Examination of Witnesses (Questions 520
- 539)
MONDAY 21 APRIL 2008
Dr David Heymann, Dr Paul Gully, Mr Pat Drury and
Dr Max Hardiman
Q520 Baroness Whitaker:
A quick bit on the Alert Response, if I may. You receive reliable
information regularly about vaccine delivery. Some vaccines still
need to be kept cold, and in some countries the power supplies
are really poor, say in Kenya, and the fridges go off. Do you
receive information that the vaccines are no good any more? Is
there some way you can tap into that? Also, what power can you
exert on this different area, nothing to do with health, of the
power supply?
Mr Drury: I will leave the power supply for
my boss! We rely almost exclusively for our cold chain delivery
of vaccine on the polio network. If this is in countries where
there is not a big active polio infrastructure, it is a challenge.
For any outbreak or any event where WHO is facilitating the delivery
or the purchase of vaccine by a country, we encourage the country
to engage in adverse event surveillance, so part of our support
to the country is, "We can get you the vaccine, we can help
you develop the plan for the delivery of the vaccine", but
it is also important we are monitoring implementation of the immunisation
campaign and any adverse events that are being picked up in it.
It is a function of our operations in the field to monitor the
efficacy and side-effects of the vaccine and our logisticians
and operational infrastructure will be looking at issues of breakdown
in the cold chain and how those might be addressed.
Q521 Baroness Whitaker:
So you do what you can basically?
Mr Drury: We do, but in a very limited way.
It is a big problem.
Dr Heymann: Just a couple of additional points
on this. The comparative advantage is not with WHO but with UNICEF
and the cold chain. UNICEF provides all of the purchase of the
cold chain equipment and tailors that equipment to the possibilities
in countries, either a petrol fridge, a solar fridge or an electric
fridge. They do the assessment and provide the fridge based on
that. In addition, vaccine vials each have a temperature indicator
which will show if that vaccine has ever been exposed to temperatures
above which it should be stored. The minute that happens the indicator
turns colour and the vaccine is discarded.
Q522 Lord Desai:
Is there too much specific investment, vertical investment, disease
specific and not enough horizontal? Or are you satisfied with
the way that these investments occur? Are there too many people
who want not only to invest but to have their signature on what
happens?
Dr Heymann: Vertical systems like the Global
Fund, which provides directly for AIDS, TB or Malaria, and other
partners who provide that funding, provide that with the understanding
that health systems cannot function if there are not goods in
those systems. If you only concentrate on strengthening a health
system or strengthening the infrastructure, you risk having the
equivalent of a school bus with no students. What the Global Fund
and others who give vertically to disease control programmes provide
is the students in that bus, or the goods in the health system.
If there are goods in the health system, people will pull those
goods out to the periphery because they know they are there, they
will continue to go to the health facility to get those drugs.
If the goods are not in the system, they will not go. Vaccines
are very different because UNICEF, along with WHO, has worked
very hard to make sure that those vaccines fit into a programme
which can accommodate them and get them out safely to people through
a good cold chain. The Global Fund and others do not have all
the security mechanisms they need. In fact, one of the major needs
in these vertical programmes which are pushing drugs out is a
system to monitor the effectiveness of those drugs and to make
sure that they do not lose effectiveness because of resistance
developing, things that WHO and countries can do. The vertical
programmes require a strengthening of systems to monitor effectiveness
of drugs and resistance in laboratories, and WHO tries to make
sure that this occurs.
Q523 Lord Desai:
You do not think there is overcrowding then, an overcrowding,
overlapping of agencies?
Dr Gully: I think, inevitably, the world is
such that people will invest in things which they understand,
which are clear, precise and reflect their wishes, and an organisation
such as WHO has to deal with that. Another way of looking at it
is, if one can reduce the burden of an important disease—HIV,
TB, Malaria, Meningitis, Yellow Fever—then, in fact, one
is reducing the burden on a health system which then has a greater
ability to deal with other things that are going to come along.
