Examination of Witnesses (Questions 540
- 559)
MONDAY 21 APRIL 2008
Dr David Heymann, Dr Paul Gully, Mr Pat Drury and
Dr Max Hardiman
Q540 Lord Jay of Ewelme:
New Zealand.
Dr Heymann: New Zealand, yes. We will discuss
how we can move ahead with this partnering within the context
of the Commonwealth, so that industrialised Commonwealth countries
can partner with developing Commonwealth countries to strengthen
core capacities in countries. We do not have the resources to
do that, they will be bilateral resources, and hopefully DFID
will be involved, as will AusAID, the New Zealand development
agency, as will be Canadian CIDA, providing the bilateral resources
so that this partnering and the technical transfer can occur.
Q541 Lord Howarth of Newport:
You will be the broker in this?
Dr Heymann: We will be the broker in this. We
have begun the same thing with the Institute Pasteur in Paris,
we will do the brokering with them, and the Francophone agencies
for strengthening the partnership. We will continue to build this
partnership into a partnership which can eventually encompass
the world, understanding that we do not have the financial resources
to do this.
Mr Drury: Another example along those lines
would be in 2005, when there was a major outbreak of Marburg in
Angola, when Angola was coming out of 25 years of war and its
health system was non-existent. Through the Global Network of
Technical Institutions we were able to deploy a fairly significant
Outbreak Response Team to effectively run the health system in
the town of Uige for a period of three months, because there was
not any national capacity. The outbreak eventually went away.
One of the things that came out of that, and it was obvious, was
that the country was not asking for world leaders in epidemiology
or world leaders in communication; they were asking, "Whoever
you send to us, please make sure they speak Portuguese".
This was the most important thing. Because there was not a government
structure in place, being able to work with the local actors was
going to be the key to it. These were local leaders of villages
and stuff like this. Coming out of this, and partly because the
Regional Director for Africa is from Angola also, is an emerging
Lusaphone network, a network of the Portuguese language countries
of Southern America and Latin America. That is bringing the two
Regional Offices together, PAHO for the Americas and AFRO for
Africa, to try to develop this and take it forward. One of the
areas they are working on is to come to the idea of twinning Portuguese—speaking
laboratory experts in Latin America with epidemiologists and other
experts in that area.
Dr Gully: Previously you referred to the complexity
of the international environment and you have the example of the
Commonwealth and the Lusaphone, but all the other especially economic
collaborations out there can be very valuable, APEC being another
one which is an interesting collaboration between developed and
developing economies, and has quite a strong health taskforce
with collaboration between those economies in a very effective
way and, again, therefore, WHO feeding into that. Of course, the
European Union is a great example, but there are many others,
Shanghai Corporation and Mercosur and so on and so forth, which
we have to capitalise on because that is a reflection of what
those States or economies wish to do and then WHO providing the
expert technical advice and guidance in terms of where they might
go.
Q542 Chairman:
From what you have said on both of these questions so far, is
it easier to see what you are describing as working for response
rather than surveillance in the first instance?
Dr Heymann: The idea of the International Health
Regulations is to strength country capacity so that they can detect
and respond to diseases before they occur internationally. Our
role in the International Health Regulations through the Global
Outbreak Alert and Response Network is to provide a safety net
in case they do get out of countries, and then we can respond.
At the same time, the International Health Regulations permit
us to stockpile vaccine for meningitis and other goods as we do
but the goal is to have countries do the job themselves and for
us not to respond.
Q543 Chairman:
Having the ability to do the surveillance is probably more difficult
than having the ability to do the response, is that not correct?
I would have thought, and tell me if I am wrong, it requires quite
a sophisticated medical surveillance structure in order to see
something that is coming but has not yet arrived?
Dr Gully: You build what you can in a country.
Africa, for example, does have an integrated surveillance system
that is syndromic, it does not relate to specific diagnosis but
a collection of symptoms which may indicate a particular disease
around gastrointestinal disease or haemorrhagic disease, for example.
I was talking to someone from Afghanistan and I said, "How
do you manage?" and they said, "We do have people in
each village who do report to us what goes on, although it is
a bit difficult in the southern part of the country", the
polio people. One would never want to transplant a surveillance
system which you had in a sophisticated developed country into
those countries but you have to design one, and this is where
the Regions do come in and are very valuable, and give support
which is then applicable to the Member States.
Q544 Chairman:
Are you suggesting that this is a sort of informal structure in
some developing countries because, in the Afghanistan example,
someone knows and they pass that on? Is that what you are suggesting?
