Examination of Witnesses (Questions 220
- 239)
MONDAY 3 MARCH 2008
Professor Sir Michael Marmot, Professor Anne Johnson,
Professor Angela McLean and Professor Neil Ferguson
Q220 Chairman:
That is fine. This is the horizontal versus the vertical, as we
understand it.
Professor Johnson: I think this is an absolutely
critical issue. I think it is very easy to throw out the vertical
programmes completely, and one should not do that. The vertical
programmes have, undoubtedly, achieved a great deal in certain
areas—anti-retroviral therapy is making a difference and
so are TB programmes, vaccination programmes, and so on. But the
difficulty that arises is, if they are being set up without the
underlying horizontal infrastructure with which they can interface,
you begin to distort the health economy, so you get people coming
out of what little infrastructure exists, which is often very
little indeed, and further pushing resources into the vertical
programme. To give an example, HIV programmes are being rolled
out, HIV screening is being undertaken in ante-natal settings,
because at least part of maternal mortality is due to death from
HIV and neo-natal problems due to transmission of HIV. But then
people stopped screening for the entirely treatable condition
syphilis, and therefore you get the reappearance of congenital
syphilis, to give an example. To develop that infrastructure in
health systems it does seem to me to have the need to work very
closely with Member States and governments, as Professor Marmot
has said we have to build the kind of infrastructure which may
be less glamorous for certain NGOs that are single-focused, to
build district health services and systems. That requires huge
investment in the training of individuals. In Malawi, for example,
there are very, very few doctors. In other countries, as you know,
we are seeing net importation of trained staff into developed
countries, into the Western world, so we have to invest quite
heavily in that, and I think Lord Crisp has written about how
we can assist in the UK in doing this. People are now talking
about diagonal programmes. That is, of course, trying to invest
in vertical programmes but making sure that they interface with
horizontal programmes. We have vertical programmes, remember,
in this country which work like that. We have vertical programmes
for tuberculosis control in this country. It could not be done
just by managing in primary care; we need to use the primary secondary
interface and specialist services.
Professor Mclean: I think there is reason to
be hopeful, because all that vertical money could leave a legacy.
Remember, the ultimate vertical programme was the eradication
of smallpox, and for some time after smallpox was gone the childhood
vaccination programmes that have been set in place by it functioned
well, and in many places they still do function well, so we do
have a model where a vertical programme leaves a legacy behind
it that can do other things too.
Q221 Lord Jay of Ewelme:
Developing the same point a little bit further. The consensus
I get is that you need both: you really need some vertical programmes,
you need some horizontal programmes. Do all of you think that
at the moment, the way that funds are being allocated, there is
either a risk of, or there is, an actual distortion of priorities
away from what you would think would be the right balance between
the building up of basic healthcare systems and the focus on individual
diseases?
Professor Sir Michael Marmot: I think there
is another issue that I am sure you have come across in your deliberations.
In 1978 the World Health Organisation had its Alma-Ata Declaration
on Health for All and said that the means to achieving health
for all was comprehensive primary healthcare. That meant building
health systems—not a new idea. 1978 was the Alma-Ata Declaration.
It will be revisited this year in Alma-Ata, 30 years on. What
happened, in practice, was that health system reform essentially
meant marketising health systems. It was seen as a very bad thing
to have everything controlled by the state, by the centre, "public"
was a bad word, and the structural adjustment programmes that
were foisted on low-income and middle-income countries also affected
health systems. So the bold declarations of Alma-Ata did not happen
by and large. They were vertical programmes and countries were
told to privatise everything in sight to do with health systems.
In most low-income countries the majority of healthcare expenditure
is out of pocket. There is good empirical evidence that, the higher
the out of pocket expenditure, the worse the health figures. Whether
that is a causal link between out of pocket health expenditure
or there is some common factor to do with poverty and disorganisation.
But it is, nevertheless, the case that, the greater the proportion
of healthcare expenditure that is out of pocket, the worse the
health record. Rich countries do not do it that way, by and large.
In Europe we do not do it that way, very little of our healthcare
expenditure is out of pocket, and we have good health records.
