Examination of Witnesses (Questions 240
- 259)
MONDAY 3 MARCH 2008
Professor Sir Michael Marmot, Professor Anne Johnson,
Professor Angela McLean and Professor Neil Ferguson
Q240 Baroness Whitaker:
That is one thing we can consider, of course, but everybody always
recommends more funding. We shall be talking to WHO, and I quite
see that it is not your job to reform the whole of WHO. But are
there any mechanisms, any institutional measures which you think
should be adopted to improve this, because it seems to me this
is a really important weakness?
Professor Sir Michael Marmot: I think Dr Chan
is very receptive to this. Once the organisation accepts that
health equity is a core value for the organisation (and she is
very receptive to this idea that it is a core value), then you
cannot achieve health equity without taking action across the
whole terrain that I have been laying out, and that means that,
for her organisation to deliver on that core value, it has to
function in a different way. There are mechanisms that she can
set up. For example, there is a cluster devoted to evidence for
policy and information. It seems to me easily feasible to set
up a cross-cluster activity, as we have been doing with these
key people who are working in different vertical programmes. We
have got a priority Public Health Conditions group that meets.
I went to meet with them to encourage what they are doing. So
we have actually set up a potential mechanism which she could
support easily and make it part of the way the organisation functions.
It would mean bringing in some extra expertise, so when people
say "We do not know about education", bring in some
people who do know about education, and they would help you to
interface with the other relevant organisations.
Chairman: Before I bring you in, Professor
Mclean, Lord Desai, you wanted to come in.
Lord Desai: I just wanted to try out
an idea. When governments or NGOs want to give money, they probably
find that a vertical programme is much more directly effective,
they can see it can actually fight disease. Forget about clean
water, development, education; it is very hard to raise money
for that. Or, they may think, you are not getting the bang for
the buck: "We actually put this money in to fight disease
and you are telling me you have started a primary school."
So it is partly a matter of showing from previous example that
education of mothers, for example, is effective, but beyond that
I think it would be difficult for horizontal programmes to command
respect. That may be a conceptual difficulty rather than an administrative
difficulty.
Q241 Chairman:
Would you like to respond, because I suspect this might be an
area of your interest too, Professor Mclean?
Professor Mclean: I was very taken with Baroness
Whitaker's question about, apart from giving money to WHO, how
could one change it. Partly I am interested for personal reasons.
My life plan, when I was in my twenties, was that I would train
myself up as an epidemiologist and then go and work at the World
Health Organisation, because it seemed like such an amazing organisation.
Then, fortunately for me, my PhD supervisor said, "Perhaps
you had better spend a summer there first." So I did, and
it was like swimming through treacle. I do not know if you have
been there. I am sure that at moments of emergency it all gets
pretty exciting, but it is not an energetic place. I think that
is a very interesting question, especially if one had some clout,
because you might be thinking about putting in some more money.
What could you do so that there are some little moments of energy?
I think perhaps there are things one could do. One could think
about sending people in for a while, bringing them out again,
sending in people to do specific things, not necessarily vertical
things. So I think that is a really fascinating idea. I do not
understand why international civil service has to be like that.
Professor Ferguson: I think some of that is
happening now. Part of a recent criticism of WHO is that it is
almost entirely staffed by CDC people, and a few HPA people, and
they are drawing hugely on the expertise of short-term people,
particularly on programmes they want to get moving quickly. The
downside of that is there has been a degree of resentment between
long-time, arguably less competent, staffers within the core organisation
and the new brought—in people, and also that they lose that
expertise when people leave. They gain quick expertise in priority
areas and then it is not sustained within the organisation. I
think a lot of the institution's inertia is about the constitution
of the organisation, it being governed by the World Health Assembly
formally and the same inertia exists with all UN organisations
in trying to achieve major change. I think also the quality of
some of the people they get has not always been what it needed
to be . I have seen different areas, say on the avian flu side,
where a lot of money and expertise and effort has gone in and
it has been a priority and it has actually been quite fast-moving
as an organisation.
Q242 Chairman:
There is a very big issue around this. I want to move on, though.
I will do this fairly briefly, because to some extent you have
covered it, but it is an area between intergovernmental organisations
to which I think we have to pay a bit more attention. It is this
one between those which monitor human health and those which monitor
animal health. I wonder if you could say a word about that.
