Examination of Witnesses (Questions 320
- 339)
MONDAY 10 MARCH 2008
Dr Christopher Conlon, Dr Maureen Baker, Dr Helen
Williams and Dr Imelda Bates
Q320 Chairman:
So it would not be enough, for example, to say, "We will
set up a diagnostic centre in a particular area" unless there
was an underpinning for it?
Dr Williams: Yes, you would need an appropriate
infrastructure, including the expertise that understands how to
use the diagnostic tests, so you can actually do it properly and
interpret it properly.
Q321 Lord Avebury:
Do you think it is possible to identify the countries or centres
where the proper infrastructure does exist?
Dr Bates: I think we are talking about two separate
things. One is about the actual technology and, if you want to
impact on health, you have to get simple technology out to the
communities because most people cannot travel to a centre where
you have good diagnostics. There has to be much more investment
in developing technologies that are field-friendly and also in
the systems that support that. One of the problems in the past
has been that people put those simple diagnostics in the villages
and they just leave people to get on with it. There is no quality
monitoring or no training, so the diagnostics should not go in
without the whole capacity of system strengthening on top of it.
There is no investment in any of those. Diagnostics is now becoming
a major bottleneck in delivering these disease control programmes
in many countries now because it has been so neglected.
Q322 Lord Desai:
Is this where the Regional Offices of WHO could have a role, the
basic R&D of diagnostics could be done there? Once they have
found some simple technique, then that could be disseminated to
new countries. Is that kind of division of labour possible?
Dr Bates: The actual development of the technology
could happen here or anywhere, but the field-testing in a real
life situation could be facilitated by WHO Offices. They should
not do the R&D themselves; that is not what their remit is.
Q323 Baroness Eccles of Moulton:
I think we are mainly talking about Africa because that is where
your general knowledge lies. But I was just trying to get a feel
while you were talking about the distribution of population, because
there is a general global movement of people out of the country
into the city and we know some of the pretty awful health consequences
of that. There has been a lot of mention of villages, so we have
an idea of the village and the market and the herbal remedies
and all that. But what I was really wanting to try to get a feel
for is the local traditional access to the first line of cure
which you described earlier on that is available in the city,
and maybe a little bit more general information about what is
happening, if there is a big population shift and the effects
that is having.
Dr Bates: We have done some research on urban
poor and how they access health care. In the rural villages at
least the structure is clear: you go to the village heads, they
have a town crier, you can mobilise the community. Once they get
into the town it is much more difficult. They are not a discreet
population; they have lost their family social support networks;
they are often poorer than they were in the village because they
have no land. The way you deliver healthcare to them in the cities
has to be reorganised. Certainly there is some evidence now that
malaria mosquitoes which previously would only breed in nice clean
water are now beginning to breed in dirty water. If we now get
malaria hitting the towns as hard as it has hit the villages,
we are going to be in big trouble.
Q324 Baroness Whitaker:
There is some scepticism in your evidence about the effectiveness
of the new International Health Regulations, but I imagine you
would agree they are an advance on the previous ones. Could you
say what you think they ought to be doing and how should their
problems be better coped with if they are not doing it and who
ought to be doing it among the organisations?
Dr Conlon: Who ought to do it is a difficult
question. What we might be addressing is to do with cooperation
rather than coordination, so that if new pathogens arise those
pathogens are made available for study, that there is easy movement
of investigative teams internationally to look at outbreaks to
try to determine what is going on and to look at how you would
deal with the movement of populations with infections. I think
all those things are do-able, but who coordinates them?
Q325 Baroness Whitaker:
You say "teams"; you are not then thinking of a requirement
on each national government to have this surveillance system but
expertise moving around?
Dr Conlon: In an ideal world you would say that
each country would have a surveillance system but that is not
possible. So what you would like to have is a bit like they do
in the States with outbreaks within the states, where they have
Outbreak Investigation Teams that can move and help local investigators
to deal with outbreaks and to allow that to happen internationally.
I can see the International Health Regulations helping that quite
a bit.
Q326 Baroness Whitaker:
Do you think the WHO would be capable, as presently constituted,
of organising that?
Dr Conlon: Could they do it? Possibly. I am
never quite clear what the WHO sees as its remit both in terms
of devising policy or doing things in the field. I do not see
the WHO initiating research; I see them implementing successful
research with enough guidance for them to do that. I would be
doubtful whether they would necessarily coordinate investigations
into things other than saying that there is a problem in such
and such a country, can we send a team from the UK or the US.