But, when you hear about Nigeria, two-thirds of its healthcare
expenditure is out of pocket and the majority of women, as I said
a moment ago, do not get skilled care during their maternities.
The whole idea of developing a health system just foundered after
1978. We have had the vertical programmes but there has been almost
nothing else, and, at long last, WHO is rediscovering the importance
of primary healthcare, and that is one of the things Dr Chan is
hoping to make part of her legacy in WHO and that is why this
year's World Health Report will be on primary healthcare, to bolster
it. It is not just that there is a mix. I would say the only game
in town has been vertical programmes and we need to rediscover
how important health systems, primary healthcare must be to make
vertical programmes work better, quite apart from the fact that
they are needed for all the other things that are left out of
the vertical programmes.
Professor Ferguson: I would agree with much
of that. I think there are some positive steps to be taken in
a gradualist approach rather than tackling health system reform
head on. Organisations like the Gates Foundation are deliberately
forcing 90 per cent or so of funding of their big programmes to
be in-country and increasingly are moving to enforcing that there
is a transitional hand over from initial governance of those programmes,
typically in academic or other expert institutions in the West,
moving to being sustained on the ground without necessarily that
same input. The transition from a sustained, self-directed, if
not self-funded, vertical programme to a horizontal programme
is an easier one to see than, in essence, flying in experts who
run a programme for four years whilst they have funding and then
fly out again. So, for instance the Schistosomiasis Control Initiative,
which is run out of my department, has treated 45 million people
with a very simple drug against one of the so-called neglected
tropical diseases. It has been a relatively cheap programme, but
it has been effected by nearly all the delivery being done through
local healthcare systems rather than a single one-off additional
programme with additional staffing. There are other examples along
those lines. Also, there is the rediscovery of simple interventions
rather than necessarily complex therapeutic interventions—for
instance, going back to bed nets and vector control for malaria,
gives programmes which can be implemented easily on the ground—similarly,
some of the ones for diarrhoeal diseases. They are not necessarily
the programmes that scientists in the West want to get involved
in and other people want to advocate though.
Chairman: Can we move on to WHO leadership,
which we have touched on in a way already, but it is becoming
relevant.
Q222 Lord Geddes:
We have, indeed, Lord Chairman. It is difficult now to know how
to phrase the question. If I can put words into your mouth, the
pendulum has swung too far into vertical and you would like to
move back a bit to horizontal. Those are my words and not your
words. If that were to happen (and the consensus of opinion from
the evidence we have had so far all points towards the WHO), is
the WHO geared up to take on that role? And, as has come out in
a question, there is a big difference between WHO centrally and
WHO in the regions. There are two parts to each of my two questions,
and I would very much appreciate hearing from all four of our
witnesses.
Professor Sir Michael Marmot: In answering that,
can I raise another issue. We have been talking about vertical
programmes and horizontal programmes, but there is a third issue
which relates to the commission that I am chairing, the Commission
on Social Determinants of Health, which is based on the understanding
that the main drivers of the health status of the population lie
outside the healthcare system.
Q223 Chairman:
In poverty, and so on, you mean?
Professor Sir Michael Marmot: Yes, it is arguable
that the best intervention to improve infant and child health
is education of mothers, not more healthcare, and it is actually
cheaper. I would never, for one moment, argue that we should not
have healthcare for infants and young children; we should have
it, but we should also have education of mothers. It would make
a huge difference. When you talk about lack of joined-up architecture,
it is not just the lack of joined-up thinking among the various
actors interested in healthcare, but it is lack of joined-up action
in the various actors concerned with the main factors that affect
health. There are good reasons for dealing with child poverty,
apart from poverty being a bad thing, because poverty affects
the health of the next generation. But it is not being combined,
it is not being sorted out, it is not being co-ordinated to, for
example, invest in early child development, which is very important
for subsequent health. One of the areas that my Commission is
going to emphasise is the importance of early child development,
not just child survival but physical development, linguistic and
cognitive development, social and emotional development of children.
