Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 299 - 313)


Dr David Nabarro and Louise Fresco

  Q299  Chairman: Good afternoon, Dr Nabarro. Can you hear me?

  Dr Nabarro: Yes, very clearly, thank you, and we can also see the group. Thank you for waiting.

  Q300  Chairman: Thank you very much and we very much appreciate your being willing to speak to us. As I think you gather, we are the Science and Technology Committee of the House of Lords. We are in the middle of this inquiry, what we call a short inquiry, into pandemic flu, so it is very relevant that we be able to speak to you. May I open the discussion perhaps with our having learned that the President has just made an announcement about the United States' position on pandemics. Perhaps you could fill us in on what he said, especially the prospects for international, particularly the US support for, UN efforts, please.

  Dr Nabarro: Can I just start by thanking you for giving me this opportunity and I would like to make one, possibly surprising, aside to you. I am sitting in the offices of FAO here in Washington and one of my most senior FAO colleagues, Louise Fresco, is here also because we have done some other testifying work that was necessary over here. If at any point there are issues for which you would want to get the latest update on FAO thinking, she has indicated to me that she is very prepared to be brought in. I have just come from an event at the National Institute of Health where the President of the US talked for about 20 minutes in detail about the US national strategy for pandemic influenza. He started by acknowledging the presence of both J W Lee, the Director-General of WHO, and myself and then making the point that, as far as he was concerned, preparedness and response in the United States were things that involved an international effort as well as strong national action. He made it very clear that anything which the US was doing was with a view to supporting international capacity-building and action. He spelt out, in particular, his concerns for there to be greater openness and transparency amongst countries with regard to influenza issues that they face. He talked about the importance of the international partnership on avian and pandemic influenza that the United States set up in October and described a little bit about what that had done. He mentioned that the US strategy is in three parts: detecting and attacking outbreaks in animals and humans; stockpiling necessary medicines, vaccines and other requisites to enable a response to a pandemic to take place; and then the actual undertaking of that response. Most of his conversation from then onwards was pretty domestic in focus. He was very clear on the need for bio-surveillance globally and then for having a national bio-surveillance initiative that would stop or slow the spread of any pandemic inside the United States, having spent some time stressing the difference between pandemic influenza and avian influenza. On stockpiling he talked a little bit about the importance of medicines, referring to both Tamiflu and Relenza, and said that there would be some investment in the purchase of antiviral drugs, a billion dollars, in order to help equip first responders and frontline personnel, but he was very clear that this is not a very satisfactory mainstay of pandemic preparedness. The most important thing, as far as he was concerned, was to get vaccine development improved. He mentioned that current vaccine production required waiting for the virus, which is going to cause the pandemic, to appear and using 1950s slow technology, as he put it, would take a long time to develop. He is launching a crash programme to develop new-style vaccines using cell-culture techniques, very much working initially on H5N1-derived vaccines. The ones that have already been produced are in clinical trials from NIH and NIAID. He wants to have enough for the vaccination of a large number of US citizens and so is putting $2.8 billion into this vaccine programme. Also he wants to protect vaccine manufacturers from litigation. Moving on to the third strand, the response side, he was very clear he is investing very significant money, half a billion dollars, in pandemic preparedness at local and state level; setting up a whole stack of mechanisms to make sure local and state are in line with their preparations with medical personnel and equipment, some stockpiling of equipment and medical goods; rosters for people, who participate in search activities and the preparedness of facilities for possible pandemic; plus a huge public information campaign and a new website. Then he went back, having talked about this, for which there is quite a significant price tag that I mentioned earlier, to state how important it is what the US does locally is reflected in the US's global involvement in prevention and preparedness work, and how important it is that the US co-ordinates with other countries, so there is no duplication, and gives international assistance. He did not mention a figure, but I understand that there is not an insignificant amount of money for the USAID and CDC, which from the USAID side will be routed through FAO and WHO; that was in private discussion with Andrew Natsios, the head of USAID. He stressed that all of this is going to have four spin-offs for the US. One of them is the development of a much stronger national public health infrastructure here which is too weak. Second is the development of cell-based technology for vaccine production. Third was the real step-up for the domestic vaccine industry, which he feels is not doing too well. Fourth is an emergency planning capability being put in place which will enable either dangers to be addressed, for example bio-terrorism, or other major convergences, but he did not refer back to some of the recent difficulties they have had, though that was the implication. That was a quick summary of what I heard and I must say that it was pretty impressive both to hear and read it, but, as I often feel when we have discussions on influenza, although he started with a long description of the bird flu problem, I felt he did not refer enough to what that means for the world. It would have been nice to have a few more paragraphs, perhaps talking about the US's role on helping countries to address influenza in animals. Thank you.

