Examination of Witnesses (Questions 180
- 199)
MONDAY 25 FEBRUARY 2008
Professor Peter Borriello, Professor Mike Catchpole,
Professor Francis Drobniewski and Professor Peter Chiodini
Q180 Baroness Whitaker:
The desire to pursue such developments on the part of terrorists?
Professor Borriello: Yes, absolutely.
Q181 Baroness Whitaker:
Do you think we would be correct if we devoted attention in our
inquiry on how to control this particular risk of infectious disease?
Is it a subject of real concern, would you say?
Professor Borriello: I think yes, for two reasons.
The key reason actually is a public health one more than a security
one, in that any improvement in detection, alerting and responding
that might be put in place due to an interest in the threat of
bioterrorist release of a pathogen is very good and useful at
improving the structure for response to any natural infection.
Q182 Chairman:
Can I just summarise that, because it is a very important point?
My understanding, certainly the conclusion I have reached so far,
without committing myself, is that the natural spread is a greater
danger than the unnatural spread or the spread by terrorists but
the spread by the latter is a very real danger that we should
not under-estimate. Is that a fair analysis of the situation?
Professor Borriello: That is absolutely right
and, again, one of the problems is that consequential to any outbreak
that has been induced artificially is the associated fear, panic
and concern. It is fearful enough in response to a natural outbreak,
but the fear then of somebody purposely trying to infect somebody
else just adds another dimension to the problems of control and
dealing with the public response to such an incident.
Q183 Baroness Whitaker:
Are you aware of the Intergovernmental Organisations having a
good hold on all this?
Professor Borriello: G8 are actively involved,
in which the UK has a very strong presence, of course, and G7.
There is also a European Commission global health response based
around bioterrorism. One of the alerting systems that was referred
to, in saying "Why do we have that?" is put in place
exactly because of this issue, which is to analyse the intelligence,
to look at natural outbreaks to determine whether or not they
really are natural or were a failed bioterrorist threat attempt.
Chairman: Thank you very much. I want to move
on to International Health Regulations.
Q184 Baroness Whitaker:
This is meant to help with the surveillance problem, among others.
People from the Government have told us about weaknesses they
see, that there is no provision for enforcement and that there
were problems, for instance, in the case of Indonesia's refusal
to share influenza viruses, and you yourselves have said that
there is room for improvement. Would you like to tell us what
more could be done to improve the implementation of the regulations?
Why has this Declaration empowering the ECDC to access WHO data
not been made? What is holding it up?
Professor Catchpole: A major role for us is
in risk assessment and surveillance and so on. I am going to focus
perhaps a bit more on that than on the response side. Clearly,
we very much welcome the new regulations. They are a much more
all-hazards, risk assessment-based approach, which is much more
suited to the patterns that have emerged in recent years—there
have been new emerging infections—assessing the risks, determining
what a proportionate response is. It is a clear step forward on
what we had before. The principle that lies behind those international
regulations is that rapid reporting, before it is clear what the
risk is, so that the WHO and the reporting country can then rapidly
undertake a risk assessment, should allow us to be in a position
to try and control something at the source rather than wait for
it to be disseminated around the world. All that is good, and
clearly there is a lot of support for that, both within the WHO
and certainly within Europe, in the Member States I have spoken
to. We flagged up that we felt that there was a bit more to be
done, particularly around the slickness with which information
is moved around and the speed with which risks assessments are
undertaken. I was delighted to hear at a meeting in November/December
last year that in fact the World Health Organisation are investing
quite a lot of time and effort into putting in place a new information
system that will actually address some of the issues that led
us to say that we felt there was some room for improvement. However,
that is largely around the alerting process, the process for rapidly
gathering information, the risk assessment, which may then lead
to a response. I got the impression that in some ways some of
your questions were more about the response side and touching
on the Indonesian question. I do not feel so well qualified to
comment in detail on that. I do not know whether other colleagues
do. I think that in terms of the surveillance and alerting side,
the risk assessment side, we very much welcome what we have seen,
which is that the World Health Organisation has taken a little
bit of time to get up to speed with their own system but they
are clearly getting better at that and we are better off now than
we were a year ago.
Professor Borriello: I would like to see the
evolution of the IHRs to have a more rapid and broad-based risk
assessment. I would like to see more guidance at the front end
for people in terms of what is reported in there. What is the
definition of a public health event of international concern?
