Examination of Witnesses (Questions 1000
- 1018)
MONDAY 12 MAY 2008
Professor David Fidler and Dr Kelley Lee
Q1000 Lord Avebury:
Maybe Dr Lee would be able to answer this. In the Crisp Report
there is a recommendation that DFID, in particular, is to meet
with representatives of HPA, HCC, NICE, HCS, CIC and the private
sector, to see how practically they could collectively strengthen
health systems in developing countries and agree on plans for
doing that. Would this be a general approach? Crisp is making
that recommendation for us as a donor country. Might it be applicable
to other donors as well?
Dr Lee: I think there is a shift beyond the
UK to other donors and agencies in this direction. The World Bank
certainly has a Health Systems Development Initiative now. Not
the Gates Foundation so far, although there are ongoing discussions
that they need to emphasise less the kind of magic bullet approach,
the biomedical focus. There has been a shift in the debate in
the last five years, perhaps, which is encompassing the WHO as
well. I think there is a recognition that things are not working.
Hopefully, it is not going to be the latest thing and people will
focus on health systems as long term strategy—which is not
a new message, it is just that nobody seems to want to listen
to it. There are opportunities for the UK at present to try to
push that message.
Q1001 Lord Avebury:
It might be a new thing to co-ordinate the health authorities
and health private sector partners in developed countries, to
co-ordinate what they are doing with regard to the development
of health systems in the third world?
Dr Lee: I think you are right. There is this
consensus emerging. There are individual voices but I have never
seen—though I have only been in public health for 20 years—such
a shift in the discussion as marked as this in terms of support
for health systems development. So I think you are right, there
is something new there to grab on to perhaps and push.
Chairman: In Switzerland, in the second
tier of their structure on the Department of Health there, they
have appointed someone with responsibility for global health.
It is an interesting development.
Q1002 Baroness Whitaker:
I think we also have a global health concept now within the Department
of Health. Turning to the splendid International Health Regulations,
I think you mentioned, Professor Fidler, the problems about implementation.
It is readily understandable that developing countries do not
have diagnostic or surveillance capacity, nor for that matter
preventive and treatment capacity for other aspects of health
care. We also know that new serious infections emerge quite rapidly
perhaps once a year, so the International Health Regulations have
never been more needed. Would you say that the developed countries
ought best to use their funds to help the developing countries
have the infrastructures which could implement the IHR? Would
that be the correct enlightened self-interest approach to prevent
the spread of communicable diseases?
Professor Fidler: I think the IHR 2005 provide
a sort of gateway for donor countries to re-focus some of these
resources, again in a sort hybrid way-vertical but having the
capability for horizontal impacts through the implementation of
the IHR. Again what is worrying is that no one seems to be terribly
interested in funding that implementation. Even in the context
of things like Prime Minister Brown's launching of the International
Health Partnership, they are not talking about the implementation
of the IHR, and so it leaves me to wonder whether any strategy
is going to emerge that is going to address those issues directly.
Everybody talks about implementation, but there is no strategy
and there are no funds and seemingly no interest in doing this.
Particularly given how important the International Health Regulations,
are an opportunity is being missed here. Again, it is a hybrid
approach. I think Kelley is absolutely right. We need to get away
from verticality. You begin to build those core, basic systems
and that is going to create, within the countries, synergies with
regard to building that outwards as well. I see this being a multiplier
effect with regard to doing this. I have to be honest and say
that I do not see right now interest from State actors, from the
NGOs either for that matter, in IHR implementation. That is not
resonating with the source code. That is a big concern with regard
to how I perceive that potential missed opportunity.
Q1003 Baroness Whitaker:
Organisations do not seem to see the funding of a new laboratory
as quite as sexy as a primary health care clinic. But that might
well be a recommendation we ought to make. Even if they were much
better implemented, so that you could detect and identify a new
communicable disease very rapidly, they do not have much place
in reducing the spread, do they? What about restrictions on travel
and trade? That is not their bit. Should we do something about
that?
Professor Fidler: Let me run through where the
IHR 2005 are useful with regards to controlling or preventing
spread—and, again, some of this is in theory remember. It
is not only in building the core capacities for surveillance,
but you are also obligated to build core response capacities.
Assuming everybody had those core response capacities, that may
in fact give you a better chance of controlling and mitigating
the spread of infectious diseases if everybody has reached a certain
baseline level. The problem we have now is that that does not
exist, so it escapes, it gets away.
