Examination of Witnesses (Questions 400
- 419)
WEDNESDAY 26 MARCH 2008
Dr Scott Dowell
Q400 Baroness Eccles of Moulton:
Good afternoon, Dr Dowell. You were talking about how well WHO
have responded to SARS, and I suppose one would put the avian
flu pandemic possibility into the same category as SARS. You say
there is still considerably more work to be done on that front,
but they are moving forward and presumably the SARS experience
has proved useful. The other three diseases that we are particularly
looking at—Malaria, TB and AIDS—fall into a rather
different category in that they are chronic and ongoing, as it
were, whereas these pandemic diseases come and go—and, in
the case of SARS, went rather quickly because it was so well-handled.
I suppose my question is; WHO is not doing too badly on the pandemics,
but what about their progress on dealing with those other three
diseases?
Dr Dowell: Now we are straying a little bit
beyond my expertise. The issue of the Global Fund and dealing
with HIV, TB and Malaria epidemics is not an area that I deal
with on a daily basis. I might just mention that the HIV epidemic,
although it is a chronic and ongoing epidemic as you say, started
out as an emerging infectious disease outbreak, as we thought
in the early 1980s. But now we find out that probably for two
decades or more before that it must have been circulating in West
Africa undetected and uncontrolled.
Q401 Chairman:
Thank you. Before we move on to the next section, I just want
to be clear. The World Health Organisation, UNAIDS and the Global
Fund for AIDS, TB and Malaria, are all in a way either expected
to work together or to work efficiently individually. It might
be a bit outside your knowledge, but I get the feeling you have
some experience of how they co-operate. Do you think they are
working well together? Or do you think there could be improvements
there? Are there other organisations which are, if you like, part
of that synergy or not functioning as they ought to? Perhaps you
could also comment on PEPFAR, and the US Presidential Initiative
for Malaria
Dr Dowell: As you say, it is not a part of my
daily work but I do see those organisations working on some of
the same things in parallel. I do not see the competition but
there may be people who know more about the interactions of those
organisations who would give you a different answer than that.
Chairman: Thank you very much. I want
to move on to this issue of horizontal healthcare versus the vertical
treatment of disease.
Q402 Lord Desai:
Many of our witnesses have emphasised that intervention in a specific
disease is not very effective unless you can do something about
the basic health infrastructure. Your GDD Centers are dedicated
to "build in-country capacity" by training local people.
Do you think there has been too much emphasis on vertical intervention
and not enough on horizontal health capacity building?
Dr Dowell: I personally believe that both are
indicated and are useful. As you point out, part of the Global
Disease Detection Program is in building capacity horizontally,
if you will, by training epidemiologists, for example, in the
Field Epidemiology Training Programme, or by training laboratory
scientists or by providing diagnostic capacity to the country
to broaden their capacity to identify new and different pathogens.
There are also vertically-oriented components to the programme,
focused on population-based surveillance for pneumonia, for example,
with an eye towards understanding of the disease burden from influenza
and thereby promoting domestic vaccine production capacity in
that country. This mix of horizontal and vertical approaches is
part of our programme and more broadly part of CDC's approach.
We have some parts of the agency that are focused on horizontal
capacity building and other parts, like the polio eradication
programme or the PEPFAR programme, that are very much vertically
oriented programmes.
Q403 Lord Desai:
The PEPFAR programme has been criticised, of course, as being
too vertical at the expense of public health infrastructures.
Do you have any specific comments on PEPFAR and what lessons have
been learned from PEPFAR?
Dr Dowell: Again, this is a little bit outside
my area. As an observer, I am an unapologetic supporter of the
PEPFAR programme. From what I have seen, there have been some
fantastic accomplishments already. As you probably know, there
is a proposal to expand the budget for the PEPFAR programme this
year and, in doing so, it will do some of the things you are alluding
to, which is to expand the horizontal reach of the PEPFAR programme
by incorporating broader approaches to disease control than simply
anti-retroviral treatment for people with HIV.
Q404 Baroness Eccles of Moulton:
I just wanted to ask you, Dr Dowell, whether when you are establishing
and maintaining GDD Centers in-country, there is a big difference
in the extent to which you are assisted by the ministries of those
countries, the interaction between your Centers and the various
in-country governments that will inevitably be playing a part
in the success of your Centers?
