One medicine, or the idea of equivalent global standards of veterinary education and medicine, has been around even prior to 2004. So, what is the current ground reality in Sri Lanka?
There is a lack of access to good education and knowledge, to good referral centers or diagnostic equipment. Veterinarians have no access to the opioid analgesics (buprenorphine, oxymorphone, fentanyl, morphine, butorphanol) or new drugs such as maropitant, pimobendan; and though ticks and other parasites are abundant, spinosad, milbemycin, lufenuron, imidacloprid, moxidectin and selamectin are not available. Most veterinarians do not have gas anesthesia or an autoclave, and still perform major surgery ranging from pyometra to fracture repair with injectable anesthetics such as thiopentone and ketamine/diazepam.
The situation has improved appreciably over the last 5 years largely due to a few special individuals. Improved Asian standards were initiated by Dr Douglas Bryden of Australia and Dr Siraya Chunekamrai through Thailand's Veterinary Practitioners Association (VPAT). Their effort was not only focused to increase standards in Thailand but also to impact the region. The example of VPAT led to the formation of Sri Lanka's Society for Companion Animal Practitioners (SCAP); where through the extraordinary generosity of various veterinarians worldwide, who provided time and knowledge pro-bono, biannual continuing professional development (CPD) programs are regularly conducted. These initiatives were complemented by WSAVA-sponsored CPD programs with contributions from a range of veterinarians. Most recently the Massey University and OIE effort to improve standards of teaching to international level, at Sri Lanka's solitary veterinary faculty, will be of overriding importance.
One stumbling block is that most of this training is CPD based, which though vitally important, is most valuable when augmenting a good solid foundation of knowledge. A framework is required, on which to assemble the pieces of new information gained through CPD, so they can be integrated and used effectively in clinical practice. Currently in Sri Lanka (SL) this foundation or framework is lacking, and though CPD imparts useful knowledge, it can be difficult to recall and utilize it effectively in the clinical setting.
More structured learning is essential to create a definitive impact on standards of care. This is being addressed to some extent by the current WSAVA program focused on a problem-oriented approach in which all CPD follows the same fundamental system and builds on the principles of the previous ones. Ideally, programs such as the Murdoch University postgraduate certificate and masters, or similar clinical online courses, are best able to provide this formal structure. I specifically mention the Murdoch University program only because, having experienced it, I know it is fundamentally applicable to the Asian/SL clinical reality. It pulled together years of diverse CPD into one framework. It was like finally completing a complex jigsaw puzzle, providing both relief and a sense of satisfaction.
The progress of veterinary medicine in Sri Lanka to the next level would be significantly benefited by at least ten Sri Lankan veterinarians completing such a course. This will inject needed impetus and capacity for better standards of care. The ground reality! One medicine is not here yet, but it is definitely on the way in Sri Lanka.
A related and primary topic is One Health; and I will focus on rabies, the classic example. Is rabies elimination in Sri Lanka a realistic goal? The initial evidence is encouraging. There are excellent and readily available vaccines for dogs (though government is still using an Indian product) and effective postexposure prophylaxis (PEP) for people. R0 value (the average number of new cases generated by a single case) is low, between 1–2 across the world, despite wide variation in dog density and demography. It is an island country and can regulate imports/immigration. There is a well-developed public health system with previous experience in eradication of several diseases. An extensive network of government hospitals provides free and often overzealous PEP for dog bite victims. A high literacy rate (98%, 2012) ensures that people can be educated and motivated to follow dog bite prevention guidelines, seek appropriate post-bite care and vaccinate their dogs as responsible owners/caretakers through a good marketing campaign. There is a well-established, widespread, government veterinary system (though principally focused on production animals). Many roaming dogs are owned or community owned and not particularly fearful of people. True feral roaming dogs are few. Thus, most are accessible for vaccination, though net catching may be required as these dogs are suspicious of being restrained. Central government and the international community are fundamentally supportive of rabies eradication efforts. The suggested deadline for eradication has been stated as 2020! Diagnostic capacity and laboratories have been recently created and should encourage improved surveillance. The Colombo Project (as detailed below) and other recent studies provide field experience and reasonable dog population data, though gaps exist. Recent developments in rabies control in Sri Lanka are noteworthy. In 2007, the "Humane Dog Population and Rabies Management Project" (Blue Paw Trust [BPT], with the Colombo Municipal Council [CMC] and the World Society for the Protection of Animals [WSPA]), using a One Health model, was initiated for Colombo. The objectives were to develop herd immunity in dogs, control stray population, prevent dog bites and improve awareness to seek PEP if bitten.
