Healthy Ecosystems Are a Prerequisite for Human Health—A Call for Action in the Era of Climate Change with a Focus on Russia

Throughout history, humans have experienced epidemics. The balance of living in nature encircled by microorganisms is delicate. More than 70% of today’s emerging infections are zoonotic, i.e., those in which microorganisms transmitted from animals infect humans. Species are on the move at speeds never previously recorded, among ongoing climate change which is especially rapid at high latitudes. This calls for intensified international surveillance of Northern infectious diseases. Russia holds the largest area of thawing permafrost among Northern nations, a process which threatens to rapidly disrupt the balance of nature. In this paper, we provide details regarding Russian health infrastructure in order to take the first steps toward a collaborative international survey of Northern infections and international harmonization of the procured data.


Introduction
The primary perspectives on climate, ecosystem functionality and transitioning landscapes began to form at the turn of the eighteenth and nineteenth centuries. Alexander von Humboldt was the first scientist to talk about harmful human-induced climate change. This German investigator born in 1769 was the founder of "ecosystem sciences". During his Russian expedition in 1829, von Humboldt listed three ways that humans were affecting the climate at that time: through ruthless irrigation, deforestation and the use of steam and gas for industrial purposes [1]. Svante Arrhenius  further developed von Humboldt's ideas on the possible emergence of an Anthropocene era as a result of the industrial revolution which started in 1769 [2]. However, the Swedish scientist thought that this would take several thousand years. Today, we know that it is happening right now and at the fastest speed in the Arctic. The world has a lot to learn from what is happening up north.

Climate Change in the Arctic
According to the Intergovernmental Panel on Climate Change (IPCC) [3,4], warming in the Arctic is happening twice as fast as in the rest of the world. Regarding hot extremes, the strongest warming is

Species on the Move
Large global species redistributions associated with climate change have been taking place since the last glacial maximum. The geographical ranges of species naturally fluctuate in space and time, but recent climate changes could cause massive movements of animal populations to new territories. If cold-loving species cannot adapt to warming local conditions, they will seek new habitats closer to the poles, higher in the mountains or deeper in the oceans. [23]. On average, terrestrial taxa move poleward by 17 km per decade [6] and marine taxa by 72 km per decade [7,24], as meta-analyses have shown. Just as terrestrial species on mountainsides are moving upslope to escape warming lowlands [25], some fish species are now being driven deeper as the sea surface is warming [26].