It is absolutely vital. It is not just a concern of rich countries,
it is a concern of all countries; it is a global concern. There
is nobody really tasked with that. There are bits—UNESCO,
UNICEF, WHO—there are bits and pieces all over the place,
but lack of co-ordination.
Q224 Lord Geddes:
What is your answer?
Professor Sir Michael Marmot:
I have been struggling with this a great deal, and it is one of
the things my Commission is wrestling with, and I see an issue
that is quite similar to issues of governance within a country.
The question is what is the role of the Minister of Health, in
this country the Secretary of State for Health, if you argue that
the key drivers of health lie outside the healthcare system? The
levers which the Secretary of State for Health can reach are all
within the healthcare system, so those are the ones for which
he tends to reach, but the main drivers are elsewhere. It seems
to me (and I think it gets back to your question about WHO) that
the Minister of Health, the Secretary of State for Health, has
a key role, because nobody cares as much about health as she or
he ought to be doing. Nobody has the added capacity to look at
the drivers for health other than those that tend to lie within
the sphere of influence of the Ministry of Health. The Minister
of Health has a key role as an advocate, as an analyst, in monitoring
how well things are happening and measuring health status and,
more importantly, the distribution of health, health inequities
within countries; so the role of the Minister of Health, I think,
is vital, a leadership role, and I think that is the role that
WHO ought to be playing here. I think WHO ought to be playing
a leadership role among other international government organisations
looking at the key drivers that affect health globally because
of their concern particularly in low-income and middle-income
countries. That is very difficult. I work in a university. We
talk about cross-disciplinary work, and getting people to talk
outside their own academic department is extraordinarily difficult.
Everybody tries it and everybody finds it very difficult. I have
been advising, in one way or another, across government in this
country for a long time. We talk about cross-department working.
It is extraordinarily difficult. People pay lip- service to it,
but it is really very difficult. Since my Commission got started,
we have been to ILO, we have been to World Bank, we have been
to UN DESA to talk to people about how they might link up, and
everybody says, "Yeah, great idea", and then, when I
get out of the room, they go back to business as usual, so it
is extraordinarily difficult. But, to come back to your original
concern, what would the role of the British Government be? The
British Government has a very respected voice, certainly in WHO
and, I presume, in other inter-governmental organisations, but
it is a highly respected voice in WHO. It could play a very powerful
role in trying to bolster, push, encourage a WHO leadership role
among the various actors in the healthcare system but, more broadly,
among the various actors whose core business is to effect the
key drivers of health and health equity.
Q225 Chairman:
That was a very full and helpful answer, but would any of the
other three like to come in?
Professor Ferguson: I would agree whole-heartedly
but would voice maybe a slight cynicism. The WHO annual budget
is about 1.65 billion US dollars per year, of which about one-third
is core budget, which can be applied to both administration and
horizontal programmes. Most of the rest is earmarked for vertical
programmes by Member States such as our own. We, the Japanese,
the Germans and, of course, the United States are big donors to
WHO and, increasingly, the Chinese, but overall it is a tiny budget
to do any significant amount of global development. Even if you
took the sum across all the UN agencies, we are talking about
a tiny budget. If you compare it with what the Bill and Melinda
Gates Foundation has to spend, then the people who are actually
going to determine what is spent on the ground and, because they
are not having to filter the money to governments, have much greater
ability to implement things on the ground are going to be those
NGOs, and influencing those NGOs to have a broader health perspective,
I think, is where, to some extent, WHO but also governments have
a role. To be fair, I think the Gates Foundation is moving in
that direction already. Even from the outset they identified population
concerns, women's health, women's education as key determinants.
They have not invested as much in that and they are internally
getting rather siloed at the moment, just because of the difficulty
of spending money fast enough, but if you take a market approach,
and follow where the money is, then influencing Gates and the
other NGOs is where the focus should be, given they collectively
spend as much as all the UN agencies on developing per year.
