Rabies in India: Current Scenario and Prospects of Elimination

IN A NUTSHELL
Author's Note
India has the highest burden of human rabies, as annually an estimated 20,000 deaths are known to occur and this accounts for nearly one-third of the annual global burden of about 55,000 to 60,000 deaths. This article turns the spotlight on what this scourge means for India whereby prospects of (and difficulties in) eliminating dog mediated human rabies from India by 2030 are taken into consideration

By Professor (Dr) Tanushree Mondal

Editor – APCRI  Journal

Professor of Community Medicine, RG Kar Medical College, Kolkata, India

profcmrgkmc24@gmail.com

Dr. M.K. Sudarshan*

Founder President and Mentor

APCRI, Bangalore, India

Email: mksudarshan@gmail.com

Rabies in India

Current Scenario and Prospects of Elimination

 

Rabies is a practically 100% fatal disease and the very few who have survived are with residual neurological disabilities for the rest of their lives.  Rabies is caused by a virus known as rhabdovirus that is present in the saliva of rabid animals.  Following bites, scratches and even licks on wounds by rabid animals, the virus is deposited in the wound/s.  If timely and proper lifesaving post –bite/ exposure prophylaxis (PEP) is not received by the rabies exposed person, then the virus travels via the nerves and reaches the brain. This usually takes about 3 weeks to 3 months, known as incubation period. Subsequently the person manifests with symptoms of the disease like fever, headache, body ache, fear of water (hydrophobia), fear of breeze (aerophobia), fear of light (photophobia), spasm or paralysis, etc and ordinarily survives for 2 to 5 days. In the majority, the death is very painful and agonizing.

The Current Scenario

The burden of human rabies

India has the highest burden of human rabies, as annually an estimated 20,000 deaths (1) are known to occur and this accounts for nearly one-third of the annual global burden of about 55,000 to 60,000 deaths (2). The principal vector of the disease is dogs accounting for 99% human rabies globally and 97% in India. The other animals involved in rabies transmission in India are cats (2%) and wild animals (1%) like mongoose, jackals, wild dogs and others. But this figure is now two decades old and not tenable. Interestingly, another national multicentric rabies survey done recently in 2022-23 by Indian Council of Medical Research has shown that 5726 human rabies are estimated to occur annually in the country (3), which appears realistic but needs its acceptance by Government of India. The sooner it happens it is good for India.  This is because in the last two decades much progress has been made like the sheep brain/Semple vaccine was discontinued and replaced by modern rabies vaccines in 2005, cost–effective intra-dermal rabies vaccination (IDRV) was introduced in 2006, vast improvents in the logistics of rabies biologics following better transportation and communications and lastly, there is an overall upliftment in the socio-economic status of the people.  All these have contributed to the reduced number of human rabies deaths in the country. 

The dogs and their role in disease transmission

As per Indian ethos and constitution, all living beings have a right to live and co-exist in the society. The dogs are popular pets in 11.3 % households in India (4). Also, there are a large proportion of dogs in the neighbourhood known as community dogs, also referred to as stray/street dogs. It is estimated that there are about 90 million dogs in the country of which 30 million are pets and 60 million community dogs/strays. In 2001, for the safety and welfare of these stray dogs under the prevention of cruelty to animals act (PCA 1960), animal birth control (ABC) rules were passed in the parliament that ensure no harm is done to stray dogs and the civic municipal bodies take care of them.

The World Health Organization – Association for Prevention and Control of rabies in India (WHO –APCRI) national multicentric rabies surveys done in 2003 and 2017 showed that 96.2% and 83% of human rabies deaths respectively in the country were following dog bites.

Figure 1: A dog chasing a motorcyclist, a common sight in the cities of India 

The WHO – APCRI national multicentric survey of 2003 showed an estimated 17.4 million animal bites occurred annually in India. However, two decades later in 2022-23, the national multicentric survey of Indian Council of Medical Research (ICMR), showed it to be around 9.1 million, but this survey had some limitation like the effect of the ongoing Covid pandemic in the country, etc.

Unfortunately, rarely there are instances of unsupervised infants and toddlers and the very old being mauled to death by pack of dogs in the communities.  Also, the sudden and unexpected aggression by street dogs have led to injuries, maiming and even human deaths due to accidents.  As a result, often there are conflicts in the populations about having strays on the streets. The animal welfare organizations (AWOs) are very protective and vocal about welfare of stray dogs in the country. Recently, as per the guidelines of animal welfare board of India (AWBI), there are attempts by civic bodies in the country to feed these stray dogs timely in the day at designated places by identified and trained community volunteers and that is expected to reduce aggression of the street dogs.

Prospects of elimination of dog mediated human rabies from India by 2030

The World Health Organization and other UN agencies in 2015 together pledged to eliminate dog mediated human rabies from the world by 2030, and the slogan is zero by thirty.  That is to eliminate 99% of the global burden of human rabies by 2030. Consequently, in sync with the global plan, in 2021 Government of India, despite the ongoing Covid-19 pandemic, launched the national action plan for rabies elimination (NAPRE) (5). As India has a federal structure, based on the NAPRE, the states have commenced state action plans for rabies elimination (SAPRE) by 2030.  To prioritize and accelerate the progress, from 2024, rabies free cities action plans are being implemented (6). The key components of all of these are – providing free rabies post – exposure prophylaxis (PEP) to all rabies exposed individuals timely, correctly and completely; mass dog vaccination (MDV) covering 70% of the dogs in the community, dog population management (DPM), promoting responsible pet ownership and advocacy, awareness, education, and operational research. The key elements for achieving these are – 3Ps i.e. prevention, promotion and partnership.

