The journey, not just the destination

In Round Two, Maria José Espona identified an "atomization" in this roundtable. The various authors, she wrote, were mostly emphasizing issues relevant to their own expertise. And she argued that the roundtable's "atomization" was symptomatic of the global health system's inadequacies in communication and coordination. In Round Three, Oyewale Tomori expressed deep frustration over African states' failure, as he sees it, to take responsibility for effective disease surveillance and response. He characterized African nations' reliance on international support as evidence of a "dependency stupor."

Espona and Tomori, in their different ways, highlighted the global health system's critical need to become more integrated, more responsible, and more responsive. But the vision that they effectively share represents a destination. Before the destination can be reached, it is necessary to recognize and gain a better understanding of a multiplicity of factors that impede progress (in addition to those already identified by Tomori and Espona). Several of these factors involve either inadequate information—regarding what works, what doesn't, and why—or a failure by health care and science practitioners to advocate forcefully for change.

In many cases, important issues surrounding the establishment and administration of health systems in developing countries are poorly understood. The broad forces that underlie these systems—historical, social, economic, and ethical—are rarely documented or investigated in an extensive fashion by in-country researchers. As a result, though it is easy to identify problems in a given country's health system, it can be hard to know where to lay the blame for problems, or how to remedy them. Also, poor understanding of local circumstances (and the factors that underlie them) often causes "donor" countries to offer or impose solutions that do not suit local contexts, or don't correspond precisely to local problems.

Conversely, a lack of in-depth data about a particular country's health system can also cause what does work—and why—to be overlooked. Not all developing countries share the same risks and capacity constraints or exhibit the same systemic failures. For example, the health systems in South Africa and Kenya differ considerably from those in the Democratic Republic of Congo and Guinea. Disease surveillance systems in the former nations have their shortcomings, but these countries’ capacities to detect and respond to disease outbreaks are far more robust than in countries that, for example, have experienced prolonged conflict. Thus, a lack of discussion about why some initiatives work makes it difficult to adapt successful strategies from one context to another and diminishes the potential to learn from successes.

An important dimension to these information gaps is that developing countries' health practitioners are often relatively silent and invisible in international policy forums. Because these practitioners are responsible for providing health services on a daily basis, they are ideally positioned to offer insights and propose remedies. When they don't contribute insights and remedies, or their contributions are not heard, outsiders often impose solutions that fail to address underlying problems, or that don't receive buy-in from policy makers and health care providers. Thus it is imperative that developing-country scientists, at conferences and in the context of collaborations, assert their needs and explain their realities—that they advocate for change more actively. A related stumbling block to progress is that many in the scientific community are reluctant to be vocal about—and active in—addressing weak governance and other systemic problems that hinder disease control efforts. It is crucial to determine why this reluctance to force positive change exists.

Similarly, national and international professional associations that are in a position to advocate for change could use their positions to greater effect if they pressured governments and donor organizations to heed the recommendations of scientists and health professionals. If they exerted such pressure, key issues might find their way onto national or international agendas. Such issues might include the difficulty of implementing improvements in biorisk management when, for example, core funding for laboratories isn't available (as is the case in many countries). Discussion of these issues is necessary if a clearer understanding of mismatches between health policy and health practice is to be achieved.

Ultimately, making the world safer from emerging pathogens requires a multi-faceted approach that includes improved bioethics educations (as we, the authors, discussed in Round One) and greater collaboration among developing countries (as we discussed in Round Two). It also requires health practitioners at the national, regional, and international levels to take more vigorous action to effect systemic change.