Q1004 Baroness Whitaker:
Do you mean that on the back of IHR implementation, a government
would have, as it were, a mandate to restrict trade or travel?
They might not want to do that.
Professor Fidler: In terms of trade or travel
restrictions, what the new International Health Regulations do—and
this is part of why they are so radical in their design—is
to give the WHO Director-General the authority to issue temporary
recommendations which could, depending on the disease, involve
recommendations about trade and travel restrictions that other
countries do not have to implement but have to take into consideration.
The mere fact that the WHO Director-General might do that is going
to give you the incentive to co-operate early and often with the
WHO in the event of a breakout you do not understand. If you get
WHO assistance in early, and you are transparent in your reporting,
that early assistance may help control the spread of the disease.
Other countries too are going to be more willing to give you assistance
if you have been transparent with regards to the outbreak that
has happened. That is exactly what we want from a public health
point of view. We want to create the incentives for getting the
WHO and public health focused on that and get the assistance targeted
right where it needs to be—because you do not want to be
in the position where the WHO has to contemplate issuing travel
or trade restriction recommendations against you. To a certain
extent, that is part of how it plays with the self-interest of
governments to do exactly what we would want from a public health
perspective. It is not enforcement then; it is the fear of those
recommendations. Even though they are non-binding, you do not
want that to happen. You saw what happened with SARS: countries
got hammered politically and economically when the WHO issued
those recommendations—without any legal authority to do
so. Now they have legal authority to do it. Your incentive? Work
with WHO early when this happens. Be transparent, so we can get
the assistance we need. That, I think, could have positive implications
for the control of some diseases. A lot of this is in theory:
it depends on having some capabilities, in country but also more
in the sense of capabilities that the WHO needs to be able to
ride to the rescue when they are asked to do so. They have done
an admirable job of that with the resources they have at the moment,
but I do not think anybody there would pretend that those resources
are adequate for their responsibilities under the IHR.
Q1005 Baroness Whitaker:
It is your assessment that the WHO themselves cannot fully implement
the IHR in their action unless they have more targeted resource
there?
Professor Fidler: They would be more able to
implement the obligations they have effectively if they had more
resources. There is no question in my mind about that.
Q1006 Baroness Whitaker:
Particularly related to that?
Professor Fidler: Yes. Again, this is what is
worrying. Even in connection with empowering the WHO to use the
authority that the States, in an unprecedented way, gave them
authority to do this, they are starved of resources.
Q1007 Lord Jay of Ewelme:
While we are still on the WHO, I would like to pick up on something
you said earlier on. You said that we should not forget that there
will be areas under the new dispensation when the WHO will become
more important. Could you say very briefly what those would be?
Professor Fidler: Surveillance and responses
to outbreaks. Remember, the new IHR builds in these non-State
actors informations, so the WHO can get information from anywhere.
Utilising the power of information technologies, somebody with
credibility and legitimacy has to sift through all that to figure
out what is noise and what is a problem. That credibility is not
going to exist for a single State—certainly not the United
States, but not even a country like Canada, which is held in high
regard with regard to this. It is just not possible. You need
the WHO. You would have to create it if you did not have it. You
need the WHO that has the legitimacy and the credibility to sort
through that, so that, when it picks up information from an NGO
source about something going on inside a country, and the WHO
calls the health ministry of that country, they can have a productive
conversation about that. Here is a situation now where the WHO
is even more important than it has ever been with regard to surveillance,
because it has the ability to take in all these new sources of
information, whereas before with the IHR all it could take action
on was information it got from governments. That was part of the
problem. Second, the States Parties to the IHR have given the
WHO real power. Except for the Security Council's authority under
Chapter VII of the UN Charter, I cannot think of any other international
organisation the States Parties of which have granted to the Director-General
material power in this way, to do countries severe economic and
political damage, over their objection. This is remarkable. Here
again is a situation where the WHO possesses an authority which
makes it more important than it has ever been with regard to thinking
through how countries should respond with trade or travel restrictions
to an outbreak. Again, the only entity that is really able to
do that credibly is the WHO.
Q1008 Baroness Eccles of Moulton:
But they cannot do it because they do not have the resources?
Professor Fidler: You could see a situation
where we know, given the disease—if it is virulent, highly
pathogenic, and it is easily transmissible—you are going
to be in a situation where the WHO can exercise its authority.
You know we are not going to be able to control it in that particular
developing country: it is going to hit everywhere else. Everywhere
else needs to be ready for when that hits, but you have to be
sure that you are not engaging in irrational behaviour. "Here
is what you should do," the WHO is telling Member States.
