Strengthening a One Health approach to emerging zoonoses Samira Mubareka (Chair)a*, John Amuasib, Arinjay Banerjeec, Hélène Carabind, Joe Copper Jacke, Claire Jardinef, Bogdan Jaroszewiczg, Greg Keefeh, Jonathon Kotwai, Susan Kutzj, Deborah McGregork, Anne Measel, Lily Nicholsonm, Katarzyna Nowakg, Brad Pickeringn, Maureen G. Reedc, Johanne Saint- Charleso, Katarzyna Simonienkop, Trevor Smithq, J. Scott Weesef, and E. Jane Parmleyf aSunnybrook Research Institute, University of Toronto; bKwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana; cUniversity of Saskatchewan, Saskatoon, Saskatchewan, Canada; dUniversité de Montréal, Montréal, Québec, Canada; eIndigenous Knowledge Holder, Whitehorse, Yukon Territory, Canada; fUniversity of Guelph, Guelph, Ontario, Canada; gUniversity of Warsaw, Warsaw, Warszawa, Poland; hUniversity of Prince Edward Island, Charlottetown, Prince Edward Island, Canada; iSunnybrook Research Institute, Toronto, Ontario, Canada; jUniversity of Calgary, Calgary, Alberta, Canada; kYork University, Toronto, Ontario, Canada; lSelkirk First Nation Citizen, Selkirk First Nation, Yukon Territory, Canada; mUniversity College London, London, England; nCanadian Food Inspection Agency, Winnipeg, Manitoba, Canada; oUniversité du Québec à Montréal, Montréal, Québec, Canada; pForest Therapy Center, Białowieża National Park, Poland; qGlobal Affairs Canada, Ottawa, Ontario, Canada *samira.mubareka@sunnybrook.ca Abstract Given the enormous global impact of the COVID-19 pandemic, outbreaks of highly pathogenic avian influenza in Canada, and manifold other zoonotic pathogen activity, there is a pressing need for a deeper understanding of the human-animal-environment interface and the intersecting biological, ecological, and societal factors contributing to the emergence, spread, and impact of zoonotic diseases. We aim to apply a One Health approach to pressing issues related to emerging zoonoses, and propose a functional framework of interconnected but distinct groups of recommendations around strategy and governance, technical leadership (operations), equity, education and research for a One Health approach and Action Plan for Canada. Change is desperately needed, beginning by reorienting our approach to health and recalibrating our perspectives to restore balance with the natural world in a rapid and sustainable fashion. In Canada, a major paradigm shift in how we think about health is required. All of society must recognize the intrinsic value of all living species and the importance of the health of humans, other animals, and ecosystems to health for all. Key words: One Health, zoonoses, policy recommendations, governance, technical leadership, equity, education, research Executive summary Time for a paradigm shift Leading up to the COVID-19 pandemic, there was an acceleration of global zoonotic pathogen activity. It is now abundantly clear that we have established socioecological conditions that favour zoonotic pathogen amplification, spillover, spread, and disease. Yet, we continue to fail to recognize OPEN ACCESS Citation: Mubareka S, Amuasi J, Banerjee A, Carabin H, Copper Jack J, Jardine C, Jaroszewicz B, Keefe G, Kotwa J, Kutz S, McGregor D, Mease A, Nicholson L, Nowak K, Pickering B, Reed MG, Saint- Charles J, Simonienko K, Smith T, Scott Weese J, and Jane Parmley E. 2023. Strengthening a One Health approach to emerging zoonoses. FACETS 8: 1–64. doi:10.1139/facets-2021-0190 Handling Editor: Russel MacDonald Received: January 20, 2022 Accepted: June 15, 2022 Published: January 12, 2023 Note: This paper is part of the Royal Society of Canada’s COVID-19 Task Force Collection. Copyright: © 2023 Authors: Mubareka, Amuasi, Banerjee, Carabin, Jack, Jardine, Jaroszewicz, Keefe, Kotwa, Kutz, McGregor, Mease, Nicholson, Nowak, Reed, Saint- Charles, Simonienko, Weese, Parmley, and The Crown. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. Published by: Canadian Science Publishing SCIENCE APPLICATIONS FORUM FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 1 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 mailto:samira.mubareka@sunnybrook.ca http://dx.doi.org/10.1139/facets-2021-0190 http://creativecommons.org/licenses/by/4.0/deed.en_GB http://creativecommons.org/licenses/by/4.0/deed.en_GB http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com the interconnectedness among determinants of health for all animals1, including humans, and ecosys- tems; the drivers of pathogen emergence; and the disproportionate impact of emerging zoonoses on racialized or economically disadvantaged people, women, and Indigenous communities. One Health proposes a paradigm to address issues at the intersection of society, health, and the environ- ment. The One Health view recognizes that the health of living beings and the land are interdependent. A collaborative approach to complex challenges, One Health highlights the need for diverse perspectives to identify potential actions that maximize health for all lands and animals, including humans. Given the enormous global impact of the COVID-19 pandemic, greatly exacerbated by the intra- pandemic emergence of novel variants of concern (VOCs), and multiple, ongoing outbreaks of highly pathogenic avian influenza (HPAI) in Canada (Canadian Food Inspection Agency 2022), there is a press- ing need for a deeper understanding of the interface where humans and other animals interact in their shared environment, and the intersecting biological, ecological, and socioecological factors contributing to the emergence, spread, and impact of zoonotic diseases. The SARS-CoV-2 pandemic was heralded by international outbreaks of SARS-CoV in 2003 and Middle East respiratory syndrome coronavirus (MERS-CoV). However, significant pre-pandemic gaps persisted in coronavirus surveillance and research on coronavirus virology, ecology, and the development of medical countermeasures. We also failed to anticipate and mitigate the disproportionate impact of COVID-19 on marginalized populations at higher risk of exposure and severe disease; and, we did not predict the effect non-pharmaceutical inter- ventions would have on health, education, and livelihoods. In brief, we did not embrace or sustain a One Health approach to viral zoonoses. These failures resulted from both a limited understanding of viral biology and drivers of emergence and disease, as well as from a lack of political will. In Canada, there is a groundswell of One Health initiatives and a burgeoning community of practice. Leadership from the animal health and veterinary medicine sectors has been central to establishing One Health approaches to collaborative research, as well as curriculum and policy development in a range of sectors at regional and national levels. These sectors include academia, often seated in faculties of veterinary medicine; federal government; and the private sector. Organizations focused on wildlife and global health such as the Canadian Wildlife Health Cooperative (CWHC) and the International Development Research Centre (IDRC) have longstanding connections to One Health, and some schools of public health and the environment are also actively engaged in One Health discourse. A resilient and sustainable structure for a One Health approach must be tied to function and a clear One Health agenda for Canada, accompanied by established tasks, timelines, milestones, and support for execution. There is a need for diverse groups of policymakers and decision-makers to work together with other sectors of society in the design of programs and solutions, with active inclusion of community members and Indigenous knowledge holders and scholars. Further inaction is not an acceptable option—radical change is desperately needed, beginning by reor- ienting our approach to health and recalibrating our perspectives to restore balance with the natural world in a rapid and sustainable fashion. In Canada, a major paradigm shift in how we think about health is required. All of society must recognize the intrinsic value of all living species and the importance of health of ecosystems and all animals to health for all. The priorities we set today will determine the future of generations to come; we are directly accountable to them for the decisions we make in this moment, a responsibility we can neither deny nor ignore. While many hope for a return to normal, we must remind ourselves of the predisposing factors that enabled this pandemic. This is a critical opportunity to address 1Because Homo sapiens, or humans, are mammals, we often refer to other animals to distinguish them from humans. Where the term animals is used alone, we are generally implying non-human animals. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 2 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com these complex factors. Health must be understood as a shared goal with other animals and the land, to ensure wellness for all. Recommendations Here we use a functional framework (Fig. 1) of interconnected, but distinct groups of recommenda- tions to facilitate review and framing for decision and policy makers. Urgent, time-sensitive recom- mendations are denoted with an asterisk (*). Strategic Recommendations By galvanizing and expanding One Health initiatives in Canada, there is excellent potential for a sustainable national strategy on One Health to emerge to ensure that One Health considerations are foregrounded for emerging zoonoses and other pressing issues such as climate change. Currently, there is no obvious government entity responsible for coordinating or supporting One Health in Canada. The following recommendations address current gaps in governance, spanning an inter- ministerial, all-of-government approach, biosecurity, international policy, and meaningful inclusion of an Indigenous knowledge framework. 1. *Establish a One Health Council to develop, coordinate and implement a One Health Action Plan for Canada with immediate focus on emerging zoonotic pathogens. The Council must include experts and representatives from all relevant academic disciplines and ministries of the Government of Canada, as well as key non-governmental partners. The Council should be tasked with examining the policies, programs, and financial and legislative support of agencies, organizations, and institutions related to One Health at the nexus of Canadian and Indigenous Peoples, domestic and wild animals, plants, ecosystems, and the economy and society, focusing initially on emerging zoonoses and drivers of zoonotic pathogen spillover. 2. Appoint a Special Advisor on One Health to the federal ministers responsible for health. In addition to providing advice, they would play a key role in the One Health Council. 3. *Establish a Global One Health Security Office which would be mandated to monitor and mit- igate all manner of external biological threats to Canada, and with the Council, incorporate clear objectives for One Health into Canadian foreign policy to position Canada as a global leader and champion for global health and security, as part of a One Health Action Plan. Fig. 1. Framework for interconnected groups of recommendations. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 3 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com 4. *Develop and implement an Indigenous Engagement and Knowledge Policy Framework for One Health and ensure that the One Health Action Plan accounts for and addresses the United Nations Declaration on the Rights of Indigenous Peoples and the Truth and Reconciliation Commission’s Calls to Action. All levels of government must establish frameworks for inclusion of Indigenous Peoples Engagement and Knowledge systems in addressing One Health challenges. Technical Leadership and Operational Recommendations One of the principles of One Health is to leverage existing resources, tools, and programs. Many of these exist in Canada but have not been fully developed, implemented, or operated in a sustainable and coordinated fashion to (1) consistently generate accessible data for informed decision-making or (2) actively protect and nurture health and wellness for all animals (including humans) and the land. The following recommendations address technical and operational leadership around surveil- lance data collection and sharing, as well as critical programs for animal and land health. 5. *Implement and sustainably fund the Pan-Canadian Approach to Wildlife Health, as approved by all levels of Government in 2018. The Approach must be put into action immediately. 6. *Expand and coordinate existing human, other animal, and environmental emerging patho- gens surveillance and biomonitoring activities through Centres of Excellence in One Health to generate health intelligence for decision-making and research by linking teams of scientists, diagnosticians, practitioners, epidemiologists, and public health experts to action surveillance data and other relevant data sources. 7. Develop best practices for the collection, analysis, and sharing of surveillance data, and characterization of emerging pathogens. Key activities must be underpinned by principles of biosafety and biosecurity. Scientists, diagnosticians, practitioners, epidemiologists, and public health experts must also collaborate to harmonize and share data, materials, and protocols. 8. Commit to Other Effective Conservation Measures, Indigenous Protected and Conserved Areas, and Indigenous-led surveillance activities while applying First Nations’ ownership, control, access, and possession principles. Equity recommendations The burdens of zoonoses and other challenges such as the climate crisis are not borne equally. When these disproportionately affect different communities, the impacts are often linked to pre-existing and systemic inequities. The exacerbation of various health inequities during the COVID-19 pandemic underscores the need for a comprehensive and inclusive approach, such as One Health. The following recommendations address some gaps in our understanding and commitment to underrepresented and over-affected populations. 9. Engage community groups and communication scholars to help devise better access to timely, effective, and trustworthy information to populations in situations of vulnerability. 10. Collect consistent and disaggregated social and demographic health data to identify health inequities to reduce the impact of emerging infectious diseases. 11. *Ensure that Canada’s commitment to social equality is advanced by applying gender-based analysis plus (GBA+) to the analysis of all data, with meaningful inclusion of equity deserving groups, when developing interventions as part of a One Health Action Plan for Canada. Education and research recommendations The implementation of One Health curricula has been limited for One Health-related continuing education in medicine and other university faculties, learning environments, and public schools. In Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 4 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com addition, One Health-focused research funding has been sparse in Canada, with few streams or review panels with the multi- or interdisciplinary perspectives and mixed-methods expertise to evaluate One Health research applications. Some priority announcements for One Health-related challenges have been supported, but these are primarily focused on human health, narrow in scope, limited in fund- ing, and do not allow for wider-ranging One Health proposals, particularly for animal and ecosystem health. One Health education and research are essential to promoting awareness, advancing knowl- edge, and informing policy around complex challenges such as zoonoses. The following recommenda- tions address some of the gaps in existing education and research programs for One Health in Canada. 12. Develop and implement One Health curricula for accredited health education programs for veterinarians, physicians, and other licensed healthcare providers and public health practi- tioners in training. 13. Introduce One Health at all stages of education, from preschool to university. Curricular and extra-curricular learning opportunities must be developed, and One Health topics introduced in professional continuing education programs. 14. *Prioritize domestic and international research on emerging zoonoses using a One Health approach as part of Canada’s One Health Action Plan. This must include research activities across human, other animal, and ecological health from biological, ecological, epidemiological, social, environmental, Indigenous, governance, and policy perspectives. 15. Provide sustained funding, including through the Tri-Agency, for One Health through a net increase in available funding that supports collaborative biological, health, ecological, social sci- ences, and humanities research using a One Health approach through dedicated mechanisms. Panels must be multidisciplinary and capable of assessing projects using a One Health approach. 16. Embed research as a critical element of a Centres of Excellence in One Health program (Recommendation 6). These centres would focus on generating scientific knowledge and health intelligence using a collaborative One Health approach, thus also training future One Health scientists, teachers, and decision-makers to inform policy and drive societal change. 1. The SARS-CoV-2 Pandemic: A Shared Crisis Emerging challenges The first cases of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were described in humans in late 2019. Rapid global spread ensued and the World Health Organization (WHO) declared a global pandemic on 11 March 2020 (WHO 2020). Two years later, by March 2022, SARS-CoV-2 had been reported to have infected over 470 million people and has led to over 6 million deaths globally (WHO 2022). Many people infected with SARS-CoV-2 also continue to suf- fer from post-COVID-19 conditions (Davido et al. 2020). In addition to significant impacts on indi- vidual health and healthcare systems, there have been direct and profound social and economic impacts (Bonotti and Zech 2021). SARS-CoV-2-related viruses have been well-described in bat populations, suggesting that SARS-CoV- 2 originated in bats before spilling over into humans (Hul et al. 2021; Wacharapluesadee et al. 2021; Zhou et al. 2021). The setting (forest, farm, live animal market, or other) for spillover and the poten- tial role of an intermediate host remain unknown. Shortly after the pandemic was declared, several non-human animal2 species were reported to be susceptible to SARS-CoV-2 infection (Hobbs and 2Because Homo sapiens, or humans, are mammals, we often refer to other animals to distinguish them from humans. Where the term animals is used alone, we are generally implying non-human animals. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 5 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Reid 2021; OIE 2021). These included captive and companion animals, as well as wildlife, raising the possibility of a secondary animal reservoir for the virus. Re-emerging challenges The massive global burden of SARS-CoV-2 in humans has resulted in spillover to naïve animal spe- cies (e.g., mink, cats, dogs, deer) (Dhama et al. 2020; Kuchipudi et al. 2022) and to the environment, where viral RNA has been detected in wastewater (Giacobbo et al. 2021). In addition to infecting a broad range of animal species through spillover from humans, variants of concern (VOCs) are broad- ening the susceptible species range for SARS-CoV-2. For example, the Alpha variant harbouring the N501Y mutation in the viral Spike protein is capable of infecting Mus musculus (the house mouse) (Shuai et al. 2021), whereas the parental viral strain is restricted to Cricetidae species of rodents, such as hamsters and deer mice. The genomic plasticity of the virus permits rapid and impactful adapta- tions that are critical to understand; peri-domestic wildlife with host viral receptors most closely resembling the human angiotensin converting enzyme 2 receptor may be at highest risk, meriting sur- veillance particularly in areas with high rates of human SARS-CoV-2 infection. The implications of one or more animal reservoirs for SARS-CoV-2 are significant. A secondary wild- life reservoir introduces the risk of novel coronaviruses re-emerging after adaptation though muta- tions or recombination with other SARS-CoV-2 or endogenous animal coronaviruses, and may undermine the efficacy of medical countermeasures, including vaccines and antivirals. It is imperative that we understand the fundamental biology of potentially pandemic viruses, considering that the severity of clinical disease, population-level transmission, and social impact are a result of virological determinants (Kirlin 2020). For example, the Alpha VOC drove wave 3 of the pandemic in Canada, resulting in high rates of hospitalizations and further public health measures, and the genomic changes in the Delta variant translated into a 64% increase in household transmission (secondary attack rate) relative to the Alpha VOC, and is associated with increased severity of disease and risk of reinfection. Also, changes in the Delta variant genome contributed to immune escape and reduced efficacy of monoclonal antibody therapy (Allen et al. 2021; Public Health Ontario 2021). The Omicron variant (and sub-lineages) is highly diverged from other SARS-CoV-2 and has been clearly associated with reduced vaccine efficacy against infection, escape from monoclonal antibody therapy, and enhanced transmission (Accorsi et al. 2022; Escalera et al. 2022; Tatham et al. 2022). It is also speculated to have an animal origin, although no Omicron-like virus has been identified in animals prior to emergence in humans. Regardless, the emergence of Omicron and its subsequent impact highlights the significant potential for harm from new VOCs that could spillover from animal populations. White-tailed deer in Canada and the United States have been screened for SARS-CoV-2 viral RNA and antibodies to establish evidence of infection and exposure. There are high rates of positivity (up to 82.5% by PCR or viral detection) among deer in the United States, and non-VOC, Alpha, Delta, and Omicron viruses have all been reported in this species (Vandegrift et al. 2022; Kuchipudi et al. 2022; Hale et al. 2022; Marques et al. 2022; Kotwa et al. 2022; Pickering et al. in press). Based upon the genomic epidemiology, multiple human-to-deer transmission events have occurred, but the route(s) of transmission remain unknown. Viral RNA has been detected in hunter-harvested Canadian deer as well, raising important questions around wildlife health, country foods, and the potential evolutionary trajectory of SARS-CoV-2 (Kotwa et al. 2022). The highly divergent SARS- CoV-2 variant detected in Ontario deer is unrelated to any other existing SARS-CoV-2 circulating among humans, and there are data supporting deer-to-human spillover in at least one instance (Pickering et al. in press). This is the first evidence of independent, parallel evolution of SARS-CoV- 2 in another species, and of deer-to-human transmission. