Examination of Witnesses (Questions 300
- 319)
MONDAY 10 MARCH 2008
Dr Christopher Conlon, Dr Maureen Baker, Dr Helen
Williams and Dr Imelda Bates
Q300 Baroness Whitaker:
Is there any work being done either in poor countries or for that
matter in richer countries on who does not catch an infectious
disease? Obviously poverty and malnutrition makes a huge difference,
but even in rich countries there are plenty of people who do not
get flu, measles or colds; there were the Kenyan prostitutes who
did not get AIDS. Are people looking at this?
Dr Conlon: There is a whole building in Oxford
looking at this!
Q301 Baroness Whitaker:
Is it being fed into the international scene?
Dr Conlon: Yes it is, and it will form part
of the basis for some of the vaccine development that is going
on now, looking at people who are clearly exposed but immune for
whatever reason. They are looking at the genetic basis of that
to try to unravel what in their genes allows them to be immune
to that pathogen and then try to unravel that further to make
a vaccine. Certainly that approach is going on quite a lot.
Q302 Baroness Whitaker:
Would you say that would be productive?
Dr Conlon: I think for something like malaria,
for example, there is a bit of hope in that. HIV is a long way
off; TB vaccines may get better because of that. It is an approach,
because clearly a lot of people are exposed and do not get infected.
Most people walking around in Africa are not ill with malaria
or TB or HIV, and some of that is genetic.
Q303 Baroness Whitaker:
Does WHO take an interest in this too?
Dr Conlon: I am sure it takes an interest but
it would not be funding that sort of thing. It might eventually
develop policy in terms of whether this vaccine should be used
in the field and promoted by WHO; it would be in that guise.
Q304 Baroness Whitaker:
They do not have an interest in genetic research.
Dr Conlon: WHO would not have an interest, no;
it would not be their remit.
Q305 Lord Howarth of Newport:
I am encouraged by what Dr Bates was saying to ask you all whether
you think we would be right to stress in our report that different
organisations working in the same countries and the same regions
really do need to develop integrated approaches to deal with such
issues as lack of clean water, lack of sanitation, lack of education,
poverty, inequality, violence, corruption, lack of administrative
capacity, all these conditions which must have the most powerful
bearing on health within these countries. Should we stress this
in our report?
Dr Williams: I would certainly support that.
Q306 Chairman:
You are agreeing?
Dr Conlon: Part of it is also to do with how
you implement governance in the different countries.
Q307 Baroness Eccles of Moulton:
We have heard an awful lot about top-down, but surely if it is
going to be enduring and accepted it really has to be more bottom-up,
does it not?
Dr Bates: I think it has to be both. I think
bottom-up will not move if it is not coming as a directive from
on top and it has to be joined up all the way from top to bottom.
I do agree that on the ground in the villages people are doing
these things all the time as an integrated thing. It is not really
formalised. At ministry level it is really difficult to get the
ministry of education to talk to the ministry of finance to talk
to the ministry of health. It is really hard and yet when you
get down to grass roots level it is clear how that should work
and how it should be done. These village communities do a lot
of this for themselves.
Q308 Lord Desai:
I just want to ask the counter to what Baroness Whitaker and Lord
Howarth said. We know these things should be integrated—town
planning and clean water and such matters. But, when people give
money, they want to give money for malaria or for HIV. They do
not want to mess about with town planning. Is the problem not
that donors want to see the impact of their dollar and they do
not believe in these diffused, perhaps true, theories? They just
want to get an immediate reaction and that prevents integration.
Dr Bates: Yes, it does prevent integration.
One of the ways of making vertical programmes integrate more would
be to have, as their measures of success, not how many people
have swallowed anti-retroviral tablets but how much they have
managed to strengthen the health systems for other diseases apart
from HIV, for instance. That just does not happen because for
the donors it is not clean enough, it is too messy around the
edges for the donors.
Q309 Baroness Flather:
You have actually made the point that I was going to ask you about.
You said that you want to strengthen the central system so that
all these things can be looked at. When we had DFID officials
here, they said that there had been a great improvement through
DFID aid projects to strengthen health systems—I suppose
they mean the administration—in Nigeria. I am involved in
the NGO world as well and I do not get that same feeling from
them. In fact, when I said that, I got quite a big laugh around
the table. I just wanted to know how you felt. The second question
is about fevers. Coming from India, we always had fevers which
had no particular cause—or at least a particular cause was
not diagnosed. All you did was take some analgesics, drink a lot
of fluids and rest, and in two or three days the fever was gone.
You did not actually rush to take serious medication of any particular
kind and I wanted to know if that is still happening. Is that
still the case that people get fevers because they live in this
kind of environment?