Other Member States are going to continue to have the sovereign
right to issue their own travel recommendations and trade restrictions
if they want to. You cannot take that away: it is a matter of
sovereignty. But, under the new IHR, they have to follow scientific
and public health principles when they do that; and, if they are
putting something more restrictive in place than what the WHO
has recommended, they have to justify that. Even in the context
of the dynamics of that, the WHO plays an absolutely critical
role. This is part of why the IHR is so revolutionary in what
they are trying to do.
Q1009 Chairman:
You used the phrase a few moments ago "WHO rides to the rescue".
You are not saying ride to the rescue as it has this overarching
authority to say, "You must do this." They do not necessarily
do it themselves but they may offer the services or suggest the
services of other organisations, countries or whatever, or suggest
that the country does it itself. I ask this because there has
been a bit of a debate about whether the WHO ought to be doing
the job or overseeing that the job is done. Do you see what I
mean?
Professor Fidler: Yes, I see what you mean.
I actually think that is a false debate. The WHO is never going
to have the capacity to do these things.
Q1010 Chairman:
It is not either/or.
Professor Fidler: There is the sort of immediate
response—and the WHO is very skilled at this. This often
happens. If there is an outbreak in Africa, they think it is Ebola,
in goes the WHO team to help the local capacity figure out what
is going on and bring the outbreak under control. They are very,
very good at this, but, again, that is small-scale outbreaks where
the WHO can respond. If this is on any larger scale, you cannot
make WHO the world's public health agency. This is a problem in
the US too. The CDC does not have enough staff to deal with an
outbreak in California. It has to work with the California authorities.
But it is often in the role of leading how the response will occur,
and the WHO has to play the same role. It is not that you have
to have this massive capability where they can handle any outbreak.
This is never going to happen. That is why I say I think that
is false debate. But do they have enough even to do what they
are required to do under the IHR? I hear that they really do not
have enough resources. They could do a more effective job if they
had, not huge amounts of money, but a little bit more money than
they have at the moment. Remember, they are tapping into a lot
of these networks which are on autopilot. This is the other great
thing about network governance: you do not have to sit down every
year and come up with a budget for the network; it operates based
on different incentives that people have. More resources for the
WHO in that context would allow it to do a more effective job
with regard to the authority and responsibilities it has been
given under the IHR.
Q1011 Chairman:
Before I move on to intellectual property rights, could I ask
you, Dr Lee, if you would like to add anything there.
Dr Lee: I suppose I do not disagree with what
has been discussed. Picking up on what Baroness Eccles was hinting
at, there is a related issue maybe, and perhaps Professor Fidler
took the discussion a different way. It is the capacity of the
WHO, perhaps, to strengthen disease surveillance in countries.
It does not have those resources. Where there have been new resources,
disease surveillance has received quite a lot of resources but
perhaps not enough. I have nothing against disease surveillance,
and think there needs to be more resources. What I wanted to add
is my concern that there is an emphasis on surveillance without
looking at disease prevention and response. We need to have much
more emphasis on these and not only using surveillance as an early-warning
system for us—because it seems to be perceived that way
in countries like Indonesia, that we are only interested in surveillance
because we want to protect or own selves, and we want to have
early warning so that we can, whatever we do, put up the fortress
measure described earlier. It is really about enabling countries
to also respond and supporting them to do that. These aspects
gets even less resources. In fact, it probably is not even on
the agenda. Whenever we think about response, we think about stockpiling
antivirals in this country; it is not about enabling countries
like Indonesia to prepare and respond to outbreaks. I do not want
to disagree, but I think it is yet another example of a skewed
priority list for donors and for the WHO as well.
Q1012 Lord Avebury:
A thought has occurred to me. When we were discussing this a minute
ago, you said that Burma was a global public health disaster and
that the WHO does not have any entrée there, presumably,
so that, if there were outbreaks of communicable diseases, they
would not be calling the WHO to help, and the first we would know
about it would be a large-scale appearance of that disease in
the inhabited areas. Is that correct?
Professor Fidler: Yes.
Dr Lee: I suppose so, yes.
Professor Fidler: There were huge problems in
Burma before the cyclone, with HIV/AIDS, Malaria, TB. In the nature
of this regime—
Chairman: One of the things that has
struck me for a while is that the problem would be with States
like that, North Korea as well and possibly Zimbabwe at the moment,
where your opportunity to know when you have a major disease about
to hit you is very little. It is one of the issues which, I think,
does re-shape the intergovernmental structure for the future.