I have not seen the definition of that so-called PHEIC. By definition,
that is what it is, by its terminology. It is something that potentially
could or already has started to affect more than one country of
the world within the WHO that we at the moment would be reporting
as we have major Salmonella outbreaks, but WHO would do an assessment
to say "Maybe that is not that critical and we won't post
it." It means there is quite a lot of noise in the system;
that is inevitable until the system starts to mature but I think
one needs to actively manage that, to have a rapid risk assessment
so that the bulletin comes out, you receive it, you read it, and
you think, "Ah, that's what it means for me." It is
not just a statement and you think, "So what? What does that
mean for me?" So the messaging could be looked it.
Q185 Baroness Whitaker:
This is lack of capacity within WHO that you are referring to?
Professor Borriello: I think it is simply a
learning process but, like all learning processes, unless you
flag up issues to be learned early, it means they are not learned
till too late or downstream. One of the areas where things could
be improved and would involve intergovernmental action, in my
view—as well as other bodies with international roles, NGOs
and others—is that the International Health Regulations
make it quite clear that to have maximum effect you must be able
to detect the thing that needs to be alerted in the first place.
If you cannot detect it, you cannot alert about it. So you have
to be able to detect it, and you then have to have systems in
place so that detection results in a message going to the right
people for some analysis to be done so it can then go into an
international alerting system. Many of the countries where people
believe dangerous things could emerge are places where they are
weakest at being able to diagnose dangerous things. The WHO has
put in place a laboratory twinning programme, for example, so
less developed laboratories will twin with more developed ones.
They are matched, and then there is some interchange to try and
improve the capacity, which must be improved in a sustainable
way—not go in, have a chat, have some visits, take some
material away and then it is finished. It has to be associated
with some form of accreditation or improvement which is sustainable.
It is terribly difficult to secure funding for that. There must
be lots of bodies around the world who are all trying to do the
same. One could argue that there be some improved coordination
so that through the laboratory-twinning process the WHO has in
place, they could say, "We'd provide all the governance,
we'd provide all the accreditation read-out and the security.
Give us the money. We will do what you are trying to do."
I think things could be improved from within existing resource
and it does take intergovernmental interaction.
Q186 Lord Howarth of Newport:
We have lamented the deficiencies of coordination between Intergovernmental
Organisations but your evidence at 5.3 suggests that there are
also deficiencies inside the UK in terms of our capacity to deal
effectively with these IGOs. In particular you suggest that our
influence with the World Health Organisation is not commensurate
with our contribution. Would you expand on those thoughts?
Professor Borriello: Yes, I am happy to. It
is similar to the comment about the ECDC, where, due to the page
constraints, we did not put all the very positive things; we just
picked up on areas where we felt there could be some improvement.
Of course, being at the operational end of the business, our definition
of policy might be somewhat different to Government and Government
Departments. Certainly it seemed to us, at the level of implementation
of policy or putting the detail into policy, when at the strategic
level there has been in our view very good influence from the
UK, in many areas some countries, particularly the United States
and others, take a very coordinated, joined-up approach to trying
to influence the detail. The detail, of course, can have effects
on any given country. We have raised this with the Department
of Health and we are already in discussions on how we can improve
the way we interact on understanding what is trying to be achieved
and to ensure that, when some of our staff and other agency staff
in the UK get involved at that flesh-on-bones, dotting—Is
and crossing-Ts level, there is a better understanding of what
the overall strategy is and what the UK Government position is
on some of that. We also mention the DFID issue. I know at the
moment, as for all Government agencies, there is a review on how
it sources its evidence and makes use of evidence. We do believe
that DFID could make more use of the expertise in the Health Protection
Agency in forming some of its own decisions on infectious disease,
maybe also chemical and radiological areas, and certainly for
those areas I think it could draw on the HPA more. Whether it
chooses to accept or ignore or modify our advice is a separate
issue but I think it could draw on the Health Protection Agency
more than it does.
Q187 Lord Howarth of Newport:
Can I press you to be as precise as you possibly can and perhaps
give us an instance of where the Department of Health's efforts
are falling short, and where in DFID. And are there particular
cases where, as you just now suggested, the HPA is not enlisted
and involved as it might most effectively be by these departments?
Can you give us some examples?
Professor Borriello: Firstly, examples of where
it works well, which would be on global security, international
bioterrorism, that sort of level; global warming, climate change.