In view of large reservoir of rabies in the dog population in the country, federal structure and varying degrees of progress and performances by the states, inadequate resources and weak intersectoral coordination and cooperation, the elimination of dog mediated human rabies by 2030 appears difficult. Hence, it is recommended that the zero by thirty action plan be implemented as a 100% centrally sponsored programme with the same vigour and force of polio eradication. Only then tangible benefits will be seen soon on the ground.

 

References

  1. Assessing burden of rabies in India: WHO sponsored national multi-centric rabies survey 2003. Association for Prevention and Control of Rabies in India https://www.researchgate.net/publication/45261915_Assessing_Burden_of_Rabies_in_India_WHO_Sponsored_National_Multicentric_Rabies_Survey_2003
  2. WHO Expert Consultation on Rabies: WHO TRS N°1012 Third report, 14 April 2018 https://www.who.int/publications/i/item/WHO-TRS-1012
  3. Estimates of the burden of human rabies deaths and animal bites in India, 2022–23: A community-based cross-sectional survey and probability decision-tree modelling study. Jeromie Wesley VivianThangarajet al The Lancet Infectious Diseases Volume 25, Issue 1, January 2025, Pages 126-134 https://www.sciencedirect.com/science/article/abs/pii/S1473309924004900
  4. APCRI –WHO Indian Multicentric Rabies Survey , 2017 http://apcri.in/pdf/WHO-APCRI%20Rabies%20Survey,%202017%20-%20Final%20Report.pdf
  5. National Action Plan for Dog Mediated Rabies Elimination from India by 2030 https://rr-asia.woah.org/app/uploads/2022/12/india-napre-rabies.pdf
  6. Ministry of Health and Family Welfare. Government of India. Operational Guidelines. Rabies Free City Initiative. A Step Towards Rabies Free India by 2030.https://ncdc.mohfw.gov.in/wp-content/uploads/2024/11/Rabies-Operational-Guidelines_25th-Sept_24.pdf

 

* Dr M. K. Sudarshan profile: 

Founder, President and Mentor, Association for Prevention and Control of Rabies in India,
Former Professor, Principal and Director, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, 
Chief Editor, Indian Journal of Public Health 
Member, WHO Expert Advisory panel on Rabies & Expert Consultations on Rabies, Member of National Technical Advisory Committee (NTAC) on Rabies
Leader in Health Research in India
Chairman, National Expert Consultation on Rabies and Chairman, Karnataka State Covid-19 Technical Advisory Committee (TAC) and Chair, South East Asia Region(SEAR)- Rabies Technical Advisory Group.
Recipient of Dr. B C Roy Doctor's Day for Excellence in Medical Education (2010), Lifetime Achievement Award (2013), Best Community Health Professional Award (2014), Rajyotasava Award (2021), Eminent Teacher Award from Rajiv Gandhi University of Health Sciences, Karnataka(2022), National Medical Recognition Award (2022) and Honorary Doctorate (D.Sc. Honoris Causa) in Science from Rajiv Gandhi University of Health Sciences (2023) and Dr I.C. Tiwari Memorial Lifetime Achievement Award (2025).

‘Universities in the Early Decades of the Third Millennium: Saving the World from Itself?’ and 1 HOPE-TDR Regional Project Proposals

IN A NUTSHELL
Author's Note
A re-proposal here of an invited chapter published in 2020 and focused on the re-conceptualisation of the university/higher education purpose and scope inside a ‘One Health’ overarching perspective. As divisive forces are increasingly placing institutions and society, indeed the world, at risk, the importance of 'seeing the big picture' and potential consequences of human folly, appears to be even more urgent and relevant today as it was a few years ago

George Lueddeke

 By George Lueddeke PhD

Global Lead, International One Health for One Planet Education & Transdisciplinary Research Initiative (1 HOPE-TDR)

Independent advisor in Higher, Medical and One Health education / research

Southampton, United Kingdom

‘Universities in the Early Decades of the Third Millennium: Saving the World from Itself?’ and 1 HOPE-TDR Regional Project Proposals

 

In support of Operationalising 1 HOPE-TDR  project proposals across global regions and  associated terms of reference, integrated as  ‘cultivating an active care for the world and with those with whom we share it’ [UNESCO] ,  find a PDF copy  below of an invited chapter titled Universities  in the early Decades of the third Millennium: Saving the World from itself?

Universities in the Early Decades of the Third Millennium

Summarised in the Abstract, the chapter, published in 2020, argued “for the re-conceptualisation of the university/higher education purpose and scope focusing on the development of an interconnected ecological knowledge system (recognising the interdependence of the 17 UN global goals) with a concern for the whole Earth -and beyond.”

Main themes (and chapter page references) include:

  • The university in the first two millennia: historical perspectives and takeaways (pp. 230-233)
  •  Existential challenges facing the planet and society in the twenty-first century (pp. 234-237)
  • War: “Humanity’s Greatest Failure” (pp.237-238)
  •  Social progress and the university (pp.238-239)
  • Toward a new worldview (pp. 239-245)
  • The international ‘One Health for One Planet Education initiative’ (pp.245-247)
  •  Re-imagining the university in the twenty-first century (pp. 247-249)
  • Reflection on teaching and learning in the ecological university (pp. 249-252)
  • The university: saving the world from itself?
  • Concluding comments: choosing our future (pp.256-260)
  • References (pp.260-266)

 

As divisive forces are increasingly placing institutions and society, indeed the world, at risk, the importance of ‘seeing the big picture’ and potential consequences of human folly, appears to be even more urgent and relevant today as it was a few years ago

 

 

News Flash 609: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Dorid nudibranch (Felimare picta)

News Flash 609

Weekly Snapshot of Public Health Challenges

 

Health system responses to population declines: call for papers

Call for papers (CFP) for APCRI (Association for Prevention and Control of Rabies in India) Journal: deadline April 15, 2025. Submit at https://medical.advancedresearchpublications.com/index.php/APCRIJ/login  or email to profcmrgkmc24@gmail.com

