Dr. Rafael Ruiz de Castañeda is a researcher and teacher at the Faculty of Medicine of the University of Geneva, in the Department of Tropical and Humanitarian Medicine, and at the Institute of Global Health. He co-directs, with Dr. Isabelle Bolon, an interdisciplinary unit which, through a “One Health” approach, addresses public and global health issues.
For Défis Humanitaires, he presents his vision of what One Health is – or should be – and shares with us the difficulties and solutions to better integrate this approach in humanitarian contexts.
Madeleine Trentesaux: Rafael Ruiz de Castañeda, we will start with an effort to define what One Health is. It is commonly considered that the One Health approach is based on the interdependence between human, animal and environmental health. For your part, you have a definition that goes somewhat further. What is it?
Rafael Ruiz de Castañeda : The work of definition is important, but before I start, I would like to point out its limitations. Defining terms and concepts often implies separating them and marking their limits. Creating silos runs counter to the very principles of One Health.
One Health is not a discipline but a public health and global health approach that is built on the fact that there is an interdependence between human, animal and environmental health. Its added value lies in the collaboration between disciplines and sectors and in its capacity to integrate communities affected by public health issues.
It is precisely here, when you add that One Health is intersectoral, that you mark a specificity of this approach.
Yes, One Health is definitely interdisciplinary from an academic point of view, but it must also involve different sectors. It must mix the academic world with that of international organizations, humanitarian actors, etc., and, above all, it must integrate human communities. It is the affected communities that know how to identify the problems at the human-animal-environment interface and often know a lot about them.
The strength of the One Health approach is to find the right actors and disciplines to respond to the identified problem. It is not necessarily an approach that can be applied to all problems, but it is of particular interest for those at the crossroads between human, animal and environmental health.
One Health is an approach that must be interdisciplinary and intersectoral. We also hear about other concepts such as Planetary Health. What is the difference between this concept and One Health? What is the added value of the cohabitation of these two concepts?
Each of these approaches has a specific history and involves different actors and schools of thought. These concepts are more or less focused on human or animal health or on the environment.
One Health is older than Planetary Health. It has its origins in the concept of “One Medicine” put forward in the 1960s by Prof. Calvin Schwabe. The concept of One Health was established following the increase in the number of epidemics of emerging infectious diseases of animal origin in recent decades, such as AIDS, SARS, Ebola or animal influenza.
Since the mid-2000s, three major international organizations have been leading this fight: the World Health Organization (WHO), the World Organization for Animal Health (OIE) and the Food and Agriculture Organization (FAO). This is known as the Tripartite Alliance.
More recently, the notion of Planetary Health is emerging thanks to a publication in The Lancet in 2014. It focuses on the processes of environmental disruption on a planetary scale that impact human health. For example, biodiversity loss, deforestation, climate change and their consequences on human health.
These differences are valid and do exist in the current environment. But, again, I would like to emphasize the importance of collaboration, not the creation of new silos. It’s about identifying and understanding the problems and needs to find the right people and entities to collaborate with to find an operational solution.
We can clearly see the interest, particularly in the academic field, of this approach, which allows for a decompartmentalization between human, animal and environmental health. It is also a concept that has gained in popularity, but whose implementation is not obvious. Is it being done at the risk of becoming a “showcase concept”? What is its integration into policy at the international, national and local levels?
This is a good question because, indeed, the One Health approach can be difficult to operationalize. At the international level, the concept is carried by the Tripartite Alliance, which we have already mentioned.
At the national level, the difficulty in adopting a One Health approach is that we have created and organized our societies in a fragmented way. There is, for example, a ministry for human health, one for agriculture and yet another for the economy[1].
We often work in silos, and changes in behavior and ways of working are long and difficult to integrate, especially if their positive impact is not demonstrated. The role of countries where, for example, many zoonoses are endemic will be key to the implementation of the One Health approach.
Is it necessary to have supra structures labeled “One Health”? Not necessarily, because although it is important to create and define areas of work, we must not risk creating new silos. What we need are collaborative mechanisms. For example, that the Department of Agriculture can easily share data with the Department of Human Health. It is important to get into the habit of discussing between human medicine, animal medicine, zoology, animal ecology… practices and needs in order to pool some resources and collaborate on the ground.