Q327 Baroness Whitaker:
Under whose auspices might a team with really good diagnostic
equipment go into a country?
Dr Conlon: I think it would be under the auspices
of the WHO but whether it would be organised by the WHO would
be a different matter.
Q328 Lord Howarth of Newport:
I would like to pursue with you a little further the issue of
the balance between treatment and prevention. We have already
covered a certain amount of the ground this afternoon, but the
Royal College of Pathologists draws attention in its evidence
to "a lack of appreciation of relationships between diagnostics
clinical management of sick patients (including use of antimicrobials),
health protection and health promotion". Would you be kind
enough to expand a little bit on your thoughts there?
Dr Williams: It goes back a little to what I
was saying around the use of diagnostics—that, unless you
reasonably accurately diagnose what someone has, then you risk
using precious drugs and precious resources wrongly and treating
people inappropriately. You also risk—which is clearly a
major issue with HIV, TB and malaria—inducing resistance
in the organisms; resistance is a problem for all of those diseases.
It also helps you with those where you have infection prevention
measures you want to implement. Unless you have a reasonably accurate
diagnosis, those infection control measures can be very burdensome
and, if you try to impose them all the time without making a diagnosis,
people can lose their enthusiasm for actually observing them if
they are not there. There is also the issue of assessing the burden
of disease that you are trying to deal with and how effective
your interventions are. That is where diagnostics come into both
balancing up with your treatment and your prevention because they
influence both of those.
Q329 Lord Howarth of Newport:
The Hippocratic ethos tells you that you must treat patients who
are suffering. But would you prefer to see more investment through
international governmental organisations going into prevention
in the first place as opposed to treatment? Would that mean, for
example, more investment in ensuring that developing countries
were aware of research and evidence, more awareness of proven
good practice in other parts of the world and also have more trained
staff and a better capacity to retain their own trained staff?
These are all things which would help to build up capacity and
effectiveness. Would you rather see money going into prevention
and building up the infrastructure that you have been talking
about before, if we had to make the choice between that or treatment
programmes.
Dr Williams: I would rather not have to make
the choice. What I would like to do is actually to see a programme
that perhaps pays adequate attention to that aspect of it, so
that as time evolves you would not actually be doing that awful
thing of saying "I'm not going to treat people"—because
that is clearly an awful thing—but actually build your programme
so that you do start to improve the diagnostics, you do start
to improve the direction of your interventions so they are more
appropriate.
Dr Baker: It is obviously very important to
provide access to treatment for people who are ill and who are
suffering, but of course in the process of treating and providing
treatment there is money to be made. In the process of prevention
and in the strategies that are used in a number of areas for prevention,
there is not the same profit motif necessarily at the end of that.
Q330 Lord Howarth of Newport:
Not treatment?
Dr Baker: The sort of things you have been talking
about around non-health measures—the way in which you build,
town planning, public health approaches—I would just flag
up, is there necessarily the same lobbying and interest and bringing
people to take forward those programmes in the same way as there
can be for major pharmaceutical programmes?
Q331 Chairman:
It seems to me that it is the non-governmental organisations which
want to target their money onto vertical treatment because they
say they want to do something about malaria or they want to do
something about AIDS. The WHO would need to be the body that looks
at the horizontal bit for general health improvement. Is that
developing or is it happening like that by chance? Because so
much money—the Bill and Melinda Gates Foundation, for example—is
going into the treatment of disease and the WHO is concentrating
more on the infrastructure. Is that happening or is it not happening
or is anybody thinking about that?
Dr Conlon: I do not think it is as straightforward
as that. The WHO has a remit to my mind in terms of looking at
how they would implement policy to do things but may not actually
implement them themselves; they would try to get NGOs and government
organisations to do that. I think some NGOs are very good at doing
the horizontal bit, things like Save the Children and Oxfam; others
are much more diseased-focused. I do not personally get the impression
that that sort of thing is coordinated in any way by WHO. I may
be too negative but I think you are putting much more faith in
WHO organising things than I would.
Q332 Baroness Eccles of Moulton:
We have heard certain evidence which has indicated to us that
emergent infections tend to come from animals—though not
always—and that some come from the domestic animal source
but the majority of emergent infections come from the wild. It
is a question of early detection and then moving into how to deal
with preventing spread and remedies et cetera. Our impression
is that the organisations, particularly the intergovernmental
organisations that are dealing with human health and the organisations
that are dealing with animal health, simply do not share knowledge
and assist each other in preventing or dealing with these nasty
infections either before they reach the human victims or when
they have actually become a human infection.
