federal Institute of Aquatic Science and Technology), Du¨bendorf, Switzerland

5 Department of Environmental Health, Hanoi School of Public Health, Hanoi, Vietnam

Abstract: Most emerging diseases of humans originate in animals, and zoonotic emerging infectious diseases

(EIDs) threaten human, animal, and environment health We report on a scoping study to assess actors,

linkages, priorities, and needs related to management of these diseases from the perspective of key stakeholders

in three countries in Southeast Asia A comprehensive interview guide was developed and in-depth interviews

completed with 21 key stakeholders in Vietnam, Lao People’s Democratic Republic, and Cambodia We found

numerous relevant actors with a predominance of public sector and medical disciplines More capacity

weaknesses than strengths were reported, with risk analysis and research skills most lacking Social network

analysis of information flows showed policy-makers were regarded as mainly information recipients, research

institutes as more information providers, and universities as both Veterinary and livestock disciplines emerged

as an important ‘‘boundary-spanning’’ organization with linkages to both human health and rural

develop-ment Avian influenza was regarded as the most important zoonotic EID, perhaps reflecting the priority-setting

influence of actors outside the region Stakeholders reported a high awareness of the ecological and

socio-economic drivers of disease emergence and a demand for disease prioritization, epidemiological skills, and

economic and qualitative studies Evaluated from an ecohealth perspective, human health is weakly integrated

with socioeconomics, linkages to policy are stronger than to communities, participation occurs mainly at lower

levels, and equity considerations are not fully considered However, stakeholders have awareness of ecological

and social determinants of health, and a basis exists on which transdisciplinarity, equity, and participation can

be strengthened

Keywords: Emerging infectious diseases, zoonotic EIDs, Southeast Asia

INTRODUCTION Emerging infectious diseases (EIDs) have been defined as diseases of infectious origin whose incidence has increased

Published online: December 21, 2010

EcoHealth 8, 55–62, 2011

DOI: 10.1007/s10393-010-0357-3

Original Contribution

Ó 2010 International Association for Ecology and Health

Author's personal copy

within the past two decades, or threatens to increase in the

near future (Institute of Medicine (IOM),1992) There are

around 150–300 human emerging infectious diseases, and

most (60–75%) of these are zoonotic, that is, transmissible

between animals and humans (Taylor et al., 2001; Jones

et al., 2008)

Zoonotic EIDs are feared because of their potential to

shift from an animal-to-human to a human-to-human

transmission route with deadly results, as exemplified by

the Spanish flu pandemic of 1918 and the current human

immunodeficiency virus (HIV) pandemic Indeed, some of

the most important infectious human diseases originated in

animals, but are now no longer zoonotic (e.g., small pox,

measles, and whooping cough) (Wolfe et al., 2007) Other

zoonotic EIDs are problematic because they are maintained

in livestock or wild animal reservoirs Risk to humans

in-creases when behavior change allows levels of pathogens to

soar in their animal hosts (e.g., intensive farming leading to

higher levels of food-borne pathogens), or allows more

contacts with humans and infected animals (e.g.,

recrea-tional activity exposing to Lyme disease) Yet other

zoo-notic EIDs are controlled in wealthy countries, but

emerging elsewhere because of poverty or neglect Rabies

and brucellosis are examples of diseases well under control

in rich countries, but widespread in poor countries

The natural history and epidemiology of zoonotic EIDs

has implications for their management By definition,

zoonotic EIDs occur at the interface of animal and human

health: as such, a ‘‘One Health’’ approach will facilitate

surveillance and control (Zinsstag et al., 2007) Moreover,

zoonotic EID emergence is driven by disturbance of the

host (be it human, animal, or insect), pathogen, and

environment equilibrium, with the implication that

soci-ology, farming systems, and ecology can all contribute to

better understanding of the genesis and, ultimately,

detec-tion and prevendetec-tion of zoonotic EIDs As for other

infec-tious diseases, vulnerability to zoonotic EIDs is strongly

influenced by poverty, inequality, and disempowerment

Addressing these socioeconomic and political aspects is a

prerequisite for lasting health improvements

Ecohealth can be defined as systemic, participatory

approaches to understanding and promoting health and

well-being in the context of social and ecological

interac-tions (Waltner-Toews, 2009) Ecohealth approaches, by

linking health, environmental, and social processes, offer a

framework and tools for understanding and managing

zoonotic EID emergence and propagation While ecohealth

encompasses disparate schools of thought, the framework

developed by Lebel (2003) and promoted by the Interna-tional Development Research Centre (IDRC) (http://www idrc.org) is well adapted to the problem of zoonotic disease

in poor communities At its core lie three values: trans-disciplinary research and action involving not only differ-ent disciplines, but policy-makers and communities; participation of communities and decision-makers in research design, implementation, and evaluation; and, equity—specifically gender equity and social and economic fairness