Dr Gully: No. It is a formal structure, although
much less sophisticated than one would see in developed countries
but still works well. You have to develop as formal a structure
as you are able to do and you have to give people the tools. It
may be a local health worker trained to identify certain collections
of symptoms which they then report. We do hear reports of "mysterious
illnesses" from all over the world, from the depths of Nepal
and other countries as well, and we hear about what is going on
in the depths of the Democratic Republic of the Congo, not a country
which is well-organised.
Q545 Chairman:
We will treat that as an under-statement.
Dr Heymann: The goal in our strategy is to build
on the Polio Network which is already there.
Mr Drury: If I could just come in on that. In
Afghanistan it is a disease early warning system, which is very
rudimentary. In Pakistan, I think it is also called a disease
early warning system. In Kenya they had a disease early warning
system and the government on its website has a commitment that
they will publish information about any epidemic within two or
three days (I cannot remember the details of it). That was fine
until we had the election there and the crisis and the national
surveillance system. It may still be working but it does not appear
to be working to those of us outside, so we have to rely on the
other bits of the global system that feed information to us, so
the UN agencies in the field, NGOs that may be working with displaced
populations, and we try to pool the structured national surveillance
information with the information that is in the media and that
which comes from NGOs and other partners.
Q546 Baroness Whitaker:
Through the Country Office? Through the people on the ground in
Nairobi?
Mr Drury: Yes and no. At headquarters we have
a global process that does this. In Kenya, WHO takes its position
in the health cluster, so within the health cluster of the UN
family they are working ferociously to work as one UN family on
the ground there. We are working at the level of the headquarters
and we might be talking to the HQ of MSF Holland or MSF
France and then, during the teleconference that David alluded
to, you put these two pieces of the puzzle together and you are
able to move things forward.
Q547 Lord Avebury:
My question follows neatly on from what Dr Gully said a few minutes
ago, that you never want to transplant a system from a developed
country into a developing state. And yet the US Centers for Disease
Control are establishing these Global Disease Detection Centers
in various parts of the world and they are effectively performing
a regional surveillance and detection role for GOARN, as we understand
it. How do you reconcile the development of all these various
linguistic and regional detection response and surveillance systems
with what the Americans are doing with the Centers for Disease
Control?Dr Heymann: I came from the Centers for Disease
Control in the past, I spent my career there and then I retired.
The US Government through CDC, which was a very strong partner
in our Global Outbreak Alert and Response Network, is now setting
up its own bilateral Global Disease Detection Network. This was
a vision of the CDC back in the 1990s when we set up our WHO Emerging
Infections Programme, but at that time they worked multilaterally
within the Global Outbreak Alert and Response Network. Under the
current Global Disease Detection Network, however, there has been
a tendency towards more bilateral relationships, not only with
disease detection and response but with influenza, with HIV and
malaria, as well. Many times there is difficulty in knowing who
is doing what in a country when there is an outbreak of disease,
much different from a few years ago when response was being well-coordinated
by GOARN, and which we believe will be well-coordinated again.
Pat, maybe you can give some experiences we have recently had.
Mr Drury: The fact is that, in the Outbreak
Response field, position is everything. We recognise this because
within WHO we are trying to regionalise all the activities that
have been historically headquarter-centred. We are trying to ensure
that we have one system supported by software and standard operating
procedures and a concept of operations which extends to the country
office. It is no surprise that the US, with its concerns for health
security, have taken a similar position. We have known about the
development of the GDD centres and the operational hub in Atlanta
since before its inception. As David said, it goes back to the
1990s when there were various proposals to establish this type
of system. On a day-to-day basis we try to maintain coordination
between Atlanta and Geneva within the strict restrictions that
are put on WHO with regard to sharing information about one country
with another. In terms of sharing operational information, we
have tried to get along as best we can, so between the two headquarters
there is some degree of coordination. There may not be much coordination
between the response centres on the ground and us here. We would
not know what their activities are on a day-to-day basis; but,
if there are events, they do provide a role. It is a difficult
issue to coordinate and deal with but, at the same time, they
provide a capacity that would not be there otherwise. If we are
dealing with an outbreak in southern Sudan and we do not know
what it is, the samples go to KEMRI, where the CDC in Kenya is
located. When it comes to outbreak response, our activities centre
on trying to coordinate between a multilateral intervention and
the politics of bilateral intervention. From the technical and
operational point of view we try to keep very focused on the technical
and operational stuff, we develop the tools that are needed for
epidemiology case contact tracing, counting and subtracting the
living from the dead, this type of thing. But we constantly come
up against this glass ceiling. Our colleagues in Atlanta are anxious,
for whatever reason, to ensure that these response centres are
seen as part of the international infrastructure supporting the
IHR and that they continue to function within GOARN. We are taking
that at face value and are trying to develop a set of procedures
about how we will ensure that there is no compromise in the sovereignty
of the countries in which they are located, that whatever international
role they fulfil is done in accordance with the principles and
the approach that has driven the IHR adoption and the guiding
principles that we have established and run for the past seven
or eight years for GOARN.
