Examination of Witnesses (Questions 892
- 899)
MONDAY 28 APRIL 2008
Mrs Zsuzsanna Jakab
Chairman: Good afternoon and welcome.
Thank you very much for your time this afternoon. I just have
a couple of introductory points. The Intergovernmental Organisations
Select Committee of the House of Lords is charged with looking
at intergovernmental organisations, as it says, but in this case
in relation to communicable diseases. You will probably be pleased
to know that we are not looking at the internal workings of the
European Union, which is covered by a separate Committee. I do
want to say that the proceedings this afternoon will be recorded.
You will be sent a transcript of the evidence to make any factual
corrections, if necessary. Also, we would like you to contact
us further if you have any views you want to add to what we discuss
this afternoon. We may have a vote in the middle of these proceedings.
If we do, we will try to resume as quickly as possible. With that,
perhaps I could ask Lord Howarth to ask the first question, which
is about WHO and the role of your organisation.
Q892 Lord Howarth of Newport:
Good afternoon. May I ask you about the interface of your own
organisation with the World Health Organisation's Regional Office
for Europe? The WHO office covers 53 countries, including all
the EU Member States, and the role of WHO Euro is to work to strengthen
Europe's defences against infectious diseases. In what respects
does the role of your organisation, ECDC, differ? Why should two
organisations be needed which would appear to be dedicated to
remarkably similar purposes?
Mrs Jakab: Good afternoon to the Committee.
I am Zsuzsanna Jakab, Director of the ECDC, the European Centre
for Disease Prevention and Control. It is a real honour for me
to give oral evidence to your Committee on this highly important
issue, and many thanks for the first question. I would like to
say that the role of WHO and the role of ECDC are different but
they are very much complementary. WHO is clearly an intergovernmental
organisation that covers the whole world globally and regionally,
including the Regional Office for Europe. It has a very strong
policy mandate—it sets policy and targets; it has a very
strong advocacy role, of course. On the other hand, ECDC is a
new agency of the European Union which was set up just three years
ago in 2005. Our responsibility and our role have to be seen in
the whole context of the EU structure and EU architecture. Our
role is mainly for the detection of health threats, to protect
EU citizens from emerging health threats, we have to analyse these
threats, we have to come up with risk assessments, we have to
come up with scientific advice to policy-makers at a European
level and in the Member States. We have to promote the preparedness
and advise to coordinated response in Europe. This works, of course,
for the 27-plus EU countries. The WHO are responsible for 53 countries,
as you pointed out, and for obvious reasons the WHO has to put
high emphasis on the countries that are outside the European Union;
and they have to put high emphasis also on the diseases that are
not communicable diseases but are the major killers.
Q893 Chairman:
Mrs Jakab, could I briefly interrupt? Your English is amazingly
good but we have a slight echo here. If you could slow down slightly,
I would be very grateful. Your English is remarkably good; let
me compliment you on that. It seems funny for me to be asking
you to go slower, but there is a slight echo and we are not getting
everything.
Mrs Jakab: My conclusion is that there is no
overlapping in the roles and in the mandate of WHO and ECDC. The
roles are absolutely complementary: that is a very important point.
This is one of the buzzwords that I would like to give you in
my reply to this first question. The second buzzword is that we
have to have synergy. We have to make sure that the strategies
are coordinated and also established for the high-risk countries
that WHO Euro has developed. The second important notion for WHO
and ECDC is synergy. The third important issue is the partnership.
I was myself in WHO Euro for several years before I went back
to my own country, and I was leading the country health development
programmes in WHO Euro. I really believe that WHO has a very important
and significant role to play, which has to be supported. Collaboration
and partnership are absolutely vital. In 2005 I signed a Memorandum
of Understanding with WHO Euro, and once a year we have a meeting
at the highest level. This year it was at the end of February
which also included the Assistant Director-General from WHO Geneva.
Once annually we have a high level meeting like this. This year
we agreed that every three months we should have a video-conference
in addition to that. At the political and at the strategic level
we already have the on-going collaboration, and at the operational,
technical level it has already been developed between our teams,
WHO Euro and ECDC, so that is already in place. The synergy is
very important and this is the way to ensure it. We also contribute
to certain elements of the Commission's and the Council's decisions.
In the European Union many of the important decisions are taken
by the Council, with the Ministers sitting there. When an issue
falls into the ECDC mandate, they ask for a contribution from
ECDC to make sure that decisions are evidence-based. Therefore,
we contribute through our advise both to the policies but we also
contribute to the work of the European Commission when it comes
to legal issues. ECDC has no policy mandate and no legal power,
but we do have an advisory role here; and, whenever the Commission
wants us to contribute, we do that. That is why I was saying that
our role has to be seen in the context and in the light of the
whole EU set up and EU infrastructure. We are not an intergovernmental
organisation like WHO, but we are an EU agency—part of the
family—with a responsibility to the EU and we bring the
scientific evidence to ensure a sound decision is made.
Q894 Chairman:
If you look down the line ten to 20 years, would you see this
type of organisation being replicated in other regions of the
world and replacing the role of the nation states to some extent?