Professor Ferguson: Diplomatically?
Q243 Chairman:
Not too diplomatically!
Professor Ferguson: My interactions with OIE
I have found intensely frustrating, FAO is a little better, but
they really do have different perspectives on health. I think
WHO, for all of its faults, is principally targeted on trying
to improve the health of humanity. OIE is nominally targeted on
that, but it is not entirely evidence-based and a lot of the infrastructure
of international regulations on animal health has been developed,
over a very long period of time and, I think, act in a largely
negative way in some cases. You have a certain list of designated
diseases—foot-and-mouth disease being one, avian influenza
being another—which, should a country which is "free
of that disease" discover the disease on its territory, a
whole set of very damaging economic consequences fall on that
country. This is because OIE designates disease-free areas and
areas with disease and they are not allowed to trade with each
other. Many people (and I am not unique in saying this) have said
this is, in essence, a way round WTO rules, to maintain protectionism
in agriculture. Some countries in the world can afford to control
some animal diseases like foot-and-mouth disease, other countries
cannot afford to control the disease. In fact, foot-and-mouth
disease is not a very important animal disease; it is not a highly
lethal disease; we create it as a disease of importance. The relevance
of this to human diseases has been sharply shown in avian influenza
crises, that countries have been slow to report outbreaks and,
indeed, avian influenza activity in countries has been detected
via human cases rather than by ministries of agriculture in those
countries reporting outbreaks. I will not give a list of those
countries because I work with them, but in many cases I have talked
to people in ministries of health who have been aware of agriculture
outbreaks, who say their ministry of agriculture is aware of the
outbreak and they have sat on the data for two or three months
before reporting it to OIE because of economic concerns. It is
fundamentally amiss. There are some efforts now to change this.
I was reading an editorial, written by the new director of OIE,
commenting on these issues, saying that in the future countries
should not use the international animal health regulations as
an indirect method for inhibiting free trade, but at the moment
the economic consequences are such that it is very deleterious
to accurate surveillance for animal diseases.
Chairman: Unless any of the three of
you would like to come in on that, I am happy to move on. Lord
Jay, the drugs issue. This again is about whether people are operating
in their own closed areas or whether they are crossing boundaries,
but perhaps we need to clarify the drug issue.
Lord Jay of Ewelme: Thank you. I should
have declared an interest earlier on as Chairman of the Trustees
of the medical aid NGO Merlin. That is going to be an interest
Lord Geddes would disapprove of! Anyway, there we are.
Lord Geddes: I do not disapprove of it!
Q244 Lord Jay of Ewelme:
I mean the organisation. Just a question on drugs. I think better
and better drugs exist, but I am certainly struck, in travelling
to some pretty difficult bits of the world, that they very often
do not get to where they are wanted at the time they are wanted:
or, if they do get there, they are then cut off and then more
are needed. I suppose the question is; whose responsibility is
it to try to overcome that problem? Is it international organisations?
Is it WHO, is it WTO and the TRIPS organisation? Is it national
governments? Is it the drug companies themselves? Can we make
more use, or could more use be made, of commercial distribution
systems within countries? I think Coca-Cola are developing a system
of distributing drugs. Can more be done in that way? I am just
interested in your thoughts on that in the face of what Professor
Ferguson was saying about the success, as I understood it, in
getting schistosomiasis drugs through to people who needed them.
Maybe there are some lessons to be learned from that?
Professor Ferguson: Yes, totally.
Professor Sir Michael Marmot: Could I start
by saying something that I should have said in answer to Baroness
Whitaker as well. Again, we are toying with the idea of an equity
gauge to look at all policies as they affect health equity. If
you take the argument that health of the population is basic and
we should not pursue policies that are detrimental to the health
of the population and the further argument that health equity
should be a fundamental value, then we should look at all policies
with an equity gauge. If we then come to WTO and intellectual
property, we should look at it with a health equity gauge, both
the agreements that we reach under WTO generally, and in relation
to pharmaceuticals and intellectual property. What impact do they
have on health equity? You do not have to be a genius to look
at the impact they are having on health equity, which is extremely
adverse. The self-serving arguments about how global health will
benefit by restrictive practices do not hold water, and if we
said that we wanted the issue of health equity to be on all WTO
agreements, not just those that apply to drugs but that apply
to everything, that is in a way saying we want to look at how
fair WTO agreements are. I think we ought to apply it specifically
to pharmaceuticals, and then the other side of it is that, if
you can get the drugs into the countries at affordable prices,
if you have got a horizontally-developed healthcare system, you
can get them to people.