Professor Johnson: I want to return to this
issue of education, training and human resources. If one takes
the view, which I do, that primary healthcare and health systems
are important for the long-term sustainability of these programmes
and the developing world, then you have to have a strong education
infrastructure. That goes right through from primary education,
through secondary education, through tertiary education. Education
is absolutely at the root of human development, in the kind of
things that we have been talking about. If people have education,
so employment follows, so greater prosperity follows, child development
improves, nations improve their overall wealth. It is extraordinarily
important, as is women's education along the lines that have been
described, but you must then invest in those education programmes.
You cannot educate five-year olds without teachers and you cannot
have teachers without tertiary education and, indeed, universities.
You cannot have doctors and nurses without a sustainable infrastructure
in the education sector. One thing I have recently engaged with
is a Wellcome Trust scheme, which is trying to develop a programme
of improved infrastructure for research in an African context
and trying to get greater interaction between UK universities
and African universities. It is pushing the African universities
to take the leadership role in building that kind of infrastructure.
That seems to me an extraordinarily important place to invest
if you are going to start from the kind of grassroots that you
describe, which will alter the parameters which ultimately affect
health. We cannot continue in a situation where those human resources
do not exist and we are always trying to take people from outside
in. When people get trained up, as Professor Mclean has described,
they often migrate out again. That is a key area for investment,
but with encouragement of leadership from developing countries.
Chairman: Lord Desai, we have covered
some of your points on European Centre for Disease Control. You
might also want to pick up some of the other regional ones as
well, I am not sure.
Lord Desai: In the structure, where does
the European Centre for Disease Control fit in? Is it an extra
leg that we could do without? Or is it a very helpful thing to
have?
Q226 Chairman:
The witness is smiling here. I am puzzled by this. Go ahead anyway,
Professor Ferguson.
Professor Ferguson: I do not think it is relevant
on the global health scene in terms of what we have talked about;
its remit is entirely within the European Union. It should be
compared with WHO Regional Office for Europe. Actually the Regional
Office for Europe for WHO is mostly looking east towards Russia
and the less developed Eastern European countries rather than
the European Union. ECDC has a small budget at the moment, and
a very limited influence. We could have an entirely separate meeting
about ECDC . I think it does some things well, in terms of co-ordinating
information and meetings, and in other ways it is achieving very
little, overall the European Union does not have much of a role
in health anyhow by statute, and what activity exists is also
fragmented. I deal with bioterrorism at both ECDC and something
called DG SANCO, the Directorate-General of Health, which actually
has a much larger budget but almost no political remit within
the European Union. So I would to some extent leave ECDC to one
side, because neither of those organisations is significantly
contributing to what we are talking about with respect to WHO.
Chairman: I want to bring in Professor
Mclean and Professor Johnson on this because they are both looking
with some interest on this. Lord Desai, did you want to pursue
this?
Q227 Lord Desai:
No, but I want to ask a supplementary without forgetting the first
question. Would it help us, as a committee, not to think about
developed countries at all, just parcel them out, and only worry
about effectiveness in combining policies in poor countries?
Professor Johnson: Developed countries, since
they have control over quite a substantial amount of resources,
are very important in the way they impact on global health. The
responses of developed countries with respect to key issues—for
example, a flu pandemic—is clearly critical as that is a
very big and sudden global health problem. But, if you are concerned
about where the major burdens of disease lie in infectious diseases,
then you are talking primarily about the developing countries,
although infectious diseases remain a really significant cause
of morbidity and mortality in the UK, just at lower rates.
Professor Mclean: I do not think you should
leave the developed countries out, because the way we behave has
such an impact on what happens. For example, the way that we hire
nurses from developing countries has an enormous impact in developing
countries, and I think these issues that we were talking about,
about co-ordinating roles and a role in education, are just very,
very important. We know that we have to stop hiring nurses from
overseas. I do not think we have stopped yet, we know we need
to, but there are other things we need to learn about education.
Setting up yet another MSc in London is not what we need.
Q228 Chairman:
Setting up what?
Professor Ferguson: Setting up yet another Master's
degree course in London in order to---.
Professor Sir Michael Marmot: In Oxford!
