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EcoHealthConservation Medicine: HumanHealth:Ecosystem Sustainability Officialjournal of International Association forEcology and Health ISSN 1612-9202Volume 8Number 1 EcoHealth (2011) 8:55-62DOI 10.1007/s10393-010-0357-3

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

Delia Grace, Jeffrey Gilbert, M. LucilaLapar, Fred Unger, Sonia Fèvre, HungNguyen-Viet & Esther Schelling

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Zoonotic Emerging Infectious Disease in Selected Countriesin Southeast Asia: Insights from Ecohealth

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

and Esther Schelling3

1International Livestock Research Institute (ILRI), 30709, Nairobi, Kenya2Veterinarians Without Borders/Veterinaires Aans Frontieres—Canada, Singapore, Singapore3Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland4Department of Water and Sanitation in Developing Countries, Eawag/Sandec (Swiss Federal Institute of Aquatic Science and Technology), Dubendorf,

Switzerland5Department 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

Correspondence to: Delia Grace, e-mail: d.grace@cgiar.org

EcoHealth 8, 55–62, 2011DOI: 10.1007/s10393-010-0357-3

Original Contribution

� 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 prevention 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.

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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 Access� and

qualitative into Excel�. We used Intercooled STATA 10 for

Windows (Stata� Corporation, College Station, TX) for

analyses of quantitative data and NetDraw 2.081 (Analytic

Technologies�, 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. Figure 1 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 (Table 1). 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.

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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-directional. 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 (%)

Risk analysis 22 78

Research skills 33 67

Systems thinking

and models

36 64

Networking 37 63

Institutional analysis 42 58

Socioeconomic studies 45 55

Ecohealth 50 50

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. Figure 2 shows

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 (Table 2). 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-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.

Author's personal copy

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,’’ ‘‘training,’’ 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

3 High; 3 Most cases; 3 Good; 3 High; 3 Increasing;

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

1 low 1 few cases 1 poor 1 low 1 decreasing

Vector-borne zoonoses 2.6 (3) 2.6 (3) 2.2 (2) 2.4 (2) 2.3 (2)

Food-borne zoonoses 2.5 (2.5) 1.9 (2) 1.7 (2) 1.9 (2) 2.5 (3)

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

Soil-borne zoonoses 2.1 (2) 1.5 (1) 1.8 (2) 1.4 (1) 1.6 (2)

Wildlife-associated zoonoses 1.7 (2) 1.7 (2) 1.6 (2) 1.4 (1) 1.8 (2)

aMedians 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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