The critical elements were:
A holistic program that ranged from community education to animal welfare and all elements in between
The collection of extensive contextual/local data and its use to create a comprehensive plan
Systematic and high quality, dedicated field implementation
Time, attention and money spent on extensive and well planned M & E with decisive upgrades to program when indicated
A strong animal welfare approach, yet maintaining a population based rather than individual animal perspective. For example, though the focus was not on treating every dog with mange, nonetheless the overall Skin Condition Score (SCS) improved in all animals.
Adequate funding was generously provided by WSPA and, thus, there was no requirement to cut corners. The project had the economic support to reach systematic and planned completion. The outputs and impacts of the Colombo Project were groundbreaking. During the project period of five years, 80% of female dog population was sterilized, 70% of total dog population was vaccinated annually for three consecutive years and 95% of primary school children were educated on bite prevention. In effect, the dog population, which was increasing at a rate of 18% in 2007, was decreasing at a rate of 9% in 2012, and the number of dog rabies cases reduced from 35 to 3, with marked improvement in animal welfare (Body Condition Score and Skin Condition Score have increased from 76% to 92% and 52% to 82%, respectively).
The graph illustrates the two strategies used for rabies control in the Colombo Municipality. From 1990 to 2006, stray dogs were culled while owned dogs were vaccinated, which held dog rabies at an average of between 30 to 40 cases per year. In 2006, a "no indiscriminate killing" policy was introduced. Thereafter, through the Colombo Project, culling was substituted with sterilization and roaming dogs were also vaccinated. This new strategy resulted in a rapid drop in rabies.
Consequent to a knowledge-sharing conference organized by BPT (September 2011), an invited stakeholder, the WHO Country Representative, recognizing the effectiveness and importance of the holistic methodology and achievements and appreciating that rabies can only be eradicated by joint efforts of several sectors, offered WHO support towards building partnerships and preparing a national rabies strategy (minutes of the meeting, Blue Paw Trust). In response, a multistakeholder workshop was held in December 2011, including WHO and FAO expertise, which generated 12 recommendations for a national strategy. These recommendations required interministerial action (health/animal health/local government/etc.) and working together with NGOs. Accordingly, Cabinet approval was sought and given in July 2012, thus initiating multisector measures towards rabies elimination.
Subsequently, the Department of Animal Production and Health (DAPH) agreed to take a lead role in dog rabies control activities. Technical committees were formed in each province (March 2013) to develop action plans, with BPT invited to the Western Province committee. As rabies control is very new to DAPH, BPT's experience and knowledge was solicited through this workshop in order to integrate the Colombo Project model with the knowledge and needs of government field veterinarians. These provincial action plans were then integrated to create an overall plan for the DAPH based on a public health veterinary network and in line with the national strategy.
The ground reality: One Health-based rabies control in Sri Lanka got off to an excellent start but is currently faltering due to several critical factors.
Veterinary medicine is considered a second-class profession, perceived as a place for failed doctors. Effective communication and working together of vets and medical doctors require mutual respect. Our medical colleagues must feel we are knowledgeable. As one medicine is not established yet, One Health becomes a challenge. As an example, if a veterinarian assesses an animal as being rabies free (adequately vaccinated) and the bite due to reasonable provocation, it is unlikely that a medical doctor would withhold immune serum. An area that is extremely problematic is creating modalities for the different sectors to share data, records and similar information, which is typically closely guarded.
Convince medical colleagues that on the issue of rabies, veterinarians are well educated and knowledgeable. How do you engage the medical profession to convince them of this when they are not listening?