Yes, I am sure that balance is not necessarily right, and it varies
from country to country, but hopefully if one is able to build
that capacity one can use it to deal with chronic diseases, for
example. How do developing countries deal with diabetes, deal
with renal disease, with cancer? Maybe they deal with them better
if they do not have to fill their beds which acute disease which
can be dealt with by the vertical programmes. There is always
going to be a balance which, as I said, WHO will have to deal
with. Our Director General has said that she recognises that,
if you look at the budgets of the large programmes, GAVI, Global
Fund, Gates and so on, some of them are larger than WHO but, therefore,
WHO has to work with those and that is where she spends a huge
amount of time and energy, so there can be some synergy, some
collaboration.
Q524 Lord Desai:
Can I just press this for one moment. The picture we have got
so far is of an immensely complicated architecture, but what you
are telling is there are very straight lines, it is very beautiful
and it all works. I am trying to reconcile these statements.
Dr Heymann: Let me give you an example that
the Director-General used just last week in our senior management
meeting. The Secretary-General of the United Nations has appointed
a special envoy on Malaria. Within three weeks that envoy had
been to visit the major financial partners that he could identify,
both in the private sector and in the government sector. He has
mobilised approximately $10 billion over the next five years.
The special envoy, who was actually nominated by our Director-General,
has done the job in three weeks and now WHO must respond in being
able to help in strengthening the human resources and other infrastructure
necessary to be sure that this money can be implemented within
country. The Director General will lead us to change our way of
working to work in a more rapid and responsive manner. She understands
many of the issues that delay our response and she has indicated
that she will try her best within the system to make it work better.
Q525 Chairman:
Have you got the balance of investment right between treatment
and prevention?
Dr Heymann: That is a very good question and
it certainly depends on the disease. If you looked at what bilateral
donors were giving, including the United Kingdom, back in 1990,
they would not provide any resources at all for treatment or patient
management, it was purely for prevention, purely for vaccines,
vaccines were the investments we wanted to make. That is why David
Nabarro and others in our Communicable Diseases Group back in
the mid-1990s worked with Brundtland to increase the understanding
of our financial partners through Jeffrey Sachs' Macroeconomics
Commission and a whole series of activities that drugs were also
a preventive mechanism. They are a preventive mechanism that help
countries prevent themselves from falling deeper into poverty,
using these drugs to cure diseases and let healthy people move
their economies ahead. This is why the Global Fund and others
have come along. Today we have investment in drugs as well. Is
the balance correct? In some areas it is not; in others it is.
It is probably not correct in HIV today, it has possibly gone
a little bit further towards the treatment rather than towards
the prevention, but that will come back eventually and WHO advocates
for that, along with UNAIDS.
Dr Gully: If I could also talk about neglected
tropical diseases, such as onchocerciasis, the treatment available
with public-private partners has been hugely beneficial in terms
of reducing the burden of disease and reducing the burden on the
health system, where otherwise there was no applicable way of
preventing that disease, apart from eliminating exposure to a
certain insect which was not possible. Even in these situations
treatment can be highly valuable, but it depends.
Q526 Lord Avebury:
You mentioned that the balance will come back between prevention
and treatment in the case of HIV, but what signs do you see of
that? Are there not tremendous political restraints on the increase
of preventive action in HIV, particularly on sexual and reproductive
health? What are you doing to promote sexual and reproductive
health in the face of some political opposition?
Dr Heymann: That is a very good question. It
is true that there is a major financial partner in HIV, the United
States Government, which has a bilateral series of programmes
on HIV which has not permitted all of the prevention interventions
from being used. WHO has advocated with the US Government, as
have many, many others, and in the new allotment of funding prevention
is now fully installed. It is a matter of education, continued
work with countries, and many times by other countries that can
help better than WHO in some of the difficult situations. I know
that the United Kingdom and Canada were very helpful with the
US Government in helping them understand the importance of all
forms of prevention in HIV. We work with others, we let others
help us if they can, and together we work on solving these issues.
These are very difficult issues and the more countries decide
to go bilaterally with resources, the more difficult it is for
the multilateral systems, like WHO and its major partners, to
have a full impact. Everyone needs to work together on these issues.
Q527 Lord Jay of Ewelme:
Can I, first of all, thank you very much indeed for your written
response to the Call for Evidence, it is extremely helpful. Whoever
put that together did a really good job. I just wanted to pick
up on something which you said earlier on, Dr Heymann, when you
talked about the problems that can arise because of the relationship
between the elected Regional Offices and other parts of the organisation.