In other words, would you see other regions creating a regional
organisation like this? Is that what you see happening?
Mrs Jakab: I think the PAHO initiative before
and after the Second World War was something similar to what we
have now in the European region. The European Union Member States
are looking into that model, how it works and how we can ensure
a partnership. Here the key issue is that WHO and the European
institutions have to develop a very close partnership. In recent
years we have gone a long way in Europe to bring WHO and the European
institutions together and we have to go further and deeper in
this exercise. That is why I would like to emphasise again that
here the issue is not about ECDC and WHO; here the issue is about
the EU and the WHO. In the EU important decisions are taken in
the Council; DG SANCO has a very important public health programme
which runs a number of programmes and takes important decisions
for the health of the European Union citizens. In addition to
that, we have the European CDC in the development phase. All these
issues together have to be looked at, and we have to see what
is the best way to ensure a very strong and very deep collaboration
between these institutions and WHO and I can assure you that this
has been on the mind of the policy-makers in Europe in the past
year.
Chairman: We are going to have to break
now for the vote. I would ask all Members to come back as quickly
as possible, and then we will start with Lord Hannay's question.
The Committee suspended from 3.46 pm to 3.54
pm for a division in the House
Q895 Lord Hannay of Chiswick:
You spoke very eloquently about the interface with WHO. Could
say just a little bit about the interface with the National Health
Authorities who, after all, have huge budgets and are very big
operators in this field, and also about your interface with the
various research institutions around the European Union, who also
are devoting big resources to all these problems? I just wondered
whether you could say something about that, because I think the
issue of potential duplication runs in both directions, upwards
to the world level and downwards to the national and research
level.
Mrs Jakab: This is a very important issue. I
would like to emphasise that the European CDC was based and built
up on a model that takes into consideration the fact that the
European Member States have very strong national public health
institutions very strong infrastructures and experize. The founding
fathers of ECDC took a very wise decision when they said that
we should not duplicate. We do not want you to have research institutions
belonging to ECDC directly; we do not want you to have laboratories
linked to ECDC; we do not want you to follow the American model
of the US CDC. What we want you to do is to network with the European
institutions, network with the European nationals. This is the
thought process behind ECDC. We have to link ourselves to the
public health institutions in your country; we have to link ourselves
with the research institutions and to the excellent expertise
that you have. Therefore, if you look at the founding regulations
of ECDC, it is very clear that we have to work with the Member
States in many ways, and I would like to highlight at least three.
One is that we are an independent institution, but we have a governing
body which is our Management Board. In this Management Board we
have the representatives of the Ministers of Council from all
over the European Union countries. We have an Advisory Forum,
where we have representatives from national public health institutions
from all the EU countries, plus we have a list of competent bodies
which are our collaborating institutions in the Member States.
The Member States of the EU have compiled for us a list of competent
bodies with which we have to collaborate. Therefore, please rest
assured that there is no duplication, and we have a lot of interaction
with the Member States to decide what are the European CDC priorities
and programmes. We only engage on those issues where we can bring
an added value into the European structure.
Q896 Lord Avebury:
You mentioned that you did not want to replicate the CDC, although
you do say somewhere in your evidence that the idea was to create
a European CDC. I wondered in what sense you thought you were
creating a European CDC and in what sense you differ from them?
Mrs Jakab: The American CDC, CDC Atlanta, was
one of the first institutions that I visited when I took up this
job. I wanted to see how they operate. There are clearly similarities
and differences between these two institutions, CDC Atlanta and
the European CDC. The similarities are the following. The decisions
for health, health systems and organisation of health care and
the financing is very similar in the United States to what it
is in the European Union, because there are very strong national
competencies. In the United States this is the same. There is
a very strong responsibility at the State level for all the health
issues and a limited responsibility at the Federal level for health
issues. Therefore, in my view, the power and the mandate of the
European CDC and the US CDC do not differ too much. I would not
say that the CDC Atlanta and ECDC differ too much in this regard.
The American CDC cannot do more at the Federal level than what
it can do at the European level with due respect to the competencies.
They have a huge budget and they use the "carrot approach"
. I was told they use the carrot approach by putting out calls
for tender to the States and they want them to apply and thus
the Federal level of the CDC financing these activities. We do
not have so much money here, therefore we compensate it through
networking. We have a very, very close cooperation with the European
Member States' institutions. There are clearly differences, and
one of the biggest difference I see is that the CDC Atlanta is
a huge establishment; it has a number of centres together which
is coordinated by a central place. They have a number of research
institutions and a huge pool of international research centres
and the laboratories. They also have a huge budget, but please
bear in mind that they are not only covering communicable diseases
but the full spectrum of public health, including communicable
diseases, food safety, occupational health, NCD and determinant,
etc plus they are not only covering the United States but also
40 countries outside the United States. Whenever I am travelling
in India, for example, I see huge operations from the US CDC.