There are lots of very positive interactions there. But there
are other areas, and we particularly flagged up TB as the example,
where, with both DFID and DH involvement on some of these activities,
we felt that, if we had been engaged a bit earlier in some of
the issues, and then had been as a consequence of that better
apprised, we might have had stronger representation at the implementation
end with WHO. As I said, those discussions are now in place. Exactly
where that should have happened is difficult to say but we are
having that discussion now with the Department.
Q188 Lord Howarth of Newport:
The Government suggests that one can sometimes be more effective
if one is not too keen to be seen to be pulling strings or calling
the shots and if you work through others.
Professor Borriello: That is absolutely right,
and again there is the issue, particularly in the public perception
in the UK; they would not make any differentiation between international
interactions and national in that we are an arm's length body
and the reason the Health Protection Agency is respected by the
public is that it is believed to be independent of government
and its departments. The way we manage that close working relationship
actually has some issues within it and we do have to be careful
on that.
Q189 Lord Howarth of Newport:
In your evidence at 6.1 you suggest that it is down to you to
do much of the coordination. You talk of your role in combating
disease and so forth; coordinating the investigation and response
to outbreaks and other communicable disease threats and incidents;
giving guidance to government, health professionals and others
responsible for the control and prevention of infectious disease;
providing a national focal point and competent body functions,
et cetera. Who is supposed to do what? Are you waiting for the
Department of Health or DFID to tell you what to do? Or are they
waiting for you to take the initiative?
Professor Borriello: These are our UK responsibilities,
and it is not fully UK in all areas. Certainly for infectious
diseases, that is not the case for Scotland, although it is for
International Health Regulations. So there are complexities within
the United Kingdom in terms of our national role, but all of those
issues are functions that we discharge on behalf of the UK Government
for our population. Of course, with an infectious agent, using
the hackneyed phrase, germs know no barriers, and it is not possible
not to have international linkages, particularly when the sources
of infection can so frequently be abroad and vice versa. We have
international relationships; we do not have international responsibilities.
So even our role as the focal point for the International Health
Regulations is to notify the WHO on behalf of the UK and its territories
and dominions, not on behalf of Spain or to blow the whistle on
Poland.
Q190 Lord Howarth of Newport:
You suggest that you should be resourced to carry out more international
work to track infections that threaten the UK population. What
do you have in mind?
Professor Borriello: I will pick up a particular
issue on TB, but in general, we did a big study on migrant health
and looking at not just the inequalities but of course the demographics
of infections in particular groups and where they arise. On that
basis, our view is that that should help to inform our international
strategy in terms of risk to the UK population over and above
just general improvement in global health. So there are areas
in which we have to be involved and work closely, and a classic
example on TB and, Francis, you had one which you alluded to.
Professor Drobniewski: Yes, indeed. I think
there are a couple of ways to pick up some of the questions that
you raised, a specific example, but also some examples of how
that interaction might occur in an intergovernmental way. For
example, USAID, the United States development agency and the Centers
for Disease Control in Atlanta have a very strong synergistic
interaction through the International Division of the Centers
for Disease Control. So USAID sees CDC as one of the principal
sources of impartial, unbiased advice at a technical and policy
implementation level.
The Committee suspended from 5.31 pm to 5.39
pm for a division in the House
Q191 Chairman:
You were in midstream, I think, were you not?
Professor Drobniewski: I was. I had mentioned
the close links between USAID and CDC but there is, for example,
an umbrella programme that the USAID funds. It is called TB CAP
and I think that is a TB Community Assistance Programme. It is
a $150 million programme over five years, where USAID co-ordinates
eight major implementers, of which CDC is the largest partner,
and in that way USAID is able to nudge those particular implementers
in the direction that it wants to go while at the same time learning
from them how in fact to actually deliver the particular strategy
that they want. You asked us if there was an example at the WHO
where this is important, that we should be intervening at a policy
and at a more technical level. Last year the WHO changed quite
dramatically the strategy used for diagnosing tuberculosis. The
problem that was faced was how do you diagnose tuberculosis in
an HIV-positive person? The conventional techniques were very
insensitive, were not doing the job and they do not tell you about
drug resistance either. So, if you want to know about drug resistance
and you want to be able to diagnose TB in that population, you
needed new technology. The WHO, through its Technical Advisory
Group, endorsed a new rapid technology, and I think it was the
right decision. But the immediate two consequences of that were
the need to suddenly train hundreds, and indeed thousands, of
technicians in what was a fairly complex technology within a short-ish
period of time, and also to develop the necessary bio-safe infrastructure
in parts of the world which until now had perhaps just used a
light microscope in a small room. Those are the two big challenges.
