Examination of Witnesses (Questions 560
- 579)
MONDAY 21 APRIL 2008
Dr David Heymann, Dr Paul Gully, Mr Pat Drury and
Dr Max Hardiman
Q560 Baroness Whitaker:
Is it an opportunity for us to explore whether it would be helpful
to strengthen the IHR in this respect and also the OIE and FAO
mechanisms?Dr Hardiman: The Regulations are mandatory and
notification is mandatory, so it is legally required of countries.
The question we face is: can WHO enforce that requirement. Of
course, we have no mandate to do that, either in our constitution
or in the Regulations. When the Member States negotiated the Regulations,
they had no appetite to give WHO such powers as to enforce the
Regulations.
Baroness Whitaker: I understand it would
be a political act to do such a thing, and not for the Secretariat,
but we are in a position to recommend what we like.
Chairman: Within reason!
Q561 Baroness Whitaker:
So we would want to do something helpful.
Dr Heymann: To go back to the BSE issue in the
United Kingdom in the early 1990s, with the UK Government we were
consulting regularly on this disease and were looking in Europe
to see if there was an increase in Creutzfeldt-Jakob disease anywhere
in Europe. This was an activity that was going on between the
United Kingdom and WHO, and WHO and other European countries and
that way we were safeguarding health without the International
Health Regulations. There are other mechanisms besides this. Max,
is there not a special Article which does bring in other international
organisations to the IHR?
Dr Hardiman: They have a requirement to collaborate
with the appropriate international organisations, and we have
mentioned most of them here. You mentioned transportation earlier
and we also collaborate with the ICAO, the International Civil
Aviation Organisation.
Q562 Baroness Whitaker:
"We", the IHR mechanism or WHO?
Dr Hardiman: No, WHO, but particularly on IHR
issues, because there are rules about conveyances as well as people.
Also with IMO, the Maritime Organisation. Yes, we do have a requirement
to collaborate with other organisations during events as well.
Dr Gully: David mentioned earlier on the Global
Early Warning System for Major Animal Diseases, which is WHO,
FAO and OIE, which is a way the three organisations work together
in terms of disease-tracking, information-sharing and multidisciplinary
action. In fact, on two recent occasions, one related to contamination
of baby corn from Thailand, WHO did disseminate that information
to WHO Member States and it was related to a particular food product
which in theory was under the mandate of the Food and Agricultural
Organisation. It did disseminate information without direct permission
from Thailand.
Q563 Baroness Whitaker:
For contaminated corn?
Dr Gully: We have GLEWS, but we have another
group called INFOSAN, which essentially is a collaboration of
organisations within countries, such as the Food Protection Agency
in the United Kingdom, that do share information because information
such as that would come through a different route. Even though
FAO and OIE do not have the same powers as IHR, there are ways
in which WHO, because of its assessment of a situation, can take
some action which is as a result of that collaboration.
Q564 Baroness Whitaker:
I get the impression that you make the maximum use of the powers,
the networks, the relationships and the prestige that you have,
but that is not quite the same as saying you have the most desirable
structure.
Dr Heymann: Let me come back to an issue, because
I think the jury is not yet in on whether coordinating mechanisms
are the best way to move ahead. Back in the 1990s, UNAIDS was
set up and it was set up as a coordinating mechanism. It is now
an implementing agency with much more funding for AIDS than WHO.
WHO has had a difficult time in finding its place within the UNAIDS
partnership, but has finally succeeded. Another coordinating mechanism
is UNSIC, which was set up as a coordinating mechanism for avian
influenza. This was set up by the Secretary-General to coordinate
activities. It is very valuable in letting all the partners provide
their work plans to one central point and see how they fit together.
The arrangements have been orchestrated within the UN system to
support a response in a coordinated UN mechanism. It is my view
that the jury is still out on whether any formal coordinating
mechanisms are really necessary.
Q565 Baroness Whitaker:
Would it not be helpful to you and to them if the OIE had a better
mechanism for early warning and not just response?
Dr Gully: Absolutely.
Dr Heymann: Yes.