Dr Dowell: Each of the Centers is a collaboration
between the host country government and US Government, in particular
the Ministry of Health and CDC, and there are agreements between
the two about what to do together. In practice, it varies a little
bit as to the extent to which the host country government both
resources and drives the collaboration. We have a GDD Center in
China, for example, which has got plenty of resources on its own
and can contribute a lot and drive the agenda, and we have one
in Kenya, which is much less wealthy than China, that contributes
relatively less to the collaboration. At their core, they are
all collaborations between the host government and the US, with
additional partners, the first of which is WHO; the Country Office,
the Regional Offices play a greater or lesser role and Geneva
plays a greater or lesser role.
Q405 Baroness Eccles of Moulton:
So it is quite a complicated set-up in that sense?
Dr Dowell: I suppose you could look at it that
way.
Q406 Chairman:
But it works or not, in your view?
Dr Dowell: I think overall the system works
very well. This is what I do day-to-day and I am very much involved
in especially the parts that do not work very well, so I am aware
of the things that do not work very well. If I stand back and
ask whether these Centers work, I would say overall, yes, absolutely.
Q407 Baroness Eccles of Moulton:
Would you say, that by and large, where those Centers are on the
weaker side, gradually progress is being made. Or in some areas
is there a certain amount of slipping back?
Dr Dowell: Of the five Centers, the oldest is
in Thailand; that has been there since 2001, and I would say that
is the most accomplished in terms of what it is doing for global
disease detection and control, and also the easiest because the
working relationships are very well ironed out between the host
country government, the Regional WHO office and others. The newest
ones—Egypt, China and Guatemala—are the ones that
have fewer accomplishments for having been there less time and
the mechanisms for working between the host country government,
CDC and WHO regional offices are still in the process of being
worked out. To answer your question more directly, yes, over time
we will see the challenges smoothing out and progress being made.
Q408 Baroness Eccles of Moulton:
Is it your ambition to open more Centers?
Dr Dowell: Yes. Roughly speaking, we looked
at the six WHO regions and said approximately three per WHO region
would be an appropriate number given the ability of each of them
to serve not just the country they are sitting in but neighbouring
countries as well. That is a rough approximation of how far we
think this could evolve. That is three per region, a total of
18.
Q409 Baroness Eccles of Moulton:
That would seem to be a very good addition to the necessary horizontal
part of the structure.
Dr Dowell: We hope so.
Q410 Lord Avebury:
I am not sure whether I am putting words into your mouth, but
you were comparing China and Kenya as being at the opposite ends
of the spectrum, as it were, regarding the contributions that
were made by the host governments in terms of, presumably, technical
and financial inputs to the GDDs that were located in their territories.
I wondered whether that is a consideration in the establishment
of Centers, that you have to have a certain minimum degree of
competence to consider putting a GDD in a particular country.
The second part of my question is whether, in a place like Kenya,
where there has been recent political instability, that makes
any difference to the degree of collaboration that you have with
the host Ministry of Health.
Dr Dowell: You guessed correctly. We did not
place these randomly, they were placed in areas where we thought
there would be success or there was a good chance of success.
The early ones were placed where we already had good partners
and good collaborations. Kenya is not a wealthy country; however,
there is a long history of collaboration between CDC and Kenya
in a number of different areas, beginning with a Malaria Field
Station and collaborations on HIV/AIDS programmes and others,
that set the stage nicely for this Center to land there and be
successful.
Q411 Lord Avebury:
What that strategy means is that in an area such as East Africa,
where Kenya was seen as a beacon of stability in a region that
was otherwise somewhat unstable, the threat of emerging diseases
would be greatest in the areas that did not have a GDD, such as
Somalia?
Dr Dowell: This goes back to the question of
whether we can predict where the threat of emerging infections
is greatest. There was a recent paper published in Nature
about a month or so ago that put forward a model for predicting
where diseases were greatest. It was interesting to me because
the conclusion of the paper was that we ought to invest more resources
as you are saying in Equatorial Africa, South America, places
that are the poorest parts of the world. However, when they put
up a map as one of the figures in the paper and showed where the
emerging diseases have been detected worldwide, the hotspots were
the East Coast of the United States, London, and another little
hotspot around Hong Kong! So it seemed to go against what they
were saying about where you would expect to find emerging infections.