Professor Mclean: It would be fine if it was
in Oxford. Setting up yet more postgraduate training here is just
not what is wanted by the people who are trying to establish in-country
healthcare.
Chairman: But you are dealing with a
slightly different thing. The issue of the ECDC, I think, is next.
Q229 Lord Desai:
Yes. We have this thing about ECDC. Perhaps we should ignore ECDC
altogether and really concentrate on the impact of disease on
the poor countries. Developed countries appear as suppliers of
advice, money, and so on, and sometimes the takers-away of resources.
Professor Johnson: Absolutely.
Chairman: I know Lord Avebury wants to
come in on this.
Q230 Lord Avebury:
I am a bit puzzled, because in the announcement of ECDC's Mission
by Commissioner Kiprianou, he said that it was to co-ordinate
all activities regarding risk assessment, surveillance, detection
and investigation. He then went on to describe how its goal was
to co-ordinate existing networks on communicable disease. That
implies a global role, but you said it was purely European.
Professor Johnson: My understanding is that
the role of ECDC is to co-ordinate the activities in the European
Union. Therefore, they have a role in working with Member States,
as I understand it, to bring together surveillance data, to work
with Member States on the number of policies in relation to the
control of infectious diseases but, primarily, round the EU setting.
Of course, they must also be responsible if there were an outbreak.
If pandemic flu started somewhere in the EU, then of course they
would have a very important role in control and, I think, in liaising
with WHO, and so on. I think it is a little unfair to dismiss
ECDC in any sense when it is a very new organisation. It is just
building up its capacity and beginning to develop its teeth, to
be fair. I think perhaps a better analogy might be with the US
CDC, where the US CDC has a very important role in infectious
disease surveillance and control and the development of policies
within the United States and, obviously, interfaces with the WHO
but is entirely independent thereof. The analogy is obviously
not complete, because there are so many Member States in the EU.
It is parallel but not within the WHO family in quite the same
way.
Professor Ferguson: I would agree. ECDC would
like to model itself on the CDC, but the CDC has an executive
function.
Q231 Chairman:
Can you remind me what CDC stands for?
Professor Ferguson: CDC is the Centres for Disease
Control, but the Centres for Disease Control have a budget which
is roughly 30 to 40 times that of ECDC. Most importantly, they
have an executive function. They retain a lot of the US public
health service, which has a statutory responsibility and authority
to deal with public health, which supersedes that, indeed, of
states within the United States. ECDC, by its formation, has absolutely
no power to do anything at all. It can only co-ordinate. I think
it has done quite a good job in some areas, but I would say the
two organisations are only similar in name really, perhaps aspiration.
Q232 Chairman:
Professor Marmot.
Professor Sir Michael Marmot: It relates to
Lord Desai's supplementary. If I interpret the questions of this
Committee as being about intergovernmental organisations where
communicable disease is an example, the question is: should we
ignore the developed countries? If we look at the global burden
of disease—Professor Ferguson pointed to the global burden
of disease—for every region of the world outside Sub-Saharan
Africa, the poorest of the low-income countries, non-communicable
disease makes a bigger contribution to loss of disability-adjusted-life-years
than does communicable disease. If we are worried about global
health and global health inequities, we cannot focus only on communicable
disease, we must focus on non-communicable disease as well. My
concern the whole of my research life, and the concern of my Commission,
is with health inequity, or, putting it positively, health equity.
Should we ignore the developed countries? Life expectancy for
men in the most deprived part of Glasgow is 52. The average for
men in India is 62. You have got worse health in the most deprived
part of Glasgow than in India. I would argue that, if our focus
is on health inequity, then the global health agenda and the domestic
health agenda come together. We actually have to be concerned
as to how these health inequities arise and how we can deal with
them.
Chairman: I want to move on, I think,
to the investment and international use of funds. Lord Avebury,
you had an interest in this.
Lord Avebury: I think we have covered
a lot of that.
Chairman: You are right: we have covered
a lot of it. I wondered if you wanted to talk about the intergovernmental
organisations or the voluntary funds. But, if you are happy with
what we have had, that is fine.
Lord Avebury: I would like to ask another
question.