How do you now train hundreds of thousands of people in more of
a civil defence mode rather than the philanthropic mode that we
have tended to use? I and my colleagues in Europe are often asked
whether we can we take one or two or three or four people to train
them up, but in this sort of problem you really need a strategy
that will train a vast number of people or your overarching strategy
is going to be derailed, it seems to me.
Chairman: Thank you. We do need to move on.
Q192 Lord Avebury:
You said in your evidence in Paragraph 6.1 that WHO is one of
your key partners in combating infectious diseases. I wondered
if for that purpose you think the WHO is effectively structured
and whether its Regional and particularly its Country Offices
do their job to your satisfaction.
Professor Borriello: Francis and Peter, you
have quite a few interactions from a personal point of view in
specific areas.
Professor Chiodini: Yes. I would like to start,
if I may, and take the example of malaria and then other parasitic
tropical diseases. Beyond the level of the Country Office there
is then the run-off through which policy and control programmes
need to be implemented and, unfortunately, what we are dealing
with in many areas is a very rudimentary and in some areas absent
health service. So there is no basic health structure, certainly
not diagnostics. Francis mentioned tuberculosis but most malaria
cases in the tropics are diagnosed clinically. That is now changing
with new methods coming in but it will still be slow, and the
ability not only to diagnose but then to implement control measures
requires a delivery system, and in many areas control is being
frustrated simply because those measures which are effective are
not getting out to the people that need them. My own experience
of WHO has been a positive one. I am a laboratory person rather
than a field worker, but my own experience with them has been
positive. I think many of the projects to control malaria are
not going to be easy to implement without the detailed run-off
into a health service that can receive the measures that are required,
and I think that is common to many diseases, not just malaria
that I am here to talk about today, but many other tropical diseases.
Q193 Lord Avebury:
In that case, would you have a view about the WHO's balance of
investment between improving the basic health services in developing
countries and treating specific diseases such as malaria?
Professor Chiodini: I do, and I think they are
in an almost impossible situation because there are simply not
the resources to restructure the health system in every country
they support at the same time as providing these control measures.
I think people are going to have to look again at the level of
funding—I will talk specifically about malaria now, where
we need over the next three, four or five decades a sustained
investment and the maintenance of those control programmes. That
is all dependent upon actually getting them delivered. There is
now the international will to do it and there is indeed much more
funding than there was but, until we can see it getting out to
where the cases are, I am still worried about the situation. I
do not blame WHO for that. I think they are under-resourced for
the problem that they face across the board.
Q194 Lord Avebury:
We have had a lot of evidence about the multiplicity of organisations
that are involved in these matters. There is WHO and other health-related
IGOs, business partnerships and so on. Do you believe that there
is any call for a rationalisation of these efforts?
Professor Chiodini: I do, very much so. I think
that there is a danger of parallel tracking. That is wasteful
of resources. Duplication of administration should be eliminated
as far as possible. One model would be for the WHO to take the
lead, obviously with the governments of the countries concerned,
because it is their responsibility to have their internal plans
for health but I do think some rationalisation and better coordination
between all these bodies with good intent and, in some cases,
extremely good funding would be beneficial. It would save duplication
of resources and probably get more money out to the periphery,
where it could do most good.
Professor Borriello: I would very much support
that but there are two sides to it. Firstly, that the bodies,
many of whom are independent, need to agree that there is value
in them being coordinated, and then there is going to have to
be acceptance by the WHO that they have a role in coordinating
them. It has to be signed off across the board, but it is certainly
the case in many countries that there will be a number of organisations
undertaking the same activities unbeknown to each other. The idea
maybe of a central registry which could then have benefit to each
of the component parts which are trying to be active in this area
could be a useful way forward and something on which Intergovernmental
Organisations could stimulate the debate and maybe have some conclusion.
Q195 Lord Avebury:
Is there a call, then, for a change in the WHO's mission statement
to include the coordination of activities with all other IGOs
and to provide for them to have the responsibility of initiating
the central registry?
Professor Borriello: I can only answer in a
personal capacity: it would make sense to me. The WHO may have
a different view for very valid reasons, as may others.
Chairman: This whole area is a very important
one actually and we are paying some attention to it, so those
remarks are helpful.
Q196 Lord Avebury:
Finally, you say the WHO is always short of resources. Are there
any areas in which resources could be better deployed? Are there
some areas that you would prefer to see them investing in now?
Could they have a shift in resources to make better use of them?