  Q301  Chairman: Thank you for that very concise and informative report. That is very useful. Perhaps now we could turn, though, to your personal view. You were appointed Senior UN System Co-ordinator for Influenza only in September, I think. We are particularly interested to understand what your priorities are and how effective you feel the UN can be on this issue.

  Dr Nabarro: The appointment was a month ago and the priorities were pretty clearly set up right from the beginning of my appointment by a senior steering group, set up by the deputy secretary general, membership of which includes either principals or one under the principals from each of the major agencies. It has been recognised by all in the UN that FAO and WHO, as the specialised agencies with particular expertise in animal health and human health, are at the vanguard of the response both to avian influenza and possible human pandemic influenza. The thinking from the deputy secretary-general was that there is a lot more to the UN system that can be made available to support the work that is being done by these technical agencies. She particularly picked on the resident co-ordinator system at country level and then the regional directors and other agencies which can provide support. An example is UNICEF which has a huge reach into communities, enormous experience of vaccine liaison and procurement work and then its role in communications. She then stressed the role of the World Food Programme in contingency planning and response work and then gradually, as we took forward the thinking and planning in September and into October, we were able to recognise that many of the other parts of the UN system are active. It goes beyond that though, because by bringing the UN system together we provide a core of capacity that is available to countries which then adds to the meaning that exists in other parts of the international system. For this purpose the World Bank is quite happy to be seen as part of the UN system and it is key to liaising and supporting countries on the fiscal and institutional side of action in the vet sector and human sector. In addition, we can bring in regional development banks, we can form a satisfactory relationship with a large number of international non-governmental groups, such as the Red Cross movement and the big NGOs: Save The Children Fund, Care, and the international medical corps, Médecins Sans Frontie"res, for example. So a co-ordinated UN provides a maypole around which the different organisations can dance and be more effective. It also provides us with an opportunity to fold the UN around some of the political initiatives that have come up recently, particularly the US international partnership, the Canadian initiative, the Australians' work, and emerging initiatives that we do not yet know what they are going to look like which the European Union seems to be putting together. Taking them together, therefore, the co-ordination function is not simply having UN agencies sit in meetings talking to each other. It is about making the UN a vibrant entity, supporting the specialised agencies, being able to link sideways with other similar international bodies and moulding itself around the political partnerships. Therefore, my top priority is to have a very slim co-ordination office. It is not going to be an agency. It will have six or seven staff whose main job is going to be to track what happens at country level and global level in these partnerships in regard to communications and also the kind of response planning that needs to be done, but then to work through the different agencies to make sure that they are able to take up the work rather than to second-guess it. It will be very different in style and concept from UNAIDS.

  Chairman: Thank you very much. Let me ask Lord Selborne to follow up on that a little bit.

  Q302  Earl of Selborne: Thank you very much, Dr Nabarro. From what you have told us already, it is clear there is a number of international partnerships, all of which have to be co-ordinated, and indeed you have described your own role as co-ordinating the roles of the different United Nation agencies and the World Bank. There is clearly now going to be a new initiative to the American-led international partnership. Where do you see the opportunities for synergy and, for that matter, where do you see the risk of duplication and confusion?