Southeast Asia is considered a crucible for zoonotic EID emergence, as witnessed, for example, by its selection

as one of five global ‘‘hotspots’’ in the United States Agency for International Development (USAID)-funded project on Emerging Pandemic Threats commencing in 2009 Rapid economic and population growth creates conditions and drivers for disease emergence (especially uncontrolled urbanization, livestock intensification with limited biose-curity, environmental degradation, and encroachment on wildlife habitats)

This article reports on a scoping study undertaken by a project aimed at improving the management of zoonotic EIDs in Southeast Asia within an ecohealth framework The objective of the study was to assess the priorities and understanding of zoonotic EIDs, and their surveillance and control from the perspective of relevant stakeholders in three countries of the Mekong region, namely, Cambodia, the Lao People’s Democratic Republic (Lao PDR), and Vietnam Putting people at the heart of research, the first aim was to identify the individuals and institutions relevant

to an ecohealth approach to zoonotic EID management, and their current work related to zoonotic EIDs, as well as their perceived capacity strengths and weaknesses Using information flow charts, we mapped linkages between ac-tors both to better understand existing multidisciplinarity and to help in the future building of coalitions for inno-vations Shifting to a disease perspective, the study assessed zoonotic EID priorities and trends, and lastly identified research gaps from the perspective of stakeholders The study was analyzed by a multidisciplinary team using an ecohealth perspective

MATERIALS AND METHODS The study was carried out in three countries between October

2008 and July 2009 This involved an intensive preparation phase consisting of literature review, dialogue with experts, and finally a workshop in which key informants critically

56 Delia Grace et al

reviewed the draft interview guide (Anonymous,2008) The

interview guide was pretested in the Mekong region and

minor changes made The final guide contained open and

closed questions, and had three main sections: stakeholder

mapping, analysis, and identification of boundary partners;

assessment and understanding of priority zoonotic EIDs; and

existing capacities and capacity needs assessment We

con-sidered the stakeholders of zoonotic EIDs to be those

orga-nizations, groups, networks, or individuals with an

important role in decision-making, research, training, and

education or communication about zoonotic EIDs, as well as

those likely to suffer the consequences of zoonotic EIDs

A list of potentials interviewees drawn from research,

governmental, and private sector institutes was established

for each country through expert consultation Attention was

given to a mix between research and service, and between

the three main sectors of livestock/agriculture, health, and

environment Institutes were contacted with an invitation

letter and invited to nominate an interviewee The assigned

person received the interview catalogue electronically, and

was asked to read the interview guide beforehand and to

prepare for the interview, if necessary, with the assistance of

their colleagues at the institute Interviewers (one male, one

female) were drawn from different disciplines, and had

postgraduate qualifications and several years of experience

in the region During the interview, the objective of the

study was presented and ambiguities clarified The

inter-viewee was asked to complete the form before sending an

electronic copy to the interviewer In addition, interviewees

were asked to send copies, if available, of zoonotic

EID-related reports or documents they considered relevant, and

a curriculum vitae was collected from each interviewee A

small honorarium of $100 was provided, half at the end of

the interview and half on receiving the completed forms

Quantitative data were entered into AccessÒ and

qualitative into ExcelÒ We used Intercooled STATA 10 for

Windows (StataÒ Corporation, College Station, TX) for

analyses of quantitative data and NetDraw 2.081 (Analytic

TechnologiesÒ, Cambridge, MA) to visualize and analyze

the information flows between actors

RESULTS AND DISCUSSION

Actors

A total of 21 interviews were completed (2 in Lao PDR, 5 in

Cambodia, and 14 in Vietnam) This reflected the greater

number of actors in Vietnam, but also that fieldwork

started first in Vietnam and so more time was available Interviewees were from the health sector (n = 7 from human health and n = 4 from animal health), rural development (n = 4), sociology and economics (n = 4), policy (n = 1), and ecology (n = 1) There were four women and 17 men among the respondents, and the response rate was just under 50% For a survey targeting key decision-makers with busy schedules, this was quite a high level of response; for com-parison, physician surveys in the USA typically have response rates of 40–50% (Burt and Woodwell,2005)