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 6 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com The environment has also been implicated in the SARS-CoV-2 pandemic, with substantial spillover of viral RNA from humans into wastewater. Environmental monitoring through wastewater surveillance has been an essential public health tool. Although it is unknown whether animal or human exposure to wastewater leads to infection, given the widespread detection of environmental SARS-CoV-2 viral RNA, this possibility must be investigated, particularly considering that the range of host species sus- ceptible to SARS-CoV-2 may be expanding due to VOCs. Despite heralding events such as the emergence of SARS-CoV in the early 2000s, and the ongoing cir- culation of Middle East respiratory syndrome coronavirus (MERS-CoV), we were blindsided by the pandemic spread of SARS-CoV-2. Regardless of the clear and present danger posed by high- consequence coronaviruses, we failed to prepare for this coronavirus pandemic. No coronavirus sur- veillance was in place, research on coronavirus virology and medical countermeasures was scant, and most importantly, limited efforts had been made to mitigate spillover and spread of another highly pathogenic coronavirus in the years since SARS-CoV and MERS-CoV emerged. These failures resulted from a limited understanding of viral biology and the drivers of emergence, on the one hand, and from lack of political will, on the other. It is abundantly clear that the existing pandemic planning was insufficient to address one of the most significant health threats of this century. Thus, there is a pressing need for a deeper understanding of the interface where all animals, including humans, interact in their shared environments, and the intersecting biological, ecological, and socio- ecological factors contributing to the emergence, spread, and impact of zoonotic diseases. This is essential to enhance resilience at all scales, gain insights into the connections between animal and land health, and to better understand how human actions are impacting this relationship. Anthropogenic impact Because of the interdependence of human, other animal, and ecosystem health, the decisions humans make have consequences beyond human society. National and international travel and trade played important roles in the rapid global spread of SARS-CoV-2, and urbanization, food insecurity, and trade of wild and domestic animals are contributing factors to the emergence of several other high consequence pathogens. As the human population grows and our cities expand, we encroach further into natural areas and clear land to produce more food for burgeoning populations of people and domestic animals. This expansion not only reduces natural areas providing critical habitat for wild plants and animals, but also creates new intersection points where humans, vectors, domestic animals, and wildlife come into contact. These changes increase opportunities for new pathogens to adapt (emergence) and infect non-traditional hosts (spillover). Environmental factors, such as climate, seasonality, and habitat availability determine the lifecycles and geographic range of different host species, vectors, and micro- organisms, thus affecting where and how zoonoses emerge, spillover, and survive. It has been pre- dicted that as the pace of change of these environmental factors becomes even greater, there will be more spillover events and increased incidence of emerging infectious disease (Jones et al. 2008). Societal impact Along with the impacts on health and healthcare systems, COVID-19 has worsened many pre- existing inequities associated with poverty, race, ethnicity, and gender, both regionally and interna- tionally. Throughout the pandemic, marginalized populations have been the most heavily burdened by both viral infection and policies put in place to prevent the spread of COVID-19 (WHO 2021; Cronin and Evans 2022). The large social and economic costs associated with the control of and response to the COVID-19 pandemic provide a strong and inarguable case for substantial investments in reducing inequities by addressing the structural drivers of inequities. One approach to reduce the Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 7 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com interconnectedness of inequities would be to enact Canada’s commitment to implement gender-based analysis plus (GBA+) and the Calls to Action of the Truth and Reconciliation Commission. The COVID-19 pandemic has highlighted existing societal inequities and continues to degrade health, healthcare, social, and economic well-being. Our shared experience with COVID-19 is sharpening the focus on the urgent need for new ways of tackling and preventing future pandemics in this time of pressing environmental threats. 2. Addressing Complex Challenges with One Health The history and evolution of One Health At its core, One Health is about recognizing the connections between all living things and our shared spaces. Others call this concept by different names (e.g., public health, Ecohealth, and traditional eco- logical knowledge) (Lerner and Berg 2017). One Health is often portrayed as three pillars (or circles): Human health, animal health, and environmental health (World Organisation for Animal Health, n.d.; Centers for Disease Control and Prevention 2021; Destoumieux-Garzón et al. 2018). By recogniz- ing the shared determinants of health (or disease) and interdependencies among these pillars, we high- light the foundational importance of the intrinsic value of all species and generations, and the importance of reciprocal care for each other (as people), animals, and the spaces we all share (Stephen and Gallagher 2021). The importance of equity, value, and reciprocal care are well-described in EcoHealth (Charron 2012). These three critical elements are needed to address sustainability and to build more resilient and equitable systems able to withstand many complex and growing health threats. One Health encompasses synergies described as One Medicine by Calvin Schwabe (1984) over 40 years ago. Broader concepts of health and the critical consideration of interrelatedness between health and the environment are embodied in the Ottawa Charter for Health Promotion (World Health Organization 1986), which advances the notion of reciprocal care and pledges to “counteract the pressures towards harmful products, resource depletion, unhealthy living conditions, and environ- ments.” Caring, holism, and ecology are deemed necessary for health promotion, and the Ottawa Charter called for international action to achieve Health for All by the year 2000. In 2004, the Wildlife Conservation Society hosted a symposium in New York, where the Manhattan Principles underpinning the concept of One World One Health (OWOH) were established (Wildlife Conservation Society 2004). These principles were advanced through a series of consultations on influenza in Beijing (2005), Bamako (2006), New Delhi (2007), and Sharm el-Sheikh, Egypt (2008), as well as International Ministerial Conferences on avian and pandemic influenza. The Beijing Principles were outlined early in this process, and ultimately the OWOH approach was formally adopted by the WHO, the Food and Agriculture Organization (FAO), the World Organisation for Animal Health (OIE), the United Nations Children’s Fund, the United Nations System Influenza Coordination, and the World Bank, based on recommendations made at these meetings. The OWOH approach is summarized in the report entitled Contributing to One World, One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystems Interface (2008) (Food and Agriculture Organization of the United Nations et al. 2008). This founda- tional document was sparked by outbreaks and the pandemic threat of the highly pathogenic avian influenza virus (HPAI) H5N1, which was causing widespread outbreaks by 2003 (after its initial detection in 1996 in Hong Kong) (Sonnberg et al. 2013). This virus is resurging globally now, with unprecedented levels of activity in Canada. The emergence and spread of HPAI H5N1 virus at that time highlighted an urgent need to understand the drivers of emergence, transmission, and persist- ence of emerging infectious diseases at the interface where humans interact with other animals and ecosystems. National authorities were encouraged to consider key priorities for surveillance; public health responses; and strategic research through collaboration, multidisciplinary, cross-sectoral Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 8 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com partnerships; integration of governance; and technical and sociocultural aspects of implementation. The current H5N1 situation is an acute reminder of the importance of these key activities. The OWOH Strategic Framework encouraged decision-makers to reinforce existing mandates, insti- tutions, and programs, and to include all levels of government. Emphasis on technical leadership in surveillance and data sharing, risk assessment, and capacity building helped strengthen national lab- oratory testing and reporting systems, highlighting gaps in communication and coordination. This focus on improvements included acknowledging the importance of integrating wildlife and ecosys- tems into surveillance and control programs and the need to establish effective financing frameworks. Key research areas were identified in the OWOH Strategic Framework, including understanding zoo- notic pathogen emergence, spread, and persistence; pathogen biology; diagnostics and prevention; sociocultural determinants; and implementation. A range of specific initiatives emerged from an unprecedented orchestration of efforts, stemming from the control of the HPAI H5N1 virus. Building upon the pre-existing Global Framework for the Progressive Control of Transboundary Animal Diseases (2022), these initiatives included FAO’s Emergency Centre for Transboundary Animal Diseases (2022), the joint FAO/OIE/WHO Global Early Warning System (GLEWS) (2022), and the Network of Expertise on Avian Influenza (Edwards 2006). In November of 2012, the World Veterinary and World Medical Associations signed a collaborative Memorandum of Understanding in Bangkok, Thailand (Wilson 2012). The scope of this memoran- dum included joint educational efforts, cross-species surveillance, the responsible use of antimicro- bials, and collaborative research. More recently, the original Manhattan Principles, released in 2005, were updated as the Berlin Principles in 2021 (Gruetzmacher et al. 2021). Presently, there are a myriad of definitions and descriptions of One Health, but all share common fea- tures (Gruetzmacher et al. 2021; Centers for Disease Control and Prevention 2018; One Health Commission 2022; World Organization for Animal Health 2022). First, One Health is about health—the health of people, animals, plants, and ecosystems. It is about how health is the result of the interdependence between species living in shared environments, over time, and across space. One Health is also about collaboration, trust, and sharing of responsibility. By recognizing health interdependencies, One Health calls for more and better inter-, multi-, and transdisciplinary efforts to break down silos and work together to preserve and promote health gains. The UN Sustainable Development Goals (United Nations 2015) are a key example of how upstream drivers can have far-reaching consequences. Building health, promoting resilience, striving for equity, and ensuring capacity to cope and adapt are all hallmarks of holistic health approaches, be they One Health, EcoHealth, Planetary Health, or other. Indigenous context for One Health Western notions of One Health were long preceded by traditional forms of knowledge, including Indigenous ways of knowing. Indigenous knowledge recognizes and respects the interconnectedness among all things and is a distinct approach from the Western concept of One Health, using a different set of assumptions than those advanced