Examination of Witnesses (Questions 480
- 499)
MONDAY 31 MARCH 2008
Dr Sylvia Meek, Mr Alastair Burtt, Mr Paul Sommerfeld
and Ms Tina Harrison
Q480 Lord Howarth of Newport:
They should be coordinating further down the line, should they?
Mr Sommerfeld: You have to also bear in mind
what is the function and role. If you are talking about a body
like the World Health Organisation, they are not a directive organisation.
They are a body to give technical advice to government. I absolutely
agree with you that there are many, many issues about what happens
on the ground. Some of us, as NGOs, can be as territorial as the
next person, let alone what is happening between all the many
different donor agencies and so on. That is the attempt with the
present Government initiative of the International Health Partnership,
to try to develop a more effective coordinating framework. We
will see if that has much impact. Again, as regards tuberculosis,
because of the strength that has been built up over the past 20
years of national tuberculosis programmes, almost all of us understand
that, whatever we are doing, we work with the national programme.
Sometimes that is a somewhat difficult relationship.
Q481 Lord Howarth of Newport:
In the case of Uganda it is, where in the north you have no administrative
capacity and no governmental goodwill that I could discern. Where
does the responsibility lie for ensuring better coordination and
effective use of the energy and the resources that have been put
into that region?
Dr Meek: My organisation was the first working
in that particular part of northern Uganda giving out mosquito
nets. I know exactly what you mean.
Q482 Lord Howarth of Newport:
Were you not frustrated?
Dr Meek: More and more came in. Each time a
new organisation comes in, there are the start-up processes. It
seems to be a fact of life because of the way the funding is structured.
It was almost like the donors were competing among themselves
to fund organisations to support a cause. There was a real need
there and the mortality was way above what it should have been.
In terms of who can take on that coordinating role, it is extremely
difficult. In Uganda it should be the national government there
because it is not a refugee situation exactly.
Chairman: This is an important issue. I understand
there will be a difference between different countries depending
on the governmental structure but if you have any more thoughts
on that and on Lord Howarth's questions please send them in.
Q483 Baroness Eccles of Moulton:
We have heard a lot over the last few weeks and quite a bit in
the last evidence session about the relationship between horizontal
health structures and the vertical application of treatment. I
do not think very much has been said about the need within the
horizontal health structures for having diagnostic ability, because
unless you have the diagnoses it is presumably much more difficult
to pinpoint the correct forms of treatment and also prevention
as well. All that is so dependent on there being the facilities
at absolutely local level to get on and prevent and treat. I wondered
what your individual and collective views were on this very big
question and what ideas you might have about a way forward which
would make this very important part of the whole subject we are
talking about so vital.
Mr Burtt: We need a combination of the two.
We need good vertical health systems. We need the specialist inputs,
but they have to be embedded within a good horizontal system.
For example, in the Mkushi district of Zambia until recently you
had to travel 300 kilometres from that district to get an HIV
diagnosis. Much the same was the case for tuberculosis, particularly
a diagnosis of Multiple-Drug-Resistant tuberculosis. Now, a great
deal of input has been put in on the HIV side, so there is lots
of local provision but there is none in the tuberculosis field.
In a way, we are beginning to see a disparity there, whereas in
fact it should be happening together, particularly because as
you know there is a close association between TB and HIV.
Mr Sommerfeld: You have to focus on the training
and the competence of the staff at the periphery. The poorly trained
person or the person with limited training and often limited facilities
and back up is often the person somebody will go to. In other
words, the paramedical worker in the clinic in the village. From
our perspective the interesting thing is: does that person have
the competence, not to diagnose TB, but to suspect that there
might be TB and to refer the potential patient on to someone else
who will begin to do a proper diagnostic job? If that awareness
is there, it is a matter of have they been trained and is there
somewhere for them to refer the patient to, which is not necessarily
300 kilometres away.
Dr Meek: On the malaria side, there has been
a very long and rather fruitless debate for decades on the balance
between horizontal and vertical. Again, it depends on who holds
the resources. In the 1970s, 1980s and early nineties, there was
very little money going into malaria. There was quite a lot going
into general system strengthening, so there were complaints then.