It is a question about the internal structures of the WHO. Perhaps
the best way to ask the question is this. Suppose you are a Country
Director, you are sitting in Kinshasa, Kampala or Nairobi, and
you have a relationship with the local government, a relationship
with the Regional Office and with Geneva. When you are sitting
there, who is your master? And how do you reconcile all of these
conflicting pressures that may come upon you?
Dr Heymann: The organisation is very hierarchical,
as you know. That WHO representative, although that representative
is named by the Director-General, responds directly to the Regional
Office mechanism and then to Headquarters. That does not stop
direct contact from Headquarters with the WHO representative in
a country or through the Regions. I must say the WHO system works
on the ability of a Director or an Assistant Director-General
to establish a working relationship with his or her counterparts
in a region and in a country. In our area of communicable diseases
there is a tendency for WHO representatives to be torn between
a country's wish to hide a disease and WHO's need to have transparency.
This is decreasing as time goes on, thanks to the boldness of
the Director-General at the time of SARS in encouraging China
to freely provide information. We are seeing that information
does flow. If we have a problem the mechanism that we use in the
communicable diseases area is to call a phone conference between
the WHO Country Representative, the Regional Focal Point, if necessary
the Regional Director, and the appropriate level in Geneva.
Q528 Lord Jay of Ewelme:
The initiative in doing that would come from here?
Dr Heymann: Yes.
Q529 Lord Jay of Ewelme:
You would not find the Regional Office saying, "Sorry, that
is our job, not yours"?
Dr Heymann: No, absolutely not. They would participate
in the phone call if you have a established a decent working relationship.
Some try to bypass the regions completely and those people would
have difficulty, I believe. As I say, it depends on the Director's
ability to work. In our communicable diseases area, the health
security and environment area and polio, we have no difficulty
in convening a telephone conference whenever we need it to solve
a problem.
Q530 Lord Jay of Ewelme:
On this question of the slight tension between the desire of the
country to maybe hide a disease and the desire of Geneva to see
it as transparent as possible, where along that spectrum would
the Regional Director tend to sit?
Dr Heymann: It would depend on the issue, I
think. The Regional Director would respond to any message sent
to him saying, "This is necessary". In avian flu they
would understand that this could be the beginning of a pandemic
and it cannot happen. In polio they would understand the issue
and in meningitis. I often like to say that WHO spends more time
collaborating internally than it does with its external partners,
which is many times true. Having said that, this is what our function
is, to make things work. We are a multi-cultural, multi-language
organisation and we must work hard at it, and we do work hard
at it, and we succeed.
Dr Gully: If I could add to that. I think changes
to the International Health Regulations in terms of being able
to respond to rumours, as opposed, in the past to official notifications
has made a huge difference. We are now able to go to a country
through a region to ask specifically what is going on and that
country realises that the world knows a particular country has
a problem. Other sectors, such as agriculture, do not have that.
For example, the OIE, the World Organisation for Animal Health,
can only respond to a report from a country, an official report,
and it does make a huge difference. The fact that everyone knows
we are there asking puts pressure on a country. I did not work
in WHO before, although I was aware of the old International Health
Regulations, but I think there is a difference.
Chairman: That is a very important point
actually about the OIE.
Q531 Lord Jay of Ewelme:
The last point about the OIE was really interesting.
Dr Heymann: Let me add to that briefly. There
was an outbreak of Rift Valley Fever in East Africa. Rift Valley
Fever is caused by a virus that comes from cattle to humans by
way of a mosquito. This outbreak was occurring in East Africa
in Sudan in October and November of last year at the same time
that animals were being traded across the Red Sea to Saudi Arabia
and Yemen for religious sacrifices. This was a formula for serious
human disease in Saudi Arabia when infected animals were being
transferred across the Red Sea from Sudan, where people were dying
from the disease. FAO was frustrated because reports of animal
disease were not as forthcoming as were reports of human infection
and we worked together with FAO through the International Health
Regulations and reported to Focal Points in every country in the
world that there was a Rift Valley Fever outbreak in East Africa,
that this was killing animals and animals were a very great danger
to human populations. The FAO worked with WHO and WHO passed the
message to countries through the IHR with the clear acknowledgment
of FAO.