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COP16 Deal Commits Nations to Raise $200 Billion Annually for Biodiversity; But Funding A Big Lift

 

 

 

 

 

Examining the U.N. Sustainable Development Goals (SDGs) Using a One Health Approach: Profiling Cambodia, Laos, Thailand, and Viet Nam

IN A NUTSHELL
Author's note
…My One Health analysis on Cambodia, Laos, Thailand, and Viet Nam has shown that there are gaps in the SDGs, primarily in the domesticated animal and crop realm that impact human health and well-being. Antimicrobial resistance, zoonotic diseases, food safety, food security (from the production standpoint), soil health, pesticide use, and animal waste management are important areas that are being overlooked. Livestock and their wastes produce methane and nitrous oxide, potent greenhouse gasses. Unexploded ordnances contaminating environments and killing innocent people are also not tracked. SDGs that specifically follow these areas would provide important information to improve global health, well-being, and sustainability…

By Laura H. Kahn, MD, MPH, MPP

Co-Founder, One Health Initiative

Examining the U.N. Sustainable Development Goals (SDGs) Using a One Health Approach: Profiling Cambodia, Laos, Thailand, and Viet Nam

 

In 2024, I compared the Ecuadorian Amazon Rainforest to the Galapagos Islands using a One Health approach. One Health is the concept that human, animal, plant, environmental and ecosystem health are linked. This concept can be visualized as a multi-dimensional matrix, assisting health professionals, researchers, and policy makers to analyze and address complex health challenges in a concise, systematic, and comprehensive way.

One Health Multi-dimensional Matrix:

In this paper, I will use the One Health matrix as a lens to evaluate five of the United Nation’s Sustainable Development Goals (SDGs) as they pertain to four Southeast Asian countries: Thailand, Laos, Cambodia, and Vietnam. The five SDGs are: 2. Zero Hunger, 3. Good Health and Well Being, 6. Clean Water and Sanitation, 15. Life on Land, and 16. Peace, Justice, and Strong Institutions. Each of these SDGs has targets and indicators. An example of a target is SDG 6.1: By 2030, achieve universal and equitable access to safe and affordable drinking water for all. The indicator for this target is: Proportion of population using safely managed drinking water services. Targets typically have two or more indicators which are tracked over time. The trends are either positive, negative, or neutral.

United Nations Sustainable Development Goals:

The SDGs were developed in 2012, at a United Nations Conference on Sustainable Development in Rio de Janeiro, Brazil. The delegates created seventeen SDGs to reduce hunger, disease, deforestation, biodiversity loss, and other global issues by 2030. Since 2016, the UN’s Department of Economic and Social Affairs has issued annual SDG Reports, which evaluate progress towards the goals using indicator trends. For example, Goal 2: Zero Hunger has targets for success including ending malnutrition, stunting, and wasting in children under age 5. Goal 3. Good Health and Well-Being has targets that seek to reduce rates of mortality in infants, new mothers, children, and other groups as well as reducing rates of infectious and chronic diseases. For Goal 15. Life on Land, the targets range from halting deforestation to ending poaching and trafficking of endangered species. Other SDGs also involve One Health elements (i.e., SDGs 11, 12, 13, and 14), but for the sake of time, will not be included in this analysis.

The 2024 report, released on June 28th, found that while some of the SDGs have made progress, such as preventing HIV infections and improving education access for girls, others have fallen short or have regressed, particularly in the wake of the Covid-19 pandemic. Problematic areas include worsening food insecurities, diminishing vaccine delivery to children, worsening access to clean water and sanitation, escalating geopolitical conflicts, and increasing species extinction risks. Country Profiles of the 17 SDGs targets and indicators for the 193 UN Member States highlight the trends.

Since I recently visited the Southeast Asian countries of Cambodia, Laos, Thailand, and Vietnam, I will examine them at the population level using the One Health matrix and compare the findings with the SDGs.

To understand the political, social, and economic factors of Cambodia, Laos, Thailand, and Vietnam, we must first briefly review the history of the region. 

Brief Historical Background

The ancient Khmer empire (802 CE to 1431 CE) of Cambodia encompassed much of the region that would subsequently become Thailand and Laos, influencing their languages, cultures, and traditions. In the mid-14th century, a Tai army attacked the Khmer empire’s capital at Angkor, contributing to its decline, and eventually becoming a Tai vassal state. The Khmer empire was succeeded by the Ayutthaya Kingdom (1351 to 1767) which became the precursor of modern Thailand.

Of the four countries, only Thailand avoided being colonized by European powers. Britain and France decided that Thailand would provide a useful buffer zone between the British colony of Burma and the French colony of Indochina. During World War 2, Thailand was under the rule of a military dictator named Phibunsongkhram, aka Phibun, who allowed Imperial Japan to build its infamous Thailand-Burma Railway, nicknamed the “death” railway within its borders. After the war, resistance groups forced Phibun to resign. Thailand subsequently became a pro-Western country, allying with the U.S. during the Cold War, and benefitting financially from U.S. economic and military aid during the Vietnam War.

In contrast to Thailand, Vietnam had been colonized by a succession of Chinese dynasties for 1000 years, from 111 BC to 939 AD, enduring a long history of warfare.  From the 11th to 18th centuries, Vietnam conquered parts of the Khmer empire and spread southward, but outbreaks of fighting between different war lords developed. France established a colony in Vietnam after assisting one of the war lords, and by the late 19th century, it had gained control of Vietnam, Cambodia, and Laos, calling the region French Indochina. France used the colonies for their natural resources.

Resistance movements began soon after the French takeover.

Ho Chi Minh (1890-1969) was the leader of a major Vietnamese resistance movement, advocating for the independence of Indochina, and became a founding member of the Vietnamese Communist Party. He sought assistance from delegates at the Versailles peace conference at the end of World War I but was rebuffed.