  Dr Nabarro: My Lord, there are three dimensions to what we are trying to do at the moment on this. The first is what I call the technical dimension which is the business of trying to enable governments to have the correct responses to an avian flu outbreak or human flu pandemic. We cover that pretty well with the WHO, the FAO and their associated agencies, the international and national communicable disease centres, the animal health groups and the OIE around the world. The second dimension is the institutional dimension which is about getting governments to be able to be sufficiently well organised, financed and managed to deliver essential services to people. The institutional dimension of veterinary services in many countries is not strong, but I am afraid public health services are also pretty weak. Go to Vietnam and see that on both sides the situation is far from satisfactory. There is the third dimension to our work which is the political dimension, the kind of thing we saw today which is quite courageous from the US President, where a senior figure steps out and gives additional political cover to the ministers of health or the ministers of finance so they can do unusual things or have access to extra resources, even though their current workbooks are very full. For me, the partnerships of providing that political impetus, which you have to have when dealing with uncertainty that requires bureaucrats to do special things, will only be effective if they do lead to real action to improve institutional capacity in the main sectors with which they are concerned. I am particularly keen to see these international partnerships leading to a lot more action to improve the functioning of veterinary services so they can detect and respond to outbreaks of disease and also, where necessary, vaccination and bio-security can be introduced. That will only happen if the minister of agriculture and his or her team feel that the deputy prime minister or prime minister of a country is really taking an interest. That high level political interest will only be there through things like these international partnerships. The first US meeting I thought was pretty well done. A lot of trouble was taken by some very good officials. The US government joined itself up. Paula Dobriansky, the Under Secretary of State, is accomplished and Mike Leavitt, the Secretary of Health here, is a pretty exceptional person as well. We were not so sure whether the Canadian meeting, which focused more on health, was going to be so good, but they managed to get both Jacques Diouf, J W Lee plus Mrs Sardie, the Vice-President of the World Bank, along, senior people from other agencies and also ministers from a lot of different countries. They worked very hard with good chairing to get these ministers of health to realise that they have got to be intersectoral in their thinking, that they have got to not knee-jerk on Tamiflu stockpiles, that they have to get much more organised on surveillance, and they produced a good communiqué. So I think that looked pretty exciting. I am not sure about some of the other political initiatives around the place at the moment. I do not know enough about what happened yesterday and is happening today in Brisbane, but I am pretty clear in my mind that these political initiatives are vital if we are going to be able to increase in energy. So much now hangs on the skill with which FAO, WHO, OIE and the World Bank are able to use the meeting next week in Geneva, which is designed to take forward the technical and institutional work in which we are all involved, within the environment of the political partnerships so that countries are going to get the backing they need to work effectively. There is an awful lot of behind-the-scenes work to try to make sure these three days with over 600 participants, with quite a lot of hype in the media, understandably, give us what everybody is expecting of them. Plus we know that there are going to be countries coming along which are wondering what sort of resources they are likely eventually to be able to get for their own work or whether they are going to get Tamiflu. The handling of that, which is, in my view, quite an important junction within the political partnerships and then action, is going to be tricky. The danger of all this politicisation is threefold. One: the possibility that we just raise the heat of the issues to such an extent that room for manoeuvre of ministers in developing countries becomes limited because they feel they are under too much media scrutiny. At the moment I do not think that has happened but it could. Number two: we raise the political temperature so that we end up having disagreements globally between different blocs. This has not happened yet; this seems to be pretty much internationally non-partisan, but I worry a little bit that we get ourselves into a tangle on intellectual property issues not because they are necessarily important but because people see these as ways to make positions for themselves that play well back home. The third and the most important risk is that each partnership will spawn its own mechanism for bringing resources to countries, and that we are all very frightened of. We are hoping to use the meeting next week and activities subsequently to try to make sure that does not happen. Louise Fresco is with me and I know that she would be able to add to this if an additional view would be necessary but I do not know what time is like and I do not know what your rules are, so she will not come in unless asked.

  Q303  Chairman: Our time is quite tight but if Louise Fresco has specific points she would like to make, I am sure, we would like to hear them.