Let’s take the example of rabies [2]. Various studies have shown that vaccination of dogs is the most cost-effective action to prevent and control the disease in both dogs and humans. Vaccination of dogs can eliminate rabies in humans. This idea is a strong paradigm shift for those involved in human health.
How can this collaboration between sectors be put into practice?
I would put forward two solutions to operationalize this approach. First, One Healh is a systems approach that attempts to identify and address problems at their source (e.g., wildlife). Thus, One Health is often focused on prevention, and that is where the effort should be made, rather than on responding or responding to events.
If we take the example of infectious diseases of animal origin (zoonoses), we must be able to identify them in animals before they reach the human population. This requires close collaboration between veterinarians, animal ecologists, field epidemiologists, etc., in terms of sharing information, data and resources. Resource sharing can take the form, for example, of joint field missions, or sharing laboratory space dedicated to human and animal research.
Communities also play a critical role because they are in contact with domestic and wild animals and can provide early warning through syndromic surveillance in animals.
Secondly, a new generation of health actors must be trained, for whom a systemic and collaborative approach is natural. These paradigm and behavioral shifts are long-term changes and education is key to these processes. However, this work must be accompanied and facilitated by the creation of institutions and structures that support this interdisciplinary and intersectoral approach.
And in the humanitarian environment, where prevention is made difficult by the context, how can this approach be put into practice?
Humanitarian settings present many difficulties in implementing action. It is an environment often characterized by urgency, instability and sometimes the high vulnerability of people in the field.
However, it is a context that would greatly benefit from better integration of the One Health approach. Indeed, human-animal-environment interactions are numerous and take various forms. Humans, in precarious contexts such as camps or migration routes, are often in contact with domestic or wild animals – livestock, dogs or wild fauna such as snakes or scorpions, mosquitoes and other disease-carrying insects.
The origins of humanitarian crises are also regularly found in the environment – natural disasters, unsafe water causing a cholera epidemic for example.
One Health approach is important to combat envenomated snakebites
In 2017, the WHO officially recognized snakebite as a neglected tropical disease. It is estimated to cause up to 138,000 deaths per year worldwide. A One Health approach to this issue allows us to consider the consequences of snakebites not only on human health but also on animal health and on the socio-economic situation of affected households. For example, snakebites on livestock can kill animals and weaken the economic situation of owners. In terms of human health, snakebites are a major cause of the health burden due to neglected tropical diseases in terms of disability-adjusted life years [3].
Faced with these situations, humanitarians must treat people with competent and efficient health personnel, but also respond to the crisis in a global and integrated way thanks to an interdisciplinary team. It is necessary to understand where the disease comes from (animal or environmental origin), the practices that allowed it to pass from animals to humans and/or from humans to humans, etc.
You have worked a lot on education issues. Why are they so important to you?
I think education is key to the integration and operationalization of the One Health approach. I mentioned earlier the importance of setting up mechanisms for collaboration between sectors and I think it is essential that the academic community offer spaces for reflection, collaboration and interdisciplinary research. This is what we are trying to do at the University of Geneva with our Master’s degree in Global Health, as well as with other programs and courses in tropical and humanitarian medicine at the Faculty of Medicine.
One Health, Planetary Health or Eco Health approaches must be integrated into human medicine studies. It is through these teachings and the appropriation of these approaches by future health care workers that we will be able to train the more integrated, committed and conscious generation that I hope for. Moreover, we are currently working on the development of a complete program at the Faculty of Medicine of the University of Geneva, which would integrate “One Health” teachings from the first years of medicine.
You have implemented and tested innovative education solutions in a variety of contexts from the University of Geneva to the Kakuma refugee camp in Kenya. What have you created with your students?
With my colleagues from the Institute of Global Health, notably Prof. Antoine Flahaut, director of the Institute, and Dr. Isabelle Bolon, we created the MOOC [4] Global Health at the Human-Animal-Ecosystem Interface which involves more than 30 experts from some 20 institutions based in Geneva and elsewhere, including many colleagues from the Institut Pasteur.
This course is followed in parallel by three groups of students: those from the University of Geneva, others living in the Kakuma refugee camp and a group of students from the University of Nairobi in Kenya. The teaching combines classes and project creation. It aims to bring out the public health problems in the Kakuma camp by the students living there, as well as the practical solutions to address them.
