While organizing health systems most often continues to fall within the jurisdiction of States, health security is now described as a global public good. Accordingly, health risks are now recognized as being risks shared by all on a global scale and for which solutions exceed the jurisdiction of a single State. Indeed, for a very long time, epidemic risks have prefigured a form of globalization plus, now, health risks related to medicine security and food security.
Over the past 20 years, France, following the example of many other European and North American countries, has set up agencies specialized in health security (the Agence française de sécurité sanitaire des produits de santé (French agency for health products safety, AFSSAPS), the Agence sanitaire des aliments (French food health agency, AFFSA), the Agence française de sécurité sanitaire de l’environnement et du travail (French agency for work environment health safety, AFSSET). These agencies are intended to act at the international level at the request of States or the World Health Organization (WHO)
On the global scale, the WHO is, within the United Nations system, the guiding and coordinating health authority. It is responsible for guiding global health actions, providing validated statistical data on the state of the world’s population, setting standards and criteria on medical conduct (diagnosis or treatment), presenting political options based on conclusive evidence, providing countries with technical support and monitoring and assessing public health trends.
Its programme is based on six objectives, including one devoted to health security:
Promoting health security,
Improving health systems,
Capitalizing on research, information and facts,
1. Health security in terms of health products at the global level
The availability and use of recognized quality medicines is accomplished through the formulation and adoption, by States, of regulations relating to their manufacture, registration, marketing and distribution.
The granting of Marketing Authorizations (MA) is a fundamental procedure for setting up these processes. There are competent authorities at the national and regional levels (AFSSAPS for France, Food and Drug Administration for the United States, European Medicines Agency for the European Union).
Since 2001, the WHO has set up the prequalification of medicines programme. By guaranteeing a certain level of qualification, this programme is intended to facilitate bulk purchasing of medicines for certain diseases, specifically HIV, malaria and tuberculosis, through the United Nations Organizations and other international organizations, such as the Global Fund and UNITAID.
Many WHO initiatives and programmes are run by the Essential Medicines and Pharmaceutical Policies department and help to improve world pharmaceutical safety, such as: collecting data on countries’ pharmaceutical sector, supporting countries in the development of pharmaceutical policies and good governance, the medicine quality assurance programme and strengthening national regulatory authorities, and the creation of the International Medical Products Anti-Counterfeiting Task force (IMPACT).
Despite all of the efforts made by States, the WHO and other partners, many low income countries suffer from the existence in their markets of medicines that do not meet quality standards, even counterfeit medicines. Some statistics indicate alarming levels of these products that are harmful to health and that jeopardize every effort to improve health management. The poorest countries are most affected, due in particular to poor human and material capacities, the heterogeneity of pharmaceutical distribution systems and the difficulty for patients to obtain quality medicines at an affordable price (sharp increase in buying medicines in the street). Industrialized countries are also concerned, specifically through Internet purchases (50% of non-identifiable sites in terms of their origins, according to the WHO).
2. Health security in terms of surveillance of infectious diseases
Global and regional surveillance and response systems:
- The revised International Health Regulations (IHR 2005) have applied since 15 June 2007.
Its scope extends to all events that might present a danger to public health (in compliance with existing international agreements). The IHR were revised, because the mandatory notification of only three diseases (cholera, plague and yellow fever) in the IHR (1969) did not cover the many risks of this day and age, in addition to certain restrictions to travel and trade that had caused certain countries to be reluctant to report epidemics quickly. The IHR (2005) sets new rules that are applicable to international collaboration in the field of infectious disease control. Its scope extends to all events that might present a danger to public health in compliance with existing international agreements. Transparent notification of these events in a timely manner, plus the coordinated evaluation of the risks by State concerned and the WHO, as well as effective communication about risks, should improve international confidence and make it possible to avoid imposing unilateral restrictions to trade and travel. In order to determine whether a particular event constitutes an international public health emergency, the IHR (2005) provides for the creation of an independent emergency committee to advise the WHO Director General.
- The Global Outbreak Alert and Response Network (GOARN)
Today, an epidemic in a given country may become an international public health emergency. Regional and global warning and response mechanisms are necessary to ensure quick access to technical reports, financial resources and support for public health systems in the countries concerned. No one institution or country possesses all of the capabilities to respond to a public health emergency due to an epidemic, an emerging disease, or even nuclear or toxic accidents. The WHO, which acts as the secretariat for the Global Outbreak Alert and Response Network (GOARN), guarantees countries quick access to the best experts and necessary resources. Created in April 2000, the GOARN network facilitates the coordination of the response to international epidemics and provides an operational framework concentrated on providing States concerned with the necessary resources and expertise.
- Centres for Disease Control and Prevention (CDC)
Centres for disease control and prevention (nine sites in the United States) are present in more than 50 countries to bolster epidemiological surveillance of communicable diseases. The CDC’s total budget, including the United States, is 20 billion dollars a year. The global disease detection operations centre has been set up in Atlanta for a few years. It is an “epidemic intelligence” unit focussed on early detection of international events for which the CDC may be called. This unit provides funds to support CDC interventions in the event of an international epidemic.
- The European Centre for Disease Prevention and Control (ECDC) was created in May 2005.
Based in Stockholm, this structure aims to build Europe’s capacity to defend itself against infectious diseases. The structure is dedicated exclusively to infectious diseases. It is based primarily on a network of national structures which it supports and has been accommodating international networks since very recently (Euro TB, Euro HIV, Epiet, etc.).