  Ms Fresco: I quite agree, my Lord, with the statements made by Dr Nabarro so far. I just want to emphasise that the real key issue will be the speed with which we can deal with the avian side, the animal side of it. It is very clear increased exposure of humans to animals which are infected is increasing the risk of reassortment or genetic drift or whatever risks we have on the human side, so to control the animal side is absolutely key. We have to recognise that not all countries are at the same level of being able to control and deal with this. So while it is important to have a worldwide and global approach, it is also very clear we must identify the countries which are most in need of a specific approach, specific strengthening. There are countries which are quite overwhelmed by what is happening, a case in point being Indonesia where we have probably 1 billion backyard chickens, and that is an enormous task. So I would just make a plea for understanding, on the one hand, the diversity of the situation and, on the other hand, the great importance of dealing with the animal side before we spend too much time in meetings and trying to generate resources and concentrate ourselves on co-ordination. The real work has to be done in the backyards in Indonesia, in the waterways of the Mekong Valley, in very, very concrete ways.

  Chairman: That sounds very logical. Perhaps we could move on now to a question which Lord Mitchell has about funding.

  Q304  Lord Mitchell: Dr Nabarro, I wanted to ask you a very specific question about the FAO which may well have been overtaken by events. We have heard that the FAO was under-funded and was unable to function as it should do, and I wanted to know if this is the case. If it is the case, what should be done, particularly by our country in the UK?

  Dr Nabarro: I am going to speak as though Louise is not here because I know this question is to me in my co-ordination role. Louise has actually made the point which I would have said in the beginning in response to your question. Really it is absolutely vital to get countries better able to deal with the avian flu outbreak at source and we are not winning this battle in several of the severely affected countries. The only organisation we have globally which has the potential penetration to do this is the Food and Agricultural Organisation of the UN. They are under-funded. In the animal health area I sense they might have been under-funded for quite a long time. They do need more resources but also they need encouragement from governments to help them build up their capacity very quickly so they can act, so it is not just money, it may also be people. I have been very impressed by the Dutch government's approach. I talked a lot to the chief vet of the Dutch government when I was in Beijing recently and what they are doing is not just offering cash, they are offering people and they are offering to use their own bilateral links to link up the people they offer with a number of key vet institutions with their training institutions, reference laboratories or specific programme elements in order to drive this up. You cannot expect FAO to move from the present situation to having two or three times the field capacity, which is what I believe it needs, just using funding alone; it needs other inputs. I have been in discussion with the UK Government a little on this. I was rung by the influenza point person while I was in Beijing, who had been in discussions with Hilary Benn about this explicit issue, and I said FAO needs cash, it needs support to build up its institutional capacity to back up vet services at country level, and it needs it yesterday. So I do hope that this is seen to be a priority by all governments but particularly those governments who see themselves naturally as supporting the multilateral system and being prepared to provide bilateral assistance alongside.

  Chairman: Thank you. Baroness Finlay would like to talk a little about China and Vietnam.

  Q305  Baroness Finlay of Llandaff: Thank you. Perhaps the question goes to you both. We have heard about some of the serious difficulties faced in monitoring development of avian flu in China and Vietnam and particularly some of the diplomatic challenges that that poses as much as scientific challenges. I wondered if you could tell us about the steps which are being taken through the FAO and the UN to improve access of international agencies and experts to the region and to get information from the region. It may be that you have some examples from the Dutch model you have just referred to.

  Ms Fresco: Indeed there has been a problem with degrees of transparency in the Chinese situation. The Vietnam situation is not entirely identical. Vietnam was more overwhelmed than China. The Chinese government however has been in touch with us at a very intensive level lately and I am pretty confident the situation is improving. They have indicated to us, for example, that they are willing to exchange bio-sequence data and bio-isolates possibly, and that augers quite well. Nevertheless, I think we can only put pressure on these countries in the international context. I think the awareness is growing that they stand to benefit from part of the international trans-boundary effort. The main reason is that there are so many biological links between what happens in China and what happens in the rest of the world through migratory pathways and the fact that this particular area, south west China and north east Vietnam, is a concentration of so many of these diseases and potential problems that I think the awareness is growing in China. We have found them certainly opening up more than some time ago. As David said, one of the key problems is the lack of co-ordination at national level between the veterinary and the public health services and also down the levels to the districts. This is a major problem also in Vietnam where the central control does not always reach out to village level.