Chairman: The International Health Regulations.
Lord Geddes?
Q245 Lord Geddes:
I am hoping to get through this rather quickly. Could we have
your comments, please, on the International Health Regulations,
on which we have heard a considerable amount of scepticism. In
your opinion, are they useful? And, even if they are or are not,
are they enforceable?
Professor Ferguson: I think they are useful
because they state a country's responsibilities and what countries
expect of the WHO, which was implicit before but not fully stated,
and so from that point of view I do you think they are valuable.
They give countries an obligation to report certain diseases,
i.e. building on the SARS, experience and expectations of WHO.
As to whether they are enforceable, then if you tell me an international
law regulation or treaty which is enforceable fundamentally, I
would be glad to hear it. Particularly at a UN level rather than
necessarily an EU level, there are not the mechanisms in place
for enforcement but I think, (again, China learnt this lesson
in SARS) being a good global citizen is the implicit enforcement
mechanism. Countries have signed up and WHO is already starting
to do naming and shaming exercises when countries start to slide
back on their responsibilities. So I would be actually quite positive
about the international health regulations.
Q246 Lord Geddes:
Is that view held across the board?
Professor Mclean: They are better than what
we had before.
Q247 Lord Geddes:
That does not say an awful lot!
Professor Mclean: No.
Q248 Chairman:
I pick up from what some of you are saying that you feel there
have been changes in the WHO which mean that it is working more
effectively—I am jumping back a bit—than it was before,
because you actually seem to have been less critical of the WHO
now than it was previously. Is that right? Do you think the WHO
is getting better?
Professor Johnson: It is a difficult question
to answer in the absolute. I think in some of the areas that you
have highlighted, particularly the response to things like SARS,
the point that Neil has made is important. The fact that WHO is
seen as the body that is respected and is seen probably to deal
a fair hand, I think that is very important too. The recent efforts,
for example, around flu pandemic plans is one internationally
that WHO has had a very important role in. I would certainly support
the view that this is an agency which needs to have that leadership
role internationally, but all the problems that have been described
pertain, such as funding. There are obviously a lot of different
political interests in how WHO operates. One issue is that there
is quite a high staff turnover, because people come in with relatively
short-term secondments and there is a lot of reliance on consultants
coming in for relatively short periods. This has the advantage
that you bring new blood into the organisation, but, on the other
hand, you have got quite rapid throughput of staff from a large
number of Member States. Broadly, some of these new efforts in
infectious diseases, I think, have borne fruit. I know relatively
little about the new regulations, but they are new and, as understand
it, Member States are still trying to explore how best they be
interpreted, and I suspect that will be an ongoing process for
some time to come.
Q249 Baroness Whitaker:
A quick question. Of course the new regulations are an enormous
advance in their reach from the previous ones, but as for the
premium they put on surveillance systems, obviously many countries
just have not the capacity to implement those properly. Is it
not possible that, because of the existence of the regulations
and their mandatory obligations, countries might get more funding
from the developed world to improve their surveillance systems?
You do not necessarily know the answer to that, but would that
be a desirable outcome?
Professor Johnson: There is no doubt that across
the piece people are recognising the need for investing and strengthening
surveillance systems, and that has been said by a whole range
of organisations. FORESIGHT said it loudly, WHO said it presumably
also partly through the regulations and, I suppose regulations
do always provide a sense of imperatives which may allow money
to follow, but I think there are a number of other bodies trying
to strengthen that area in addition.
Q250 Lord Hannay of Chiswick:
Following up this line of thought, it must, surely, be fairly
evident that a lot of very weak countries are going to find it
very difficult to grapple with these new regulations but that
it is in our interests as a developed country that they should
succeed in grappling, not just for their good but for our good
too. In which case we and other developed countries ought to be
giving them more help to do it, not saying we doubt whether these
regulations were enforceable, which I am sure they are not in
many weakly administrative bodies, but (and this is what Baroness
Whitaker, I think, was saying) giving them more assistance to
actually implement regulations which it is in our interests they
should implement.
