Memorandum by the Nuffield Council on
Bioethics
1. In November 2007, the Nuffield Council
on Bioethics published a report on Public health: ethical issues.
The report uses a number of case studies to illustrate a discussion
about ethical issues in public health, one of which was that of
infectious disease.
2. In this response we draw your attention
to a summary of the principal findings from our report that are
relevant to your inquiry. Page and paragraph numbers are provided,
which refer to the respective sections in the full report, a copy
of which is included with this response.
Question 3: What intergovernmental surveillance
systems exist to give early warning of outbreaks of infectious
diseases? Are these systems adequate? And what improvements might
be made?
3. In the report, we highlight two examples
of international disease surveillance systems that have been problematic
in some way. The first relates to the handling of the SARS outbreak;
the second to recent controversy about Indonesia's refusal to
share influenza virus isolates with the WHO-sponsored pandemic
surveillance systems.
4. In the case of SARS, "China was
criticized by WHO and countries internationally for delays in
reporting cases and an initial lack of cooperation with WHO"
(p 71). This development was one of the major precipitants to
changes in the International Health Regulations, which
were published in 2005 (p 71). While these may reduce the likelihood
of such a scenario arising again, we nevertheless drew the following
conclusion:
"Countries have an ethical obligation to
reduce the risk of ill health that people might impose on each
other across borders. Therefore countries should notify other
relevant countries and bodies about outbreaks of serious diseases
at the earliest stage, following the relevant procedures laid
out by WHO" (Para 4.50).
5. Aside from any political considerations
that may affect the transmission of relevant information, countries
differ widely in their capacity to monitor the outbreaks of any
infectious diseases. Applying the ethical framework which we set
out as the "stewardship model" (p 25) to the global
context, we concluded that there was a need for greater investment
in surveillance capacity in poorer countries (identified also
by both WHO and the UK's Foresight Programme). We recommended
that:
"Countries such as the UK should seek to
enhance the capacities of developing countries to conduct effective
surveillance of infectious diseases. The UK health departments,
in liaison with the Department for International Development,
should work to take this forward with international partners such
as WHO, the European Centre for Disease Prevention and Control
(ECDC) and the Centers for Disease Prevention and Control (CDC)
in the USA" (para 4.50).
6. In the case of pandemic influenza surveillance,
we note that "a controversy in early 2007 highlighted the
fragility of global pandemic preparedness, when the Indonesian
Government decided to suspend the sharing of clinical specimens
of human avian influenza viruses with the surveillance system
managed by WHO" (Para 4.51). We go on to explain that this
situation was "a cause for serious concern because of the
risk that it would severely hinder international surveillance
and preparedness activities" (para 4.52). Despite several
special meetings and a dedicated WHO Resolution at the World Health
Assembly in May 2007, the situation as we understand it was that
cooperation had still not resumed in January 2008. This example
is further relevant to question 14, and we copy our recommendations
concerning ways of making progress in the controversy below.
Question 14: Are there any difficulties with
regard to patents or intellectual property which are impeding
the flow of medicines or other control methods to those infected?
Is intergovernmental action needed to improve the situation?
7. The situation in Indonesia over pandemic
preparedness arose in part because of considerations relating
to intellectual property, and the country's concern that it would
not be able to access the benefits such as vaccines. Further background
to this situation can be found in the report at paragraphs 4.52-4.55.
We concluded as follows:
"WHO is in a unique position to enable centralised
and transparent determination that a novel virus has emerged,
to evaluate pandemic-related evidence, and to develop response
strategies, as acknowledged in the International Health Regulations
2005. This capacity must be sustained". (para 4.54)
"WHO should not merely facilitate access
to virus isolates for commercial companies, leaving the question
of availability of vaccines to market forces. It should use its
authority to impress on pharmaceutical companies their social
responsibilities. Patents and other forms of intellectual property
rights can be useful ways of rewarding research investment and
stimulating innovation and progress, but they can also come into
conflict with the interests of the wider public, as the Council
has reported elsewhere. While we cannot address here all the complexities
raised by the sharing of virus isolates for the purpose of monitoring
and developing vaccines, virus isolates should not be treated
like any ordinary commodity, as adequate access and use is of
the greatest importance for public health, both on a national
and global level. Therefore, we urge WHO to explore, in liaison
with governments and relevant industries, the notion of viewing
virus isolates as a form of `public good', and to take a flexible
approach to patenting and intellectual property protection".
(para 4.55)
Question 19: What resources does the UK Government
commit to intergovernmental bodies to help in the fight against
the four diseases listed?
8. While we are not best placed to comment
on the resources currently committed by the Government, we draw
attention to a relevant conclusion concerning capacity building
which can be found above, below paragraph 5 of this response.
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