Given the absence of a definitive sampling frame of stakeholders of zoonotic EIDs in the three countries, there

is inevitable concern over identification and response bias Stakeholders were identified by expert consultation; we found that this soon resulted in circular recommendations, indicating a small number of relevant actors (or, less plausibly, the existence of unknown actors not linked to easily identifiable actors) It should be borne in mind that there are many nonnational actors working on zoonoses issues, but we deliberately focused on national actors Our impression was that response rate was related to self-per-ceived knowledge and confidence For example, some se-nior staff from a university agricultural faculty were nonrespondents, because they felt that they did not have expertise in diseases So, although we might consider them

as stakeholders, they did not consider themselves as such

As a result, expert, well-informed, and self-identified zoo-notic EID actors are likely to be overrepresented; we feel this is not likely to invalidate results

The interviewees identified 95 key national and/or international zoonotic EID actors as stakeholders during the interviews, of which 37 were cited more than once The public-funded sector dominated (87% of actors), nongov-ernmental organizations (NGOs) were scarce (11% of actors), and the private sector was negligible (2% of actors) Private sector participation has been a longstanding preoc-cupation for disease-control decision-makers; our study shows how large the gap still is between aspiration and reality

We further subdivided the public sector into research institutes, policy-making and implementing bodies (departments in a government ministry), and universities

A related category is international organizations (such as World Health Organization) and nonnational organiza-tions (such as Western universities) which are generally public or quasi-public Outside the public sector were nongovernment organizations (research and/or develop-ment NGOs) and the private sector Figure1 shows the proportion of actors according to these categories

ZEIDs in SE Asia: Insights from Ecohealth 57

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Although most interviewees were drawn from the

veterinary, agriculture, and rural development sector, a

high proportion of stakeholders considered key were drawn

from the medical disciplines (41%), which may reflect the

preconception that human health is the preserve of the

medical discipline Animal health (18%) and rural

devel-opment (17%) were also well represented among

stake-holders considered key, but sociology, economics, policy,

and ecology individually accounted for less than 5% of key

stakeholders A fundamental premise of ecohealth is that

human health is influenced by four interacting subsystems:

ecological, sociological, political, and economic, and the

integration of these epistemologies is needed to ensure

relevance and impact of health research (Lebel, 2003)

While it is positive to note that stakeholders from these

disciplines were listed, they were not well represented For

example, no actors from the disciplines of ecology,

soci-ology, policy, or economics were listed for Lao PDR, and in

Cambodia only one stakeholder from the four supporting

disciplines (ecology) was identified It seems there is an

opportunity for greater integration of supporting

disci-plines into the control of zoonotic EIDs Networking is

another aspect of multidisciplinarity; stakeholders were

aware of 12 networks relevant to zoonotic EIDs, with

highest recognition of the Association of Southeast Asian

Nations (ASEAN) networks, followed by the Asian

Part-nership for Emerging Infectious Diseases Research (APEIR)

and the Mekong Basin Disease Surveillance (MBDS)

In-terviewees perceived these regional networks as efficient

platforms for exchange of information and lessons

Transdisciplinarity has been defined in different ways,

but in the IDRC ecohealth framework used in this study, it

implies not only a transcendence of disciplines, but also the

participation of scientists, communities, and policy-makers

in research (Lebel, 2004) We found that while policy-makers were well represented in the constellation of zoo-notic EID actors identified by interviewees, communities were less often cited, being mentioned by only two inter-viewees

Confused and overlapping mandates have long been identified as an impediment to disease control Our study found that a promising development was the establishment,

in many countries, of a specific intersectoral body for coordination and management of communicable diseases For example, in Lao PDR, a coordination office for influ-enza has developed into the National Emerging Infectious Diseases Coordinating Office (NEIDCO), with a mandate covering all emerging infectious diseases This seems to be

an externality of the avian influenza pandemic which has led to a strengthening realization that different disciplines need to work together to effectively tackle zoonoses However, this coordination body remains dependent on external funding and not integral to long-term restructur-ing, calling into question long-term sustainability