Now the balance has switched a bit, so the other side is complaining
but it is definitely an issue. You cannot have control of malaria
without strong systems and those systems need to be strong enough
to undertake malaria interventions. It seems to me that there
is a bit of an issue at national level in terms of who controls
the information, the resources and the performance. Within ministries
of health who is performing depends on who has the resources to
be able to perform. The disease control initiatives are pulling
quite a lot of resources in which are being used to strengthen
health systems, and what I think is very good at the moment is
that, if the disease control programmes can start to articulate
and quantify what the systems parts of doing their jobs are, then
we could really make good progress. People are very ready to say,
"This is how much the drugs cost", but getting the drugs
to the people is often less well quantified and I think more emphasis
on that part of it could get the two sides realising that they
are the same people in the end.
Q484 Baroness Eccles of Moulton:
How much of it is dependent on the national and regional local
governments playing their part, which must vary hugely from country
to country?
Mr Burtt: It does. In India, for example, which
is a federation, the state governments vary enormously in what
they do. In terms of the diagnostic facilities, the delivery of
treatment, it can be very different, because it has been delegated
down to state level and different states have very different ways
of operating.
Q485 Baroness Eccles of Moulton:
You think that within a unified country, as it were, you get these
big differences?
Mr Burtt: Yes.
Q486 Baroness Eccles of Moulton:
Presumably in Africa the differences are even more pronounced?
Mr Burtt: They can be.
Q487 Baroness Hooper:
Because of climate change, apparently malaria is now becoming
endemic in countries where it was not formerly known. Do you see
this relationship between vertical and horizontal being sorted
out in any way in relation to these countries?
Dr Meek: Climate change has not really shown
much evidence for increasing the range of malaria, fortunately.
Q488 Baroness Hooper:
Paraguay, for example, as a country has been experiencing malaria
where it never had it before.
Dr Meek: In some countries you see more malaria
at higher elevations. How climate change will change the patterns
is a bit unpredictable because, together with increased temperature,
you may also get less humidity and the two will work against each
other. There are a lot of effects in terms of what people are
doing in terms of land use, but in terms of how that relates to
the vertical and horizontal debate one big issue, when the malaria
goes down rather than when it goes up, is that when there is less
malaria around there is much less justification for having strong
workforces dedicated to malaria. That is always quite a difficult
time and a number of countries in Asia have been through this,
where you have to redeploy your workforces so that you do not
have the strong malaria control teams you used to have, but to
do that without maintaining adequate surveillance means you lose
the gains, because in a number of places you do start seeing that
there are gradual increases in malaria. It is a very difficult
issue to work out what is the best kind of deployment of these
disease-specific staff and how to redeploy these people when they
are not needed and yet still stay on top of the problem. A lot
of it boils down to having good surveillance.
Q489 Lord Hannay of Chiswick:
I hope I am not being unfair but it strikes me, not only listening
to this group of witnesses today but to others on other occasions,
that everyone subscribes to the view that there is a need to balance
horizontal programmes in public health and vertical programmes
dealing with individual diseases; and, even within the vertical
ones, to balance the public health aspect of it with the drugs
and so on. No one seems to have any idea what that balance should
be over time and no person or organisation seems to have identified
it and set it down. The application of the balance on the ground
seems to be totally haphazard and depends on a series of inputs
over which no single individual, group or person has any control,
so it just comes out as it comes out. Is that wrong?
Mr Sommerfeld: I would be happy to forward to
the Clerk a very useful document produced about six to nine months
ago by the World Health Organisation Stop TB Department, precisely
trying to give chapter and verse to what we mean as the balance
between vertical and horizontal—i.e., in what ways should
a decent, national TB programme work as part of an overall horizontal
programme? What are the essential things that you do not want
to lose from the point of view of the vertical concerns? And why
is it extremely important to work closely with the horizontal
aspect?
Q490 Baroness Eccles of Moulton:
Does that involve AIDS?