Zoonoses: Diseases Common to Animals and Humans
One Health (an initiative committed to designing and implementing programs, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes; https://www.onehealthinitiative.com) takes a holistic approach to health risks and their mitigation among humans, animals and in the environment. The One Health concept emphasizes that human health and welfare are dependent on ecosystem health.
Pandemics occur as a result of the emergence of new diseases to which people do not have immunity. Zoonoses transmitted from animals to humans play an important role [27,28]. More than two thirds of current human infections and many of the emerging infections in northern regions are zoonotic [29].
Zoonoses may be caused by bacteria, viruses, parasites, fungi or prions (proteins linked to several fatal neurodegenerative diseases). They have different means of transmission, including through direct contact between animals and humans, hematophagous arthropods, intake of food and water contaminated with parasites and through the air [30]. The Spanish flu of 1918, caused by the Influenza A virus found naturally in wild aquatic birds, claimed between 30 and 50 million lives [31] and is perhaps the best-known and deadliest example of a zoonosis. Other examples include the rabies virus and recent emerging diseases such as the Ebola and Zika viruses, as well as the ongoing pandemic caused by the SARS-CoV-2 virus [32].
The number of nosoforms observed in Arctic species has increased in recent years. These include avian cholera outbreaks in marine birds in Alaska and the Canadian Arctic Archipelago, as well as mortalities within walrus and seal populations in the U.S. Arctic [33]. Thawing permafrost can potentially release anthrax spores, as was seen in 2016 in the Yamal Peninsula in the Russian Arctic. This outbreak was the largest in decades and resulted in the death of a 12-year-old boy, the hospitalization of around 100 people, laboratory confirmed diagnoses of anthrax in 36 patients and the deaths of 2300 reindeer [34]. There is, furthermore, a risk of the appearance of ancient microorganisms unknown to science as a result of the thawing of permafrost [35][36][37]. Migratory birds also have the potential to transmit ticks across long distances along with antibiotic resistant genes.
The spread of zoonotic diseases can take a major economic toll on many industries, including those in the manufacturing, agricultural, travel and hospitality sectors. Furthermore, the peace and economic stability of communities is both directly and indirectly connected to disease outbreaks [38].
The connection between human and animal microbiology was originally recognized by Virchow and Osler in the nineteenth century [39], and the connection of diseases with ecosystems (natural focal disease theory) was posited by Pavlovsky in the first half of the twentieth century [40]. However, it is only recently that this relationship has been emphasized through the One Health initiative, which promotes equitable collaboration between practitioners and researchers in human and comparative medicine and in wildlife, domestic animal and human observation programs. Despite the fact that the term "One Health" is quite new, this concept has already gained recognition both nationally and globally [41].
According to the WHO, the majority of zoonoses arise in natural ecosystems. Due to growing human involvement in natural landscapes, natural foci of infections, which have undoubtedly existed for a long time, have become more active. This problem is especially pressing because of the extensive incorporation of previously untouched territories in agriculture and recreational activities, as well as increased rates of tourism and migration [42]. Zoonoses can be classified according to the ecosystem in which they circulate. These diseases are either synanthropic zoonoses, denoting an urban (domestic) cycle in which the sources of infection are domestic and synanthropic animals (e.g., cat scratch disease, zoonotic ringworm and urban rabies), or exoanthropic zoonoses, denoting a sylvatic (wild and feral) cycle in natural foci outside human habitats (e.g., Lyme disease, arboviroses, tularemia and wildlife rabies). However, some zoonotic diseases can circulate in both natural and urban cycles (e.g., Chagas disease and yellow fever). Many zoonoses can be attributed to anthropogenic changes. The loss of wildlife habitats to development and the consumption of bushmeat, necessitated by poverty or resulting from cultural preference, increase opportunities for cross-species jumps. Climate warming may also increase the geographic range of arthropod vectors, such as ticks and mosquitoes, which serve as vectors and reservoirs for infectious agents [32].
Zoonotic disease management requires the collaboration of different types of disease-control and health specialists, since zoonotic disease agents can exist in humans, animals and the environment. Disease control should include host-control (mammals, birds, fishes) and vector-control (ticks, fleas, mosquitoes) programs; environmental cleanup or protection may also be required to control disease agents that remain viable on different surfaces, in water or in the soil [32].
New infectious diseases seem to be inevitable and previously rare ones are increasingly seen in unexpected places due to global warming, deforestation, human intrusion into previously underexplored or never-explored sites, world travel and the increasing threat of biological terrorism or warfare. Increased human contact with wild and domestic animals, population growth and urbanization and a lack of necessary sanitation can increase the incidence and severity of zoonotic diseases [43].
In 2019, a Nordforsk-funded Nordic Center of Excellence, Clinf (clinf.org) arranged a seminar with Russian colleagues at the Lomonosov Moscow State University Faculty of Geography focusing on the impacts of the transmission of infectious diseases in the North. It was decided that the discussions should be published as a paper with a focus on Russian research infrastructures in order to facilitate further collaborations.

International Collaboration Needed for Surveillance
A dataset produced by CLINF showing the variability of certain diseases by country and over time is presented in Table 1 [44].  1995-2016 1995-2014 1995-2016 1995-2016 1995-2016 1998-2016 1995-2016 1995-2016 Greenland n/a n/a n/a n/a n/a 2007-2007 * n/a n/a Iceland n/a n/a -n/a n/a n/a n/a n/a As is clearly shown here, despite the obvious need for the harmonization of surveillance data, there is still a long way to go before international comparisons can be quickly and efficiently made in order to project and predict, and even prevent, outbreaks. Even in a part of the world where infrastructures are quite similar, as in the Nordic countries, surveillance data are far from harmonized. With the largest tundra in the world (in Russia) thawing, collaboration with Russian colleagues and harmonization with Russian health databases and infrastructures are essential. As these aspects of Russian health care are still quite unknown to many, here, we provide details of the pertinent infrastructures and suggest how collaboration could be approached. There are no data on gender and age among the official open data in Russia, but these can be found through the local (regional) departments (Appendix A).