Dr Conlon: I think you are right. If you look
at veterinary services in a lot of the countries there are problems
with how they are organised and how many people there are on the
ground. Most countries that I have come across in the tropics
have medical schools of some sort but very few have vet schools.
Again the expertise, if it is available, tends to go to commercial
farming rather than husbandry or surveillance of animal diseases.
It is a real problem. If you think about most of the epidemics
over the last few years that have derived from animals, it has
usually been the human disease that has pointed to the problem
in a retrospective analysis, finding the animal source. The caveat
to that would be in South America, where they are much better
at finding yellow fever in monkeys through surveillance and warning
about human yellow fever, but that is a pretty isolated example
of that I think.
Q333 Baroness Eccles of Moulton:
The lack of integration or exchange of information between the
organisations is quite serious and maybe effort should be made
to try to make that better. Do you have any ideas about how this
could be done?
Dr Conlon: I would go back to the infrastructure
in terms of how people are educated and what they are educated
for and how you resource veterinary schools or interest in infectious
pathogen research in countries and, of course, exchange of expertise
between the west and the south, if you like.
Q334 Baroness Eccles of Moulton:
Could the responsibility for this lie largely with the World Health
Organisation? Or could one, as it were, point the finger at other
organisations and say that they should be getting on with doing
something about it?
Dr Conlon: Again I think it would be helpful
for other organisations to be involved rather than just WHO.
Q335 Chairman:
Dr Bates, would you agree with that?
Dr Bates: Yes, I think so. We started talking
about having sentinel sites and monitoring in places where it
is possible these diseases would emerge. That means really rural
Africa—because that is where a lot of these diseases come
from—and it will require the zoonoses people, the human
to animal interface, to be much stronger. How you actually achieve
that on the ground is difficult. WHO is not an implementer and
is not a researcher; they just should take evidence and build
it into policy and then advise how this policy should be implemented.
The guidance could come from them but actually what you need on
the ground are the ministries of health and agriculture to join
together.
Q336 Baroness Eccles of Moulton:
Once again?
Dr Bates: Yes.
Dr Conlon: Even in this country, if you look
at some of the vet science, it is a lot better than some of the
medical science in terms of some pathogen research. But we do
not go to the same meetings, we do not come across each other
easily and that is magnified ten-fold in Africa or in South East
Asia.
Q337 Baroness Eccles of Moulton:
What about in the United States? Are they better at it than we
are?
Dr Conlon: I do not think so, no. I think it
is much more disintegrated in the States because of the federal
system and because of private practice. This is one of the things
you mentioned about urban-versus-rural health, and when you start
throwing private practice in for both vet medicine and human medicine
there is another complication to add in in terms of surveillance.
Q338 Baroness Eccles of Moulton:
I think you did actually have something to add to the conversation
about urban-versus-rural?
Dr Conlon: Just that, at least in rural areas,
you can sort of work out what is happening. But, once you get
to a large city where there is a lot of health-seeking behaviour
and you may go from one private practitioner to somewhere else
to a state hospital with no communication between them, there
are many more opportunities to pass diseases on in urban areas,
so the whole thing becomes much more complicated.
Q339 Chairman:
Coming on to the issue of flu detection, which I think the Royal
College of Physicians raised, it was your argument that we should
divert more funds to the developing nations because you actually
thought that intergovernmental organisations could not solve the
problem of flu pandemic in a developing nation. Can you tell us
a little more about what you mean by that?
Dr Conlon: I think there are two aspects. One
is, as we have just been talking about, trying to identify things
happening, emerging from animals to humans—that is clearly
what has happened with avian flu—so that you are able to
pinpoint when that is happening at an earlier stage. Then you
can put in control measures more quickly locally. Strengthening
local vet services would have allowed people to have got onto
the poultry culling and other control measures in South East Asia
more quickly. That is one issue. The other issue, of course, is
to do with the fact that once humans get a disease it is pretty
hard for any organisation to stop it moving. I think that is particularly
true with flu. You can be incubating flu but not be symptomatic;
there is so much travel going on it is pretty hard to see how
intergovernmental organisations are going to stop that, unless
you have very draconian measures during a declared pandemic to
stop travel, but by that stage it is too late anyway because it
is pandemic.
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