Stakeholders were also asked to self-evaluate their capacity in seven areas which had been identified as key to better managing zoonotic EIDs during the lengthy design phase of the study These were: zoonotic EIDs and eco-health, systems thinking and models, risk analysis, socio-economic analysis, institutional analysis, networking, and research skills Interviewees reported many strengths, but in all areas they listed more perceived areas of weakness than strength Perceived shortfalls (where the difference between strengths and weaknesses was greatest) were highest in the areas of risk analysis and research skills (Table1) Although the respondents reported strengths in many components of

Figure 1 Stakeholders involved in zoonotic emerging infectious disease research and man-agement, in three countries in the Mekong region, according to sector

58 Delia Grace et al

ecohealth, overall there was a lack of understanding as to

what an ecohealth approach actually entails

In the open section, interviewees were given the

opportunity to share their views on other strengths and

weaknesses Lack of human resources, financial resources,

knowledge, data, and training, were frequently listed as

challenges, as was a dependency on external funding (and,

as a result, a tendency for priorities to be driven by

inter-national actors) Despite cooperation between sectors

(especially medicine and veterinary/livestock) being

re-ported as a strength, integration of all disciplines (e.g., for

socioeconomic analysis) was repeatedly listed among the

weaknesses Lack of epidemiology capacity was also listed

frequently as a weakness of their own institute or key

partner institutions As a special strength, the willingness of

young dynamic people to learn new methods and

ap-proaches was highlighted Another strength identified was

the established cooperation between sectors and available

funding for some specific approaches

Activities

The majority of interviewees reported involvement in

zoonotic EID research (either as researchers or promoters

of research) There was also a high involvement in

aware-ness-raising, although this tended to follow top-down

models of information transfer, as shown by references to

‘‘awareness campaigns’’ and communication strategies

based more on telling communities what to do, than on

learning from them This perhaps reflects the above-noted

lack of integration of sociology and economics into health

extension activities From an ecohealth perspective, it was

encouraging to observe good links to policy-makers: more than half of interviewees reported being involved in policy and/or advocacy activities, such as influencing policy or organizing exchange visits for policy-makers Of course, this also reflects the preponderance of public sector actors among the stakeholders Only a few interviewees reported involvement in fund-raising, which is a challenge for stakeholders in being able to set their own priorities and develop long-term research programs

Linkages

Social network analysis was used to map information flows across different types of actors engaged in zoonotic EIDs in various capacities In general, policy-making and imple-menting bodies were seen to be recipients of information more than providers of information Their sources of information were other departments within the same or other ministries, research institutes, NGOs, and commu-nities; only in the case of one ministry, in Vietnam, was industry seen as a source of information One thing to note

is the general lack of, or limited, feedback loops between the policy-making body and the source of information, particularly where sources are the communities or farmers;

an ecohealth approach can potentially contribute to enhancing the effectiveness of this linkage

Research institutes, on the other hand, were more likely to be providers of information on zoonotic EIDs, and their main recipients were the government ministries that are usually the main source of their budgetary resources It was also noted that, in most cases, the information flow is only one-way, that is, the research institute provides the information but does not receive feedback (or information)

in return from a specific actor However, bi-directorial information flows between research institutes and com-munities were present in some cases Our study suggests that research institutes may need to expand their sources and outlets of information, to widen the scope of the influence and potential impact of their research findings, and, as a corollary, to widen their source of funding Most universities perceived the majority of informa-tion flows to be bi-direcinforma-tional This may reflect the nature

of the relationship between the universities and the pro-viders of their budgetary resources for research, from whom they receive and to whom they are required to provide information from their research activities, mostly

to inform policy-making bodies Some, but by no means all, research units in universities also have links with

Table 1 Self-reported capacity strengths and weaknesses in a

survey of stakeholders involved in zoonotic emerging infectious

disease research and management in three countries in the

Me-kong region

Capacity area Report area

is a strength (%)

Report area is

a weakness (%)