  Dr Nabarro: With regard to China, when I visited just over a week ago I did note with my Chinese interlocutors that there still seemed to be some serious concerns from many outside groups that things are not as open and transparent as they should be. The reaction was quite strong. I was told very clearly that if others feel this, that is not the because the Chinese are not trying, they have a number of internal difficulties they have to deal with themselves with regard to centre and province relationships, and also there are a number of other challenges such as the vastness of the country. But the willingness to be open, particularly on avian flu issues was stressed to me again and again. They have also decided to put control of the whole influenza issue up to Vice-Premier and Premier level above the individual health and agriculture level, and they have indicated to me in public and in private that they want to become a global player on influenza issues, and they realise that if they do not demonstrate transparency in a way that satisfies the outside community they are not going to be taken seriously in the international arena. The same kind of thinking happened when I was in Vietnam. It was nothing to do with the fact I was visiting but at the time they were also putting the issue up to Vice-Premier level in Vietnam, and they were increasing the extent to which the whole political machine was getting engaged, so that the chairs from 64 different provinces were brought into Hanoi and the Premier and then the relevant Vice-Premier spoke to them very clearly, saying ­You have to sort this out. I do not want any more nonsense between health and agriculture at provincial level and information does have to reach us." They have a bit of a problem in Vietnam in that there is a true disincentive for information to go up because if a provincial person reported they had a problem at provincial level they got charged for the cost of dealing with it, even bringing in the central capacity. So, in sum, it is only the national governments which can really sort out this problem of openness and we are seeing signs in the two countries you have mentioned there has been some shift. Then because we really only have a relatively small number of UN staff - even if you take the whole UN family together our penetration is quite slight - I do not think we will ever be in a situation where we can keep a supervisory role in place, we have to instead work by building trust and by building the general pressure on governments to believe they will only be taken seriously by the rest of the world if there is pretty good evidence of transparency. I am sorry that is not a direct answer to the question but I think you can see from that the way I am trying to go about this.

  Baroness Finlay of Llandaff: Thank you.

  Chairman: This is somewhat encouraging, particularly in respect of fast action should something break out. I think Lord Patel has a question on this.

  Q306  Lord Patel: Thank you very much, Lord Chairman. Nice to see you, David, even if it is on the video screen.

  Dr Nabarro: Hello.

  Q307  Lord Patel: My question relates to how to stop the pandemic in its tracks. Modelling suggests that the pandemic could be stopped by early and decisive intervention at source. Given the source is likely to be south east Asia, what steps are you taking to make such intervention practicable? What will you do with the 3 million doses that Roche has donated of Tamiflu? What else can we do to build capacity in south east Asia?

  Dr Nabarro: I am quite interested in the way you posed the question, so this is a good head-scratcher.

  Q308  Lord Patel: You should be used to that!