The students are then asked to create projects, implemented with the help of InZone[5], adopting a One Health approach to address the issues identified.
This curriculum has multiple benefits. First, the collaboration between students from the University of Geneva, Nairobi and Kakuma camp makes this program viable in the sensitive humanitarian context of the refugee camp. The students help each other and communicate regularly with each other.
It also provides a space for exchange between students from different backgrounds and between multiple sectors – the NGOs and international organizations that organize life in Kakuma, the academic community and the health sector. This mix is of interest to individuals, but also provides professional opportunities for students in Kakuma, Geneva and Nairobi.
Finally, this program is a model for teaching a One Health approach in refugee camps and, given its success, would benefit from replication in areas other than public health [6].
You are involved in the One Sustainable Health Forum, carried by Benoît Miribel and the Fondation Une Santé Durable pour Tous. This initiative aims to make the One Health approach operational. What do you expect from this approach?
I congratulate this approach. The international working groups that have been set up will draft recommendations to better integrate One Health into research and operational projects in the field. They will also make recommendations on ethics, advocacy and education. This will be a key input in the process of operationalizing One Health.
In my opinion, the interest of such an approach will be to show the added value of collaborations between disciplines and sectors and to highlight the most effective ones according to the targeted problems. It will be necessary to highlight the positive impacts of these collaborations – financial impact thanks to the pooling of resources between human and animal medicine, or representing a saving of time thanks to an integrated surveillance system for zoonoses, for example.
Interviewed and transcribed by Madeleine Trentesaux
Dr. Rafael Ruiz de Castañeda
Dr. Rafael Ruiz de Castañeda leads the One Health Unit at the Faculty of Medicine of the University of Geneva, where he works as a senior lecturer and researcher. He has a broad interest in public and global health issues at the interface of human, animal and environmental health, ranging from ongoing projects on emerging zoonoses, pandemics and the role of One Health in Health Diplomacy, One Health approach to snakebite envenoming in endemic countries, innovative approaches to One Health education and capacity building in humanitarian settings etc. Rafael also serves as a consultant for the World Health Organisation and currently supports the implementation of several projects around Neglected Tropical Diseases.
Madeleine Trentesaux
Interested in humanitarian and public health issues, Madeleine Trentesaux is currently doing a master’s degree in Health Anthropology at the University of Aix-Marseille. Previously, she completed a bachelor’s degree in anthropology at the University of Paris Nanterre and a master’s degree in “Human Rights and Humanitarian Action” at Sciences Po Paris. She has completed numerous internships, notably at Fondation Mérieux and the Fondation Une Santé Durable pour Tous. She also participated in international solidarity and development projects in France, Armenia and India. As an intern for Défis Humanitaires in 2020, she wrote an article on anthropology and humanitarian.
Madeleine Trentesaux on LinkedIn : https://www.linkedin.com/in/madeleine-trentesaux-1257a8185/
[1] L’organisation des ministères varie selon les pays, mais nous retrouvons globalement une structure cloisonnée entre secteurs.
[2] Voir, par exemple, Zinsstag, J., 2017, “Vaccination of dogs in an African city interrupts rabies transmission and reduces human exposure”, Science Translational Medicine, 9(421), https://www.science.org/doi/10.1126/scitranslmed.aaf6984
[3] Babo Martins, Sara, et al., 2019 “Snakebite and its impact in rural communities: the need for a One Health approach”, PLOS Neglected Tropical Disease, Vol. 13, Issue 9, accessible sur : https://archive-ouverte.unige.ch/unige:123745.
[4] Massive Open Online Course
[5] “InZone est un programme de l’Université de Genève qui met en place des approches innovantes en matière d’enseignement supérieur dans les communautés touchées par les conflits et les crises humanitaires. L’objectif ultime est d’autonomiser les personnes en mouvement bloquées dans les pays de transit.” – https://www.unige.ch/inzone/
[6] Pour plus d’information sur le déroulé de ce programme : Bolon et al., 2020, « One Health education in Kakuma refugee camp (Kenya): From a MOOC to projects on real world challenges”, One Health, 10, https://www.sciencedirect.com/science/article/pii/S2352771420302597?via%3Dihub