through Western thought. In Indigenous knowledge systems, the process is often more important than the endpoint itself, and there is no single path or approach for a given process. Based on common principles, Indigenous knowledge differs among Nations and com- munities. AlthoughWestern focus is shifting toward more collaborative, comprehensive, and interdiscipli- nary approaches through broader incorporation of concepts of land stewardship and health, important gaps remain in listening to Indigenous perspectives and leadership (WHO 2017b; Hillier et al. 2021). It is also important to recognize the Indigenous context for health and to address the disparities that exist due to colonization and institutional and systemic barriers to good health. First Nations, Inuit, Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 9 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com and Métis peoples living both on and off reserve experience clear disparities in health and wellness (McGregor 2009; Statistics Canada 2015). We cannot consider applying Indigenous models of One Health, on the one hand, while disregarding these inequities, on the other. Good health and clean water are basic human rights and must be ensured for Indigenous Peoples, recognizing Indigenous Peoples’ rights to individual, community, and land health. The right to a self-determined future for land, animal, and human health must be recognized in an active, enabling way. A rapid decline in land health due to human exploitation and climate change also merits focused attention. Cultural genocide and colonialism have coalesced with these anthropogenic drivers, leading to environmental dispossession through direct disruption of land health or the rupture of Indigenous Peoples’ relationships with the land. Connection with the land is considered one of the key determi- nants of health for Indigenous Peoples (Government of Canada 2018). Thus, environmental dispos- session has a profound impact on ways of knowing, ways of life, and spiritual, physical, and mental health (Big-Canoe and Richmond 2014; Jones 2019; Mashford-Pringle et al. 2021; Tobias and Richmond 2014). Also, as land health erodes, so does landscape immunity (Ruscio et al. 2015), increasing the risk of zoonoses for those closest to the land and adding to the disproportionate burden of disease incurred by Indigenous Peoples. This issue has been underscored during the pandemic and goes beyond baseline health and severe outcomes associated with COVID-19 and includes hunting and gathering and other key practices for sustenance and wellness, which were severely affected by individual exposure/quarantine or illness, population-level states of emergency and other regional measures (Tobias and Richmond 2014). The Convention on Biological Diversity clearly underscores the importance of Indigenous knowledge systems in resource management (Plowright et al. 2021). This knowledge is diverse, participatory, and experiential, and not readily defined using static Western frameworks. Supporting Indigenous concepts of One Health includes respecting natural laws and implementing earth-based solutions through land pedagogy (Convention on Biological Diversity n.d.; Learning the Land n.d.). A key element of some Indigenous knowledge systems is using different ways of knowing through collaboration, including Two-Eyed Seeing or Etuaptmumk in Mi’kmaq knowledge systems (Bartlett et al. 2012). Incorporation of Indigenous knowledge systems ensures Indigenous leadership and self-determination in One Health solutions to specific challenges; it also increases the impact by applying culturally and environ- mentally relevant knowledge that is absent or sparse in more Eurocentric approaches to One Health. One Indigenous approach to One Health, outlined by Joe Copper Jack, has been applied to key activ- ities in land planning, culture, and education in Yukon (One Health Concept Box 1). It is essential that these activities begin with (1) relationship building and (2) the implementation of traditional Box 1. One Health Concept Box. Beyond One Health for Indigenous-guided recovery: The Land and Peoples Relationship Model Joe Copper Jack Knowledge collaboration is essential to One Health I use the metaphor of a stream when talking about knowledge collaboration: Traditional knowl- edge (TK) on one side, Western knowledge (WK) on the other. The knowledges regard and respect each other but do not necessarily meet. If you take away one knowledge system, you get a less healthy stream. We need both stream banks, both ways of knowing. We need to keep both banks healthy, prevent them from eroding. The concept of One Health may be new to Western knowledge systems, but the interdependence of people, other animals, and land, as well as the Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 10 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Box 1. (continued ) knowledge that the health of other animals and the health of the land is tied to our own, is inher- ent to most if not all Indigenous knowledge systems (Hueffer et al. 2019; Jack et al. 2020). It is not ‘natural’ to talk about land and people without each other or the health of one without the health of the other (Fig. 2). Yukon First Nations’ Long-Ago Peoples have always defined themselves as being part of nature and as beings sent here by the Creator to care for Mother Earth. Their key laws centered around the principles of Respect, Care, and Share, which were treated equally and used in combination with other natural laws. Respect is the law applied to all other natural laws. Long-Ago Peoples’ laws are applied internally first, and then to others, moving outwards into the broader worldview. For instance, Long-Ago Peoples’ laws apply to self, immediate family members, Clan, commu- nity, Nation, pets, dwellers, plants, land, water, air, and the universe. Respect is both the greatest consideration given to life and everything created by the Creator. Care is taking care of the land and each other and is the responsibility of all peoples. Share is the passing down and sharing of knowledge openly and in a respectful manner. Western scientists are beginning to realize the importance of these laws. For example, Arctic researchers Kutz and Tomaselli (2019) assert, “In many ways, Indigenous knowledge provides an ideal example of the ‘One Health’ approach, in which animals and the complexities of their environment, including the human element, are considered simultaneously.” British Columbia- based biologist Eric Balke says, “Natural ecosystems are infrastructure” (Ligeti 2020), adding that many scientists are now talking about “nature-based solutions.” Long-Ago Peoples’ approach to their relationship with and care of the land included the perspec- tives of all affected parties, such as future generations, non-human relations, and land and waters, in planning and decision-making. Key to this approach is the No-Voice perspective, the idea that the views of future generations, non-human relations, and land and water are considered in all decisions with the potential to affect them, either now or in the future. Fig. 2. Joe Copper Jack’s Knowledge Stream. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 11 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Box 1. (continued ) The COVID-19 pandemic has reasserted the need for fundamental and monumental change in relationships between human beings and other living entities. The land relationship is an integral part of this recovery. Indigenous Peoples have existed in healthy relationships with land for gen- erations and continue to do so. Care, Share, Respect are our laws for all things created by the Creator. As a land planner in the Yukon, I promote the collaboration of traditional and Western ways for better planning. Likewise, traditional and Western ways can be used together for One Health (Montesanti and Thurston 2015). Places with co-management have better outcomes for land health. Healthy land can be thought of as an essential service (Copper Jack and Nowak 2020). The Land and Peoples Relationship Model The Land and Peoples Relationship Model is a collaborative knowledge-building process that respects both the ways of Yukon First Nations’ Long-Ago Peoples and Western knowledge. The model attempts to rebuild equal respect between the land and people, knowing that recon- ciliation cannot happen if people continue to view themselves as superior to nature and life. The model also aims to rebuild respect between people, where no knowledge system, gender, or group is superior to another. Collaborative knowledge-building is a process by which participants reach favourable conclu- sions through the sharing and exchange of knowledge. Participants are asked to show the greatest respect possible during the planning and decision-making stages. The model uses the three key laws (Respect, Care, and Share) combined with two decision-making tools (No-Voice and Knowledge Stream Tree) that include affected parties’ viewpoints and long-ago knowledge. The model includes “those with no voice” in all discussions and decisions made at the round- table, and their presence is represented with a sign or symbol. Participants are asked to contribute what they feel represents the No-Voice reaction to the issue at hand. The No-Voice reactions are part of the information that is assessed in decision-making. In the event of a stand-off on a par- ticular issue, the No-Voice contribution become a critical factor in the final decision. In this way, the model guides, directs, and balances the collaborative planning process. The crux of the model is how respect is shown among participants within the planning and decision-mak- ing processes. The roundtable experts function as a neutral body focused solely on resolving issues, based on relevancy and usefulness. The model also describes a sacred space. Rules of engagement The purpose of the model is to allow issues to be resolved through collaborative planning and consensus building. It is important to recognize and respect that some people communicate through storytelling and animation, while others verbalize and record. Participants of the round- table are responsible for developing their rules of engagement, which include the following requirements: 1. Show respect for each other, affected parties, and the land; 2. Feel as much as you think; 3. Listen to understand what is being said; Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 12 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Box 1. (continued ) 4. Clarify what you say and hear; and 5. Have patience. The Knowledge Stream Tree and No-Voice for One Health The COVID-19 pandemic has wrought significant disruption to health and well-being and will continue to impact future generations through a significant health, environmental, and economic debt. The coronavirus pandemic may also represent the first of many. The SARS-CoV-2 virus existed in balance with its likely host, the bat, until humans intervened to facilitate spillover and spread through activities such as intense global travel. To mitigate future pandemics, we must strive to restore balance through reciprocal care of the land and the plant and animal spe- cies it carries. Re-establishing the balance requires an understanding of what constitutes balance and how it can be achieved. In addition to collaboration, openness to seeing things from a new perspective is an important aspect of land stewardship and the One Health approach. Being open includes seeing from each other’s points of view and from the perspective of the land and the animals that inhabit it; what are they saying to us? This openness changes how we understand and feel about those with No- Voice and how they interact, for example, the forest, the bats, and the virus. An open, accepting viewpoint reorients our frames of reference and may lead to novel and more effective avenues of study and implementation. As well as being based on the principles of Respect, Care, and Share, the Land and Peoples Relationship Model includes the Knowledge Stream Tree (Fig. 2) and the No-Voice. These ele- ments are intrinsically tied together and components cannot be extracted or considered in isola- tion without losing meaning. Much like a snowshoe that depends on well-crafted bindings, a frame, and meshing to function effectively, one cannot think about the model without all these interdependent parts (Fig. 3). We propose the following as a means of collaboration and implementation of the Knowledge Stream Tree: Fig. 3. Interdependent parts of the Land and Peoples Relationship Model. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 13 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com knowledge protocols—processes that must be respected. Extracting Indigenous knowledge and using it out of context for convenience or other purposes is harmful and unacceptable. While Western knowledge strives for endpoints independent of relationships, Indigenous knowledge systems revolve around relationships. Relationship building and protocols allow trust and understanding to be established and to evolve over time. The current reality and health challenges Avian and swine influenza viruses, human immunodeficiency virus (HIV), Zika virus, SARS-CoV-2, monkeypox, antimicrobial resistance, climate change, pollution, biodiversity loss, economic collapse, and inequality—none of these challenges are independent of the others. Worsening climate change contributes to biodiversity loss, the emergence of new pandemic viruses threatens economies, and responses to disease emergence exacerbate inequities and create vast amounts of waste that pollute waterways and landfills, further threatening biodiversity. In most cases, responsible agencies react after the harm has occurred and work within their own disciplinary silos and mandates to control the problem as best as they can. Despite lessons learned from every new pathogen emergence, we con- tinue to be surprised each time a new threat appears. Even with investments in understanding the emergence and spread of highly pathogenic avian influenza virus, Ebola virus, Zika virus, and SARS-CoV—and even with greater investments in disease control and prevention—we were still caught off guard by the appearance of SARS-CoV-2 in 2019. Humans are only one of an estimated 7.8 million animal species on earth (Mora et al. 2011). As mem- bers of the animal kingdom, humans are just as susceptible to infectious agents as any other animal Box 1. (concluded ) Establish and sustain a Circle of Traditional Knowledge Holders and experts for consultation and knowledge sharing. We propose close and collaborative efforts between federal entities, indepen- dent scientists, and traditional knowledge holders to address priority questions using an Indigenous One Health approach. This collaboration begins with a relationship-building phase anchored in humility and mutual respect. This work is possible under knowledge agreements and with the consent of the Elders to share their knowledge for this mutual purpose. Experts at a roundtable are independent individuals with adequate knowledge who are at arm’s length from the government. Content knowledge varies depending on the questions and chal- lenges at hand, so this group may be fluid depending on theme, geographic region, host species, or peoples involved. Fairness and truthfulness guide discussions to reach mutually beneficial paths forward that are useful, relevant, and concrete. Indigenous knowledge systems and traditional knowledge keepers are critical and essential to effective planning and implementation of projects and interventions aiming to address questions and challenges around zoonoses using a One Health lens. Inclusion puts Indigenous knowledge sharing into action in a participatory and translational manner, enabling ongoing collaboration as challenges arise and providing opportunities for collective post-implementation sustainability and evaluation. Sustainability is essential and required. Short-term visions and solutions have not met the needs of future generations; we need to maintain a 1,000-year-long view since the implications of decisions made now will have long-term effects. This focus on sustainability requires significant investments now and for generations to come. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 14 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com species. The likelihood of infection and associated negative impacts of disease depend on health determinants— biological, environmental, social, and economic factors that determine whether a per- son (or animal) has the resources to stay healthy (World Health Organization 2017a). Although a determinants-of-health approach is less commonly applied to non-human species, several determi- nants are shared by all species, such as the necessities of daily living (access to food, water, and hab- itat). A determinants-of-health model is useful for health planning and policy development for different species (Wittrock et al. 2019). However, studying human health and disease separately from animal and ecosystem health and disease is not only reductionist, but also undermines the survival of the human species. Pathogens differ in their ability to adapt to new host species. The World Health Organization recog- nizes 200 zoonotic agents, but many more agents with zoonotic potential are discovered every year as genomic technology and molecular biology improve and as conditions such as human encroachment create new opportunities for zoonotic and reverse zoonotic transmission to occur (Grange et al. 2021; Plowright et al. 2021). Disease agents like SARS-CoV-2 are highly adaptable and very difficult to eradicate; agents such as Mycobacterium bovis, are linked to food security, and thus introduce other challenges (One Health Case Study 1). The fact that only two infectious agents—smallpox and rinderpest—have been eradicated underscores how difficult it is to control infections, particularly zoonoses. Another aspect of zoonotic disease is that it may cause chronic sequelae in humans and other animal species. For example, Echinococcus granulosus (a parasite with life stages in wild carni- vores and deer species) can cause protracted liver and lung disease in humans, and SARS-CoV-2 is associated with post-COVID-19 conditions, or ‘long-COVID’. Because zoonoses are challenging to control, greater efforts are needed to prevent the establishment of pathogens in new hosts and to promote and maintain the health of all species and ecosystems and build resilience. Further, the health impacts of changing environmental and economic conditions are becoming increasingly urgent. Adding to current social and environmental stressors are the com- pounding pressures that are threatening the health of all communities, especially those most vulner- able. Consequently, an approach that recognizes the interdependence of health is needed to better prevent, respond to, and reduce health impacts today without compromising our ability to respond in the future (WHO 2021). Case Study 1. One Health Case Study. Mycobacterium bovis in cattle, badgers, deer, and cats Scott Weese Mycobacterium bovis is a bacterium that causes bovine tuberculosis (TB) and can also infect various other species. The World Health Organization estimated a burden of 147,000 new cases of zoonotic TB in people globally in 2016, with 12,500 deaths—recognizing that the disease is likely underdiagnosed (who.int/tb/zoonoticTB.pdf). The disease is transmitted to people most often through unpasteurized milk, but direct contact and aerosol transmission are also of concern for people exposed to infected animals. While the focus of M. bovis is its ruminant reservoir, this bacterium can also be harboured and spread by other species, both domestic and wild. There can be complex and surprising trans- mission patterns. For example, in the United Kingdom, M. bovis is widespread in Eurasian badgers (Meles meles), complicating control of M. bovis in cattle (Clifton-Hadley et al. 1995; Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 15 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 https://www.who.int/tb/zoonoticTB.pdf http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com One Health solutions To get ahead of the ongoing, extraordinary social and environmental changes that are expected, new partnerships, tools, and approaches are urgently needed. One Health offers a pathway towards trans- formative change. One Health is evolving by enabling all species, places, and generations to achieve their full health potential: Optimal health for all—today and tomorrow and around the world. One Health can be viewed as a continuum of activities intended to prevent, mitigate, or solve prob- lems occurring where environmental systems and animals, including humans, intersect. The tradi- tional topics of focus have been emerging zoonoses, antimicrobial resistance, and food safety, but expectations for One Health are changing to address other persistent and complex issues including climate change, sustainable development, environmental pollution, and food insecurity (Zinsstag et al. 2011). Behind these changing expectations of One Health, and other holistic approaches to health (e.g., EcoHealth, Planetary Health, Global Health), is a growing recognition that global 21st century pressures (climate change, poverty, biodiversity loss, among many others) are root causes of the tradi- tional problems that One Health has addressed (antimicrobial resistance and zoonoses). One Health needs to address today’s challenges and to prepare for future health threats through building commu- nity resilience and ecosystem stability. One Health is about the health of animals (including humans), plants, and ecosystems and the interdependencies among them. It is also about filling an increasingly urgent need to change how we do things, to mobilize and co-produce knowledge, to “do better,” and to inspire positive change across society in a collaborative and cooperative manner. A One Health approach is adaptable to a wide range of contexts and purposes including emergency responses to current threats, preventing emerging threats, and preparing and adapting to ongoing, persistent, and future challenges. As an approach, One Health uses methods and tools already devel- oped and in use across different sectors and disciplines. Indigenous knowledge systems, among others, have long recognized the interdependence of all things and the critical importance of balance among them. One Health practitioners and advocates are striving to bring tools and methods together in novel ways and to facilitate conversations between sectors and knowledge holders that do not typ- ically engage with each other. Sharing information and perspectives leads not only to more timely, complete, and accurate information but also to new opportunities for innovation. Case Study 1. (concluded ) Corner et al. 2011). Unexpected bridges between wildlife, domestic animals, and humans can be encountered and companion animals such as cats are increasingly infected through contact with wildlife (Gunn-Moore 2014). Unexpected routes of exposure have also been encountered, such as a cluster of infections in pet cats that were fed a commercial raw-meat diet made of venison (O’Halloran et al. 2021). While apparently rare, transmission from cats to humans has been doc- umented (O’Connor et al. 2019). Risks for direct human exposure and spread of M. bovis between regions and to wildlife reservoirs can also be created through the widespread and poorly controlled international movement of companion animals, as shown through importation of M. bovis into Germany and Italy from cats originating in Ukraine (Attig et al. 2019; Černá et al. 2019). The presence of this bacterium in hunted wildlife also poses a risk to hunters and high- lights the need for a One Health approach to hunter education (Wilkins et al. 2003). Therefore, control of this important human and animal pathogen is complicated by its presence in food ani- mals, companion animals, and wildlife; its potential transmission between regions through movement of people or animals; and its interconnected but poorly understood pathways of transmission. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 16 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com The One Health concept underscores that health is the result of the interconnections among humans, other animals, plants, and ecosystems. While the idea is attractive and relatively easy to grasp, practic- ing One Health can be challenging. The operationalization of One Health requires strong governance, shared responsibility by all sectors and individuals involved, and a commitment to collaboration across sectors that do not always view things the same way or use the same vocabulary or methods, but that have a shared purpose. The siloed infrastructure of government globally, nationally, provin- cially, and locally is difficult to dismantle, making successful One Health programs and projects chal- lenging to initiate and sustain (Rüegg et al. 2017). As a zoonotic agent, SARS-CoV-2 is precisely the type of problem to which a One Health approach has been applied. Recent focus has been on discovering viral origins and exploring potential pathways of introduction and mechanisms of transmission and spread of zoonoses (e.g., yellow fever and avian influenza viruses) (Kelly et al. 2020; Mackenzie et al. 2014). However, little emphasis has been placed on identifying key leverage points that could reduce virus spillover in the future and even less on how to reduce the impacts of the inevitable emergence of such viruses. Moreover, most surveillance efforts have focused on human infections, with very little interest or investment in monitoring spread to domestic and wild animal species. However, COVID-19 has shifted the conversation due to the scale and inequitable distribution of the impacts associated with (1) infection and disease and (2) unintended negative consequences of prevention and control measures. The critical yet often indi- rect connections among all living things, ecosystems, and societies have been highlighted, and calls are being made for a radical change to our approach (Bates et al. 2021; Leach et al. 2021; Thoradeniya and Jayasinghe 2021). The COVID-19 pandemic, climate change, animal health, food systems, global economy, and biodi- versity loss are no longer seen as completely independent issues. Recognition of these connections is changing our expectations for what One Health can offer and where it can be applied. One Health is now being called upon to help prevent future viral emergence and to enable multidisciplinary col- laboration to help reduce the impact of future pandemics. If these expectations are to be met, the highest levels of government need to commit to One Health. Practitioners of One Health will also need a new tool kit that includes innovative partnerships, different types of knowledge and expertise, and novel methods. Although One Health is now globally recognized as a concept and an approach to address environ- mental and health challenges of the 21st century, there is an urgent need for more and better research on how to practice One Health, to learn from past successes and failures, and to adapt proven strate- gies to new settings and circumstances. Creating this pathway will require commitment to One Health and a global paradigm shift that promotes health and resilience over economic growth and power. One Health in practice Investment is needed to support the development of new tools and forums for respectful discussion and engagement, including with marginalized populations, and new mechanisms to measure health and success, beginning by determining what defines One Health success. As the traditional focus of One Health projects, infectious diseases such as COVID-19 can be used as a springboard to launch new initiatives. Our shared experiences with SARS-CoV-2 have many people involved in One Health asking not only how to prevent the next pandemic but also how to reduce the impacts while working to build resilient communities and sustainable policies and practices. Participatory methods and a One Health approach are also relevant to the prevention, surveillance, and control of “non communicable diseases,” which can be the result of air pollution, chemicals, or heavy metals polluting environments and affecting the health of all living beings. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 17 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com To provide a picture of some of the programs and institutions working on topics related to One Health, a network analysis is shown in Figs. 4 and 5 in this section. This network analysis was not exhaustive, as it was not possible to include every program and institution within the area of One Health. However, this program mapping represents a useful starting point. In Fig. 4, the programs and institutions are mapped based on their topic of focus and colour coded by type of institution. The figure includes international and Canadian institutions that focus on one or more topics within the concept of One Health. Each institution is linked to nodes representing differ- ent One Health topics (e.g., food safety, trade, or animal health). Central topics are those that a high number of programs and institutions address: One Health, Human Health, Emerging Infectious Disease, and Animal Health, followed by Environmental Health. These topics are those that One Health has historically used to understand and respond to zoonoses. Other topics that are less central in the figure such as Social Determinants of Health represent topics that are newer additions to One Health. In Fig. 5, programs and institutions are organized based on their centrality, and the more central organizations are represented by larger squares. In this network analysis, centrality is based on the number of other programs/institutions to which each organization is connected. The COVID-19 pandemic and climate change are creating new urgency and accelerating long- standing intentions to ensure that the steps taken today to protect well-being are equitable and sus- tainable so that future generations, other species, and ecosystems can also be healthy. One Health can be a pathway to health security by connecting systems and programs for healthcare and surveil- lance across species and by providing a mechanism to recognize interdependencies and support recip- rocal care for health and our shared future. Fig. 4. Network analysis by type of institution (black circle = intergovernmental, pale blue circle = governmental, pink circle = academia, green circle = networks, dark blue circle = NGO/NPO); white boxes represent different One Health topics. See supplementary material. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 18 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Interconnectedness, value, reciprocal care, multi- and inter-disciplinarity and inclusion underpin the One Health approach, which can be used to address multifaceted challenges such as emerging and zoonotic infectious diseases. These interrelated facets are depicted in Fig. 1 of the Executive Summary and include elements of strategy and governance, operations and technical leadership, equity, and education and research. This framework serves as the foundation for the sections and rec- ommendations that follow, beginning with recommendations addressing an overarching national strategy for One Health in Canada. Recommendations Implement a Canadian One Health Action Plan with supporting governance structures and executive functions. Urgent gaps related to the COVID-19 pandemic must be addressed at the highest level of government; these efforts must be leveraged for a One Health approach to all emerg- ing zoonoses through a One Health Council. The Council must include experts and representatives from all relevant academic disciplines and ministries of the Government of Canada, as well as key non-governmental partners. The Council should be tasked with examining the policies, programs, and financial and legislative support of agencies, organizations, and institutions related to One Health and guide implementation of a One Health Action Plan through respective ministries and partners. Reporting on key activities will be essential to ensure accountability. To ensure One Health priorities are met, a Special Advisor on One Health must be appointed to one or more key ministries overseeing health, which may include human, other animal, and environmental/climate health; this individual would be external to the government and have a key role in a One Health Council. One Health must also be tied to Canadian foreign policy. To promote both national and global health and security, Canada must demonstrate leadership in One Health on the international stage. Fig. 5. Institutions linked by topics to show centrality. See supplementary material. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 19 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Develop and implement an Indigenous Engagement and Knowledge Policy Framework for One Health. This work must be done at municipal, provincial, national, and international levels. First, Canada must address the impacts of colonialism on Indigenous Peoples’ health and relationship with the land. Land degradation and cultural genocide are tied to environmental dispossession, impeding the ability of First Nations, Inuit, and Métis Peoples to observe early signs of emerging zoonoses and to protect themselves and others from disease. Important tools such as Other Effective Conservation Measures, Indigenous Protected and Conserved Areas, and Indigenous-led moni- toring activities should be included in an Indigenous framework for One Health. Given Canada’s commitment to upholding the United Nations Declaration on the Rights of Indigenous Peoples, the One Health Action Plan for Canada must also address the Calls to Action of Canada’s Truth and Reconciliation Commission. 