Professor Borriello: I think probably the prioritisation
of resource has so many variables to it, not least of which is
the country in which the actual problem exists, as well as their
do-ability, because some of the things that have a high priority
are not easy to actually make happen. I gave an example of where
some sort of coordination potentially could have a huge beneficial
effect, which is the lab-twinning project, a role in improving
capability in a sustainable way throughout the world, otherwise
the IHR do not mean very much. For that there are lots of different
bodies all trying to do the same thing. A simple register of that
with some central coordination in my view would be invaluable.
Professor Drobniewski: Just following on from
that point, one of the real difficulties that the WHO has, and
indeed countries and then the particular cities and facilities
that have expertise brought to them, is often that the expertise
is conflicting. There may be a British expert for a couple of
days this month, there will be an American next week, perhaps
a French person, and if they are working to different technical
standards and so on, that may cause more confusion. So I think
there is clearly a role for the WHO to streamline what actually
goes on and to take perhaps a greater leadership in terms of the
bigger picture. You mentioned training and twinning; we are also
talking about training hundreds of people as opposed to training
the twelve that twelve or so particular NGOs could do. That could
perhaps also be an intergovernmental aspect where you are using
funds to say "We are going to leave you to decide how best
to do it but here is the money to train across this larger area,
but we are looking for something imaginative, bold, and that will
actually try and address the problem, perhaps across a wider swathe
of Africa than one small portion of it."[5]
Q197 Baroness Eccles of Moulton:
Can I ask one very quick question? Where does the WHO's authority
come from which would enable it to actually create a coordinated
system? It cannot just march in and say "You do this, and
you do that."
Professor Catchpole: It would have to do it
through the World Health Assembly, would it not?
Professor Drobniewski: I take it your question
in a more broad sense is that it has the authority because of
its particular position globally but also I think it would feel
more confident about taking that role if it had a multiplicity
of technical expertise so that it could say "We are an authoritative
source of global advice" in exactly the way its title suggests.
Q198 Baroness Eccles of Moulton:
That is what it needs?
Professor Drobniewski: Yes.
Professor Borriello: Those to be coordinated
need to accept that coordination is useful and the WHO needs to
be given the mandate to be able to coordinate.
Chairman: The WHO does come under the United
Nations at the end of the day, so that is an important point.
We must finish, I am afraid, but pandemic influenza does need
a question here.
Q199 Lord Howarth of Newport:
We are told we must anticipate another influenza pandemic with
consequences that will be devastating in terms of lives lost,
and in terms of economic and social disruption. In that kind of
situation surveillance is obviously extremely important. In your
view, are the intergovernmental arrangements that are intended
to detect the first signs of such a pandemic coming towards us
adequate, and the measures that have been planned to act rapidly
to counter this? Is the structure going to do the job?
Professor Borriello: It is one of those areas
where there has been the most long-standing intergovernmental
action, so the surveillance for influenza to help inform vaccine
policy has been established by the WHO since 1952 and is still
very effective. They used that network to deal with SARS; it was
the influenza network of the WHO. Since 1996 there has been a
very good European-wide surveillance scheme also looking for putative
emergence of antiviral resistance. The pandemic influenza issue
that is the concern amongst the population now is—is it
all trailer and no big movie? And, having to deal with that, sustaining
a high level of response when people have been waiting for something
to happen and it has not happened yet? The point with pandemic
influenza is that it is not an "if"; it is a "when,"
but the scientific understanding will not allow us to tell you
when. All we can say with certainty is that, if the current avian
influenza strain, which is killing people when it gets into them,
had been able to transmit regularly between people, we would have
been in the midst of a pandemic now. We still do not really understand
why it has not happened. In terms of preparedness, we are better
prepared than we have ever been globally. Alerting, even at the
syndromic level, without a lab diagnosis is much enhanced. Our
ability to respond is much enhanced but where the problems lie—I
am not sure you can have excellent plans in place for it; the
UK has a global reputation for being one of the most pragmatic
and best prepared and, in fact, is helping to train other countries—is
the logistics issue. If there is a pandemic, who is going to deliver
the antivirals? Even if they are not affected, they are going
to be at home looking after relatives, family etc. The whole logistics
issue, that whole infrastructure issue is a major problem which
I know governments, at least the UK Government, is paying a lot
of attention to. I do not know the extent to which those plans
will hold tight in the face of a pandemic.
5 Note by Witness: For example, Lord Crisp,
in a recent paper, estimated that the WHO AFRO Region alone was
short of 1.5 million health workers. Back
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