Examination of Witnesses (Questions 387
- 399)
WEDNESDAY 26 MARCH 2008
Dr Scott Dowell
Q387 Chairman:
Good afternoon, Dr Dowell. Or should I say Good Morning, from
where you are sitting, I think.
Dr Dowell: Good afternoon. It is good to be
here.
Q388 Chairman:
First of all, thank you very much for your time and the papers
you have sent us, which have been very informative, very helpful
and have already raised a number of questions in our minds. Let
me tell you, of course, this session, as you would predict, is
being recorded. You will be able to see a transcript of the session
before it is published officially. After this session, if there
is anything you think we have missed out or anything else you
would like to add, please feel free to write to the Clerk, Mr
Preston, with whom you have already been in contact and add those
comments as you wish. Can I say that the important issue to us
is Intergovernmental Organisations. We have been concerned for
some time about how well intergovernmental organisations operate
together as well as with non-governmental organisations, private
companies and so on, in order to deal with communicable diseases.
It is the intergovernmental organisation structure which we have
most focus on, so that is what many of the questions will be about.
Having read your papers, I can see it is something that you have
some knowledge of and we welcome that. My understanding is you
are the Director for the Global Disease Detection Program, is
that correct? Is there anything else you would like to add before
we begin?
Dr Dowell: That is correct. I would be happy,
if I could take merely a minute, to give you a little bit more
background about me. It might help to start off by telling you
that I have worked here at CDC for about 15 years. My initial
work was focused on respiratory tract infections and international
outbreak response. Over the last five or ten years it has broadened
a bit. I spent four years in Thailand, assigned from CDC to start
a programme called an Internationally Emerging Infections Program,
and I have been back here for about two years working on the Global
Disease Detection Program. In terms of the intergovernmental organisations,
I have been familiar with and worked with the WHO over this 15-year
period. In terms of some of the others—I saw UNAIDS and
the Global Fund listed—I would have much less familiarity
with those groups.
Q389 Chairman:
Thank you for that. I was going to say to you that, if there are
areas where you are unsure, just say so and we will pass on that.
I have read your CV and it seems to me your experience will be
very helpful and could be very useful to us, so many thanks again.
Can I begin by saying, in relation to the papers you sent through—and
the web links as well, it is very clear that a lot of what you
do around the world in the Centers you have to some extent does
what people would expect the World Health Organisation to do.
One of the things that has been coming up to us as a Committee
from various sources is that the architecture of the intergovernmental
organisations is very fragmented,, there are many groups to it,
many parts of it, and we are not quite sure how well it is operating
together. That is really my first area to question you on. Are
your CDCs, your Centers, doing what you would anticipate the WHO
ought to be doing, but maybe cannot do, possibly for funding reasons?
Or are they doing something different? How do you see them being
part of the intergovernmental structure?
Dr Dowell: I would like to agree with your statement
that the CDC is doing what one would expect WHO to do, but maybe
take a different angle, and that is in our view of what WHO does.
It is a convening and leadership function and they depend on Member
States and other organisations to do a lot of the carrying out
of the actual work. We hope that what we are doing fits well into
the overall umbrella of what WHO is intending to accomplish and
that our networks fit into the WHO-led network of networks, if
you will.
Q390 Chairman:
Supposing other countries took a view similar to the view taken
by the United States, which I understand and sympathise with,
that we have to try and deal with these global diseases on a global
level and, therefore, we need the Centers you are talking about.
Could we not end up with a lot of duplication if we all go down
that road? Is there not a case for saying we ought to be doing
this through the WHO?
Dr Dowell: Exactly. One could imagine a situation
with each country doing what they think is indicated and there
would be a lot of duplication and, therefore, there is a very
important role of WHO in controlling and convening all these different
contributors. You know, of course, about the new International
Health Regulations. We see this programme very much as fitting
into some of the requirements of the International Health Regulations,
which essentially recognise a requirement for each country to
do a good job of detecting, reporting and controlling new infectious
disease threats as they arise, but also recognise that many Member
States simply do not have the resources to do a good job of that
by themselves, so there is a component of the new IHRs that requires
wealthier Member States to work with less wealthy Member States.
As you point out, if that was done in an uncontrolled fashion
without the leadership of WHO, you might end up with a chaotic
situation. I do agree with what you are saying that it is not
just the US that should be doing this, it is other wealthy Member
States that should be contributing to this kind of capacity building.