3. Human drivers of pathogen emergence Over recent decades, we have gained substantial knowledge about emerging infectious diseases (EIDs). We know that approximately 60% of EID first-time clusters or outbreaks that infect humans are zoonotic in origin, that more than 70% of these EIDs originate in wildlife, and that EIDs are increasing in frequency (Jones et al. 2008). EIDs include severe acute respiratory syndrome coronavi- rus (SARS-CoV and SARS-CoV-2), which most likely originated in horseshoe bats (genus Rhinolophus; Holmes et al. 2021; Latinne et al. 2020). Global hotspots for disease emergence have been identified, with areas of elevated risk including forested tropical regions experiencing land-use changes (Allen et al. 2017). We also know that RNA viruses may be more likely to emerge as EIDs than other types of pathogens (Woolhouse and Gowtage-Sequeria 2005). Understanding the risk associated with composites of host, pathogen, and environment allows surveillance programs to focus on high-risk scenarios to strengthen global capacity to detect and discover zoonotic viruses with pan- demic potential (One Health Institute University of California Davis 2019). As a key step in pandemic preparedness, surveillance is vital (discussed in Section 6). However, given the complex and multifac- torial drivers of pathogen emergence and spread, pathogen surveillance alone is insufficient to predict and prevent the next pandemic. There are a wide number of underlying socioeconomic, environmental, and ecological factors that drive disease emergence (Jones et al. 2008). Twenty years ago, in 2001, the Committee on Emerging Microbial Threats to Health in the 21st Century identified, reviewed, and assessed the state of knowl- edge on factors in the emergence of infectious diseases. In their report, the committee examined 13 factors, all of which still apply today. These include key elements such as pathogen adaptation, host susceptibility, climate and ecosystems, demographics, socioeconomics and inequality, industrial and technical developments, behaviour (including travel), conflict, politics and intentional harm, among others (Smolinski et al. 2003). Emergence at the human interface with other animals Zoonotic disease emergence in humans is driven by human activities and behaviour that change human, other animal, and (or) vector interactions. Addressing how humans interact with other ani- mals, including wildlife, is a key component of EID risk management and response (Watsa 2020). Decreased habitat availability, pollution, and climate change impact the health of wildlife and other animals, including humans (One Health Concept Box 2). Over the past 50 years, wild animal populations around the globe have declined by 60% on average (Grooten and Almond 2018) and 28% of assessed species are threatened with extinction (IUCN 2021). Ecosystems have been degraded, changing how different species interact and increasing the risk of exposure to novel pathogens. Prevention of EIDs will require us to tackle these underlying factors, including climate change, ecosys- tem degradation, and land-use change. Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 20 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com We know that ecosystem and land-use change can have dramatic impacts on pathogen transmission patterns. For example, in Malaysia, the development of large-scale swine production facilities near mango orchards where fruit bats roosted is believed to be a driver of Nipah virus transmission from fruit bat reservoirs to pigs, with spillover into humans (Pulliam et al. 2012). Although there are many cases in which land-use change is associated with increased disease transmission, this is not always clear, leading Gottdenker et al. (2014) to suggest that “there is still uncertainty regarding the direction, magnitude, and mechanisms of anthropogenic disturbances on infectious disease transmission and persistence.” More research is required to fully understand the impacts of changing landscapes on disease emergence; however, land-use change should be considered as a key risk factor. Box 2. One Health Concept Box. Advancing forest health as part of One Health Katarzyna Nowak, Katarzyna Simonienko, and Bogdan Jaroszewicz The United Nations 5th Global Biodiversity Outlook has defined eight major transitions needed to stop the decline of nature (Secretariat of the Convention on Biological Diversity 2020). Two of these are “the land and forests transition” and “the biodiversity-inclusive One Health transi- tion.” These transitions are inextricably linked in Canada, which harbours more than a quarter of the world’s remaining boreal forest. According to the Center for International Forestry Research (CIFOR), connections between forests and One Health require strengthening (CIFOR 2020). We focus here on the benefits of healthy forests to One Health, primary pandemic preven- tion, and pandemic recovery. Forests enhance health by providing services such as clean air and cooling effects through the absorption of carbon dioxide and provision of shade from solar radiation. Intact forests are nature-based solutions to slowing down climate warming. Forest biodiversity matters because more biodiverse forest stands are superior at reducing air pollution, diluting disease vectors, and providing people and other animals with plant-derived foods, medicines, and herbs (Wertz-Kanounnikoff and Rodina 2020). Forests also provide therapy that improves our physical and mental well-being and assures high restorativeness (through the landscape’s ability to renew the cognitive capacities of forest visitors) (Kortmann et al. 2021; Simonienko 2021). Being in a forest environment reduces both physiological stress (heart rate, blood pressure, cor- tisol, and adrenaline levels) and psychological stress (Engemann et al. 2019). A forest environ- ment has been shown to be particularly effective at reducing stress in people with lower socioeconomic status (Marselle et al. 2020). Exposure to the forest environment is associated with greater resistance to future stressors and faster regeneration after a stressful experience, sug- gesting that forests are important in the prevention of mental and neurodegenerative diseases (Annerstedt et al. 2013). Being in the forest may also strengthen the immune system (Li et al. 2006). People’s reliance on access to nature as a source of health during the COVID-19 pandemic was a worldwide phenomenon (Naomi 2020; Weinbrenner et al. 2021). A challenge related to the mass extinction of species, disappearance of wild areas, and reduction of biodiversity is the phenomenon of negative feedback called the extinction of experience. When wilderness recedes and nature declines, encounters between humans and other free-living ani- mals and plants become less frequent, depriving humans of stimulation. Nature becomes boring, interest in it dwindles, and consequently concern for its protection declines, resulting in further Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 21 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com The wildlife trade also provides opportunities for disease transmission that may affect the health of humans, domestic animals, wildlife, and ecosystems (Karesh et al. 2005). For example, monkeypox emerged in the United States as a consequence of the wildlife pet trade in 2003. Human exposure resulting in 47 confirmed or probable cases in six states was traced to contact with pet prairie dogs that had been co-housed with monkeypox virus-infected rodents imported from Ghana (Prevention 2003). Currently, a global outbreak of monkeypox is being sustained through human-to-human transmission. This serves as a stark reminder of the critical importance of supporting regional efforts for control in endemic regions, and of investing in global health and security. The wildlife trade has been investigated as one of the key factors leading to the emergence of SARS in 2003 and SARS- CoV-2 in 2019 (Mallapaty 2020; World Animal Protection n.d.). International regulation of the legal wildlife trade falls under the Convention on International Trade in Endangered Species of Wild Fauna Box 2. (concluded ) reductions in biodiversity and fewer opportunities to experience nature outside of ourselves. People who know less and experience less also care and act less (Miller 2005). Mental health and environmental stewardship are closely related and connected to human economies (Buckley et al. 2019). That “the land is a healer” is well-known among Indigenous knowledge holders and societies (Redvers 2020). Canada is well-positioned to support meaning- ful partnerships between Indigenous and Western scientists and knowledge holders in ways that help realize One Health and inform One Health programs around the world, including through forest ecosystem scale thinking. More than 80% of the world’s forests are degraded (Watson et al. 2018). Deforested areas and forest margins have higher risks of disease and a higher likelihood of spillover events (Dobson et al. 2020). For example, in Peru, mosquito bites are significantly more frequent in deforested areas, and in Brazil, the incidence of malaria increases with deforestation. Disease is prevalent in these regions because land clearing often creates pools of stagnant water and because human-induced ecological changes reduce mosquito diversity, favouring those species that trans- mit malaria (Robbins 2016). Deforestation also contributes to the spread of waterborne patho- gens such as giardiasis, cryptosporidiosis, and microsporidiosis through increased contact between people, domestic, and wild animals (Lallo 2012). Research from Cambodia shows that forest loss is associated with an increase in acute respiratory infection and diarrhea (Pienkowski et al. 2017). In fragmented woodlots, where there are fewer predators and competi- tors (i.e., where food webs are disrupted), there is a higher density of potential disease vectors such as white-footed mice (Ostfeld and Keesing 2000). In areas where small mammal diversity is higher, Lyme disease incidence falls, evidence that biodiversity can buffer us against disease (Ostfeld and Keesing 2000). Fortunately, there is growing interest in how human health and well-being are linked to biodiversity, nature stewardship, and sustainable development in the public, scientific, and policy spheres (Naeem et al. 2016). A powerful example is the Arramat Project (arramatproject.org/), which supports Indigenous Peoples’ whole-environment approaches to the health and well-being of their communities. It is a vital movement to foster transdisciplinary and transboundary cooperation and hybrid knowledge collaboration at the nexus of human health and healthy natu- ral ecosystems, including forests. As forests can act as fortifiers against disease and against vectors of disease and environmental pollutants, they can be “at the heart of a green recovery”, and better integrated into One Health approaches (Sen 2020, p. 1; CIFOR 2020). Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 22 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 https://arramatproject.org/ http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com and Flora (CITES). Data from imports and exports falling under this agreement reveal that the legal wildlife trade is in the range of 11.5 million wild animals from 1,316 species over a five-year period (2012–16). The United States is the greatest consumer of legal wildlife (Can Ö et al. 2019). The disease risks and conservation concerns associated with the wildlife trade (both legal and illegal) have been well-documented and the COVID-19 pandemic has renewed calls to ban the global wildlife trade (Karesh et al. 2005; Roe and Lee 2021). However, some researchers have been urging caution as wild- life trade bans may have substantial unintended consequences, including socioeconomic impacts on local communities and an increase in the illegal wildlife trade (Roe and Lee 2021; Federal Provincial and Territorial Governments of Canada and Canadian Wildlife Health Cooperative 2018). These issues need to be considered from a One Health perspective, including the assessment of potential unintended consequences such as health impacts on animals from displacement and infectious diseases. Sustainable development goals Social determinants of health are also key drivers of pathogen emergence, thus underscoring the rel- evance of the Sustainable Development Goals (SDGs). The SDGs provide a critical framework to help improve equity, resilience, and sustainability around the world, recognizing the essential linkages among human, other animal, plant, and ecosystem health. Inputs and activities to achieve SDGs directly link with human health (e.g., clean water and