At the end of World War II, he sought help from President Harry S. Truman for independence from French rule. Truman sided with the French. With Chinese assistance, Vietnamese Communist troops, called the Viet Minh, defeated the French at the Battle of Dien Bien Phu in 1954. Indochina was divided into communist North Vietnam, non-communist South Vietnam, Cambodia, and Laos. One year later, Ho Chi Minh visited Moscow and secured economic and military aid from Leonid Brezhnev. This sequence of events led to war in Southeast Asia (1961-1973) as the U.S. sought to contain the spread of communism. The North Vietnamese and their allies defeated the U.S. which was forced to withdraw.

The U.S. heavily bombed Cambodia and Laos during the war in Vietnam. Civil war broke out in Cambodia, and in 1975, Pol Pot, the Communist leader of the Khmer Rouge seized control and began persecuting those whom the communists considered tainted by capitalism. Over the next four years, the Khmer Rouge committed genocide, killing over 1.7 million people. The Vietnamese invaded in 1979 and removed the Khmer Rouge from power. The horrors of the Khmer Rouge regime have inflicted long lasting traumas on the Cambodian people. Laos endured a secret war lasting from 1964 to 1973 during which time the U.S. bombed large areas of the country. The unexploded ordnances (UXO) contaminate the land and continue to kill innocent people.

Political, Social, and Economic Factors and SDG 16. 

Of the four countries, only Thailand escaped war with the U.S. and its bombing campaigns. Both Vietnam and Cambodia experienced civil war, but Cambodia alone endured the 5-year genocide involving 47% of its people. The survivors and their descendants continue to bear the scars of the atrocities. Cambodia has the lowest Human Development Index score even though Laos has the lowest GDP per capita. The Human Development Index is a composite score for life expectancy, education level attainment for adults aged 25 years, and gross national income per capita. None of the SDGs use the HDI as an indicator. 

Vietnam, a communist country, has the highest Happiness Index score. Their social cohesion appears high. The Happiness Index is based on a survey of subjective well-being by the Gallup World Poll. None of the SDGs use the Happiness Index as an indicator.

Transparency International is a nongovernmental organization with the mission to stop corruption and promote transparent and responsible government.  Of the four countries, the Vietnamese consider their country the least corrupt, with a Corruption Perception Index (CPI) score of 41/100, compared to the other three countries which have lower scores. Cambodians ranked their country as the most corrupt (CPI score 22). Thailand is the wealthiest of the four countries economically. It is considered moderately corrupt with a CPI score of 35/100 but ranked moderately happy. SDG 16. Peace and Justice targets 16.5 – 16.8 track corruption using the CPI.

(In comparison, Denmark and Finland are the least corrupt countries in the world, scoring 90 and 87, respectively, and they are the world’s happiest countries.)

The One Health matrix’s third dimension of political, social, and economic factors overlaps with SDG 16 which has targets such as: reducing rates of corruption, improving transparent government, and enforcing laws and policies for sustainable development.

Please see Table 1 below

One Health Factors and SDGs 2, 3, 6, 15 

Vietnam has the largest population and highest population density in the Greater Mekong Delta region. (Note: The region is named after the Mekong River which flows through all four countries as well as China, and Myanmar.)

SDG 2. Zero Hunger targets include prevalence rates of undernourishment or food insecurity, volume of food production, and agriculture orientation index of government expenditures, and agricultural export subsidies, among others. It does not include UN Food and Agriculture Organization data such as crop yields or national livestock inventories. The focus is on food consumption but not on food production.

Thailand has the most land surface area followed by Vietnam, Laos, and Cambodia. It also has the most arable land for agriculture. Vietnam has less than half the arable land area as Thailand, but it is an agricultural powerhouse, being one of the largest producers of rice and coffee in the world.

Although food safety is briefly mentioned in Target 2.1, none of the indicators specifically track foodborne illness rates.

Food waste is tracked in SDG 12 by a food loss index and the food waste index.

SDG 3. Good Health and Well-Being. Thailand and Vietnam have comparable life expectancies although Thailand spends over two times more on healthcare per capita than Vietnam. Both countries have lower crude death rates, infant mortality rates, and fertility rates than Cambodia and Laos. Laos has the highest infant mortality rate and lowest life expectancy of the four countries. It spends five times less on healthcare per capita than Thailand. SDG 3. follows these metrics, but its targets do not include One Health issues such as reducing antimicrobial resistance or zoonotic diseases such as rabies, particularly in dogs, which is a major problem in the region.

In 2023, the WHO listed antimicrobial resistance as one of the top global public health and development threats in the world, directly responsible for an estimated 1.27 million deaths and indirectly responsible for almost 5 million deaths in 2019. Misuse and overuse of antimicrobials occur in human, animal, and plant health. It is a major One Health issue that includes environmental and ecosystem health. In 2015, WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) to track global antimicrobial consumption using a One Health surveillance model. As of 2022, WHO provides profiles of the member countries.

Dengue is a deadly mosquito-borne disease. Over 7.6 million cases were reported to WHO in 2024. Rates have been increasing, and with climate change, are likely to get worse. WHO began a global surveillance database for dengue.

The SDGs track malaria, tuberculosis, HIV, and neglected nontropical diseases, but they do not track rabies, a deadly zoonotic disease that causes almost 60,000 deaths in over 150 countries, particularly in Africa and Asia.  Rabies is a major problem in Southeast Asia. The virus is usually spread by dog bites.

SDG 6. Clean Water and Sanitation. The targets include the proportion of a population that has access to safe drinking water and sanitation facilities that dispose of human waste. Sanitation systems are designed to process human waste, not animal waste. Animal waste, particularly domestic animal waste, is typically not processed even though most fecal waste produced is from animals. Animal waste contaminates waterways and crops and contributes to water and foodborne illnesses. It might also be a source of antimicrobial resistant pathogens, particularly in Southeast Asia.