We just do not have a way of dealing with it.
Q1013 Lord Jay of Ewelme:
I do not want to get into Burma conversations, but there have
been some NGOs working quite effectively in Burma and are continuing
to do so. It is not a completely hermetically-sealed state; something
could get out, but not via the governmental or intergovernmental
agencies. It is the non-State actors again.
Professor Fidler: That is how we know about
the problems, not through the sort of traditional mechanisms.
That is why it is critical that you build that into the global
surveillance system that we have. You avoid the problem, at least
initially, of these recalcitrant governments, but at the end of
the day you still have to deal with them and, if they refuse to
have the WHO come in ... ..
Chairman: I want to move on to
Lord Howarth on the Indonesian issue which we have already touched
on.
Q1014 Lord Howarth of Newport:
Could we pursue for a moment the line of thought that Dr Lee was
just now developing when she was talking about Indonesia and the
attitude of Indonesia? Unwillingness to fulfil the letter and
the spirit of the International Health Regulations is not confined
to developed countries and the refusal to provide the resources
needed to enable the WHO and the IHR to be properly implemented.
The perception of Indonesia, as we understand, when they refused
to provide the Avian Flu virus samples, was that these obligations
were not designed with their interests in mind; they were designed
to enable the vaccine to be produced, the benefits of which would
be experienced in other parts of the world, wealthier parts of
the world, but not for their own people. Is there an extensive
perception in the developing world that international regulations,
whether it is International Health Regulations or Intellectual
Property Rights, are engineered, if you like, in the interests
of others than themselves?
Professor Fidler: First, I think we have to
be very careful about the Indonesian virus controversy and the
new IHR. The new International Health Regulations do not require
the sharing of virus samples, so Indonesia was not violating the
IHR. This is where the WHO came out early and said that they were,
and ended up backing off from that. This is the first real test
case of the IHR.
Q1015 Lord Howarth of Newport:
Is that because the IHR were badly drafted. Was it the intention
they should have had to or not?
Professor Fidler: This is interesting in terms
of the debates that have come up with regard to this question
because, as I presented the international legal analysis that
Indonesia or any country that is party to that treaty is not required
under the regulations to share live virus samples or any biological
materials for that matter. The response was, "But that's
absolutely critical to doing global surveillance." If that
is the case, why did you not write it in the IHR? You knew at
the time that the IHR were being drafted that controversies about
virus sharing with SARS were already on the agenda, so it was
not as if this issue surprised anybody. This is not a mistake,
this is not bad drafting, it is what the parties intended. Indonesia
is it is not under an obligation under the International Health
Regulations to share these virus samples, but it is not willing
just to rest on sovereignty. Indonesia has said that the rules
that ought to apply with regard to this issue is the Convention
on Biological Diversity, a treaty which is more sensitive to the
interests of developing countries with regard to protecting their
biological diversity. The problem with that argument is that it
does not really work for Avian Influenza. The States Parties to
the Convention on Biological Diversity before the Avian Flu controversy
with Indonesia said that Avian Influenza was a threat to biological
diversity and that everything ought to be done to eliminate the
threat. What do you need to do to eliminate the threat? You have
to share the virus, so you can have surveillance. They had a very
weak argument on the flipside of that. Underneath all of this
is an agenda directly connected to the controversy about Intellectual
Property Rights. This I where I think the negotiations that are
going on now are not being productive, because it has become a
fight about IP interests and not about surveillance and the global
health crisis that the lack of the sharing of those virus samples
has become. There are issue linkages here which have made the
negotiations very, very difficult. There may be this underneath
agenda that is trying to shake up the way in which Intellectual
Property Rights are protected in international law, because there
is the perception from the developing world, as we have indicated,
that TRIPS and that high-level of protection of Intellectual Property
Rights is not in the interests of developing countries. That is
where there is the divergence of national interests on that issue,
and that is why, in Indonesia or in any other context, we have
very little progress on that issue. There is no consensus. There
is no meeting of minds on IP issues in global health. That is
bogging things down across the board.
Q1016 Chairman:
You did draw attention in your paper to the serious trouble we
are in on threats of biological weapons. You have referred us
to certain reading, which I have to confess I have not done as
yet. Most of the evidence we have had on this suggests that the
response to a deliberate outbreak is not essentially different
from a natural outbreak. Do you share that view?