Dr Gully: They would say the same thing too.
Q566 Baroness Whitaker:
More like your own position?
Dr Heymann: They run into the economic issues
much more than we do. Human health is a little bit privileged.
Q567 Baroness Whitaker:
The FAO was powerless over Rift Valley. What should the FAO have
been in a position to do?
Dr Heymann: They should have been in a position
to report this, based on reports from the ministry of agriculture
through a press release. That press release did not clear through
the system. It might have happened in WHO that a press release
would not clear, either, but because there is a mechanism with
the International Health Regulations we used that mechanism.
Q568 Baroness Whitaker:
They have no such mechanism?
Dr Heymann: No, and we did not before the IHR.
Q569 Chairman:
So the summary of this bit is that the International Health Regulations
are very important and very usable. They could possibly be considered
for extension to other areas, such as animal health. You have
an underlying problem at the end of the day that there is no enforcement
mechanism, so you are relying on the cooperation of States and
groups to make them work. Is that a fair summary of where we are
at?
Dr Heymann: Yes. If our Member States required
that they moved further into the animal area they might be able
to be adapted to do that in collaboration FAO. It is the only
international public health legislation that has all Member States
of WHO agreeing to it. It is quite a powerful mechanism.
Dr Gully: It is binding as well under the constitution
of WHO.
Lord Desai: My memory of BSE is that
the UK Government dragged its feet for quite a long time and did
not do what it should have done. I was getting up on my hind legs
and telling them that. Is it that the WHO would sometimes prefer
powerful rich countries to be better behaved, not just Indonesia
but the UK as well? Was that your feeling at the time, that purely
for trade reasons they were dragging their feet?
Q570 Chairman:
We are allowed to criticise the Government!
Dr Heymann: I would certainly not criticise.
It is the difference between a human health issue and an animal
health issue. This cost the UK billions and billions of dollars
and it had nothing to do with human health at the start, because
we were looking to see if it did and it did not. It had not yet
declared itself as a disease that transmitted to humans because
of its nature. Once it did, our collaboration was very close with
the United Kingdom and with Europe.
Dr Gully: I think other countries, such as Canada,
were very sympathetic because they were very glad that the UK
were having to deal with this as to the challenges that it presented.
Q571 Lord Desai:
The Irish dealt better with BSE than the UK did.
Mr Drury: In terms of FAO, OIE and WHO coordination,
below the legal framework there is a high degree of operational
coordination between the three organisations on a daily basis,
the GLEWS mechanism and also between the ARO and the operation
centre and the FAO/OIE Centre for Crisis Management in Rome. We
have agreed a set of standard operating procedures on information
sharing, on how to plan missions to the field. In the same way
that we shared our Event Management System software with the US
and other Member States, we have also shared that software and
thought that went into it with FAO and OIE in an attempt to build
up their capacity to do what we were doing illegally before the
IHR were updated, but if they want to choose the outlaw route
they can also do that.
Q572 Lord Jay of Ewelme:
Drug resistance is clearly becoming a more and more important
concern particularly, according to your written evidence, in TB
and Malaria, although not yet, I am glad to see, in HIV/AIDS.
Presumably, that is an area too where surveillance is necessary,
so that you can find out what is going on and work out the appropriate
responses. I wondered how far you thought there was adequate surveillance
at the moment of drug resistance of the diseases we are talking
about; and, if there is not, what role would WHO play, or could
it play, in trying to increase the effectiveness of the surveillance
of resistance to drugs?
Dr Heymann: To have an effective surveillance
of drug resistance you must do surveillance in animals, plants
and humans because the organisms of these three groups are all
targeted by various agricultural and human health programmes for
antibiotic use or antimicrobial use, so it is very useful that
those come together. Back in the early 2000s WHO did develop a
framework which included all the different groups involved in
this, whether it be those who prescribe drugs or those who use
them, growth promoters in animal food or anywhere along the way.