SDG 15. Life on Land. Laos is the only country that is landlocked, but it has the highest percentage of forested land. Cambodia has the highest deforestation rate followed by Vietnam, Laos, and Thailand.

All four countries have moderately poor air quality, but Thailand and Vietnam have the best water quality. Measurements of soil quality have yet to be published.

Endangered species are listed by taxonomic groups in the “Red List Index.” These groups include amphibians, mammals, cycads, and warm-water reef-forming corals. Endangered sentinel species are not profiled. The World Wildlife Fund considers elephants and tigers to be endangered sentinel species in the Greater Mekong region. Laos was once known as the “Land of a Million Elephants” because historically it had the most wild elephants. In the latest count, the country had approximately 400 wild elephants left. Vietnam had less than 200 while Thailand had over 3,000. Wild tigers are extinct in Cambodia, Laos, and Vietnam. Less than 250 tigers exist in Thailand. People care about specific charismatic animals, such as elephants and large cats. Tracking an endangered species index is vitally important, but profiling specific endangered animals that people feel passionate about might be equally important.

Please see Table 2 below

 One Health Matrix Identified SDG Gaps 

No Human Development Index (HDI) -life expectancy, income, education.

No Happiness Index—a measure of social well-being.

Food Security is tracked by consumption and less so on production.

No Food Safety or Foodborne Illness rates are tracked. (SDG 12 includes Food Loss and Food Waste)

Specific Antimicrobial Resistance (AMR) rates in humans or animals are not tracked.

Zoonotic diseases such as rabies death rates are not tracked.

Vaccination Rates in animals, such as canine vaccination rates against rabies, are not tracked.

Domestic Animal Health (e.g., cats, dogs, or livestock) is not represented in SDGs.

Soil health is not tracked.

Crop production and yields are not tracked.

Livestock production and yields are not tracked.

Pesticide use in crops is not tracked.

There is no Domestic Animal Waste Production Index

There is no Domestic Animal Waste Management Index.

Specific Endangered Sentinel Wildlife are not tracked.

Unexploded ordnances not tracked in war-torn nations. 

Conclusions 

Colonization and war have severe consequences for a nation’s health, wealth, and well-being. The history of the four Southeast Asian countries profiled in this paper illustrates this point. Thailand was never colonized and avoided war. From a One Health perspective, its people, animals, and environments are faring the best, although Vietnam, despite its war-torn history, is a close second. The fact that Vietnam defeated the United States during the 20th century war is a likely explanation for the optimism, social cohesion, and dynamism of its people. Comparing the Corruption Perceptions Index and Happiness Index of the four countries finds that Vietnam ranks the highest of these two measures even though Thailand is technically the wealthiest of the four based on its GDP and Health Expenditures. 

My One Health analysis has shown that there are gaps in the SDGs, primarily in the domesticated animal and crop realm that impact human health and well-being. Antimicrobial resistance, zoonotic diseases, food safety, food security (from the production standpoint), soil health, pesticide use, and animal waste management are important areas that are being overlooked. Livestock and their wastes produce methane and nitrous oxide, potent greenhouse gasses. Unexploded ordnances contaminating environments and killing innocent people are also not tracked. SDGs that specifically follow these areas would provide important information to improve global health, well-being, and sustainability.

The 17 UN SDGs represent a global vision to improve life on Earth for all countries and for all peoples. Tracking the many targets and indicators over the years has been a monumental effort and a testament to the commitment by the international community to achieve these goals. The challenges of the 21st century will make these efforts increasingly important. A One Health approach should be included to ensure healthy animals, plants, environments, and ecosystems. 

 

Table 1. Political, Social, Economic Factors

Country Cambodia Laos Thailand Vietnam
Political Factors        
U.S.-Southeast Asia

War/Bombing Campaigns

Yes Yes No Yes
Civil War Yes (with genocide) No No Yes
Current Political System Constitutional Monarchy Communist Parliamentary democracy with a Constitutional Monarchy Communist
Social Factors
Corruption Perceptions Index Score 2023 22 28 35 41
Happiness Index

2021-2023

4.34 5.14 5.98 6.04
Economic Factors
GDP Per Capita (Current US$) (2023) 2429.7 2066.9 7182.0 4282.1
Human Development Index (2022) 0.600 0.620 0.803 0.726
Health Expenditure Per Capita (Current US$) (2021) 122.42 68.88 364.37 172.55

 

 Table 2. One Health Factors at Population Levels

Country Cambodia Laos Thailand Vietnam
Humans
Population 17.6 million 7.8 million 71.7 million 100.9 million
Population Density (people per km2) 100 34 140.1 328
Estimate of total human fecal production (kg/yr) 1.9 X 109 8.5 X 108 7.8 X 109 8.9 X 109
Life Expectancy for Both Sexes in Years (2024) 70.82 69.23 76.56 74.74
Total Fertility Rate (Live Births per Woman) (2024) 2.5 2.4 1.2 1.9
Infant Mortality Rate, Both Sexes, Probability of Dying Between Birth and Age 1 per 1000 Live Births (2022) 20.3

 

32.7

 