Q532 Chairman:
That is very helpful. Before we move off this, could you say a
little about how you would co-operate with other organisations,
and I am thinking particularly of the World Trade Organisation
and one or two other organisations. They have given written evidence
to us but they are a bit reluctant to come forward. While you
are on that, a very powerful operation in financial terms is the
Gates Foundation. How do you relate to the World Trade Organisation
and the Gates Foundation? If there are any other problems you
can flag those up.
Dr Heymann: As you know, the World Trade Organisation
responds differently from WHO. The World Trade Organisation response
is after the event; our response is before the event. That gives
an interface where we can and do work very well with the Phytosanitary
Bureau. The Bureau and WTO were constant partners in the revision
of our International Health Regulations to make sure that we were
not overlapping in any way but were complementary. To give you
an example: a few years ago there was a European embargo or ban
on the importation of seafood from Tanzania, which was having
a cholera outbreak. This was unnecessary based on the known epidemiology
of cholera. The World Trade Organisation could do nothing and
Tanzania continued to lose resources, so WHO sent a letter to
the European Commission from the Director-General indicating that
this was not a health problem that required a trade embargo and,
therefore, the European Commission was able to work this through
the system and was able to lift the trade ban. That is a very
effective way of operating before the event and then after the
event WTO will take over. We included WTO in all our deliberations
on the International Health Regulations and we believe that will
be beneficial. As you know, the Gates Foundation is a major funder
of our activities. .Our support from the Gates Foundation has
been absolutely superb. I will give you one example. We needed
a new polio vaccine three years ago, we went to the Gates Foundation
and they provided the resources necessary to develop that vaccine
within a very short period of time, the vaccine was developed
and is now effectively used in programmes, and the Gates Foundation
required nothing more than providing us with the resources and
understanding that the resources were properly used. They do this
periodically in the neglected tropical disease area. They do not
usually provide resources to sustain interventions. Whereas they
will provide for polio eradication and guinea worm because those
disease have an endpoint, they will not presently provide major
for support to AIDS programmes or TB programmes at this point
while they are beginning to provide more resources for malaria,
which they have targeted for intensified control and eventual
elimination or eradiciation.
Q533 Lord Avebury:
We heard about the World Health Organisation's Intergovernmental
Working Group on Public Health Innovation and Intellectual Property.
Could you tell us who is on this group? Since it is to report
to the World Health Authority in May, can you tell us anything
about what it is likely to recommend?
Dr Heymann: The IGWG is a mechanism which was
set up by a number of countries, and all Member Countries are
a part of that mechanism, which is a series of meetings. Of course,
the issue on this is to find other ways that will guarantee innovation
which could complement or even replace intellectual property.
The discussions are still at a very early level. The report to
the World Health Assembly will be one of progress made but there
have been no breakthroughs, it is just a discussion point and
continued discussion. Many times there are very emotional inputs
by certain Member Countries of WHO which have very strong beliefs
and, therefore, at times that derails the discussions, which then
come back on target. Much remains bracketed in that discussion
at present, it is a discussion which continues.
Dr Gully: In relation to another organisation,
the World Intellectual Property Organisation, which relates to
the IGWG, we have also had discussions with them relating to the
issue of influenza virus sharing which does involve them and we
have got really very good advice from them in terms of the intellectual
property aspects of that issue. That is another organisation we
deal with.
Baroness Whitaker: When Dr Chan says
health is not just for the health sector, but, for example, also
depends on education; and we briefly touched on power supply—there
are these non-health entities. Are you content that you have the
right kind of liaison with the international organisations which
cover education, transport, et cetera?
Chairman: The other international bodies
in a sense, whether they overlap with health is the question.
Q534 Baroness Whitaker:
How would you like to see this changed or improved basically?
What should be done for the future?
Dr Gully: I honestly cannot talk about education,
but in terms of transport we have close collaboration with the
organisations related to transport in particular to the International
Health Regulations and the control of the spread of communicable
disease. I do not know in which sense you are talking about education.
Baroness Whitaker: The education that
is a part of communicable disease prevention itself.