Mr Sommerfeld: That document is largely concerned
with TB but, of course, when you are starting to talk about sub-Saharan
Africa, the HIV and TB pandemics are really one and the same thing.
Q491 Lord Desai:
Do you think your answer to Lord Hannay is life as it should be?
Mr Sommerfeld: Life is never as it should be.
It can be very depressing sometimes talking to a particular clinic
or seeing a situation in a particular country, but I think that
there is sufficient understanding of what is a reasonable approach
and sometimes one has to rather insist upon it when you go out
and visit a clinic. I am neither a doctor nor a manager of a national
programme but there have been times when I would be saying to
people, "Why are you not doing X, Y or Z?" That said,
I do not think the framework is too bad.
Q492 Baroness Falkner of Margravine:
We know it is a sensitive issue, the imposition of travel restrictions
on people with infectious diseases, and we also know from other
witnesses that in general one has to stop being politically correct
about this, so we are getting quite different signals. Mr Burtt,
I wonder whether you might be able to tell us what your views
are about the WHO's revised guidelines and whether IHRs in general
are adequate in addressing these? What is your view on screening?
I notice that your written evidence suggests that there is not
as big a problem because a lot of the migrant population that
you are seeing with this are a lot later on and they have been
in the UK for a while. Could you clarify any confusion there might
be with regard to that, because perhaps we need not be as sensitive
as this?
Mr Burtt: On the World Health Organisation guidance,
I am perhaps not terribly well versed on that.
Ms Harrison: We did mention that 77 per cent
of the cases occurred more than two years after arrival in our
submission. That is a fairly standard figure used by the Health
Protection Agency. It is important to understand the difference
between latent infection and active disease in tuberculosis. We
have one third of the world's population estimated to be latently
infected with the disease but around 9 million people a year with
the active infection. What we are finding is that people are coming
into this country, they are staying for several years without
their disease activating, and at some point later on they are
either acquiring new infection or their latent disease is activating.
It is very difficult for us to say what that true picture is,
but certainly, if you look at Heathrow in 2004, 270,000 people
were coming from high-risk countries. The total number of referrals
was 175,000, and 70,000 x-rays found 92 cases, so we are talking
about very small numbers from a new entrant screening programme.
That is simply because the majority of people are not entering
this country with active tuberculosis. Their disease is activating
at some later point, probably due to the conditions they are living
in this country in.
Q493 Baroness Falkner of Margravine:
Rather than having brought it on first arrival?
Ms Harrison: Yes.
Q494 Chairman:
This is because, presumably, they are going into multiple-occupied
housing?
Ms Harrison: Yes. You are seeing a change in
diet; you are seeing very overcrowded housing; you are seeing
stressful working conditions. All of these things can affect the
immune system, which is when a latent infection is more likely
to activate.
Q495 Chairman:
This brings out the point that poverty is an underlying factor,
whether overseas or here?
Ms Harrison: Absolutely.
Mr Sommerfeld: It is worth remembering that,
for those of us in this country who are in their late fifties
or sixties, we grew up at a time when TB was still very common
in this country. It is highly probable therefore that a reasonable
proportion, well over 30 per cent of us, are likely to have latent
TB infection that is not a problem to us all our lives as long
as our immune system keeps active.
Ms Harrison: That is certainly borne out by
the epidemiology as well. What you will generally see in the UK
is at 25 to 39 you will get a peak. Then it will go back down,
and at the 60 plus age range you will see it is likely to peak
again.
Mr Sommerfeld: There is a steady cohort of people
in this country in their eighties and beyond who develop TB, who
probably were infected 50 or 60 years ago.
Q496 Baroness Falkner of Margravine:
Do any of you have comments on the WHO's revised guidelines or
on the efficacy of International Health Regulations overall?
Ms Harrison: I do not feel that there has been
a major test case or any active case yet found.
Q497 Baroness Falkner of Margravine:
There was the US man?
Ms Harrison: No. He was very well publicised
but he did not have active TB.
Mr Sommerfeld: Also, the notable thing was he
was never infectious, so it was something of a storm in a teacup.