Russia in Detail
Russia has the largest territory (17,125,191 sq km) in the world and covers more than one eighth of the habitable part of the Earth. It consists of 46 oblasts (provinces); 22 republics; 9 krais (territories); 4 autonomous okrugs (districts); 1 autonomous oblast; and 3 federal cities (Figure 1).

Int. J. Environ. Res. Public Health 2020, 17, x 5 of 11
Russia has the largest territory (17,125,191 sq km) in the world and covers more than one eighth of the habitable part of the Earth. It consists of 46 oblasts (provinces); 22 republics; 9 krais (territories); 4 autonomous okrugs (districts); 1 autonomous oblast; and 3 federal cities (Figure 1). The health care system in Russia consists of two main institutions, the Ministry of Health (MoH) and the Federal Service for Supervision on Consumer Rights Protection and Human Wellbeing (Rospotrebnadzor), as well as two institutions which were separated from the MoH at the beginning of 2020, the Federal Service for Surveillance in Healthcare (Roszdravnadzor) and the Federal Medical Biological Agency (FMBA). The MoH is responsible for the implementation of medical aid for the population, medical education, research, the pharmaceutical and medical industries and control of private medicine. Rospotrebnadzor is responsible for sanitary and epidemiological supervision and federal state supervision in the area of consumer protection (Figure 2). Roszdravnadzor is responsible for state control of the quality and safety of medical activity through inspections and through the FMBA, which is, in turn, responsible for the implementation of medical-sanitary interventions for the management of emergency situations (including prevention, identification of causes, localization and elimination of consequences); radiation, chemical and biological accidents and incidents; and the spread of infectious diseases and mass noninfectious diseases.  (Figure 2). Roszdravnadzor is responsible for state control of the quality and safety of medical activity through inspections and through the FMBA, which is, in turn, responsible for the implementation of medical-sanitary interventions for the management of emergency situations (including prevention, identification of causes, localization and elimination of consequences); radiation, chemical and biological accidents and incidents; and the spread of infectious diseases and mass noninfectious diseases. The health care system of the MoH consists of the federal level (level IV)-the Federal MoH and the federal-level institutions directly subordinate to it that provide high-tech assistance to the population; the Regional level (level III)-the regional MoH, main regional hospitals with many departments which provide highly specialized medical care, regional insurance departments and regional pharmaceutics; the town/district level (level II)-town/district hospitals with several departments (emergency room, therapy, surgery, obstetrics, pediatrics, infectious diseases, ICU, neurology, etc.); and the primary care level (level I)-medical points (in remote rural areas), medical offices and policlinics. Emergency/ambulance services and medical sanitary aviation function across all levels of the medical system (Figure 3).  The health care system of the MoH consists of the federal level (level IV)-the Federal MoH and the federal-level institutions directly subordinate to it that provide high-tech assistance to the population; the Regional level (level III)-the regional MoH, main regional hospitals with many departments which provide highly specialized medical care, regional insurance departments and regional pharmaceutics; the town/district level (level II)-town/district hospitals with several departments (emergency room, therapy, surgery, obstetrics, pediatrics, infectious diseases, ICU, neurology, etc.); and the primary care level (level I)-medical points (in remote rural areas), medical offices and policlinics. Emergency/ambulance services and medical sanitary aviation function across all levels of the medical system (Figure 3).
Rospotrebnadzor investigates outbreaks and cases of infectious diseases at all levels of medical care, inspects laboratory diagnostics of infectious diseases(especially dangerous infections), conducts routine monitoring of the epidemiological situation(as well as of natural foci of zoonotic infections) and implements the assessment and monitoring of the quality of food, air and water.
Any doctor or nurse who suspects the presence of any infectious disease in a patient at any level of medical care, in any medical establishment, must send an initial emergency notification to the epidemiological department of the territorial department of Rospotrebnadzor. The patient will be hospitalized or transferred to an infectious disease unit or hospital if isolation is necessary or if the severity of the patient's condition requires it. The patient's samples of biological fluids will be sent for laboratory testing. After the results of the laboratory tests are produced, a second emergency notification with information about confirming, excluding or changing the diagnosis is sent to Rospotrebnadzor. In parallel with treatment in medical facilities by specialists from the MoH, Rospotrebnadzor conducts investigations into cases and outbreaks of infectious diseases. Specialists from the MoH may also be involved in this process, for example, by providing emergency vaccination or conducting examinations of contact persons, etc. Rospotrebnadzor provides all summary data about cases of infectious diseases to the MoH on a monthly basis. Rospotrebnadzor also provides regular reports on infectious diseases (there are more than 100 nosologies and postvaccinal complications on its regional and federal websites). regional pharmaceutics; the town/district level (level II)-town/district hospitals with several departments (emergency room, therapy, surgery, obstetrics, pediatrics, infectious diseases, ICU, neurology, etc.); and the primary care level (level I)-medical points (in remote rural areas), medical offices and policlinics. Emergency/ambulance services and medical sanitary aviation function across all levels of the medical system (Figure 3).  The Program for Monitoring Emerging Diseases (ProMED-mail) was organized in 1994 as an outbreak reporting system based on web technologies. In 1999, ProMED-mail started to operate as an official program of the International Society for Infectious Diseases. ProMED-mail is now an electronic outbreak reporting system for the monitoring of emerging infectious diseases globally. It acquires information from all open official and unofficial sources and works 24 h a day and seven days a week. ProMED-mail often announces outbreaks through public access systems before official notifications and makes information on them accessible to the public.
The ProMED-mail Russian language service started in 2004. The Russian language network covers Russia and the former USSR countries. The ProMED-mail RUS team provide between one and three posts every day about disease outbreaks or unusual events relating to infectious diseases in Russia and the countries of the former Soviet Union, which are distributed for free to more than 1000 subscribers. Subscription to the service is also free. Rospotrebnadzor frequently uses information posted in ProMED-mail about unusual events relating to infectious diseases abroad in its public reports. ProMED-mail RUS provides valuable contributions to the official epidemiological surveillance system in Russia for use in practical work.