Q548 Lord Avebury:
I wonder whether you have had any attempts at making the systems
interoperable between Atlanta and Geneva?
Mr Drury: Interoperable is a very big word.
Q549 Lord Avebury:
In the sense of interoperability with the software.
Mr Drury: Yes, to an extent, in that for the
past ten years we have had an in-house piece of software we are
developing called our Event Management System. That is an information
management system that allows us to record all the key information
about events that are happening around the world and to document
our decisions. It is not something that would stand up to forensic
examination but that is our main tool. We are involved in a big
programme to develop a new tool which supports WHO globally. When
GDD was being established, they asked the Secretariat of the World
Health Organisation if they could see what we do, and as a Member
State of the organisation we provided them with the details of
how we had established in parallel the EMS software and how we
worked. It is a close relationship between CDC and WHO, they have
staff seconded to WHO headquarters here and provide key human
resources, these are senior people and very knowledgeable and
capable. There is a close level of cooperation there. It is true
that not just for the GDD centres which are established in Thailand,
Nairobi, Egypt and Guatemala, and there may be others, as these
take on a life of their own they also generate opportunity on
the US side to bring in other parts of the US Government overseas,
so health attachés working in US embassies, USAID offices
overseas, laboratories where there is a twinning between Atlanta
and the NICD in Johannesburg, wherever. All of these things come
together into this Global Disease Detection that, I think, is
their response network. Of course, it causes problems for me because
I run the Global Outbreak Alert and Response Network, so these
things are very similar.
Q550 Chairman:
Let me see if this summarises the situation, and tell me if it
does. There is a political issue from the current US Administration
being rather dubious about the international organisations and
wanting to be separate from them to some degree, but what you
have got with this organisation, which seems to me to be quite
efficient in many respects, is in effect a shadow organisation,
in the early stages if you like, of the WHO that people within
those Disease Detection Centers and yourselves are trying to make
work. Is that a fair summary of where it is at? Presumably you
would like them to come right in rather than continue with their
separate system, although the separate system does seem to work
quite well? Is that right?
Dr Heymann: There is another dimension to that
and that is the obtaining of specimens, viruses or bacteria that
are occurring in these outbreaks. When these are obtained, WHO
makes sure that they are distributed to the laboratories in the
world that can do the research necessary to better understand,
and this was done with SARS if you recall. If this falls into
a bilateral system, the difficulty is that those viruses or bacteria
are not studied in any other laboratories. There is thus another
dimension in bilateralism—in specimens that might come from
that outbreak.
Dr Gully: There is a document, I believe it
is called A Global Strategy, from CDC which I might direct
you to, because I think in that whole document there is one reference
to WHO and it is more like a passing reference. Therefore, I think
that is indicative of the current situation, perhaps, in terms
of the wish to collaborate with WHO and other UN organisations
as well.
Q551 Lord Desai:
I think most of what I wanted to ask has been dealt with already.
You were just talking about the viruses, and in Indonesia there
is an example of the refusal to share. You were also talking about
Kenya, Tanzania and so on. Clearly, for infectious diseases you
may have to impose restrictions on travel, trade and so on, and
governments are reluctant to report therefore. It seems that the
new International Health Regulations are giving you the power
to override, but do you also use the power to name and shame?
Dr Heymann: When the Global Outbreak Detection
activities of WHO were set up in the late 1990s one government,
the Government of Canada, developed a mechanism to help WHO identify
what was occurring in the world, and this is called the Global
Public Health Intelligence Network. It is a web application, which
crawls the web in seven languages looking for key words that might
indicate an outbreak of infectious disease. That information is
provided to WHO and every day there is a validation mechanism
in WHO through our Country and Regional Offices to determine what
is happening. This, plus other electronic discussion sites, increased
dramatically the power of WHO. In fact, over 62 per cent of our
information back in 1998 was coming from systems such as this
rather than from countries. Fortunately, this has provided an
environment where countries know that, if they do not report,
then others are looking over their shoulders and will report and
that ratio has completely turned around, so that now we get the
majority of our reports from countries that are concerned. If
a country does not report, as Paul said, we have a mechanism where
in confidence we deal with the country, we provide them the information
and ask them to verify it; and they are required to do that under
the International Health Regulations, so progress is being made.