Chairman: It is the balance of investment
between surveillance, prevention and treatment that I was thinking
of particularly.
Lord Avebury: Before we come on to that
question, I want to ask: at Question Time today we were dealing
with the UNICEF report on the state of the world's children, particularly
the very poor records in the West African region as regards progress
on the reduction of infant and child mortality. I was wondering
whether, considering that there is a huge variation in this figure
between one region and another and the West African region is
miles behind any of the rest of the world, what funds should DFID
be allocating to international organisations to correct that imbalance?
Is that the task of the WHO to look at the Millennium Development
Goals and to remove these disparities? It touches on what Professor
Sir Michael Marmot has just said about inequities in health. Here
is a gross inequity in health; it is an order of magnitude between
some of the states in West Africa and the developed countries
of Europe in terms of child mortality.
Chairman: This is the issue of distribution
within regions, is it not?
Q233 Lord Avebury:
Is that something that the WHO should be addressing. And where
should we put our money if we want to make a difference?
Professor Sir Michael Marmot: Once again, we
have thought about and grappled with this issue on the Commission
on Social Determinants of Health, and one of the things we will
put to WHO is that WHO should take a leadership role with other
organisations. The revolution in child survival came from Jim
Grant, not from WHO. It came from UNICEF, not from WHO. One does
not want to see turf warfare here, but it is very important to
realise that there is more than one agency that is likely to have
interest in this. If UNESCO's interest is in education for all
and UNICEF is interested in child survival and WHO is interested
in child health, you have got to bring them together. I personally
do not have a big issue with who has the leadership role. What
I do think, though, with current issues about UN reform on the
table, we hear so much about the Security Council of the UN and
so little about ECOSOC. I would have thought ECOSOC would have
been more important than the Security Council, much more important.
In fact, there would probably be less need for the Security Council
if we had got economic and social development right. So, ECOSOC
really ought to be where we are putting our emphasis and ECOSOC
could then help these organisations get together. WHO could well
play the leadership role in child survival, but when I heard a
minister of health from West Africa point to the problem of rising
infant and child mortality in her country and say, "Our solution
is to empower the private healthcare sector", my blood ran
cold. She not once mentioned anything about education for girls,
the fact that all over West Africa, in fact globally, girls are
enrolled in school to a much lower extent than boys. It is just
an issue of social justice to get this right, and that must be
a key driver of child survival.
Q234 Lord Avebury:
Is it entirely a question of the leadership role? Or is it just
a matter of money? These are the statistics that we read from
UNICEF, and they, as you say, have a primary interest in the reduction
of infant and child mortality. The World Health Organisation does
not have the money to fund the delivery systems that would be
necessary?
Professor Sir Michael Marmot: Absolutely; no.
Professor Johnson: It is not their role.
Professor Sir Michael Marmot: That is why they
could play the leadership role. They are not going to deliver
the services themselves.
Q235 Chairman:
Can I intervene here? One of the things I wanted a clear answer
to here, because it is one of the important issues, is the balance
of spending between surveillance, prevention and treatment, because
that, it seems to me, would be a core part that we need to understand
about the spending issue. Do not let me take away from any other
answer you want to give there, but that I want an answer to, because
it is one of the things that keeps coming up.
Professor Johnson: Could I take the issue in
relation to HIV/AIDS programmes? There has been huge investment
in treatment for HIV in the last few years, but actually that
has not gone hand in hand with investment in prevention. It is
not just investment in prevention, it is the attempt to try and
integrate prevention and treatment services. Arguably, we have
a long way to go in this country too in integrating prevention
and treatment services. HIV is a life-long condition. We are treating
a lot of people in this country; we are treating a lot of people
in Africa. If they remain infectious, they will go on transmitting
the infection, so life-long management of HIV, particularly as
people live longer, also has to involve prevention services in
a clinical setting. It also requires that we have very strong
and continuing prevention programmes at the national level, through
widespread advertising and education programmes in schools, and
so on, which have to be sustained, just like vaccination programmes.