Q391 Chairman:
Before I bring in some of my colleagues, can I just ask you this:
do you think there is something wrong either about the organisation
or funding of the WHO that makes it difficult for them to do what
you are doing?
Dr Dowell: My view of WHO's role over the last
15 years or so is that it has grown steadily in its organisation
and its ability to organise and convene the responses to these
international outbreak threats. In particular, the SARS situation
arose when I was out in Thailand and, in my view, in some ways
that was the pinnacle of WHO's accomplishments which they had
really been working on over a ten year or so period. They were
really able to bring together a network of laboratories run by
Centres of Excellence from different countries and different places
to quickly identify the causative pathogen, they were able to
put together diagnostic tests that allowed us to focus very directly
on the people who were most affected by SARS and then they put
out a regular stream of pieces of advice and documents that allowed
case definitions to be agreed on, people to be focused on, and
the transmission that was amplified in hospitals to be brought
under control. That was a real example of WHO leadership in what
I thought was a real health crisis. When I came back here to the
US some people, having seen something like eight cases in the
US, thought maybe the concerns about SARS were overblown. But
from our perspective out in Bangkok we did not think that was
the case at all; we thought this was rather worrisome, and thank
goodness WHO was able to convene the groups it was able to and
bring that thing under control.
Q392 Lord Hannay of Chiswick:
I wonder if I could go to the other end of this piece of analysis,
that is to say a developing country with not very bountiful resources
for handling the inflow of assistance, advice, aid and so on.
Perhaps drawing on your experience in Thailand you could answer
this question. Do you not think that for a developing country
it is pretty confusing that the world is so ill-organised, albeit
with quite a lot of resources, to deal with these infectious diseases,
that there are so many different programmes coming at them from
slightly different angles with slightly different acronyms, all
seeming to do much the same thing? Does this not make life rather
difficult for a developing country which is trying to organise
its own response but needs external resources and which is trying
to focus on its own health problems and how other people can help
them?
Dr Dowell: This has been a challenge for a long
time for the poorest of the countries. They have not just not
very many resources in terms of money but not very many resources
in terms of personnel, and the few talented and qualified personnel
they have in the Ministry of Health, for example, have to do this
enormous job of managing lots of well-intentioned groups from
outside with different priorities. The thing that I think has
changed a lot in the last five or ten years or so is the magnitude
of funding, beginning with the Gates Foundation really changing
the level of funding from millions of dollars here and there to
tens of millions and then hundreds of million dollar chunks at
a time; and other large funding groups, whether it is the Global
Fund or the PEPFAR programme, bringing in hundreds of millions
of dollars at a time has changed the way that these developing
countries are facing the same problems they have been facing for
a while, just on a different order of magnitude.
Q393 Lord Hannay of Chiswick:
Could you just say a little bit more about whether you think that
slightly less diversity in programmes, donors and so on might
make it easier to get better results in developing countries.
Or do you think it is fine that there are people coming at them
from all different angles and they have 75 consultants descending
on them each year?
Dr Dowell: No, I agree that it would be better
to focus. One question one might ask is where that focus should
come from. Should the external organisations get together and
decide what is most important for these countries? Or should we
make sure that the countries themselves have the capacity to decide
what is most important for them. My view might be transparent
in that it is better, if possible, to build the capacity within
the developing countries to decide for themselves what are the
most important health problems in their areas and thereby bring
focus.
Q394 Baroness Whitaker:
Good afternoon. I just wanted to ask you about an area of work
which I am not aware WHO does and perhaps they ought to and, if
not, to ask who ought to do it. This is the area of viral forecasting—to
find out which microbes might make the jump from animals to people.
I have been reading about an organisation called the Global Viral
Forecasting Company, which I think is being piloted at the University
of California. Can you tell us whether this ought to be the subject
of more international attention and, if so, which organisation
ought to deal with it.
Dr Dowell: It has been a topic of discussion
around here even in the last couple of weeks. There was a conference
in Atlanta last week called the ICEID, the International Conference
for Emerging Infectious Diseases, and there were a number of groups
at the conference that presented a variation on the issue you
are raising, viral forecasting, or some sort of risk-based approach
to predicting where the next emerging infection might come from.
It seems to me that this is an interesting area of investigation
and also it is a field that is early in its infancy and there
is a lot of work to be done on the future on viral forecasting.
It is an exciting area for people to be working in. I am not sure
we are at the point right now where we can take any of the forecasts
that people come up with and say, "That's where we should
direct our resources" and be confident that we can predict
that, for example, the next threat will come from a corona virus.