  Dr Nabarro: I am certainly used to it from you! Let us start at the top. I must say I am very impressed by the modelling which has been done, particularly by Neil Ferguson and colleagues from the UK, and I was interacting with Gordon Conway, who as you know is acting as scientific adviser to DfID on these issues. It is interesting just how taken Gordon and others are with the results of the modelling which has been done. I am sure you have all studied this, and perhaps you have even taken evidence from that group. It really looks as though we only have a window of about three weeks to get moving if we are going to significantly delay the pandemic at source. That is the reason why we are putting number one emphasis on surveillance and early-warning systems. I am not convinced that we can do that just by simply business-as-usual working through normal channels of trying to drive up surveillance capacity. We need to be engaging with governments on what additional mechanisms they might be able to put in place through district authorities, through military, through even retail channels, because often retailers have got excellent logistic systems - we all know about how Coca Cola penetrates the places that others cannot reach - and we may need therefore in conjunction with some governments to say, ­Use all channels to collect information", particularly early rumour information which can then be put into not just the Ministry of Health but Ministry of Agriculture and which is then subject to very rapid verification and intervention. We have seen some of this for example in a recent case in Vietnam where, as you remember, from news reports over the weekend there were reports of deaths and of bodies being buried before they had been properly checked out and very quickly the information got back and action has been taken. So, number one, a surveillance capacity and an early warning capacity which goes beyond what normally exists inside the Ministry of Health. Number two is preparedness planning that means it will be possible to move frontline personnel to the first site of infection and to reduce social mobility and to restrict movement in and out of these areas. That is more difficult and we can only do that through preparedness planning but it is starting in some of the countries I have mentioned, particularly Vietnam, and I think we will see it also in the not too distant future in Laos and in Cambodia. It is already underway in Thailand and Malaysia and we have a bit of a way to go in Indonesia. The third and most difficult problem you allude to is what about the precious WHO stockpile which is building up, it is not already there yet, of 3 million treatments of oseltamivir, where is that going to be located, how is it going to be got to the sites where it might be needed quickly, what will be the rules about distribution, who will get access to it. That is still work in progress. WHO have been asked to do something on this in time for the meeting next week in Geneva. I am not sure that is going to be done in time and it is something I have got right at the top of my list of what I call global issues which need urgent action, addressing the question of where the stockpiles should be and what arrangements need to be put in place for moving them so that the frontline personnel can have them. Just a last point on this, I believe it will be necessary to have dialogue with military capability. I know all this has to go on the public record but I think it is reasonable I should say this. Given we are going to have very limited time to move stuff to where it is needed and we do not know where that is going to be, and given that there may well be difficulty with civilian air transport once the first rumours of pandemic appear, we need to have some extra back-up present. There are just the beginnings also, and they are going to have to move very fast, of dialogue to see whether or not we can get some stop-gap arrangements with the military. I was actually discussing that this morning with the relevant person here.

  Q309  Lord Patel: Thank you very much, David, and sincere good luck.

  Dr Nabarro: Thank you, Sir.

  Chairman: Lord Winston would like to ask a question about international preparedness.

  Q310  Lord Winston: Dr Nabarro, we are finding your answers really very cogent. Could you give us your assessment of the level of international preparedness for a possible pandemic, and particularly would you address what countries you think are furthest advanced and where we stand in the UK? You have been on record as saying that every country should have a Cabinet-level minister with responsibility for pandemic preparedness. Do you think there might be a risk with such a headline-grabbing proposal that you might undermine the prospects for effective action? Could you also give us some brief assessment of what action is likely to provide the best return on investment, for example, in surveillance and rapid intervention in south east Asia, the development of new vaccines, vaccine production, contingency planning and so on? That is a pretty broad question but we would be very grateful for your observations.

  Dr Nabarro: My Lord Chairman, I did not fully hear the second-to-last comment about the quotation that was put in the Times a couple of couple of weeks ago when I said there should be a high-level minister with responsibility for flu. What was the downside of that which you wanted me to dwell on?

  Q311  Lord Winston: We wondered in this room whether a headline-grabbing proposal like that might undermine the prospect for effective action.