7.0 16.2
Crude Death Rate per 1,000 population 6.78 6.05 5.05 5.5
Dengue (total reported cases, 2024) 18,983 19,486 104,681 103,078
Rabies, reported human deaths 2022 No data, but  reportedly has one of the highest death rates in the world from rabid dog bites. 20 3 70
Animals (Domestic Livestock and Sentinel Wildlife Species)
Dogs (2021/2023) 5 million Est. 5 million 12.8 million 5.5 million
Chickens (per 1000 animals) (2023) 12,817 52,235 288,758 457,221
Ducks (per 1000 animals) (2023) 8,878 3,693 15,504 87,645
Buffalo (2023) 665,269 1,211,949 889,775 2,136,009
Cattle (2023) 2,611,835 2,542,707 4,630,798 6,331,895
Goats (2023) Est.400,000 786,965 483,417 3,088,328
Horses (2023) 31,585 32,000 7,230 48,821
Pigs/Swine (2023) 2,036,958 4,525,574 7,721,375 25,546,030
Estimated Total Domestic Animal Fecal Waste (kg/year) 2.6X109 3.7X109 7.0X109 13.6X109
Wild Elephant Population 400 to 600 400 3,084-3,500 <200
Wild Tiger Population Extinct Extinct 179-223 Extinct
Plants (Domestic)
Arable Land for Agriculture

(hectares) 2022

4,120 1,224 17,150 6,754
Coffee, green (2023) 365 tons 177,662 tons 16,575 tons 1,956,782 tons
Rice (2023) 12,900,000 tons 3,835,000 tons 33,070,957 tons 43,497,625 tons
Environments and Ecosystems
Air Quality.

Average Particulate Matter 2.5 microns (PM2.5),

2023

73 ug/m3 (Moderate)

 

88 ug/m3 (Moderate)

 

74 ug/m3

(Moderate)

 

88 ug/m3 (Moderate)

 

Water Quality. Environmental Performance Index (EPI) 2023 40.0 32.2 51.3 54.3
Soil Quality Asian Soil Laboratory Network (SEALNET), established in 2017, has not yet issued a report.
Percent Land Contamination with unexploded ordnance (UXO) >20% >20% Along Thai-Cambodian border >20%

 

Methodology used to calculate human and animal fecal waste production based on 2018 Nature Sustainability paper by Berendes, et al. ChatGPT used to estimate adult human and animal body weights and to calculate fecal production per human and animal populations.

 

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INTERVIEW: Sebastian Kevany

IN A NUTSHELL
Editor's note



An accomplished professional with years of experience across global health, diplomacy, international relations, development, and humanitarian assistance, Dr Sebastian Kevany has conducted over 100 field missions to Africa, the Middle East, the South Pacific, Eastern Europe, and Asia with a focus on monitoring and evaluation, health security, human rights, biosecurity, health sector governance, research, and operational site visits.

Dr Kevany holds BA and MA degrees from Trinity College Dublin, an MPH degree from the University of Cape Town, is an adjunct assistant professor at Trinity College Dublin, an academic affiliate of the Center for AIDS Prevention Studies at the University of California, San Francisco, and specializes in short term international technical assistance.

Currently, He is publishing his third public health book, this time on the relationship between climate change and public health.

In this connection, PEAH had the pleasure to arrange an interview relevant to the thematic issues of his upcoming book filtered through his experience and critical lens

By Daniele Dionisio

PEAH – Policies for Equitable Access to Health

 INTERVIEW

Sebastian Kevany

Global Health Security and Diplomacy

United Nations University

 

PEAHDr Kevany, can you detail about the main themes of your near to be finalized book tentatively entitled CLIMATE CHANGE, PUBLIC HEALTH, AND REGIONAL SECURITY IN THE INDOPACIFIC: FROM MITIGATION TO ADAPTATION?

Kevany: Daniele, thank you. So your first question, detail about the main themes of the book.

You know, it’s unquestionably, these days, a controversial subject. So I try to stay away from the controversial side, Daniele, and, think about specifically the links between the environment, as in climate, weather events, natural disasters, whatever you wanna call it, even political, environment, economic, but mainly environmental in terms of the natural environment, and its connection with human health, not just public health, but day to day individual level human health. It could be obesity. It could be mental health. Could be infectious disease, any of the above.

And, the Indo Pacific region is, of course, where all the action is, I guess you could say, in this regard.

PEAHThe book results from a number of chapters and a group of contributors. What as regards its scope and aims?

Kevany: As regards the scope and aims of the book, it is intended to generate inputs from not necessarily experts, but day to day, normal people living in the region, Hawaii, Philippines, even as far away as Pakistan, India, and to try and get an understanding for their experiences personally and professionally. Many of these people will have come from environmental or public health backgrounds. So just sharing their stories. Could be a nurse from The Philippines or a military officer from Sri Lanka. What is this connection that they have experienced, and what do they look, what do they expect to see in the future regarding the connection between climate change, public health, and, regional security.

PEAHIs there still room to include in the book additional contributions, either personal or professional, while enhancing its impact through as many views and experiences as possible?

Kevany: Regarding additional contributions, absolutely. There is room to include, at this stage, both personal and professional reflections, essays, or other inputs, and as you rightly say, enhancing its impact to as many views and experiences as possible.

PEAH: Let us know, please, about your global health and humanitarian background as part of your engagement with international agencies and organizations.

Kevany: My background, Daniele, yes, I guess it’s been a very engaging, adventurous, just amazing journey for me regarding efforts in global health, public health, I guess you could say humanitarian development.

And it’s involved WHO-World Health Organization, various United Nations organizations, the Global Fund to Fight AIDS, TB, Malaria, bilateral initiatives and NGOs, of course.

So it’s been, I’ve been so lucky, you know, to have done that work at a stage in history when it was a very dynamic field.

And I got to see a lot of the world, I feel that the efforts made an impact, not just a charitable impact, but in terms of international relations and international security as well.

PEAHDr Kevany, what’s your position as regards sentences below by All Life Institute (as “a global think tank uniquely dedicated to protecting and enhancing all life on this planet including humans, nonhumans and the Earth.”)?

  • “All that we do depends upon abundant plant and animal life as well as clean air and water.”
  • “Our collective future depends upon the decisions that we are making now.”