Systems thinking

and models

ZEIDs in SE Asia: Insights from Ecohealth 59

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communities, the private sector, and/or industry Typically,

those who have better links with private sector actors are

those who receive more funding from international donors

NGOs generally engaged in research for development

were, on balance, providers more than recipients of

infor-mation NGOs engaged in purely development activities

were equally providers and recipients There appears to be a

lack of, or limited, feedback loop from communities and/or

farmers that receive information from NGOs; this could

possibly be an area where the ecohealth approach can

contribute to strengthening this linkage

A noteworthy finding was that actors from the

live-stock sector were better connected, both across other

dis-ciplines and to communities and the private sector, than

were their counterparts in the health sector Figure2shows

two comparable institutes located in the health and

agri-culture ministries, respectively, of the same country, which

well illustrates this Innovation systems thinking has

introduced the concept of ‘‘boundary organizations’’ or

‘‘boundary-spanning actions’’ which help bridge gaps

be-tween research and user communities (Kristjanson et al.,

2009) Veterinarians and livestock specialists have medical

training, and zoonoses are usually more important in the

veterinary curriculum than the medical (Schelling et al.,

2005) However, in developing and transition countries of

Southeast Asia, most veterinarians and livestock specialists

work with animal industries or rural development This

means that the livestock disciplines are well positioned as

boundary-spanners, which can help translate between

medical, community development, and industry

stake-holders

Priorities

Interviewees were asked which zoonotic EID they

consid-ered the most important For a majority of respondents

(66%), the number one ranked disease was avian influenza

Avian influenza has had significant effects on the poultry industry, but is mainly of concern because of the risk that it might mutate to a strain capable of causing a human pandemic (as indeed was the case for the H1N1 influenza pandemic announced in 2009, which originated in pigs) However, in terms of actual disease burden on humans, the impact of avian influenza is almost negligible: Its morbidity and mortality is several orders of magnitude lower than the number two and three priority (rabies and leptospirosis, respectively) on the stakeholders list (the impact of which

is, in turn, at least an order of magnitude lower than high disease-burden zoonoses, such as toxigenic Escherichia coli) Overall, prioritization did not well reflect disease burden caused by zoonoses Of all the zoonoses mentioned by name, only one appears on the list of Globally Important Human Pathogens (a list of the 65 pathogens, including 29 zoonoses, responsible for most mortality) (Ecker et al.,

2005) It would be interesting to explore to what extent the high priority of avian influenza among donor countries and, hence, availability of funding for this disease, together with media attention and concern among the general public, are responsible for its rank as the number one zoonotic priority in the countries studied

Moving from specific diseases to categories of diseases,

we found that vector-borne disease and food-borne disease were considered most important and also to be increasing

in incidence (Table2) Although most emerging diseases are zoonoses and the majority of these have their origin in wildlife (Jones et al.,2008), the category wildlife-associated zoonoses was considered least important, and this despite the fact that stakeholders considered control was weakest and ability to detect least Interestingly, priorities vary with sector: The health sector puts more emphasis on vector-borne and soil-vector-borne diseases, whereas zoonoses trans-mitted by close contact are rated higher by the veterinary and rural development stakeholders This probably reflects disciplinary perspectives: Dengue is an important disease in

Figure 2 Social network analysis showing perceived information flows of a medical (left) and veterinary (right) institute in the Mekong region

60 Delia Grace et al

the region, but most transmission is human-to-human

(with a minor sylvatic cycle involving monkeys), and so

veterinarians may not consider that it falls within their

jurisdiction On the other hand, zoonoses transmitted by

close contact with animals include the classical zoonoses

(e.g., tuberculosis, brucellosis, and anthrax), which are a

major focus of veterinary public health

Ecohealth thinking emphasizes the interconnectedness

and interdependence of human, animal, and environmental

health The interviewees in this study demonstrated their

understanding of this in listing the drivers of emerging

disease These included: climate change, deforestation,

encroachment into wildlife habitats, urbanization of rats,

bats, and other animals, and abuse of pesticides leading to

resistance Among the socioeconomic drivers noted by

respondents were: explosion of populations, globalization,

urbanization, changing food consumption habits,

persis-tence of ‘‘wet markets’’ (open air food markets where live

animals are sold), and food chains becoming longer, but

with low hygiene standards Some positive trends which

can act to reduce disease emergence include increased

awareness, better inspection, and greater uptake of

vacci-nations

Gaps

Interviewees identified 41 key research gaps The most

frequently cited were those relating to disease

prioritiza-tion, burden, and risk—all issues which can obviously

benefit from economic insights Epidemiology skills was the

second most cited gap Epidemiology, with its focus on

disease in populations, study design, surveys, and data

analysis, has much to contribute to health research but

remains a minority discipline in most developing countries The next most important research gap was qualitative and economic methods Interestingly, the highest ranked tech-nical gap (molecular epidemiology) came only in fourth place