- The European network for surveillance, warning and control of infectious diseases
Financed by the Directorate General for Health and Consumers (DG SANCO) of the European Commission, the European network for surveillance, warning and control of infectious diseases puts the ministries responsible for health and the surveillance institutions of the 27 Member States in contact with each other. The warning system, based on a secure remote transmission network between the Member States, makes it possible to exchange epidemiological information quickly on risks of infection that may affect several member states. It must make it possible to identify emerging threats of infection in Europe early and coordinate the response.
French public systems at international level:
- The Institut national de veille sanitaire (InVS, French national institute of health monitoring) and its international department.
The InVS collaborates with the WHO and accordingly is involved with international networks. In connection with the Ministry of Foreign and European Affairs, it can also provide third countries with technical support. The InVS is positioned at three levels within the world’s health surveillance networks: participation in the WHO office in Lyons, in the global outbreak alert and response network (GOARN) and collaboration with the regional WHO office for Europe. Specifically, the InVS contributes to the development of surveillance and control of communicable and environmental diseases in Europe and the world. It coordinates European surveillance programmes: surveillance of HIV/AIDS, tuberculosis, listeriosis, the effects of air pollution on health.
- The Instituts Pasteur (IP) network.
The Institut Pasteur participates actively in the surveillance of infectious diseases worldwide, with access to numerous expert laboratories in Paris and within the International Network, carrying out microbiological monitoring on an international scale. There are eight WHO Collaborating Centres (WHOCC) set up at the Institut Pasteur in Paris, and many other centres that have been designated in Instituts Pasteur of the International Network. In addition, the Institut Pasteur has set up a Cellule d’Intervention Biologique d’Urgence (CIBU, Laboratory for Urgent Response to Biological Threats), made up of high-level technicians prepared for various eventualities to respond to an epidemic in a natural context or in the event of a bioterrorist attack. The objective is to support dedicated laboratories in France and abroad. The Instituts Pasteur International Network brings together 30 independent institutes, united by the same missions, the same culture and the same values.
- The Institut de Recherche pour le Développement (IRD, Institute of Research for Development).
The IRD conducts scientific programmes centred around the relationships between humans and their environment in developing countries (in Africa, Latin America, Asia and the French tropics overseas). Research is organized around six scientific themes, including emerging infectious diseases. The IRD has 35 sites throughout the world, including 25 representations in foreign countries. IRD researchers act in about 50 countries.
- The Centre international de recherche médicale de Franceville (CIRMF).
Created 30 years ago, this Gabonese research institute comprises six research units, including one for emerging viral diseases and one for retrovirology, which provides major health monitoring in the Central African zone. As such, the centre is the WHO’s referral centre for haemorrhagic fever and arbovirus and is part of the haemorrhagic fever diagnostic GOARN network. Funded jointly by the Gabonese government, France and the company, Total Gabon, the centre receives considerable support from France through the presence of technical assistants. There is also a French university presiding over its scientific council and a French researcher directing the centre.
- The Centre de recherche et de veille sur les maladies émergentes dans l’Océan Indien (CRVOI).
The aim of this Scientific Interest Group (GIS), created in 2007, is to set up and operate, on Réunion Island, a research and scientific monitoring centre on emerging infectious diseases in the Indian Ocean. This centre helps monitor and warn about emerging infectious diseases in Réunion and Mayotte as well as in the Indian Ocean in partnership with the national health agencies and health authorities of the States concerned.An identical surveillance network in South Asia is currently being set up under the aegis of the CIRAD (Centre international de Recherche agronomique pour le développement, International Cooperation Centre of Agricultural Research for Development) with the collaboration of the different Instituts Pasteur in the area.
3. France’s current commitments
Regional southwest Indian Ocean project
The AFD is funding a regional epidemic surveillance and response project (6 million euros) for the member countries of the Indian Ocean Commission: Madagascar, the Comoros, the Seychelles, Mauritius and Réunion, for the period 2007-2011.
The fight against avian influenza
France agreed to earmark 36 million euros for the fight against avian influenza in developing countries from 2006 to 2009, through the following actions:
- Contributions to the programmes of international organizations (OIE, FAO and WHO): 10 million euros,
- Creation of nine technical assistant positions by the MAEE over three years for these three organizations,
- Reinforcement of the activities of the Instituts Pasteur for the surveillance and investigation of human and animal epidemics in Asia with the AFD and, in Africa, with the Ministry of Health,
- Building the diagnostic capabilities of African laboratories to control avian influenza,
- Priority Solidarity Fund: “research on the epidemiology of avian influenza in the PSZ” for 3.6 million euros, implemented by the CIRAD in collaboration with the AFSSA, INRA and the Office National de la Chasse et de la Faune Sauvage (ONCFS, National Game and Wildlife Agency), for three years,
- The CIRAD research programme and INRA (institut scientifique de recherche agronomique publique, national institute for agricultural research) on the genetic resistance and molecular virology of the avian influenza virus financed by the Agence Nationale de la Recherche (national agency for research) and the Ministry of Agriculture.Support for the WHO in the framework of the International Health Regulation (IHR).
France has supported the WHO Office in Lyons since it was set up in 2000. It is an integral part of the Department of Communicable Diseases in terms of “surveillance and action” (currently the epidemic and pandemic warning and actions department - EPR).
More specifically, the Lyons Office is responsible for supporting member states to reinforce national surveillance and action systems, to enable all countries to detect, assess and report events that may be a public health emergency of international scope and respond to them. In the framework of a five-year agreement extended in 2005, the MAEE provides technical support to the WHO Office in Lyons with two expert positions and financial backing of 900,000 euros a year.
Moreover, the MAEE supports the WHO “epidemic and pandemic warning and actions” department in Geneva, for the implementation of the IHR, with an annual grant of 1.7 million euros (NUOI) and an associated young expert position.
Updated on 09.04.10