Professor Fidler: Partly. This is what the book
goes into in great detail. It is what we call the synergy thesis:
anything you do to prepare for a biological weapons attack will
stand you in good stead if it is an outbreak of naturally occurring
infectious diseases and vice versa. You have probably heard this
over and over again. To start breaking that down into specific
public health actions that need to be taken, the record looks
is a lot different from what the synergy thesis would lead you
to believe. In some areas you can develop deep synergies. The
two greatest areas are in surveillance and response functions.
But, even there, the synergy thesis is really in theory only,
because with regard to the way countries are operating internally
as well as externally, there are what we call in the book fault
lines in this context. One fault line is between an emphasis on
biological weapons versus an emphasis on infectious diseases.
At some point the synergy breaks down and allocation choices are
made. Public health people think they are made the wrong way,
and security people think they are made the right way. The second
fault line is between your own national needs and what the international
community needs, and the tendency is to spend more money at home
than on international needs. We have, as we have been talking
about, this huge surveillance gap. Yes, theoretically you could
develop these synergies, but you are not, so there is a gap that
exists. It is the same with response. There is this huge response
gap. In between, there are other interventions in which public
health engages: prevention interventions and protection interventions,
in which you are going to find virtually no synergies at all.
When you have a choice you have to make: how are you going to
allocate the resources; for example, you take actions to eradicate
a disease from a naturally occurring infectious disease point
of view. If you eradicate smallpox, what does that do on the biological
weapons side? Oh, my gosh, you just created a biological weapon!
This is clear also if we eradicate polio. We are then going to
have to worry about polio being used potentially as a biological
weapon because nobody will be vaccinated. You do not have any
synergies there. With protection interventions you harden the
target. You know the population is going to come into contact
with microbes, so what do you need do to address that? Public
health says vaccination, wash your hands, safer sex—there
are lots of protection interventions in which you can engage.
None of those help you protect against a biological weapon. Similarly,
if you inoculate or vaccinate your troops for a potential anthrax
attack, that does not give you any benefit on the public health
side. Those interventions create no synergies whatsoever. The
synergy thesis itself needs to be broken down and looked at very
carefully with regard to specific interventions to public health
when undertaken in either context. When you look at it as we do
in the book, we analyse this in detail, you start to see the synergy
thesis has some real problems.
Q1017 Chairman:
As a lawyer, do you see there is a part solution in increasing
the authority to inspect factories or units that might produce
such material?
Professor Fidler: The possibilities for verification
or compliance protocols through the BWC are dead and buried and
will not be resurrected.
Q1018 Chairman:
You are making that judgment why?
Professor Fidler: Because the whole process
of the BWC, the traditional arms control process, is going through
the same transition that we have been talking about with regard
to global health. There is no longer confidence in the traditional
approach. That traditional arms control approach, State-centric
focused, based in a treaty, worried about the use of one State's
biological weapons against another State, is not the problem today.
We are much more worried about bio-terrorism. The BWC does not
really have anything in it that helps us with that. Second, we
are now concerned, mainly because of bio-terrorism, that we are
going to have to respond to attack. There is nothing in the BWC
to help. They did not even think about that issue, frankly. It
has never been a serious part of that arms control approach. You
see the BWC process more interested in issues which have no foundation
in the BWC—and, again, we talk about this in the book. You
see the BWC trying to catch up to governance trends which have
happened outside the BWC context. How interesting! The WHO is
trying to catch up to governance trends that are happening outside
the WHO. You see these parallel things developing in both of these
worlds. In the book we try to bring these together in a networked
governance approach, building both on the BWC norms and the IHR
to try to integrate these in a way that produces better and fully
combined biosecurity, so there is detailed explanation of the
way forward with regard to those issues. That way forward, however,
does not catch everything. It is specific to certain types of
infectious disease threats—not even all infectious disease
threats but certain types of infectious disease threats. People
who want to take a broader view would accuse us of being part
of the problem too, adding another idea to the mix of ideas that
has already been thrown out in connect with that. We, however,
see a way we can bring the concern about biological weapons and
infectious diseases closer together with a different type of network
governance structure that we think would make more progress.
Chairman: Dr Lee and Professor Fidler,
thank you very much indeed. We have kept you longer than I had
anticipated but we are very grateful for a very full and detailed
exchange there. If anything occurs to you after this hearing that
you feel you ought to have drawn to our attention, either as something
you wanted to say or some new suggestion or thought, please do
not hesitate to write to us. We would welcome that. Thank you
very much indeed for your time.
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