Dr Bates: DFID are one of the only organisations
which are very far thinking; they have pro-poor indicators on
their programmes and programmes are not disease specific. They
are very much about strengthening systems. They are going back
into Nigeria with a big governance programme. DFID are very unusual
in that respect. They have even put calls out for cross-agricultural
environment and health projects. DFID is a very good example of
the sort of innovative thinking that you can have around building
systems and structures. They have done it in Nigeria. Nigeria
is a big country, so the impact is small. But the systems strengthening
can work.
Q310 Baroness Flather:
You think there is an impact?
Dr Bates: Yes, I think there is. In terms of
fever, about 60 per cent of people in Africa do not access normal
health care at all. If we are just focusing on health facilities,
we are missing more than half the population. Those people in
the villages, if they get a fever, they will do as you say; they
will wait a bit and then they will go to buy some herbs or something
cheap and only as a very last resort would they pay for transport
and have all the aggravation that comes with trying to access
healthcare.
Q311 Baroness Flather:
Is that late then?
Dr Bates: Yes, and then they come late.
Q312 Baroness Flather:
They will not have ordinary analgesics like paracetamol.
Dr Bates: They would but that is further down
the line.
Q313 Baroness Flather:
Is that not at the early stage?
Dr Bates: The first thing they do is local herbs
and local treatments, which they will buy themselves from the
market. Then they might go to the traditional healer before accessing
healthcare.
Q314 Baroness Flather:
Could that be damaging?
Dr Bates: Most of these fevers, as you say,
are probably just viral infections and they settle on their own.
However, if it is not a viral infection, if it is something that
is going to get worse with time, then the fact that they present
late means that in the end their health suffers, they have to
pay more for their healthcare and they are getting into this deepening
cycle of poverty.
Q315 Baroness Falkner of Margravine:
Dr Conlon, I thought you were going to say something about governance
and structures but you left that behind and moved on. My question
relates to Lady Eccles's question also about bottom-up versus
top-down. I should declare a past interest. I ran an HIV/AIDS
charity across several African countries, so I know very well
what you are talking about and have great sympathy with what you
are saying. Do you find that, when you say that you are working
for the health ministry, it becomes very difficult but then out
in the rural areas at community level you get much better feedback
and much better ability to do things? Is that affected by the
level of governance structures in different countries? In other
words, the stronger the governance structure, the easier it is
to incorporate programmes and take programmes forward; the weaker
a governance structure, the more difficult it becomes because
of gate-keeping and also donor funds being much more predicated
on keeping control of the situation. Is that your experience?
Dr Conlon: I think that is right, yes. Clearly,
if it is very centralised, then nothing gets out to the rural
areas and that is a problem in itself. But, if there is a good
structure that allows decisions to be made and decisions to be
looked at when they are made, that is helpful but that is not
very common. One of the problems is that people might make decisions
based on all sorts of things which are not evidence-based; they
may be based on things to do with whatever finances come in through
their ministry at the time or what their job prospects may be.
As I said earlier, you need to start educating people about responsibility
for decision making and the use of governance.
Q316 Baroness Falkner of Margravine:
You mean educate the public servants?
Dr Conlon: Yes, but at an early stage so that
you can get this more broadspread.
Q317 Lord Avebury:
You place great emphasis on the need for better diagnostics and
laboratory facilities in a lot of countries, and we heard earlier
from Dr Bates about the particular case of malaria, where she
said that there is a 90 per cent over-diagnosis because of lack
of these facilities. Would you say that IGOs should be investing
more in this area and, if so, how would they make the necessary
choices in their investment programme?
Dr Williams: To take a specific example, if
you look at drug-resistant TB—either multi-drug resistant
or extensively drug-resistant TB—the whole future of that
programme depends on having a developed capacity for not only
diagnosing TB but diagnosing drug-resistant TB. The whole issue
of diagnostics extends beyond the individual patient and the appropriate
use of drugs in that patient. It is also using drugs in people
who perhaps do not need them, so you have exposure and development
of resistance. It also influences any infection control activity
that you might want to implement as well, which again reflects
back on the TB. It also absolutely helps you with knowing what
your prevalence of a disease is and your impact of any interventions.
It is fundamental, actually, to developing the control programmes
for these diseases.
Q318 Lord Avebury:
Which IGOs are investing in multi-drug resistant TB? Or are none
of them doing so?
Dr Williams: There is the WHO report which names
400 organisations and countries that are engaged in putting that
programme through, but it stresses the essential nature of developing
diagnostic capacity.
Q319 Lord Avebury:
Are you saying it is not so much a question of lack of investment
but a lack of coordination between these 400 organisations?
Dr Williams: I think it is a lack of investment
too in diagnostics, because diagnostics also requires expertise
and infrastructure. It is very easy for us to say that you need
diagnostics but, if you have unreliable power supplies or you
do not have the equipment that allows you to make a diagnosis,
then it is quite difficult.
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