Conclusions
Although it is difficult to encompass, all local, regional and global decision-making regarding climate change countermeasures and planning must consider and include the resulting biological/ecological chain reaction.
Epidemics have plagued humans throughout history. The balance of living in nature surrounded by microorganisms is delicate. Diseases can emerge when this balance is shifted by the various causes that occur when humans come into closer contact with previously uninhabited areas. Climate warming, which is currently indisputable, can accelerate this process. International surveillance of infectious diseases needs to be improved. However, as shown in this paper, despite the obvious need for the harmonization of surveillance data, there is still a long way to go before international comparisons can be quickly and efficiently made in order to project, predict and even prevent outbreaks.
We believe that the first step for data harmonization should be an international conference with the participation of the Arctic states' health authorities. We understand that it is difficult to hold such a conference at the global level (WHO). To begin with, it may be possible to hold such a conference at the level of Europe and Russia (the European Centre for Disease Prevention and Control (ECDC) and Rospotrebnadzor).
As we have shown in this study, well-functioning international collaboration in surveillance and data collection is needed. We also point to the need for the involvement of local communities in such efforts. We have created a database that can be used by international experts from a variety of disciplines, as addressing climate-sensitive infections (CSIs) requires a multidisciplinary approach. There are no administrative borders for microorganisms and species, and in order to keep infectious diseases under control, we need broad and trustful international collaboration and harmonization of collected data.