Examination of Witnesses (Questions 268
- 279)
MONDAY 10 MARCH 2008
Dr Christopher Conlon, Dr Maureen Baker, Dr Helen
Williams and Dr Imelda Bates
Q268 Chairman:
Good afternoon. Welcome to this session of the Intergovernmental
Organisations Select Committee. Can I tell you, first of all,
that this session is being web cast and recorded. You will see
a transcript of your comments so that you can correct any factual
or other matters; that will be sent to you. Please feel free to
answer any of the questions that are asked. A question may be
asked to one specific person, but if someone else has something
useful to say, please indicate and I will bring you in. Having
said that, you do not need to answer every single question if
you do not wish to do so. Also, I would want to encourage you
if, after this session, you feel that there are other things that
were not said that should have been said or anything you want
to clarify, not to hesitate to write in with comments to that
effect; that is very helpful to us. Finally, can I tell you what
is the difficult part of this Committee. We are actually focusing
on intergovernmental organisations and their effectiveness and
the ability of the British Government to use intergovernmental
organisations effectively. It is quite a complex area and that
means that we have to have knowledge of the medical side, but
we do not need to have the detail of the medical side unless it
is particularly relevant to that. So it is quite a delicate balancing
act, but you will understand if we focus on the intergovernmental
organisations at times. We are not expecting you to be experts
on intergovernmental organisations; if you do not know an answer,
then please do not hesitate to say so. We understand that you
are essentially people with a medical background. Can I start
by asking each of you to introduce yourselves?
Dr Conlon: I am Chris Conlon; I am representing
the Royal College of Physicians. I am an infectious diseases physician
and general physician in Oxford.
Dr Baker: I am Maureen Baker. I am Honorary
Secretary of the Royal College of GPs
Dr Williams: I am Helen Williams. I am Vice
President of the Royal College of Pathologists and I am also a
consultant medical microbiologist in Norwich. I also co-chair
the International Committee at the Royal College of Pathologists.
Dr Bates: I am Imelda Bates. I co-chair the
International Committee at the Royal College of Pathologists with
Helen. I am a clinical tropical haematologist and I work at the
Liverpool School of Tropical Medicine.
Q269 Chairman:
We have heard already that there is a view that the intergovernmental
organisations are quite fragmented and there is a question of
how effective they are at controlling the spread of infectious
diseases. We are not quite sure, in other words, if the intergovernmental
architecture, as it has been called, is quite as it should be
or whether it is overlapping and confused by too many groups being
involved and so on. Do you have a view about that? And, if so,
can you tell us what it is?
Dr Bates: To be honest, the only intergovernmental
organisation that I have had anything to do with really is WHO,
and occasionally a bit with UNAIDS and FAO a bit, where they interact,
but it is mostly with WHO. We do not see much of the other intergovernmental
organisations.
Q270 Chairman:
How effective do you find the WHO to be?
Dr Bates: In some areas reasonably effective.
It depends whether you are talking about headquarters or the regional
offices. Some of them function well and some of them seem to act
very autonomously, separate from headquarters. WHO headquarters
have some departments which function very well and some which
do not function well at all, particularly in the area of not using
evidence-based information to develop policy.
Q271 Chairman:
What you are saying we have heard before, so you are not alone
in saying this. Can you perhaps help us by giving some examples
of where you think it is not working as well as it could?
Dr Bates: I can give you two examples. One is
that WHO are very vertical in their approach. For instance, in
communicable disease programmes one of the common factors is anaemia;
and, when I wanted to talk to anyone in WHO on anaemia, I had
to go round eight different departments and get them all together
to talk across the table about anaemia. Another example is blood
transfusion, where the policies are not very evidence-based. There
is evidence there but there seems to be a party line which is
not necessarily based on updated evidence and there do not seem
to be appropriate expertise groups brought together to advise
about what should be policy updates.
Q272 Chairman:
Do you see this is a problem of the central organisation of WHO?
Dr Bates: Yes.
Q273 Chairman:
It is essentially a problem of the centre.
Dr Bates: I think so, and yet some departments
work well and they have recently introduced a system of recommendations
as to how you produce evidence-based guidelines, which seems to
be percolating through WHO, and which is a really good move forward.
However, I do not think that has reached all the departments.
I do not know whether it is something to do with the structure
of WHO or whether it is just to do with individuals running different
areas.
Q274 Lord Geddes:
Dr Bates, you used the expression just now "party line";
what do you mean by that?
Dr Bates: If you do not get a very good group
of experts bringing all different perspectives together, what
you tend to get is a polarised view. A lot of the documentation
and people's views are fixed down one line that may have been
stated long ago. What you need is new blood coming in and a sort
of panel of experts who can bring different perspectives instead
of just a biased view.
Q275 Lord Geddes:
Can I switch just slightly but still on WHO. You said you had
experience of the Centre, but you did mention the Regional Offices
as well. Do you have any experience of the Regional Offices as
well?
Dr Bates: I have some experience of AFRO, which
is the African Regional Office. I think the other Regional Offices,
from what I hear, seem to work very well with the Central Offices,
but AFRO seems to be much more autonomous somehow. Whenever you
go to Headquarters in Geneva and talk to them about something,
it does not necessarily percolate down to AFRO and vice versa.
Q276 Lord Geddes:
With other parts of the world do you think that does percolate
down?
Dr Bates: I do not have personal experience
of other parts of the world, but from what I hear from colleagues
it does seem to.
Q277 Lord Geddes:
I wonder if our other experts have any experience on this?
Dr Conlon: My experience is purely from Africa
as well, in the field of HIV. As Imelda has said, there is often
a disconnect between what is happening in Geneva and what is happening
on the ground and even on the ground the Regional Office is often
quite far away from where the field work may be going on and where
programmes are being implemented. I think I have the same view
as Imelda has—that there appears to be much more politicisation
of the Geneva headquarters and party lines—a methodology
in doing things—not necessarily the best but what is told
to them is carried on. It is quite hard to translate that bureaucratic
view to hands-on in the field.
Q278 Chairman:
So it is more a failure of the Centre than of the Regions?
Dr Conlon: I think it is a bit of both. There
has to be feedback from the Regions but I think the Centre probably
should be responsible for making sure that happens. It is quite
hard for the Regions sometimes to report back if they are not
invited to do so. I do not have any first hand of the mechanisms
by which that happens.
Q279 Lord Geddes:
Coming back to the Royal College of Pathologists, in your evidence
you used a very interesting expression, that "leadership
from the WHO is ambiguous". What do you mean by "ambiguous".
Dr Bates: Some of the policies do not necessarily
join up. For instance, for malaria WHO was very strong in advocating
for combination therapy when chloroquine resistance became very
prevalent, but they did not link that onto the need for a diagnosis
for malaria. So, although the combination anti-malarials are much
more expensive than chloroquine, they were still persisting with
the policy that says that all fevers should be treated as malaria
and yet, on the other hand, also saying that these more expensive
drugs should be focused on those who really have malaria. We know
in some countries that 90 per cent of fevers are not due to malaria,
so there is 90 per cent over-diagnosis of malaria. Where there
really is no evidence, they need to say, "Look, we actually
don't know, but we need to generate more information". It
is ambiguous in that, where it is not clear what you should do,
it is somehow not made that explicit.
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