These are clearly differences, but I would also say that the European
model is a different model because of the European specificities,
the strong national public health capacity is there and should
not be duplicated. The final comment on this is that the US CDC
was set up about 60 years ago in 1946, something like that. We
are a very young institution in the European Union, just operational
in the last three years. We are very new; we are still in the
development stage but, if we look again at this issue in a few
decades from now we may find that a different situation has also
developed in the European Union CDC. I personally believe that
it was a very good decision of the founding fathers of the European
CDC to set up this institution, because there is a big interest
among the national public health institutes to have this coordination
role in place which was not the case before ECDC was put in place.
Q897 Chairman:
One obviously hopes there will not be, but if there were an outbreak
of pandemic flu, for example, WHO Europe would have to coordinate
with all the 53 countries in their region. Would they not then
be duplicating things if they also have to go to you? The question,
in a sense, is that WHO has got to liaise with all of these countries
but also liaise with you, and there is a slight anxiety that that
might cause confusion. What would you say to that?
Mrs Jakab: I would say that there cannot be
enough coordination on such an important issue as an outbreak
of pandemic flu. We have had several simulation exercises in Europe
in the last two or three years since we were established. Some
were organised by us, others by the Commission. We have had one
big exercise on pandemic preparedness. The scenario was developed
by the Health Protection Agency in the UK, and it was a very,
very successful event. In that case the European Commission, ECDC
and WHO and the MS's participated in this exercise. We had Emergency
Operation Centres and there was absolutely no confusion in the
exercise; the roles and the mandate were very clear. In the European
Union you have to look at this in the light of the division of
roles and responsibilities between the different players. I said
that the Member States had a very strong mandate in taking decisions
on the risk management of health measures. This is coordinated
by the European Commission, whereas ECDC contributes to this process
through risk assessment. We have mainly a risk assessment role
and an advisory role. In the EU the European Commission will coordinate
the work of the Member States, with the input from ECDC, the adoption
of any public health measures. It is therefore again not only
an ECDC/WHO issue, this has to be rolled out also towards the
European Commission, and other institutions of the European Union.
There are many different players in this case.
Q898 Lord Hannay of Chiswick:
This is not entirely different from what we have been talking
about, but in our evidence that we have been taking from a very
wide range of research people, governmental representatives, international
organisations, we are continually struck by the fact that you
do have considerable difficulty in working out how all the bits
fit together and whether the architecture is really designed to
produce the maximum value for money and impact on dealing with
communicable diseases. For example, one can see that the WHO is
very heavily engaged in Malaria, and I do not imagine Malaria
is a hugely important issue for the ECDC. In some of the other
big communicable diseases, the balances between the WHO's role
and that of other organisations will be different. We are always
struck by the fact that everyone says that WHO is indispensable,
but they also say that it is under-resourced; they also say that
they wish it could give more of a lead. One is bound to ask the
question: might it not give a bit more of a lead if the field
were not so cluttered with other organisations?
Mrs Jakab: Thank you very much for this important
question. I would like to approach it from two sides. First of
all, I think it is a positive development that we are so many
players, because this shows that health has really become a priority.
It is a priority under the Development Agenda and basically we
have reached what we wanted to reach, to have a number of players
around and to involve both the community and civil society in
the decision-making process. We have seen the flourishing of all
these NGOs and civil initiatives, which is extremely positive.
On the other hand, you are absolutely right that there are so
many players on the ground and we need to have much more coordination
and much more synergy. You are also absolutely right in saying
that the WHO is under-resourced. I also believe it is, and this
is why WHO has to accept a situation whereby a relatively-small
regular budget on the one hand and rather large voluntary donations
on the other, which sometimes support the priorities that are
set by WHO, sometimes they are not. Sometimes WHO's priorities
are driven by those organisations giving the voluntary donation.
I would also suggest that WHO resources should be increased globally.
It is true that we are not dealing with Malaria in the European
Union, but with climate change this may come, so I cannot discount
it. Having said this, the number of players needs a lot of coordination,
and I think WHO has to be in a position to play this coordination
function. I would not like to see new organisations coming up
just to play this coordination role; I think WHO has to play it.
Sometimes it plays it very well, like in the Member States where
there is a large and well resourced WHO Country Office which links
all the donors and the players together. It plays it extremely
well. If the WHO office is smaller due to the size of the country
or the size of the budget, than it has a limited capacity. At
the moment I think WHO has to be more resourced to play this coordination
role more effectively together with its other global leadership
functions. Beyond this, I also believe that the various players
have to develop partnerships; from our perspective we are clearly
doing that. We have Memoranda of Understanding with all of the
important players, first of all with the European institutions
obviously to develop close collaboration, but with all the important
players. I think this is a very important issue also for the others
to follow, that on one hand you have close bi-lateral arrangements
between the players and on the other hand there is a body—in
my mind this should be WHO—which plays a coordinating role
and should be supported by resources. The best way to do that
coordination is to have a policy and strategy that is agreed upon
by the international fora which provides a very good platform
for all the partners coming in and coordinating the activities.
Q899 Chairman:
You can always send in more information if you wish to after the
hearing. But do you now have access to the WHO International Health
Regulation website? Do you or do you not have access to that now?
Mrs Jakab: Not yet but it is in the pipeline.
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