Professor Ferguson: The US has been doing this
to quite a significant degree, particularly in the avian flu area.
Q251 Lord Hannay of Chiswick:
Have you?
Professor Ferguson: I honestly do not know the
answer to that, but the US, through WHO and bilaterally with countries
on the ground, has given probably in excess of $100 million, maybe
quite a lot in excess of that. That has involved, to be fair to
them, quite good programmes of building up surveillance systems,
data systems and lab capacity on the ground. It has been quite
productive and WHO has co-ordinated much of the effort. Some of
the issues have been thrown into sharp relief by the Indonesian
crisis and in some ways that has accelerated the increase in local
capacity for lab diagnosis as well. But as regards monitoring
the burden of disease more generally, I think hugely more work
needs to be done there.
Q252 Chairman:
It has been said that the International Health Regulations cannot
be enforced in a literal sense and therefore you are looking for
a way for WHO, or individual governments like CDC in the US, or
whatever, to do it. I think that is what I am struggling with,
I do not know about my colleagues, but it is very hard to see
how you can best help. If individual nations just give that sort
of help on a one-to-one basis, if you like, do you do it through
the WHO, do you do it through regional structures? What do you
do? How do you do it?
Professor Ferguson: WHO, via their website,
in the documents they produce, represent a huge body of knowledge
about how you actually do a lot of basic heath-related activities,
particularly in the developing world. They act as a library of
knowledge for practitioners on the ground and I think with the
IHR, their protocols on how you implement surveillance systems,
what should you do, should not be underestimated in how they will
have influence. People really do just follow the guidelines WHO
issue.
Q253 Chairman:
And governments can do that individually, even though in many
countries you are talking about governments which are not very
effective, to put it mildly.
Professor Ferguson: In Sub-Saharan Africa, a
lot of activity is just trying to follow WHO guidelines, from
the people on the ground to the ministries of health. The grey
area is countries like Indonesia, Thailand, Vietnam, China, where
they do not just follow, they have more capacity than just to
follow guidelines, but even for those countries on needs to realise
that IHR would not have got through without Chinese support and
China was the country most criticised in SARS. I think the lessons
have been learned there as well.
Q254 Chairman:
I am sorry; did you want to come in?
Professor Johnson: I was going to say, on surveillance
and investment in surveillance, that this is an issue of Global
Stewardship, to take a phrase from the Nuffield Working Party
on Public Health Ethics of which I was a member. Investment in
these areas in developing countries is extraordinarily important
for identifying new and emerging infections and being able to
deal with the public health consequences. It is also a form of
enlightened self-interest, because, as you identified in your
original questions, infectious diseases move very rapidly round
the world because of the social, economic and other circumstances
in which we currently live. There is a massive amount of population-mixing
which allows problems to emerge quite rapidly, So there is, a
responsibility for investment in these areas and working with
WHO in that capacity.
Chairman: Anyone else on this before
I move on to bioterrorism?
Q255 Lord Hannay of Chiswick:
Would I be right in thinking that it is not really sensible to
think of bioterrorism as a separate subject in its own right,
because in fact the impact on world health, international security
issues, and so on, of a major bioterrorist action would not be
particularly different from an outbreak of a highly infectious
new disease, like SARS or avian flu, that had crossed the line,
and so on. Therefore, basically we should not be putting the two
things into completely separate boxes, we should be looking at
them as similarly catastrophic events against which we are probably
not very well prepared but which developed countries are infinitely
better prepared than developing ones. I am not talking about the
security aspects of stopping people using biological weapons,
I am talking about what happens if they do use them like, for
example, ensuring that there are enough drugs to deal with a situation
positioned in particular places where they can be available quickly,
that there is some machinery that links up the WHO with organisations
that are involved in security, like the Security Council and so
on, if it came to closing off a particular part of the world,
or whatever it is, in a controlled fashion rather than a completely
uncontrolled and anarchic fashion. These are all issues that could
just as well arise from SARS or avian flu crossing the line as
they could from one of Osama bin Laden's merry men getting hold
of something very nasty and releasing it somewhere.