Kevany: In regards to the statements by the All Life Institute, you know, and thank you for the description of the Institute. It reminds me of the One Health approach, of course, when you quote  ‘’All that we do depends upon abundant plant and animal life, as well as clean air and water’’. For me personally, and based on my professional experience, it’s true.

It is a true statement. Without clean air, without clean water, the effects on human health are just one part of the consequences, because you have to deal as well with effects on the environment, all of these, I guess, indirect effects on human health. You know, not just the natural environment and the health and aesthetics of that realm, but also in terms of agriculture, in terms of social functioning, in terms of economics, which then leads into politics and national stability.

And in the same way, yeah, of course, our collective future does depend on the decisions that we are making now. But for both quotes, what I would suggest is this is not obvious and it’s hard to prove. And in theory, it is logical.

But we’re just getting into a stage, I think, when we’re becoming more aware of the finite nature of the Earth’s resources in the context of human population. It’s not something that was very much in our consciousness a generation ago. It wasn’t part of economic theory, which promoted growth and gross domestic product and those kind of indicators as the number one measures of success, I guess you could say, personally or nationally.

And it was before the themes of resilience started to emerge. Now, successful countries, successful communities, even successful individuals are less and less measured in terms of their worth and value and what you might call success by economic productivity, because you can be economically productive, but also destroy the environment. So it’s short term economic productivity.

And now that we’re putting a price, a value on the environment and not just seeing it as infinite, you know, as we see species become extinct, as we see natural areas become more limited, as we become more aware of the Earth as, I guess, an organism, you know, and as we move more towards one world, one people. It’s this breakthrough that came, I think, with looking at the Earth from space and seeing it for the first time as something beautiful, but also fragile and potentially vulnerable.

PEAHThis links in with re-orienting practises and behaviours by governments, corporations and civil society towards reversing climate deterioration. What would you recommend?

Kevany: In terms of practises and behaviours by governments, corporations and civil society towards reversing climate deterioration, it’s a complex issue. It sounds so simple. It sounds as if we should simply say this is what needs to be done in order to preserve the natural environment and these should be the policies.

What I’ve experienced, one thing I’ve experienced more than anything else is exposure to extreme poverty in the world and that’s, you know, up to perhaps some might say 90% of the world’s population. And what I have noticed, Daniele, in those environments is no one is going to spend more money for environmental protection. No one is going to switch to unleaded fuel if it’s more expensive. No one is going to stop using plastic bags if it’s essential to their survival. No one is going to spend more on the environment if it costs them the price of an extra loaf of bread, so to speak. So, in a way, these are the people.

These are the behaviours that are going to determine the success of any such policies. And so the policies themselves will not be effective, I think, until global poverty and inequality has been addressed. And, of course, that is not an easy thing to do.

Maybe that is an impossible thing to do.

 PEAHIn this connection, do you agree with statement whereby “What is good for nonhumans and the Earth is virtually always in the best interests of humans, given the profound interdependence of all life.”?

Kevany: Regarding this statement, ‘’What is good for non-humans, and the earth is virtually always in the best interest of humans, given the profound interdependence of all life’’, you know, I came across a quote from Marcus Aurelius, your countryman, Daniele, and it was put very simply, what is bad for the beehive is bad for the bees. Unquestionably, what is good for the earth is good for humans. 

PEAH: Aiming to fill the health and development gaps you are dealing with, which partners do you currently count on?

Kevany: In regards to the health and development gaps, what I would suggest, Daniele, is that there’s possibly a transition happening. The world has changed so much. When my dad was a public health professional, say, in the 1960s working for Pan-American Health Organization, and in those days, it was so clear that there was the developed world and the developing world, and the developed world did its best to help poor countries, what was called the Third World, to control irradicable or to control diseases that cures were available for. It was that simple. And that happened. And since then, it’s gotten more complex, you know HIV, TB, malaria, no easy way out. And the dynamic has also changed between the developed and the developing world.

I don’t think that distinction is there anymore. There are incredibly impoverished, poor, miserable places in rich countries. And there’s a lot of prosperity, even though it can be isolated in what was formerly known as the developing world. Everything has become a little bit blurred here in the 21st century. So what I would suggest, especially given the current funding environment, is that I don’t think counting on partners is the way forward. I think anyone can be a partner, and anyone can be a reliable partner. But the movement, I guess, is away from dependence on funding and more towards technical assistance. So bring in an expert, bring in a consultant, bring in someone who knows about health systems, and let them visit the clinics, let them visit the Ministry of Health, and let them talk to the administrators and offer, if asked, their suggestions on how things might be done differently, or modernized without reliance on investment, just using the skills that are there, using the infrastructures there, that is there using the traditional systems. And that is not going to cost people a huge amount. It’s not going to be reliant on funding. You’re not going to have to count on partners. It’s going to be internally reliant. And I think that’s maybe the best strategy for now.

PEAHThank you Dr. Kevany for the excellent work joining diplomacy and humanitarian commitment.

Kevany: Thank you as well, Daniele. Thank you for your recognition of the need to connect international relations, security, diplomacy, humanitarianism, development, and health.

 

 

Framing Health and Well-Being: a Positive Confrontation Between Life and Social Sciences as a Trigger/Engine for Public Health Challenges

IN A NUTSHELL
Author's note
What are the implications for the universal frameworks of Health in All Policies and the Social Determinants of Health as mechanisms in-between recent geo-political tensions. And how do these (future) developments impact on health and well-being of global citizens, communities and cities in need of basic supplies, food and water?

