Infectious disease patterns reflect dynamic systems of global interconnectedness. Networks are not only the means through which rapid diffusion of disease can spread, but they can also become a critical alternative to formalized institutional responses to outbreaks. This is especially true for issues of transnational concern where formal governance structures are inadequate (26
). Here, we explore how regional disease surveillance networks add value to global disease detection and response and the challenges they face.
1. Complementing global, other regional, and country disease surveillance systems
. The WHO leads the global response to disease outbreaks, not just from its headquarters in Geneva but also at the regional and country levels, taking advantage of expertise available through partner institutions. In 2000, recognizing that comprehensive surveillance depends on many different players and networks, WHO created the Global Outbreak Alert and Response Network (GOARN) which serves as a network of networks “to link this expertise and skill to keep the international community constantly alert to the threat of outbreaks and ready to respond” (27
). More recently, the International Health Regulations (IHR) mandate official reporting of certain types of disease outbreaks to WHO. Complementing WHO efforts are a range of global internet-based networks and electronic search engines such as the Public Health Agency of Canada's Global Public Health Intelligence Network (GPHIN) (28
) and ProMed Mail (29
). These efforts aim to facilitate surveillance on a global scale, while offering new opportunities for information sharing and access. Global disease surveillance still faces challenges in reporting due in part from the lack of national disease surveillance capacity in lower and middle-income countries; limited diagnostics capabilities; and disincentives to reporting due to harsh economic consequences (30
). Regional disease surveillance networks have addressed some of these limitations, and have helped to cross the geographic and topical boundaries of the largely vertical networks under WHO leadership. For example, MBDS has helped to connect a small number of countries that share borders but reside within two separate WHO regions.
2. Harnessing network power
. The regional networks described here and throughout this issue of Emerging Health Threats
have gained interest among some scholars for their contributions to global health security, particularly for their role in implementing the International Health Regulations (2005) (2
). However, other scholars have critiqued the health security motive as driven by trade interests and fears of bio-terrorism. Critics argue that vertical disease surveillance networks sometimes unfairly challenge low-income countries to upgrade their surveillance capacity for the benefit of more developed countries; and that efforts to harmonize definitions, detection and reporting benefit nations with more advanced surveillance systems and developed economies more than they benefit less advantaged nations (4
). If many low and middle-income countries lack access to the tools and knowledge to participate effectively, the networks are rendered less significant to the global response and less relevant to their own needs. Indeed, in coining the term “network power,” Grewal (35
) suggested that globalization implicitly benefits powerful nations and groups through the establishment of dominant “standards” adopted through networks.
But network power can work to the advantage of low and middle-income countries. We posit that investing in regional disease surveillance networks strengthens national health systems and regional and global cooperation, thereby promoting health security everywhere (36
). Regional disease surveillance networks prioritize building trust-based relationships that enable informal reporting and the rapid sharing of sensitive information; and enabling cross-border collaboration and the strengthening of technical capacity to detect and respond to infectious diseases in peripheral border areas with marginalized populations. When organizing their networks, nations and individuals make decisions based on local needs and priorities. In sum, regional networks strengthen social and intellectual capital, capacity, and connectedness
Network power of this type is maximized when multiple mechanisms in the region are well coordinated. For example, in the Mekong region there are many mechanisms in addition to MBDS that can enhance disease surveillance, including WHO, ASEAN, the Asian Development Bank Mekong Project, and Aryawadee-Chaophraya-Mekong Economic Cooperation Strategies (ACMECS). The coordinating office or steering committee of each regional network needs to recognize and work with these other mechanisms to avoid duplication and to utilize the strengths of each mechanism. For example, with WHO or ACMECS support, MBDS was able to involve Myanmar in regional activities when funding for Myanmar was embargoed due to political sanctions by western governments.
3. Adapting to complex challenges
. As network scientist Albert-Laszlo Barabasi pointed out, “The truly important role networks play is in helping existing organizations adapt to rapidly changing conditions. The very concept of network implies a multidimensional approach” (37
). The rapidly changing conditions associated with infectious disease spread require multinational, multi-sectoral, multi-disciplinary solutions. In part because of their local reach, regional disease surveillance networks can contribute to these solutions by engaging other institutions and sectors in their efforts to establish multi-sectoral cross-border outbreak response teams or multi-disciplinary research teams.
4. Making networks work
. Multi-country networks work when principles of sovereignty are maintained, when trust and confidence are established, and when technical professionals can freely deliberate and make collective decisions (38
). Further, the networks featured in this supplement illustrate other essential features as outlined by Anklam (40
). Each regional network began with voluntary, not mandatory, participation; involvement is based on expertise, not by formal position, with expertise becoming available to the network as needed; and network members have a sense of belonging that fosters trust and cooperation. In sum, the networks featured here have cultivated a growing capacity to detect and curtail global and regional threats through local action and collaboration.