Professor Johnson: I think the concerns about
bioterrorism probably have strengthened our health protection
function in this country. I think it has been one of the drivers
for improving the health protection structure. The Health Protection
Agency has been significantly strengthened over the last decade
and taken on a broader range of activities. So, I think I agree
with your point that the same mechanisms will be put into place,
and to some extent the same protection functions would be put
in place by government, as would be the case if there was a threat
of avian flu, and with concerns about H5N1 in poultry flocks recently
in the UK. Those same sort of mechanisms are put in place to protect
the health of the public. So, yes, I think it is important to
think of the two going hand in hand and not requiring entirely
separate infrastructures for the management of the protection
of the population. The Ministry of Defence issues are entirely
different, but the human containment issues would use the same
infrastructure, as I understand it.
Q256 Lord Hannay of Chiswick:
Following on from that then, has the WHO got a handle on this
sort of thing? Are the huge range of developing countries even
remotely capable of operating any of these necessary disciplines
and prophylactic measures and goodness knows what else? Or are
we, again, living in a world in which we are all preparing ourselves
for the worst, probably quite effectively, but we are forgetting
about the rest of the world which has got no defences at all?
Professor Ferguson: One has only to look at
the threat assessments to see the catastrophic scenarios of an
infectious disease release are actually very unlikely. The only
real candidate is smallpox but we were more concerned about that
a few years ago. The developed world is much more prepared than
the developing world for smallpox. All the other potential candidate
agents are non-infectious. Without doubt, the developed world
is, again, much more prepared than the developing world here as
well but those agents do not pose quite the same cross-border
risks you were perhaps implying. In my own honest opinion, having
worked in this area for quite a while now, the threat is very
minor. The capability of potential people who might use biological
agents is very limited at the current time. That is not to say
it should be completely dismissed, because that capability will
grow significantly, but at the moment I would agree with what
Ann said. It is actually a lesson the US learned in the last few
years in terms of their investment in this area. It is much more
cost-effective to invest in dual capability response measures
which can be used against acute natural occurrences as well as
deliberately introduced agents than very specific counter measures
against particular pathogens which may or may not be used. Specific
counter measures are very expensive to develop and you do not
get very good value for money for the size of the investment.
The Bio-shield initial investment in the States was not terribly
productive for such a large amount of money. The second generation
of that initiative post—H5N1 avian flu has been much broader
in its scope and arguably better invested. In terms of WHO, there
are a few discussions of these things, but the general consensus
there, if I was to be a little bit cynical, is that most people,
I think, view it as a threat which has been invented in the States
and propagated in the Anglophone world and it is really not a
serious public health threat. They may be being a little narrow-sighted
in that, but I think the perspective is that there has been such
a distortion of spending in the United States on this issue that
they will focus on what they are doing and let the US invest.
Q257 Lord Hannay of Chiswick:
If you are agreeing with the analysis that there is not a huge
difference between how you handle SARS and this, then WHO should
not have to ask themselves too many questions about how real the
threat from bioterrorism is?
Professor Ferguson: I feel, and others feel,
the real threat in bioterrorism is not in the human health side,
it is much more likely to be deliberately introduced animal pathogens
targeting developed countries. That is easy to do and has economic
impact.
Q258 Chairman:
I was going to ask you about that, because my understanding is
that the problem for anybody choosing to do this, be it a state
or a non-state organisation, is actually weaponising it, making
it something you can transport. But some of the work that has
been done by some of the countries that were looking at it, and
they were actually developing countries, if you look at Hans Blix's
report on Iraq, it was things like wheat germs, so it was targeting
crops. Is that not right?
Professor Ferguson: If you take the foot-and-mouth
virus—and the United States Homeland Security are very concerned
about this—it is very easy to transport, you can deliberately
cause an outbreak which has no human health consequences but has
a very significant economic impact. I would agree, again, that
some of the plant pathogens are a risk as well.
Q259 Chairman:
The answer, in a sense, is still this issue of having a really
good detection, identification and monitoring programme which
applies whether it comes about from natural or unnatural sources.
Is that right?
Professor Mclean: And a contingency plan and
practice.
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