  Dr Nabarro: First of all, I do not think the world would do very well if the reassortment or mutation occurred within the next few months and we were to start to see pandemic influenza start. I think we would in fact be in a pretty bad way. Although a number of countries have started to think about preparedness planning and have started to get different government departments together, joining up perhaps sometimes, as in the France case, eight departments working together, and I know there is a similar cross-governmental approach in the UK, with the necessary work of different department officials thinking through what might actually happen under circumstances of a pandemic emerging not necessarily inside their own shores but some way away, I am finding there is still quite a gap between the planning process being put into place and people actually beginning to articulate with each other the reality of what might actually happen in terms of being able to mobilise people, being able to mobilise stocks, being able to move people, being able to move stocks and being able to communicate with countries in a reasonably productive way. There is still I think a lack of perception among those who have started to do this work that there are likely to be a number of countries which are going to really close the door, and which are not going to be prepared for their own professionals to be moving around outside, they will want them to stay inside, they are going to be very nervous about their own diplomats being at large and who will be extremely concerned if they have military contingents abroad to get them back. If that is the case, if we are going to see a fairly quick wish of countries to contract, of pilots not wanting to fly, logistics organisations finding they have to cut off branches, the impact of how we as a world community respond will be really very dramatic. I have seen very few groups really focus on this. The only ones I have been impressed with doing this are large multinational companies who have started to do their own risk assessments and risk planning, business continuity scenarios, and I am finding them very, very scary. They are closing down, retrenching, lock-down of personnel, staying in their homes, one or two months' survival rations, their own Tamiflu stocks in some cases and other medications. That kind of reaction will make the necessary joined-up early response work very, very difficult. One of the tasks that the participants in the first US international partnership on avian and pandemic influenza gave to my office was to think about what steps we can take to try to prevent there being a sort of general lock-down the moment the thing starts. I mentioned that I thought there was a necessity to take the responsibility for preparedness planning above the level of the Minister of Health versus the Minister of Agriculture versus the Minister of Interior versus the Defence Minister and to have an over-arching ministerial responsibility, because all the evidence I have had over the last few months before I took this job and since I have taken this job on any emergency work is that it is very hard to get different government departments and ministers to work together in a joined-up way on contingencies unless they are encouraged to do so by the highest authority in the country. That was the basis behind what I said. The thing was given perhaps, as I am learning more and more each time I deal with the media on this issue, more prominence than you sometimes want, but I stick by it and I have not actually noticed any backlash, in fact I think the reverse, that governments have been at pains to tell me that they have taken this suggestion quite seriously and I have seen some good results. Certainly the well-prepared countries, and I do put the US as reasonably well prepared though Bruce Gelman, the first point person here, says he is still very nervous. I think the UK Government is moving forward quite nicely, but again the Minister told me, and she might have told you in her evidence just now, that there are still quite a lot of difficulties, so generally I think a lot more has to be done. My assessment of international preparedness is nowhere near good enough and I think we have least six months' leeway - perhaps a year, perhaps longer - to get ourselves planned, and that is why I am using every invocation I can to request the mutation does not occur for another year or so. I have not dealt with all the parts of your question but you will see I am sufficiently worried about this that I think I have some way to go to deal particularly with your last point.

  Lord Winston: Thank you very much for the clear view.

  Chairman: Thank you very much for that. I am going to turn to Lord Mitchell now to talk a little about international relations.

  Q312  Lord Mitchell: I wanted to ask the question about the prospect the pandemic is having on international relations. There are a number of issues. First of all, the whole issue of international patent laws and whether companies will be side-stepping these. Secondly, whether the pandemic when it comes, if it comes, could lead to a serious break-down in international relations. I think you have touched on these points but it would help if you could elaborate a little further.