From an ecohealth perspective, an obvious area for improvement in the study population is understanding of ecology, ecosystem health, and wildlife disease In two of the three countries, no stakeholders from the discipline of ecology were mentioned, and in none of the countries was a surveillance system for wildlife reported, although wildlife are the most important source of new disease emergence The Canary database, a compilation of evidence on animals

as sentinels of human health hazards, offers numerous examples of how useful wildlife studies can be in surveil-lance and early warning (http://canarydatabase.org) Equity is considered a fundamental pillar of ecohealth

In our survey, several interviewees mentioned remote, marginalized, and poor communities as having been ne-glected or needing special attention, because they are most impacted by zoonotic EIDs However, although gender has been shown to be an important factor in both risk, sus-ceptibility, and access to health care (Grace et al., 2008), none of the interviewees made reference to this

Although respondents reported that linkages with communities existed, it appears these were mainly at lower levels of participation (Pretty, 1995), that is, researchers saw their role in ‘‘extracting information from,’’ ‘‘inform-ing,’’ ‘‘train‘‘inform-ing,’’ and educating communities, rather than learning with and from them Without high levels of dia-logue and interaction with the end-users of research, it is likely that the outputs will neither be useful nor used In the ecohealth framework, the principle of participation

Table 2 perceived importance, ability to detect, response, research efforts, and trend (mean and medians) of categories of zoonotic emerging infectious disease by stakeholders in three countries in the mekong regiona

Category Importance Ability to detect Response/Control Research efforts Trend

2 medium; 2 some cases; 2 medium; 2 medium; 2 static;

Zoonoses transmitted by close contact 2.2 (2) 2.0 (2) 1.9 (2) 1.4 (1) 2.1 (2)

a Medians in parentheses.

ZEIDs in SE Asia: Insights from Ecohealth 61

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recognizes the importance of including communities and

policy-makers in the research process

CONCLUSIONS

It is not easy to obtain information from zoonotic EID

stakeholders in Southeast Asia With recent and ongoing

crises, the few key people are much in demand and have

little time for lengthy interviews Moreover, there may

be reluctance to provide nontechnical information that

reflects beliefs, opinions, and priorities The study was

successful in using a participative and intensive process to

obtain insights into the thinking of key stakeholders for

zoonotic EIDs in three countries in Southeast Asia

While it is encouraging to note that stakeholders from

disciplines outside the medical community were identified

in the countries involved in the study, it was also clear that

these are few in number and weakly linked to the human

health community Ecohealth approaches offer an

oppor-tunity to break out of the disciplinary silos that are often

observed in the research and development communities,

thereby potentially increasing the effectiveness and impact

of research into zoonotic EIDs There may also be an

opportunity for the veterinary and livestock disciplines to

act in a ‘‘boundary-spanning’’ role that can help integrate

human health, agricultural development, ecological, and

socioeconomic disciplines Our study shows concern over

zoonotic EIDs, awareness of socioeconomic and ecological

determinants of health, an articulated need for better skills

and capacity building (with an emphasis on epidemiology

and social sciences, rather than technical training), and

linkages between researchers, policy-makers, and

commu-nities This suggests that the conditions are in place for

ecohealth approaches to be well accepted and deliver

important benefits

The ecohealth approach promotes national ownership

by addressing the country’s priorities as identified by

na-tional stakeholders Currently, many emerging infectious

disease and zoonoses projects are driven by donors or the

international technical implementing agency, and hence

may not fully reflect local priorities In this study,

stake-holders considered prioritization of diseases a key research

gap Disease prioritization studies would not only allow

national priorities to be identified, but could also serve as a

model for integrating different disciplines, empowering

communities, and strengthening the relationship between

researchers and decision-makers

ACKNOWLEDGMENTS This study was funded by the International Development Research Centre, Ottawa, Canada We also acknowledge the contributions of the participants in the study from Vietnam, Lao PDR, and Cambodia

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