You have to sustain them and refresh them if you are going to
go on through time to achieve that. I think a lot of agencies
now would see that we have got a mismatch between investment in
treatment and prevention, which often happens. Once a treatment
hoves into sight, the prevention agenda gets forgotten. While
we may be seeing globally a relatively stable prevalence of HIV,
that is because people are dying so you are maintaining a number
of new cases. On the surveillance front, the surveillance systems
vary enormously between countries and the sophistication varies
enormously between diseases. The Foresight programme on infectious
diseases, on which I was a member of the expert group, emphasised
the need for improved surveillance programmes and systems which
harness new technologies to improve surveillance. These things
are critical to understanding the future transmission dynamics
of these infections.
Q236 Chairman:
Do you want to come in on this, Professor Ferguson?
Professor Ferguson: Coming back to child healthcare,
we know how to reduce childhood mortality. I would actually be
more direct and say that, quite often it is a failure of governments
in the countries concerned. They are largely simply failed states
and it is very difficult to operate in that backdrop. Coming to
detection, I think one needs to distinguish between routine surveillance
for endemic diseases where the goals of surveillance, are really
to monitor treatment programmes, monitor trends in incidence and
prevalence and take corrective action if the trends are in the
wrong direction or at least to understand the trends. Then the
newer sense, post-SARS particularly, of surveillance being outbreak
detection, and response. I think a lot has been done on outbreak
detection and response, particularly for acute respiratory diseases,
even in some very challenging settings, with limited infrastructure
such as rural Indonesia or Cambodia, where we are picking up single
cases and certainly clusters of cases in a relative short timescale.
I am quite positive here—I think the moves are in the right
direction—and we are also putting in generic capacity; there
is a degree of capacity—building going in on the ground
on that. There are questions from individual countries about what
they get out of such systems, but CDC, in particular, has put
a lot of money into it. Where I would agree with the others is
on monitoring of burden of disease. In particular, to monitor
disease prevalence and incidence through time. Those systems are
much more patchy. They are also more expensive quite often, because
you are not just looking for an early warning, and it is particularly
easy just to get a signal; you are having to do quantitative,
representative monitoring of the whole population in a setting
where, as we have just commented, there is no infrastructure and
primary healthcare to actually do what we would normally do in
this country to monitor. It means it is a very challenging issue.
Q237 Lord Hannay of Chiswick:
I would like to come back to this question which we have been
circling round about WHO, horizontal, vertical, and so on. All
the answers we have had from you seem to indicate that, first
of all, you think the WHO does play a very valuable role in co-ordination
in so far as it has authority to do so now and, secondly, that
it is really the best place to do that with your remark about
ECOSOC. I have to say, having been to rather a lot of ECOSOC meetings,
that I would not share your enthusiasm. The trouble about ECOSOC
is that it is in a worse position than WHO: it has no resources
at all. It actually has no budget or money. It strikes me that
in terms of the WHO, if it were to have a wider remit, a co-ordinating
remit, it probably will not be very effective at it if it does
not have also some more money, though not, I hasten to say, oodles
more money, drawing it away from other financial centres. But,
am I right in thinking that, as far as co-ordination is concerned,
as far as striking a balance between healthcare systems and individual
diseases, and so on, really it has to be the World Health Organisation
which provides the forum in which you can try and get a balancing-off
of these items? In which case, should one not be saying that the
WHO needs a wider, more fully supported remit of a co-ordinating
kind than it already has now and that, if it is to be taken seriously,
it almost certainly needs some more money as well? Or have I got
that completely wrong?
Professor Sir Michael Marmot: If I may, I would
say you have it completely right. Its co-ordinating role at the
moment, I would say, is more potential than actual, but it has
real status. If you did not have WHO, you would have nobody else.
Bill and Melinda Gates—it is wonderful that a philanthropist
wants to use his money to improve global health. But WHO has real
status in the system, and people love to criticise it; but, if
we did not have it, we would need to start again and develop it
and then people would criticise it all over again. I think we
cannot do without WHO. We ought to support it, build it up, try
and fix the creaking problems, give it an expanded role model.