Chairman: Are you thinking of prevention
impacts?
Q535 Baroness Whitaker:
Yes. These are all prevention measures.
Dr Gully: We have close contact with UNICEF
which, quite apart from the logistical aspects we have talked
about already, has a great deal of funding, in particular into
avian influenza. I was in a meeting in Rome last week with FAO,
OIE and UNICEF in relation to a five-year strategy for infectious
diseases, particularly zoonotic diseases. UNICEF was there as
a player with funds and with expertise in terms of social mobilisation,
which is a fundamental part of communicable disease prevention
and control.
Q536 Baroness Whitaker:
So you are content that nothing more should be done?
Dr Gully: I am never content that nothing more
should be done.
Q537 Baroness Whitaker:
What would you like to be done?
Dr Gully: I think the challenge with social
mobilisation on the ground is often the understanding at the local
level of how social mobilisation works. For example, we have realised
in Burkina Faso, looking at prevention of avian influenza, that
it is the children who collect the eggs and have close contact
with chickens, because the chicken hutches are built in such a
way that they only allow children to go in, to protect from thieves.
So it is the children who are exposed. Therefore, who is at greater
risk depends on the particular social and cultural environment.
It becomes very specific and we have to have that capacity on
the ground, which is often what is missing.
Q538 Chairman:
I am afraid we are quite well into our second hour, and we want
to move on to the Global Outbreak and Alert area. If we are all
terribly disciplined, I might allow some time if we have got it
at the end for any mop-up, but I have got a horrible feeling we
are not going to achieve it without coming back for another two
hours, which perhaps indicates the importance of this session.
We need to be very focused on this. Your written evidence refers
to "gross under-investment" in the Global Outbreak Alert
and Response system and it being dependent on "strong, capable
and transparent national systems", which was I think your
phrase. Can you tell us how you think these problems can be met
and the deficiencies can be addressed, if you like? Who is going
to take that?
Mr Drury: It looks like me. There is a later
question where it asks if this is a crisis or not, and in my mind
gross under-investment and crisis is the equation we need to look
at. In the work plan for the Alert and Response operations area,
and WHO has some 32 million for the next biennium, we would have
a fraction of that, maybe 25 per cent of the money available at
this stage to fund the activities. That is still only the tip
of the iceberg. The same thing is reflected in each of the Regional
Offices of the organisation, there is fairly limited human resource
capacity and fairly limited funding. If we had not had bird flu,
I think it would be much more obvious because over the past four
or five years there has been a large amount of money that has
come in and been invested at a national level and in the international
system because of the threat of a pandemic. Our role always is
to cannibalise and feed off these opportunities to find the money
to fund our activities and keep them going. If we had not had
that investment, then the capacity of the organisation would be
even further limited.
Chairman: I might come back to that later.
Q539 Lord Howarth of Newport:
Alert and response are not going to work well where individual
Member States lack the healthcare infrastructure to be able to
perform that role. WHO is constructed on the principle that countries
should assist each other across national boundaries to promote
good health internationally, certainly to prevent the transmission
of epidemics, and the International Health Regulations state that:
"Member States have a responsibility not only to develop
their own infrastructure but also to help less developed countries
do the same". How does that work in practice, or how should
it work in practice? If an individual Member State does not have
the capacity, what is the responsibility of other Member States?
How is that responsibility allocated? And how can it be made to
happen?
Dr Heymann: Let me start by giving you the example
of a meeting we had with Pat Troop at the HPA just before she
retired. We discussed with her an initiative which will be followed
through this week with a meeting to the Commonwealth and in a
few weeks here in Geneva at the Health Ministers' Meeting of the
Commonwealth. The Health Protection Agency would like to partner
or twin with agencies in developing countries within the Commonwealth
and provide to them the technical guidance and resources necessary
to strengthen their manpower to better implement the core capacity
requirements of the International Health Regulations. This was
the beginning of a series of meetings, the meeting with Pat, which
will now continue with the Commonwealth to talk with them about
this issue, and after that meeting we will meet here with specific
donor countries—Australia, Canada, the UK and a fourth industralised
country—about assuming a broader role in partnering within
the Commonwealth.
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