sanitation, good health, well-being, zero hunger, and no poverty) and One Health (e.g., climate action, life below water, and life on land). Actions to meet the SDGs and improve the overall health of all animals, including humans, and ecosystems also offer solutions for challenges related to zoonoses. For example, interventions to improve access to water, sanitation, and hygiene can contribute to lower disease rates, enabling marginalized individuals and households more opportunity for employment and better livelihoods. Multiple calls have been made to develop multi-pronged, comprehensive approaches to complex health challenges of the 21st century. This type of health promotion approach would recognize the many factors interacting in different ways to drive emergence of zoonotic diseases, antimicrobial resistance, and climate change, among many other challenges. Many of these root causes are also addressed by actions taken to meet health and equity targets set as part of the global SDG agenda. Pan-Canadian approach to wildlife health Moving from our current reactive approach to wildlife health and emerging disease issues to a sus- tainable, proactive approach will improve our ability to quickly detect emerging threats, promote col- laboration, anticipate problems, and sustain healthy populations of all species, including humans. The Pan-Canadian Approach to Wildlife Health (PCAWH), approved in the spring of 2018 by all federal, provincial, and territorial ministers responsible for biodiversity and conservation, promotes a sus- tained, collaborative One Health approach to wildlife health (Federal, Provincial and Territorial Governments of Canada and Canadian Wildlife Health Cooperative 2018; Stephen 2019). A key goal of PCAWH is to strengthen “Canada’s capacity to identify and reduce wildlife health threats that put conservation, public health, or economic and cultural opportunities at risk” (Stephen 2019). Although approved by all levels of government, PCAWH has yet to be implemented, a critical step to ensure that Canada has a sustained, proactive One Health approach to wildlife health. Recommendations Develop and implement a One Health Action Plan for Canada to identify and mitigate drivers of zoonotic pathogen spillover. Mitigation of new spillover events is dependent on directly and effec- tively addressing predisposing conditions, beginning with reciprocal care of land and water. New tools and approaches are urgently needed to address underlying drivers and factors sustaining interspecies Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 23 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com zoonotic disease transmission. There are immediate actions to be taken, which include developing a One Health Action plan that prioritizes identification and mitigation of drivers for infectious diseases spillover. Key drivers of pathogen spillover, endemicity, and spread are not well understood in Canada. Addressing the root causes of emerging zoonotic diseases will support efforts toward the United Nation’s Sustainable Development Goals and advance Canada’s leadership on a global scale. Urgently implement the Pan-Canadian Approach to Wildlife Health. The PCAWH has been approved by the federal government and provincial and territorial partners to close gaps among existing programs and protect wildlife health, particularly during this time of accelerating environ- mental change. Clear benefits to ecological, human, and other animal health are gained by ensuring health and biodiversity among wildlife. With a focus on threat reduction, program and policy devel- opment, and coordination of services, key activities must concentrate on generating health intelli- gence, responsible management, innovation, and effective governance. Considering the spillover of SARS-CoV-2 into wildlife populations, and the circulation of monkeypox in humans, implementing PCAWH is now an even more pressing matter. 4. Surveillance as a critical tool for response and preparedness The emergence of novel pathogens, including those with pandemic potential, cannot be completely prevented. Therefore, there is a need both to respond to new challenges quickly and effectively and to reduce impact of emerging infectious diseases (EIDs). Underpinning the response to EIDs is the availability and use of reliable information. Accurate and timely understanding of a situation is critical for the assessment of risk, development of interventions, effective communication, and situational awareness. As a result, surveillance is a core component of pandemic preparedness and response, and is used both proactively and reactively. A broad term, surveillance encompasses a range of information gathering and assessment activities and includes dissemination of information, so action can be taken to control disease (Thrusfield 2005). Surveillance is a core component of emerging disease identification and control and allows us to: (1) identify and respond to new infectious disease challenges, (2) prevent or mitigate outbreaks, (3) implement pharmaceutical and non-pharmaceutical interventions, (4) guide targeted laboratory and field research, and (5) assess the impact of control measures. Surveillance is important in the context of rare, high-profile events (e.g., the SARS-CoV-2 pandemic), but it is also essential for responding to disease emergence occurring over longer time scales (e.g., the gradual expansion of tick- borne disease ranges, the spread of antimicrobial resistance), highlighting the need for a robust, responsive, and comprehensive surveillance structure. Within these broad aims of surveillance, there is a diverse toolbox that can be used. Active surveil- lance involves efforts to obtain specific information (e.g., field sampling of dead birds for avian influ- enza, genomic analysis of viral or bacterial pathogens), while passive surveillance involves the use of data available from other sources (e.g., analysis of clinical diagnostic laboratory data and reportable disease data). Each approach has inherent strengths and weaknesses, but both must be included and used in a coordinated manner. For example, passive surveillance can identify a reportable disease case, and then active surveillance can be used to follow up and check for that reportable disease in a pop- ulation that would not otherwise have been investigated. Sentinel surveillance is an additional approach used selectively to discern pathogen epidemiology and risk in selected scenarios. For exam- ple, the Canadian Lyme Sentinel Network has conducted sentinel surveillance of ticks in seven prov- inces, establishing baselines for the abundance and prevalence of Borrelia burgdoferi (the etiologic agent of Lyme disease) and other tick-borne pathogens (Guillot et al. 2020). Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 24 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com Many surveillance systems rely on laboratory data, which are best for providing information about known problems. Diseases or pathogens that are not readily identifiable using laboratory-based sur- veillance may be missed or identified late. In contrast, clinical or syndromic surveillance (e.g., mortal- ity events in wild animals) can provide an early warning of unidentified and new potential threats. Although insensitive, syndromic surveillance is an important tool for identifying new issues that require further investigation, speeding initial detection of problems, and generating significant health intelligence when implemented and coordinated effectively (Dórea and Vial 2016). Surveillance gaps and challenges There is a pressing need for an action-oriented, comprehensive plan for One Health surveillance in Canada and for surveillance to be adaptable enough to respond to changes when needed. Key to accomplishing a suitable plan for surveillance is identifying some of the major gaps in current surveil- lance systems and recognizing the challenges inherent in establishing an ideal One Health surveillance system. To address emerging zoonoses, One Health surveillance systems need to operate across a range of jurisdictions, and Canada participates in numerous international, national, provincial/territorial, regional, and sector-specific surveillance efforts. However, when one considers that One Health surveillance requires detailed information about diverse human, other animal, and environmental sources, the need for multifaceted and integrated surveillance is apparent. Despite some excellent surveillance efforts and programs (e.g., Canadian Integrated Program for Antimicrobial Resistance Surveillance and the Canadian Wildlife Health Cooperative) (Public Health Agency of Canada 2007), the scope, depth, and connectivity of surveillance efforts in Canada across the One Health spectrum is suboptimal. Optimal surveillance should be standardized, goal-oriented, transparent, comprehensive, adaptable, sustainable, have adequate surge capacity and be integrated within and across human, other animal, and environmental health sectors. It should also be informed by existing knowledge of biological determinants of transmission and disease. For example, surveillance for novel coronaviruses among animals would include advanced genomic sequencing methods and computational biology to examine key determinants of spillover risk and pathogenicity (Mercer and Salit 2021) and biological characterization to assess risk to health. Data are only useful if they are used. Inadequate effort or ability to access and translate data into action, particularly in real time, can hinder surveillance systems. Some degree of delay is inherent in the surveillance process as time is required to gather, analyze, and transfer information, but when dealing with emerging issues, time lags diminish the value of surveillance as an early identification or intervention tool. A One Health approach to surveillance necessarily involves integrating the surveillance activities of diverse specialists and stakeholders (One Health Case Study 2). In Canada, surveillance is performed by a wide range of individuals and groups, including governments (Indigenous, federal, provincial, territorial, and local), academic institutions, healthcare facilities for humans and other animals, pro- fessional networks, and private diagnostic laboratories. Within government, surveillance is often per- formed across multiple departments. This intersectionality highlights the complexity of the issues surveillance tries to address and the importance of intersectoral and interdisciplinary work, but it also creates potential barriers (e.g., timely and comprehensive information exchange), inefficiencies, dupli- cations, and gaps. Communication of surveillance activities is key and should be multidirectional and ongoing. Stakeholders and rights holders need to be included early in surveillance initiatives to ensure that Mubareka et al. FACETS | 2023 | 8: 1–64 | DOI: 10.1139/facets-2021-0190 25 facetsjournal.com FA C E T S D ow nl oa de d fr om w w w .f ac et sj ou rn al .c om b y A gr ic ul tu re a nd A gr i- fo od C an ad a on 0 7/ 02 /2 4 http://dx.doi.org/10.1139/facets-2021-0190 http://www.facetsjournal.com needs are met, to identify resources to support surveillance, to identify potential synergies, and to facilitate rapid and effective use of surveillance data. Communication between people involved in surveillance and stakeholders must continue throughout, to ensure that surveillance data are properly used and that emerging issues are identified and acted upon. How and when surveillance data are communicated is also important. Surveillance reporting should be as granular and timely as possible, but it is limited in some surveillance programs, as the time