Notably, there has not yet been a documented case of active TB
developed as a result of sitting in an aeroplane. There have been
documented cases of people becoming infected, but that is a very
different issue than developing active disease.
Q498 Baroness Falkner of Margravine:
I think the guidelines were about how the surveillance and notification
was working rather than specifically tuberculosis.
Mr Sommerfeld: The International Health Regulations
also relate specifically to particularly serious situations, and
in the TB world that would mean dealing with multi-drug resistant
cases.
Ms Harrison: It is about a perception of the
level of infectiousness. With tuberculosis, airlines studies are
the things that inform us on this. It is estimated that you need
eight hours plus close, prolonged contact, so the majority of
flights are not affected by this. The guidance does very clearly
state that for those of over eight hours there should be another
exercise.
Q499 Baroness Hooper:
I think we can all agree that the quality of drugs is essential
and the problem of fake drugs and that sort of thing is something
that has to be dealt with. The WHO Prequalification Programme
was designed as a solution or at least as a means of control in
both these areas. Doubts were expressed by the Malaria Consortium
about the efficiency of that prequalification process and about
the time that is taken over it. Do you have any idea about the
reasons for these delays? And do you have any recommendations
to improve and to speed up the process? If I understood him correctly,
one of the witnesses earlier said that UNAIDS was the only organisation
that had representation from civil society. I just wondered what
your contact with, say, the WHO was on this sort of thing. Are
you consulted? Do you have your own contacts within the organisation?
Or is there any straightforward process by which your views can
be heard?
Dr Meek: The prequalification and fake drugs
are slightly separate issues. When I wrote the written submission,
there were real concerns that there were only two manufacturers
globally that were prequalified to allow their drugs to be bought
using funds from global funding, some of the big, multilateral
buyers. At that time, one of the issues was that there was not
the capacity of the people who have to check the factories and
the products and product lines to provide the prequalification
status. It seemed that not enough suppliers were there to supply
a hugely increased need for these relatively new antimalarials.
Since then things have moved on quite a lot, in that the Gates
Foundation and UNITAID have given funding to the WHO, which manages
the prequalification system, to increase their capacity. Now there
is not a backlog there. The problem is perhaps more at the manufacturers'
end. A number of manufacturers are not submitting all the information
that is needed to be able to become prequalified. If they do,
the delay will not be from the monitors in the WHO but more from
how they provide the information. There has also been another
fairly recent change in the antimalarial world in that there is
about to be this initiative called the Affordable Medicines Facility
for Malaria, trying to bring the cost of medicines right down
through a co-payment to the manufacturers. There has been a lot
of debate over the last three months on how to make sure that
the people who manufacture the drugs are reputable but also that
you do not create a complete monopoly. They have come up with
criteria for accepting companies to be providers which are quite
stringent. There is a worry because a number of developing countries
have their own pharmaceutical manufacturing companies and we do
not want to crowd them out or suppress their development by having
the big player always at a competitive advantage. For these particular
drugs, it seems that what is happening now is that a number of
the Indian and Chinese companies are investing in African pharmaceutical
manufacturing capacity. There is quite a nice technology transfer
going on which does need investment, but most of the funding for
it is coming from the Indian and Chinese pharmaceutical sector.
It does not seem to be reliant on aid from donor organisations.
It is kind of complicated, but it seems that some of the earlier
problems are being ironed out. The fake drug issue, which is quite
different, is where drugs produced mostly by the Chinese are getting
into the market, and that is something that needs a lot more attention.
That is where collaboration between intergovernmental and different
governmental organisations is going to be crucial, because that
could really destroy the progress that is being made, certainly
in the malaria control field. It is a problem at the moment in
South East Asia, where there is not that much malaria these days,
much less than before; but already they are starting to find it
infiltrating parts of the African market. There was a report recently
discovering fake ladies' handbags in Lagos and that probably is
a sign of things to come, so anything to encourage this involvement
of Interpol and others, together with the WHO, needs to be encouraged
and supported.
| 