Q395 Lord Howarth of Newport:
On the question of increased magnitudes of funding which you touched
upon just now, I noted that the budgets of your own organisation
and your staffing have increased very substantially in recent
years and that clearly enables you to do more very important work,
but I wondered what the background was to that. Am I right in
thinking that is federal funding?
Dr Dowell: My specific programme, the Global
Diseases Detection Program, started in 2004 with about $11 million
from the US Congress and this year the budget is about $30 million.
So it is true that it has grown but it remains a relatively small
programme compared to some of the others we have mentioned.
Q396 Lord Howarth of Newport:
Taking the budgets of the CDC in all, there has been a very large
increase in recent years. I wondered if you were able to say what
the background is in terms of why the Federal Administration and
Congress, should have concluded that so much more funding was
needed and, if so, why they have chosen to route it through your
own organisation rather than through intergovernmental organisations.
Dr Dowell: I am not the best expert on the overall
CDC budget. There have been increases over the 15 years I have
been here and in the last couple of years the budgets have been
relatively flat. What I would say is the perception that it is
appropriate to invest US taxpayer dollars in global activities
has grown and the lessons from the SARS outbreak of 2003 and other
recent outbreaks have not been lost—the idea that one of
the ways the US CDC protects the health of American citizens is
by strengthening the ability of other countries to protect the
health of their citizens. I have seen a gradual shift, independent
of particular administrations, over the last ten or 15 years towards
increased funding of international health and global health activities.
Chairman: I think underlying this was
some puzzlement I have had too as to why the US Government was
choosing to work through the CDCs rather than the WHO, but I understand
also about the governmental policy approach too.
Q397 Lord Geddes:
Dr Scott Dowell, you said in reply to Lord Hannay that in your
opinion the initiative, if I can use that word, should come from
the individual countries, in other words upwards rather than be
imposed upon them downwards; and, if that is your view, it is
one with which I concur. To whom would such countries make their
views known and make their requests known? This comes back again
to who is it worldwide who should be co-ordinating the whole of
this effort? Is it the World Health Organisation? Is it yourselves?
Or is it the Gates Foundation? Where should the decisions be made?
Dr Dowell: If by who should be co-ordinating
this effort, the effort refers to the effort to identify, control
and contain new infectious disease threats, to me it seems clear
that should be co-ordinated by the World Health Organisation.
My view of the evolution of the World Health Organisation's capacity
in that regard has been that they have continued to strengthen
their ability to co-ordinate those activities. Those threats,
threats like SARS and other new emerging infectious diseases,
by their nature are not threats that are dealt with one government
at a time but, as SARS, the HIV epidemic and others have, they
quickly cross national boundaries. So there is clearly a necessity
for a trans-national organisation to deal with them when they
occur, and to me that is exactly what the leadership role of WHO
is and what they have moved towards doing over the last few years.
Q398 Lord Geddes:
The $64,000 question, if I can put it that way, is: in your opinion
is the World Health Organisation properly equipped to deal with
that role?
Dr Dowell: I think the WHO has steadily improved
its ability to deal with that role. Do I think the job is done
and no more is needed? No, certainly not. We have increased our
funding to WHO over the last few years to help with them carrying
out that role, but that is only a small part of what is needed.
If, for example, we look forward and ask what is the next big
threat that we are concerned about, I would say the answer is
clearly H5N1 influenza at this point. Is WHO adequately equipped
and resourced to deal with a pandemic of H5N1 influenza, to me
the answer is they are far better equipped than they were two
years ago but nowhere near ready to deal with a pandemic in the
way that one would like.
Q399 Lord Avebury:
Could I come back to the answer you gave to Lord Howarth a couple
of questions ago concerning your budgets and the fact that the
amounts of money you were getting from the Federal Government
over recent years were relatively flat. Do you think this is a
reflection of the fact that new money is coming in, particularly
from the Gates Foundation—you mentioned them earlier on
as being a major contributor? I wonder whether there is a temptation
for not only the US Government but for everybody else to think,
"Well, if Gates is pumping billions of dollars into this
field, then we do not need to bother so much?"
Dr Dowell: That seems possible to me, but I
have not been party to those kinds of discussions on those budgetary
decisions, so I cannot give you a very good answer about why the
overall budgets have been flat. It seems possible to me, but I
do not think I am the one to give you any more of an informed
answer than that.
Chairman: That sounds like a wise answer
in your circumstances, thank you.
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