A. Target one of the major annual medical congresses (i.e., College of Microbiologists annual conference) and request a session on rabies control. There is adequate interest in the topic to justify this. Invite international veterinarians of high caliber to educate the medical doctors. In addition, have a few knowledgeable SL vets introduce achievements, including the Colombo Project and the national plan.
Expected output of workshop: Gain buy-in to a One Health approach and create avenues/platform for human and animal medical professionals to interact positively.
B. Subsequently, use these same speakers to educate a broad range of veterinarians who will be the future implementing agents for dog rabies control. Most veterinarians in the government sector have focused on production animals and are unfamiliar with recent advances in rabies control. Also, discuss and create avenues for working with the human medical sector.
C. Create a neutral body that will play a liaison role between DAPH and health sector as well as other stakeholders. One Health involves stakeholders from a variety of backgrounds, ranging from local communities to local government, education ministry and schools, media and the veterinary faculty, to mention a few. It is definitely a human relations challenge which cannot be ignored.
Such a facilitator should have networking and consensus-building proficiency to initiate interactions between government medical and veterinary fields and local government as well as nongovernment organizations. The facilitators should have experience and expertise in bringing together multiple stakeholders effectively and building cooperation through highlighting the importance of each. They must initiate effective communication, coordinate engagements and guide stakeholder interactions towards effective implementation of the rabies elimination action plan. An advocacy campaign and facilitating unit will ensure realization of the interdisciplinary DAPH and health sector program of rabies control. In developing countries such third party intervention is both useful and necessary to promote successful inter sector cooperation. BPT is confident that we have the experience and skills to undertake this role and have been fundraising for this, though with minimal success at this time.
Problem 2: Economics and Funding
Economic studies on the Colombo Project, among others, are now more readily available. Although long-term gain can be demonstrated, comprehensive programs of high quality, which maintains good animal welfare standards with statistically valid proven impact, are by definition expensive.
Consequently the ground reality is that many cut corners and carry out ad hoc projects. Many SL private and government groups deal with 300–500 animals in one location or another. This will impact the welfare of those 300 dogs but not the roaming dog problem or rabies overall. Data from Bali has shown that elimination of rabies is dependent on high level of contiguous vaccination and even small pockets of low coverage can cause a significant delay in progress (Townsend et al. 2013; Cleaveland, Beyer et al. The changing landscape of rabies epidemiology and control. Onderstepoort J Vet Res. 2014;81). Surgical standards are compromised, with incomplete ovary removal and minimal if any sterility or pain medication. Often, monitoring and evaluation (M & E) is not carried out at all, done superficially, or data manipulated to show more impressive results than is the reality.
It's an easy one, at least in theory. Find enough money to do it well. At the scale of nationwide eradication, large INGO and government funding is indispensable. It is essential that this funding is output and impact driven, transparently monitored and available to all contributing stakeholders to encourage a One Health model.
Until recently rabies control in Sri Lanka was conducted exclusively by the government human health sector. Their strategy focused on human postexposure prophylaxis (PEP), with USD 2.7 million spent in 2010 (PHVS statistics 2010) compared to animal rabies vaccination (USD 230,000/yr). Rabies control is expected to reduce the amount spent on PEP. In SL, however, due to the well-educated public and good low-cost or free healthcare, people will seek out and be given PEP, as there is zero tolerance for uncertainty. Thus PEP cost is likely to remain high even with reducing rabies numbers, until eradication is finally achieved or the medical sector is extensively re-educated on rational PEP use. Thus in the Sri Lankan situation, financial outlay is both high and immediate, while economic gain and better human and animal welfare will be a relatively distant reality.
Problem 3: Sharing Money and Resources Between Stakeholders
This is always a contentious issue. No one wants to give up or share any of their difficult to procure finances. Traditionally, funds for rabies control are allocated to the health ministry. Expecting them to then distribute significant amounts from this to the agriculture ministry and DAPH, or anyone else, is unrealistic. The ground reality is that although the health ministry is expected to divert funds to DAPH etc. As expected this is not happening. The DAPH has ideas and a program, but no money to implement them.