I think probably the answer to that is the emerging infections
are being detected where the light is being shone most brightly
and that is why the map looks the way it does.
Chairman: I hope you are right, otherwise
we are going to have to move!
Q412 Lord Hannay of Chiswick:
When you choose a new site for a GDD Center—you say you
are trying to expand the network all the time—is that a
joint decision between you and WHO? Or is it entirely dictated
by US Government priorities? Or is there a consultation of WHO?
And, if so, is that WHO in Geneva or WHO in the regions? Secondly,
these GDD Centers, once they have been set up, are they sharing
everything that they find and produce with the WHO? Or is there
some limit to the amount that WHO finds out from these GDD Centers?
Dr Dowell: The decision about starting a new
GDD Center is primarily at the invitation of the host country.
The first issue: is does the host country request this? And do
they want it there? We also work with the WHO Office in Geneva,
so we have a monthly call, for example, with Geneva where we talk
about these issues, update on the GDD Centers and thereby get
their views on what is needed and how we modify things. In terms
of the question about the information that is collected from these
Centers and whether it is shared with WHO, this goes back to the
International Health Regulations. They are different, in that
they do not simply require the reporting of smallpox, cholera
and yellow fever as the old ones did; they define a public health
event of international concern as one that requires reporting
to WHO. All of those public health events of international concern
are reported to WHO and it says no matter who becomes aware of
it. Ideally they are reported by the host country, but if another
country becomes aware of it technically IHR requires the other
country to report that to WHO as well. We have not run into that
situation so far, thankfully, but it is possible that would be
the case in the future. The short answers to your questions are
(1) primarily a decision about basing a new GDD site is a decision
by the host country, and (2) communication with WHO about these
outbreak events is an open one.
Q413 Lord Hannay of Chiswick:
You must presumably have more requests for these Centers than
you have funds to put them in place, so there must be some element
of choice as to where you decide to put them?
Dr Dowell: True. We are at our budget this year,
so we are not in a position to add a new one in the near future.
In the strategic document that I think was sent to you all, there
are five criteria laid out, and I may not be able to remember
them all, for the selection of a new site. They are: public health
importance of the country; the presence of strong partnerships,
including WHO, other universities, Department of Defence laboratories
in some cases; ability to serve as a regional hub or regional
centre, and that relates both to the country's relationships to
its neighbours and also to more practical things like the ability
to travel in and out of the country. There may be one other I
cannot think of right now.
Q414 Lord Avebury:
Can I refer to the publication, Protecting the Nation's Health
in an Era of Globalisation. That suggests that in the years
ahead there should be an expansion of the regional surveillance
networks and their interaction and evolution into a global "network
of networks" that provides early warning of emerging health
threats. My first question is: is that not exactly what GOARN
is supposed to be doing?
Dr Dowell: Yes, you are correct. You will recognise
the language because the language is used similarly by GOARN and
the Infectious Disease Strategy of the CDC. We do use a lot of
the same words. The concept of a "network of networks"
is one that has been promoted both by WHO and us for at least
ten years or more now.
Q415 Lord Avebury:
So that means you see some deficiencies in the way that GOARN
is structured if you think that it should be evolving into something
else?
Dr Dowell: To clarify: we see ourselves as one
of the networks that is part of the network of networks, if that
makes sense. GOARN is interesting. It is not actually a part of
WHO, although it is convened by WHO as its secretariat. It is
a conglomeration of the different groups involved in these kinds
of activities. GOARN, in effect, is the network of networks and
it is convened and chaired by WHO, but it is made up of individual
networks, some of which are like ours, governmental networks,
and some of which are not governmental, they are private. I am
thinking of Médicins Sans Frontie"res and other
groups that contribute.
Q416 Lord Avebury:
So there can be additional components coming into the network
at any time and there is an evolution of the network of networks?
Could you say how that will relate to the regional offices of
the WHO.