By Dr. Tomas Mainil

Phd, Ma, Msc, PD, Senior Lecturer/Researcher and Strategic Policy Analyst Breda University of Applied Sciences, the Netherlands

 

Framing Health and Well-Being

A Positive Confrontation Between Life and Social Sciences as a Trigger/Engine for Public Health Challenges

 

An innovative combination of life and social sciences – with the aid of disruptive technologies, such as AI, Lidar and Blockchain – can generate technological approaches to cater solutions for global patients and health professionals.  Both our own well-being as patients and our health systems could be influenced by a sustainable insertion of disruptive technologies, but only if these strategies are framed within the 16 UN sustainability goals.

Data and knowledge of patients and medical records which have been gathered in the past could aid to set up health data dashboards.  It is useful to argue what happens with patients (micro), societies (meso) and globally (macro) in relation to technology, exemplifying two directions: one scenario (A) which is sustainable for patients and health organizations and another scenario (B) which is framed within a more market driven development.

Micro-level

Scenario A: patients will be in the possibility to alter their state of illness or disease if local governing health bodies and organizations implement health in all policies in the near future and use disruptive technologies to support these treatment needs.

Scenario B: patients will suffer from market driven decision policies on the local level if disruptive technologies are going to enhance further commercialization of these health services.

Meso-level

Scenario A:  societies should be built on sustainable and well-defined health systems and clear defined rulings. This should be in place for the near future because of climate change: this is in relation to the responsibilities of the WHO and UN and their policy making.

Scenario B: full tension in societies on commercialization of health care, medical technologies and the commercial position of MDs. This will result in more lethal damages in a dangerous societal system

Macro-level

Scenario A: the needed change in human nature/health is not to conquer but to be aware that our own conception of life is systemized and should be framed towards inclusiveness.  Inclusiveness could mean a new road to dignified social and human capital, where also sustainable AI could enrich our joint goals as a society and global community.

Scenario B: Confrontations/economic tensions in healthcare could lead to lost lives, poor patient health trajectories and even worse: a lost sense of urgency.

 

It is clear that the UN and WHO should take responsibility as trans-national organizations to strive for universal coverage, to sustain support for local and global public health challenges and envision a path of policies as enablers for the urgent benefits for our growing populations across a globalized health and well-being system. Disruptive technologies should never shut down our human approach towards health, but are necessary to support decent public healthcare, on a local and global level.

Africa’s Health Systems after USAID Funding and the Road Ahead

IN A NUTSHELL
Author's note
For decades, the United States Agency for International Development (USAID) has been a cornerstone of global health support in Africa, channeling billions into combating infectious diseases, malnutrition, and strengthening healthcare infrastructure. Programs targeting HIV/AIDS, malaria, maternal health, and nutrition—such as PEPFAR and Feed the Future—have saved millions of lives. However, recent discussions about the potential termination of USAID funding raise critical questions: How will Africa cope? Is the continent prepared to sustain these vital health gains independently?

By Kirubel Workiye Gebretsadik

Medical Doctor, Ras Desta Damtew Memorial Hospital

Addis Ababa, Ethiopia

 Navigating a New Era

Africa’s Health Systems after USAID Funding and the Road Ahead

 

The Lifeline of USAID Funding

USAID’s contributions have been transformative. For example:

  • HIV/AIDS: PEPFAR has provided antiretroviral therapy to over 15 million Africans.
  • Malaria: Investments in bed nets and treatments helped reduce mortality by 44% since 2000.
  • Nutrition: Programs like Feed the Future improved food security for 23.4 million people.

These initiatives often fill gaps in underfunded national health budgets, particularly in fragile economies. Countries heavily reliant on aid, such as Ethiopia, Malawi and Mozambique, may feel the pinch acutely, while others with diversified funding streams could fare better.

Africa’s Preparedness: A Shift toward Self-Reliance

While the loss of USAID funding is a blow, Africa has been laying groundwork to reduce dependency:

  1. Domestic Health Financing:
    • Rwanda and Ghana now allocate over 15% of their budgets to healthcare (per the Abuja Declaration), investing in national health insurance and community-based care.
    • Kenya’s “Linda Mama” program offers free maternal health services, funded domestically.
  2. Regional Collaboration:
    • The Africa CDC, established in 2017, has strengthened outbreak responses, exemplified during COVID-19 and Ebola crises.
    • The African Union’s Partnerships for African Vaccine Manufacturing (PAVM) aims to produce 60% of the continent’s vaccines locally by 2040.
  3. Innovation and Technology:
    • Digital tools like Kenya’s M-Tiba (mobile health financing) and drone delivery of medicines in Ghana are bridging gaps in access.
    • Startups are tackling malnutrition with fortified foods, such as Nigeria’s Releaf Group, which processes nutrient-rich crops.
Challenges Ahead

Despite progress, hurdles persist:

  • Funding Gaps: Many nations struggle to mobilize domestic resources due to economic inequalities and debt burdens.
  • Infrastructure Deficits: Rural areas still lack clinics, labs, and trained personnel.
  • Political Instability: Conflicts in regions like the Sahel and Sudan disrupt health services.
  • Brain Drain: Medical professionals often emigrate for better opportunities, weakening local systems.
The Path Forward

The termination of USAID funding is a pivotal moment for Africa. While the continent has made strides in self-reliance, the transition requires nuanced strategies:

  • Sustainable Financing: Expanding health insurance and taxing sectors like extractive industries could boost domestic funding.
  • Strengthening Partnerships: Engaging diaspora communities, private sector actors, and regional blocs can foster resilience.
  • Advocacy for Equity: Global solidarity remains critical. Wealthier nations must honor commitments to climate and health financing, recognizing that disease knows no borders.

Africa’s journey toward health sovereignty is fraught with challenges but also brimming with innovation and determination. As the continent reimagines its future, the world must pivot from aid to equitable partnerships—because health security anywhere depends on solidarity everywhere. By investing in homegrown solutions and equitable systems, Africa can turn crisis into opportunity, ensuring health for all remains within reach.

 

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