So, I would endorse that completely.
Professor Ferguson: It is difficult to underestimate.
I have experienced it just once in South East Asia. How dominant
is WHO? It is the first point of call of most developing countries'
ministries of health if they have any crisis whatsoever, particularly
an infectious disease crisis. They will call on the WHO local
office and then on Geneva, and WHO has status because it is perceived
as being representative. Frankly, while such organisations waste
money, WHO needs ten times the budget, then they really could
actually do something, they could actually start implementing
programmes and have real clout. The problem WHO has at the moment
is just too limited resources to actually implement programmes
on the ground.
Chairman: I want to move on to health
and non-health intergovernmental organisations. Baroness Whitaker?
Q238 Baroness Whitaker:
We have touched on the social determinants of world health. In
fact, I was just wondering if WHO did not show some joined-upness
in setting up your Commission already. What I would like to know
is what is the picture of co-ordination between health and non-health
IGOs? You have mentioned education, of course, poverty itself,
but there is also trade, migration, there are a lot of other things
which affect healthy habitat too. I know that UNICEF has quite
a unified programme, which they call "wellbeing" and
which encompasses quite a lot of what you call "child development".
Can you tell us, first of all, are there people from other IGOs
on your Commission apart from distinguished independents? Is it
UN-representative, as it were? And are there some other co-ordinating
entities? Or ought there to be? Is that one of the creaking problems?
Professor Sir Michael Marmot: This is such an
important issue. The only representative of another organisation
on the Commission is from UN-HABITAT. Anna Tibaijuka is a member
of the Commission. All the other commissioners are independent.
For example, Ricardo Lagos, the former President of Chile, who
is a Commissioner, has been very much involved in UN reforms;
he was on the committee looking at UN reforms, so although he
does not represent another UN organisation, he certainly has been
close to UN activity. The issue of co-ordination, I would say,
is not working well. I described before going in and out of offices
of other members of the UN family and getting a very warm reception,
but then I go back and talk to people at the secretariat level
and say, "I have met the Director-General of ILO, he is very
keen on our agenda, he wants to work with us. Can you make some
link?", and it does not happen. I go to the World Bank and
I get the same very positive reception, and then I report back
to the colleagues at WHO and say that World Bank in their new
health strategy recognises explicitly that their lending in the
non-health sector has a huge impact on health and that they need
to monitor the health impact of what they do, and I put it to
World Bank, "You need WHO to help you do that." They
say, "Yes, absolutely right." I go back to WHO and say,
"There is a real opportunity here for you to play a key role",
and it does not get picked up. I think it is a vital issue, the
co-ordination issue. I am not sure I know how to do it.
Baroness Whitaker: That was my next question!
Q239 Lord Geddes:
Why does it not get picked up? Is it lethargy? Are they frightened?
Professor Sir Michael Marmot: I think there
is a lot of human nature in these organisations! I think it is
why a Professor of Medicine has difficulty talking with a Professor
of Anthropology in the university. People understand their own
turf. In setting up the Commission on the Social Determinants
of Health I did not realise at the time what a bold move J W Lee
had taken, because as I now have seen it play out, everybody within
the organisation, by and large, is involved in vertical disease
control programmes and they were quite threatened initially, saying,
"We do not know what all this is about. We do tuberculosis
control, we do malaria, we do smoking, we do HIV/AIDS, we do cancer,
diabetes." What has happened now, and it is very positive,
is a group of these people from the different disease control
areas, say, "We cannot do our work properly unless we take
these issues on board", and we have actually, in a rather
subversive way, I think, got people involved in these different
programmes at WHO talking to each other and recognising that the
issues we are talking about—to do with human settlements,
with employment conditions, with education—help them do
their work in tuberculosis control better, in safe pregnancy,
in violence, and so on. The next step, in a sense, is to institutionalise
that within the organisation and to get the forum right (and I
am naive but that is why I was thinking of ECOSOC) to make it
easier to talk across organisations, and there is nothing like
money to give an incentive. If there were money to get these organisations
to talk to each other, they would talk to each other.
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