Dr Gully: I will talk about Indonesia because
there was a statement at the Intergovernmental Meeting in November
about International Health Regulations and the responsibilities
of Indonesia to report. There had been an interpretation of the
International Health Regulations in relation to a Member State's
responsibility to report. WHO does not have any means of sanction,
WHO is the Member States and we are just the Secretariat, so if
the World Health Assembly wishes to do something then it could.
The information that has been available to all Member States about
what Indonesia has and has not done, and the WHO Secretariat has
been quite clear as to the deleterious effects of that, I think
means that most States would respond to that, but Indonesia for
all sorts of very good reasons perhaps have not done that.
Dr Hardiman: I just want to say that, in addition
to having this fallback mechanism if countries do not report,
most of our effort is going into winning the argument that transparency
and early reporting are not only good for the rest of the world
but are good for the country that is suffering the problem. We
do not have sanctions but we do have monitoring of compliance,
if you like, with the International Health Regulations both through
our own reporting of progress with implementation on the website
but also a formal mechanism through the Assembly where both WHO
and countries will report on the functioning and compliance with
the regulations. The first Assembly to receive such reports is
going to be in May.
Q552 Baroness Whitaker:
We have touched on animals, so this is an opportunity to bring
it all together. It was mentioned that we should deal first with
the animals, so it would be helpful if you could tell us about
your Global Early Warning System for Major Animal Diseases and
how it operates. But also, in doing so, I have picked up a couple
of other things which are about the whole international architecture.
Dr Gully thought that the OIE does not seem to have a mechanism
for early warning, am I right? Then again, I think Dr Heymann
indicated that the FAO was virtually powerless over Rift Valley
Fever. My question is not only a bit more about what happens now
but really what ought to happen, not only in WHO but in any of
the other organisations. And I am not quite clear. Is there a
role here for the IHR? Or are they only about diseases that affect
humans?
Dr Gully: If I could answer that. IHR do relate
to a specific number of diseases which are human diseases, polio
and SARS, for example. They relate to public health emergencies
or events of international importance and that would be open to
interpretation as to what situations the IHR applied to, but if
it was just an animal disease then they would not apply.
Q553 Baroness Whitaker:
There is no equivalent, then, for animals?
Dr Gully: There is no equivalent. The equivalent
is in terms of the responsibilities of the Member States of OIE
to report to OIE a certain number of diseases, but OIE can only
respond to reports from governments.
Q554 Chairman:
Should there be?
Dr Gully: Let us put it this way, I think there
is interest certainly from OIE and FAO in terms of what WHO has
in terms of the IHR. One can say it would be valuable, but the
IHR have been in place ever since the beginning of—
Dr Hardiman: 1951.
Q555 Baroness Whitaker:
The first ones, yes?
Dr Gully: Maybe Max would like to come in, and
I will come in with a response to the other part of your question.
Q556 Lord Desai:
Before you answer, if those animals have been traded, like you
said in the case of Rift Valley Fever, that is a legal situation
of having to report?
Dr Hardiman: Yes. If you assess the animal disease
as posing a risk to human health, then it can be notified under
the IHR or reported under the IHR if there is a public health
risk associated with that outbreak among animals. Therefore, foot
and mouth is generally not considered to be a risk to human health—it
is a terrible agricultural problem—so that would never get
reported through the International Health Regulations, whereas
Rift Valley Fever, an outbreak which was threatening human health,
could be.
Q557 Chairman:
Could be or must be?
Dr Hardiman: It depends on the nature of the
outbreak. The Regulations give you a series of questions, an algorithm
to work through, to see if this event you are looking at is actually
something that should be notified to WHO under these Regulations.
Q558 Lord Jay of Ewelme:
Suppose you simply do not know but you think it might?
Dr Hardiman: Then the Regulations provide you
with an option of consulting with WHO without formally notifying,
so you can still consult and say, "Do you think this is a
risk to public health?" and we can use our other forms of
information and experts to help the country come to a decision
on that.
Q559 Baroness Whitaker:
Must consult or may consult?
Dr Hardiman: May consult. It is an option.
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