Research Article: Justice Is the Missing Link in One Health: Results of a Mixed Methods Study in an Urban City State

Date Published: January 27, 2017

Publisher: Public Library of Science

Author(s): Tamra Lysaght, Benjamin Capps, Michele Bailey, David Bickford, Richard Coker, Zohar Lederman, Sangeetha Watson, Paul Anantharajah Tambyah, Sanjay B. Jadhao.


One Health (OH) is an interdisciplinary collaborative approach to human and animal health that aims to break down conventional research and policy ‘silos’. OH has been used to develop strategies for zoonotic Emerging Infectious Diseases (EID). However, the ethical case for OH as an alternative to more traditional public health approaches is largely absent from the discourse. To study the ethics of OH, we examined perceptions of the human health and ecological priorities for the management of zoonotic EID in the Southeast Asia country of Singapore.

We conducted a mixed methods study using a modified Delphi technique with a panel of 32 opinion leaders and 11 semi-structured interviews with a sub-set of those experts in Singapore. Panellists rated concepts of OH and priorities for zoonotic EID preparedness planning using a series of scenarios developed through the study. Interview data were examined qualitatively using thematic analysis.

We found that panellists agreed that OH is a cross-disciplinary collaboration among the veterinary, medical, and ecological sciences, as well as relevant government agencies encompassing animal, human, and environmental health. Although human health was often framed as the most important priority in zoonotic EID planning, our qualitative analysis suggested that consideration of non-human animal health and welfare was also important for an effective and ethical response. The panellists also suggested that effective pandemic planning demands regional leadership and investment from wealthier countries to better enable international cooperation.

We argue that EID planning under an OH approach would benefit greatly from an ethical ecological framework that accounts for justice in human, animal, and environmental health.

Partial Text

In the last 20 years, several novel zoonotic viruses with pandemic potential have emerged from Asia–Severe Acute Respiratory Syndrome (SARS), Nipah virus, and A H5N1, A H7N9 and other novel avian influenzas. Given the public health impacts of these pathogens, governments in the region and international agencies have been on high alert for zoonotic Emerging Infectious Diseases (EID) with endemic and pandemic potential. [1]

The Delphi survey is a systematic multistage method for obtaining, exchanging, and developing an informed opinion from a range of stakeholders to generate themes and agreement on a policy issue. [23] We modified our Delphi method from Holey et al (2007) [24] and combined the survey with qualitative interviews. The Institutional Review Board of the National University of Singapore approved the protocol (15 September 2014, A-14-174).

Thirty-two experts consented to participate (see Table 1 for the expertise of panellists by employment sector). Of the 32 panellists recruited, 25 responded to the first and second survey rounds and 19 responded to the third round. This process produced a response rate of 78% and 59%, respectively. Analysis of the data was organised around three emergent themes: 1) conceptualisations of OH as promoting the health of humans, animals, and the environment; 2) the global and regional responsibilities of Singapore as an example of a high income country to monitor and contain EID in countries with fewer resources; and 3) the prioritisation of human and animal health in responding to EID. We discuss these themes in more detail with reference to bioethical concepts of justice below.

Three key themes emerged from our analysis, which we will now discuss with reference to the published literature on OH and critically analyse through the conceptual lens of justice. This analysis forms the basis for our assertions about opportunities for developing OH ethics.

Our findings, as categorised under the three themes, may be viewed through the conceptual lens of justice. The Bioethics Advisory Committee of Singapore has interpreted the concept of justice as meaning: “access to the benefits of research, and the burden of supporting it, should be equitably shared in society.” [38] More generally is the idea that societies should organise themselves to secure cooperative benefit from and for its members; and justice provides a set of principles to allocate the benefits and burdens of this cooperation fairly (i.e. procedural justice). The notable 20th Century philosopher, John Rawls, states: “social cooperation makes possible a better life for all than any would have if each were to live solely by his own efforts”. [14] This concept resonates with many ideas of public health, including the influential UK Royal College of Physicians’ statement that public health is:

Our study examined the conceptual and ethical priorities of OH for preventing and managing EID in Singapore. We used a modified Delphi survey and qualitative interviews with a panel of opinion leaders in Singapore, and had a good response from a diverse range of experts. However, there may have been a selection bias with those having a greater interest in OH being more likely to respond to the surveys. Additionally, since the study focussed on Singapore within tropical SEA, some of our findings may not be generalizable to all countries. Nevertheless, our findings may be informative for policymaking in other urbanised states.