Dr Dowell: I can try. As we talked about earlier,
one can imagine an uncoordinated evolution of different partners
coming in and resulting in chaos. I think back to the first outbreak
I was involved with, way back when I was in training in 1995,
which was Kikwit, Zaire, which was the first real emergence of
Ebola virus for probably 12 years or so after the 1976 discovery
and a couple of outbreaks after that. This new virus emerged in
Equatorial Africa, it was rather frightening, certainly newsworthy,
and it attracted lots of news media and lots of different international
organisations to the outbreak. WHO was at the centre but was trying
its best to control this chaos in Kikwit and it was somewhat successful,
and ultimately the outbreak was brought under control. I think
that experience and similar experiences with haemorrhagic fever
outbreaks in the early 1990s was what drove WHO to develop this
GOARN concept and to push for the revision of the International
Health Regulations that seek to impose some sort of order on these
chaotic events. Some of the progress I was alluding to earlier
over that time was imposing some sort of order on the chaos.
Q417 Lord Avebury:
So, if you had a new outbreak today, it would be handled quite
differently, GOARN would be capable of approaching it in an orderly
manner which would bring the most effective resources of the international
community to bear on it?
Dr Dowell: I think you can point to concrete
steps where there has been progress since those days in the early
1990s. For one thing, there is an agreed—on set of International
Health Regulations that requires countries to report this early,
so we should get an earlier signal about this new threat than
we did in the past. In the past, all that countries were required
to report were smallpox, cholera and yellow fever; now, if it
is a new corona virus causing SARS, they are required to report
that as well and anything else that comes up that might be a public
health event of international concern. I see that as real progress.
A second thing, and I do not know how much this has been discussed,
is this idea that the WHO can use sources of information besides
the officially reported sources that the countries send in. In
the past, in some ways WHO's hands were tied because the only
thing they could act on was what the countries officially reported
to them. First, there was sort of tacit acknowledgment that WHO
could use open-source information from media reports and others
to pick up on these things, but that was formalised in the new
International Health Regulations and now WHO can go to a country
and say, "You have not reported anything about this, but
we are reading media reports from your country about such and
such an outbreak, we require you to tell us something more about
that". They can go to other partners if they do not hear
from the country and ask the other partners what they know about
it. All of that has been approved through this process and codified
over time. There is a lot in the way this has evolved that is
real progress in this area.
Q418 Lord Hannay of Chiswick:
We have had quite a lot of evidence given to us that in medical
terms there is not really any particularly significant difference
between a bioterrorist event—ie one caused by human activation—and
a surprising and sudden outbreak of some new pandemic disease
that occurs, I suppose naturally would be the word. Could you
perhaps comment on whether that is true, whether the two are rather
similar both in the way they would hit the world and in the sort
of response that would be needed to cope with them? If that is
so, is not the treating of bioterrorism in a kind of separate
stovepipe from infectious diseases a bit counter-productive, particularly
since a lot of developing countries do not take anything that
comes with a hyphenated terrorism terribly seriously? Would it
not be better to deal with the phenomenon as a single phenomenon
rather than two different ones?
Dr Dowell: Yes, I fully agree and I think that
reflects the approach of our program as well as a number of other
programmes, and that is strengthening the capacity of countries
to respond to a naturally occurring outbreak and believing that
gets you most of the way there in addressing the threat of bioterrorism.
There are some minor exceptions where you have to think a little
bit more about intentional outbreaks. I use as an example the
difference between biosafety in the laboratory and biosecurity
in the laboratory. Biosafety is focused on safely handling dangerous
pathogens in the laboratory, ensuring that your laboratory staff
do not inadvertently get infected or inadvertently spill or release
some of these dangerous pathogens that might affect other people.
That is the biosafety aspect. The biosecurity aspect is being
aware that this might not just happen by accident but that somebody
might do this intentionally, get into the laboratory and take
things or do something malicious with those. The biosecurity approach
requires some slight modifications to your thinking about biosafety,
like making sure there are locks on the doors and those sorts
of things. By and large, I think your point is well taken. If
we focus on strengthening capacity to deal with naturally occurring
events, then we have got most of the way there to dealing with
bioterrorist events as well.
Q419 Chairman:
On this issue, am I right in thinking that at the present time,
leaving aside what might happen in the future, the difficulty
of weaponising biological elements makes it difficult to spread
deliberately in the sort of way sometimes envisaged?
Dr Dowell: I am not an expert in that area.
There are people here who could give you a better answer on that.
What you just said is my understanding as well, but I would not
be speaking as an expert in the area.
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