INGOs and other funders must look at the national plan and fund each expected output separately, to the group who is expected to carry out the tasks, again not excluding the local NGO sector.
Problem 4: Corruption and Kickbacks, or More Diplomatically, Commissions
The process of rabies eradication provides access to lots of jobs, funds, including vaccine and PEP procurements, payments for sterilizations, etc.; thus, there may be many who are reluctant to close this lucrative source by achieving eradication.
This may be a considerable challenge. Funding agencies, including government and local government, must undertake close monitoring and demonstrate transparency by engaging external auditors.
Problem 5: Surveillance
Effective surveillance of dog rabies is only available in Colombo at present. Rabies is mostly tracked through the reported human cases via hospital records. Although legally dog rabies is a notifiable disease, the ground reality is that veterinarians and the public rarely report it, often due to logistical difficulties. Diagnostic capacity is being upgraded, which is a good start.
Effective and practical systems of surveillance need to planned and implemented urgently, which will be a considerable challenge.
Problem 6: Administrative Difficulties
There is a lack of knowledge on recent advances in rabies control at the decision-maker level. There is quite a strong and overriding bureaucracy in most government departments with conventional staff and processes, habitually quite intractable and inflexible.
High-level government officers are difficult to educate as they invariably attend initial opening session of meetings to provide a token presence or support, but are mostly too busy to sit through the main sessions that impart learning. Effective decisionmaking can be difficult if they cannot correctly choose between the varieties of professional opinions voiced. As an example, many veterinarians still feel culling and reducing dog numbers helps both rabies and, more importantly for some, the nuisance factor. This seems intuitively valid and influences policy.
Almost all key decisionmaking administrative officers are faced with conflicting interests and diverse priorities. Short-term priorities and benefits may be perceived as more important. These may, in fact, be more important from their perspective. It may be useful to develop a series of progressive milestones with innovative incentives for stepwise achievement. A pertinent example is the conflicting issues of nuisance, city beautification and rabies control. In Sri Lanka the current developmental drive is for roaming dog free cities. City planners want this to happen yesterday. In Colombo they have begun to catch and remove vaccinated, sterilized dogs and thus seriously destabilize the Colombo rabies control project.
Identify key decision makers. Create a short, but complete and interesting, information session that covers all indispensable features. Work closely with these authorities to identify the time periods where they are most available. Determine creative incentives for the identified leaders to stay through the program. INGOs may be able to link full participation as a condition of funding.
Problem 7: Cost and Effort for M & E and the Need for Objective and Unbiased M & E Are Challenging Factors
Planning, executing and analysis of information gathered, as well as accepting weakness, shortcomings and constructive criticism of programs, are important, yet can be awkward and are often sensitive issues.
It is best if the M & E is done by a neutral and independent organization to the one carrying out the project. Thus, this is an area where NGOs such as BPT can play a significant role. Again, donors should identify the organization, methodology and standards of M & E required at commencement.
Problem 8: Difficulty in Field Implementation
Detailing out the more general national plan to action plans at local implementation level is a critical undertaking. Adapting and modifying the national plan to meet the requirements and limitations of the different local areas where implementation has to occur, yet ensuring that national level impact is secured will require creative and diligent effort. Creating flexibility in plans so changes can be instituted in a timely manner based on practical field situations and results of M & E will be important.
The current proposal by the DAPH to create a Veterinary Public Health Network, though ambitious, is in my opinion essential if high quality field level implementation plans are to be prepared and effectively executed.
One medicine must be in place for One Health to become a ground reality. Mutual respect between various sectors, with sharing of knowledge, resources, data and information in a coordinated, efficient & integrated manner is paramount. This is a serious HR challenge that is sometimes recognized but rarely given adequate prominence or translated into a definitive action. A knowledgeable yet neutral 3rd party specifically empowered and entrusted to realize this aspect is central to making One Health happen.
All components will require strong commitments from global as well as local decision makers and must be coupled with adequate financial, strategic and human resource capacity if rabies elimination in Sri Lanka is to become a grounded reality.
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