  Dr Nabarro: Again I am going to see whether Louise wants to come in, because I think this is the most difficult question in a sense. Here goes: I think the current avian influenza epidemic is potentially quite bad for international relations, because we have seen it before. Louise and I worked in my previous job on a whole stack of issues to do with food safety, and we have found issues between countries on food trade can have very bad consequences, especially when they are located within health concerns, and it is really very important when countries make decision about the import or non-import of particular kinds of food from particular countries those decisions are based as far as possible on good evidence rather than on other possible concerns. So I still am not happy about what the avian flu epidemic is doing for trade relations in particular. I am very pleased that the FAO has come out quite strongly on this following Turkey - was it? - who came out on it. Secondly, I think the threat of a pandemic is having a relatively positive impact at the moment on international relations. So far I have seen no evidence of anything other than countries putting their heads together and being really very focused. I am a bit nervous about whether that dream environment will stay for the next few weeks and months, especially as there becomes some prospect of competition over money, and we will see more and more concerns from African and Middle Eastern nations, but they need as much help as the Asian ones do or possibly more. I think that the patent laws issue maybe, maybe, a bit of a red herring. My reason is as follows: I have talked and others have talked to Roche and I am starting to get involved, but not directly myself, with GlaxoSmithKlein, and the suggestion that the way to deal with lack of access certainly to oseltamivir or Tamiflu is to encourage the production of the compound by generic manufacturers, perhaps in some way disregarding intellectual property provisions, is not really relevant I do not think. Certainly from what I have been told in this situation, Roche, which is a licensee of the manufacturing process, has indicated that it is very happy to discuss and then to conclude sub-licensing arrangements with anybody who can make oseltamivir effectively because they are aware that their manufacturing capacity, even with the projected increase over the next year, is far, far too little. The difficulty however is that the production process, as you may have heard in other evidence you have received, is really quite complicated - there are three difficult stages and secondly the raw material is not available in abundance - so unless some new synthetic process becomes available the production of antivirals is going to be limited more by capability, and particularly at the production side, rather than anything to do with intellectual property. When the Secretary-General says he does not want intellectual property to stand in the way, he is merely exhorting preferential pricing by the major producer so that poor countries can access the stuff cheaply, and Roche are certainly practising that. Secondly, he is exhorting the companies to do deals with generic manufacturers who can do it and they are trying to do it. So I am hoping that we are not going to see spats over this, though I did hear one or two remarks in one of the recent meetings that suggested that not everybody shares my view on this, and I have to watch it, and we may need to do some careful communication work. But the most serious point to your question is what might be done to international diplomatic relationships once the pandemic starts, whether it is access to viral material, antigen production in order to produce a vaccine, or access to information, or closure of borders and the stigmatising of people who come from particular parts of the world. This happened on a small-scale with SARS which was a relatively minor thing compared to the pandemic and I believe we will need to get groups, for example Chatham House, to start looking at this quite seriously and to see what can be done to anticipate potential snap decisions, knee-jerk decisions, being made which might have really long-term adverse effects on diplomatic relations. Certainly I would like to encourage countries to approach the pandemic from the point of view that if you do not find a way to support the country which is facing the pandemic in its first stages, where they are facing it, with all the resources you can sensibly put to bear on it, it will come back and hit you later when the pandemic gets out of control and starts going across the world in a phase-like way. So to deal with the problems, for example, that might be faced in the long-term by the UK requires urgent action at the site. Secretary Leavitt's quote which I like to use is that it is like fire, ­A forest fire starts with a little spark and you can easily stamp it out with a foot, but if you wait for hours or perhaps days then it gets out of control and you have lost hectares of land due to the fire and have a huge amount of damage and you regret you did not put that spark out in the first place." So diplomacy at the early stages must be one of international solidarity.

  Ms Fresco: The discussion on access to patents and so on is also very relevant for the animal vaccines, which is the subject which is somewhat an orphan of this discussion. You may be aware of the fact we feel very strongly we should find alternative ways of administering the vaccine to animals because of the problems involved in actually injecting it. That requires more research and although international efforts are going on, it is very clear that we need to be absolutely sure that the investments in research - and the UK is very much involved in this - really be shared as soon as possible with all the countries concerned. With an increasing crisis, as David indicates, the sharing of research results may become more difficult. The second issue is that I am less worried perhaps about snap decisions being made by governments than I am about the lack of understanding by the public and the knee-jerk reaction of the public, as we see for example already in Italy where chicken consumption has gone down by 40 per cent, which is not based on any significant data or facts, to the contrary there is not even avian influenza in wild birds in Italy let alone in domestic birds. These kind of reactions have major potential impacts on trade relations, on international relations, and they can only be dealt with if we put in place parallel to all we have mentioned a massive effort on risk communication for the public. We have some experience of this for example in an area like biotechnology but it requires us all giving the same kind of message to the public, whether to the private sector, government, local government, internationally. This is something I would really like to make a plea for, and David and I will discuss it with our colleagues, that the issue of risk communication on which there is some good evidence and good experience from before really needs to be tackled, because it is how the public reacts, how individuals react, to people for example coming from Vietnam or Laos. That is going to be hugely important for international stability I believe.

  Q313  Chairman: Thank you very much for those remarks. I am afraid we have come to the end of our time here but we have covered a lot of territory and I think we are, all of us, very impressed with your answers, Dr Nabarro, and with yours, Louise Fresco, perhaps a more realistic and down-to-earth view-point than we have heard from almost anyone. Although it does not necessarily fill one with calm, at least it is reassuring to know you are there and appreciate the seriousness and difficulties which would be ahead of us as we face a pandemic. Let me thank you very much indeed for spending this time with us. We very much appreciate it, it will be very valuable to us and your input will appear in our report which will be published before Christmas. Thank you very much indeed.

  Dr Nabarro: Thank you for the opportunity.

  Ms Fresco: Thank you.

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