That framework needs to be implemented and it has not yet been
fully implemented. We have just moved it to a new level, however,
by moving it to the Patient Safety Initiative which, as you know,
has been supported by the United Kingdom and is the concept of
Sir Liam Donaldson. That group will make a challenge to health
facilities in the year 2010 on antimicrobial resistance in the
hope that we can move this up in the political agenda because
it is very important. We have drugs going out in massive quantities
from the Global Fund and other organisations, and there are not
systems in many countries that are monitoring resistance to these
drugs. These are public goods, they must be preserved and we need
to strengthen the surveillance activity. We are working to do
that, but it is a job which has not yet been done. The framework
fell into disuse after 2003 in WHO, it was not moved ahead as
rapidly as it should have been but now it is being moved again.
Whereas individual programmes have been monitoring very closely
what is going on with their drugs, overall in antimicrobial resistance
the framework has not been implemented.
Q573 Lord Jay of Ewelme:
Presumably the Global Fund itself is concerned about this too
if they are dishing out lots of funds?
Dr Heymann: They will give countries resources
for monitoring if countries ask. They will give resources if countries
ask and, with a solid proposal for monitoring resistance, they
will provide resources.
Q574 Lord Jay of Ewelme:
But they would not be encouraging countries to do it?
Dr Heymann: Not proactively, no. That is a question
you should ask but, as far as I know, they still do not promote
this as one of the major issues.
Dr Gully: There are very few countries that
have good surveillance of antimicrobial resistance, even in a
lot of developed countries. Even if you had good surveillance,
you would also have to ensure a good response ensuring close collaboration
of the healthcare sector, physicians and nurses. I am talking
of nurses particularly in terms of infection control. The second
part is that, even in developing countries, or at least in a lot
of developing countries, there is a huge private sector and, again,
the question of getting information about antimicrobial use and
then control in terms of utilisation in the private sector is
a huge, huge challenge. I think the Patient Safety Initiative
is a really good one but no-one has got a really good answer to
this yet. Denmark has a good system.
Q575 Baroness Whitaker:
Viral forecasting was something that we came across, a new project
at the University of California that was in an article in The
Economist. We asked a former colleague of Dr Heymann's, at
the CDC about it when he gave us evidence and he said they had
been discussing global viral forecasting as a future topic but
that it is very early days. As I recall, this is analysing clusters
of virus infection before the outbreak in animals so as to predict,
with all sorts of interesting mathematics, where might be an animal
pandemic of the sort which could jump across to humans. I wondered
if WHO had any thoughts on this and whether it is an area of work
for you at this time.
Dr Heymann: It is an area of work for us. We
are working with several different laboratories that are developing
multi-antigen diagnostic tests that can diagnose up to 30 or 40
known diseases and in some instances determine the sequences of
unknown viruses that we do not yet understand. In fact, the Gates
Foundation has just provided resources to WHO and a laboratory
in New York, which are working together to develop a mechanism
which can screen animal populations and understand what the different
organisms are. That will not, however, tell us the risk factors
associated with these animals and whether or not they could eventually
infect humans and cause disease: unfortunately, that is something
we do not yet know how to examine, so we will have to just continue
good surveillance.
Q576 Baroness Whitaker:
Thank you. Roughly what proportion of resource is it appropriate
for WHO to put into this very future sort of work?
Dr Heymann: It will depend on what is going
on outside WHO.
Q577 Baroness Whitaker:
What are you putting in now?
Dr Heymann: The two million that will come from
the Gates Foundation.
Q578 Baroness Whitaker:
The Gates Foundation is quite useful?
Dr Heymann: Yes, it is very useful in new areas.
Q579 Baroness Whitaker:
Would it have been the case that the national donors would have
been a bit chary about it because it is all a bit speculative?
Is that where the Gates Foundation is useful?
Dr Heymann: Yes, it is something that is speculative,
and that is why what we have done is assessed the landscape outside
and we know that there is activity, for example at UCLA and I
think that is what you are referring to, Dr Wolf working at UCLA.
Around the world there are groups working on this and, therefore,
we are only trying to stimulate partnerships in this outside WHO
with the money that comes from the Gates.
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