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The International Health Partnership, which, I know, the Minister in the House of Commons, Gillian Merron, sees as very important, encouraged close co-operation between the donor countries and the recipient countries. That is important, and we want to keep an eye on it. I know that the Government place a high priority on that. The Government’s response to this has been very positive, although we have some disagreement in one or two areas, including that of the OIE. I would like some clarification at some stage on the World Bank: are we saying very clearly that it ought to invest more in health infrastructure?
The committee was set up as an ad hoc committee—there is a long history to that, but I do not wish to repeat it. The development of global systems is now so rapid, so important and uses so much money from taxpayers that this House will miss the great opportunity of playing a key role in looking at the way we spend money and how these international organisations develop, particularly, as they move increasingly into the area of legal requirements, as with the international health regulations. If we do not find an alternative to the existing committee, which will now come to an end, we may regret losing such an opportunity, given the House’s specialist membership, with so much knowledge of both disease and intergovernmental organisations.
3.27 pm
Baroness Eccles of Moulton: My Lords, it is a pleasure to speak in this debate on Diseases Know No Frontiers, which results from the work of the committee so ably chaired by the noble Lord, Lord Soley, who has pretty well done my job for me. The committee could have chosen a great many topics for its first inquiry into intergovernmental organisations and how we are making use of our membership of them. However, examining how IGOs are tackling the global spread of infectious diseases turned out to be a complex and worthwhile exercise. We took evidence from many dedicated and experienced witnesses, who enabled us to build up a picture of how things are at present and what most urgently needs to be done to contain future threats. Following the old maxim that prevention is better than cure, we believe that preventing the spread of disease is an important factor to be pursued. I should like to say a few words on prevention of each of the four diseases that we selected for special attention, but I shall concentrate a little more on HIV and pandemic influenza than on the other two.
With malaria, control is achieved through a combination of practical measures, such as the spraying of dwellings and the provision of insecticide-impregnated
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Preventing the spread of HIV is largely dependent on changing lifestyles, including, for example, sexual relations and the use of contaminated needles. However, the balance between prevention and treatment has reached a Catch-22. The evidence suggests that effective treatment through the use of antiretroviral drugs could actually increase the prevalence of the disease unless it is accompanied by effective and sustained prevention measures. The will to change behaviour may be undermined by a sense that, with the effective antiretroviral treatments available, the disease is no longer such a threat and horror. Nick Partridge, chief executive of the Terrence Higgins Trust, said that,
- “good therapy ... makes people healthier but it certainly does not reduce, it increases, the prevalence of HIV overall ... It also creates an ongoing need for funding drug therapy which can squeeze out funding for good prevention campaigns. What is vitally important is that both go hand in hand”.
In the case of pandemic influenza, prevention is largely dependent on surveillance so that the necessary steps can be taken to prevent the virus from spreading rapidly. In order to achieve comprehensive surveillance, rather than in richer countries only, an effective global alert and response system needs to be maintained to help to identify emerging infections and deal with them at source. We understand that the University of California is carrying out research into patterns of emerging infections with a view to developing risk-based forecasts of what the next pandemic might be and where it might appear. That research is still in its infancy.
The London School of Hygiene and Tropical Medicine believes that global disease surveillance has improved markedly in the past decade. Dr Coker, reader in public health there, told us that,
- “the SARS crisis forced a re-think globally on global surveillance and was really, in a sense, a dry run for pandemic flu”.
The noble Lord, Lord Soley, drew our attention to GOARN; I am sure that noble Lords will remember what those initials stand for. However, it is worth emphasising the need to invest in basic health infrastructure to provide a firm foundation on which more specific disease control initiatives can be built. That is in our national interest as well as in the interest of other countries. The committee recommended that,
In their response, the Government stated that they are currently preparing their international pandemic influenza strategy, which details the direction and objectives of the UK’s international efforts on pandemic preparedness over the next three to five years.
I end by endorsing the plea made by the noble Lord, Lord Soley, for consideration of the importance of the topics still in the pipeline that could relate to our membership of IGOs. There will be many more
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3.34 pm
Baroness Whitaker: My Lords, this new and, to my mind, very important committee had a good start with the chairmanship of my noble friend Lord Soley and the services of our Clerk, Robert Preston, and his team. They succeeded in confining a potentially vast subject into a manageable space and enabled us to discover some alarming and relatively unknown areas of concern. They are not unknown to all; my right honourable friend the Prime Minister identified dealing with disease and global pandemics as an element in the national security strategy last March, one which required a global response. My noble friend Lord Robertson of Port Ellen and the noble Lord, Lord Ashdown, wrote in the Times last June:
“The pandemic threat is not so serious just because of the possibility of a disease outbreak but because, in a world of people moving on this scale, a disease could be upon us long before we know it is even there ... This is not a temporary state of affairs but a permanent one and an interdependent world is a world of shared destinies”.
One of the most striking things that I learned was the high proportion—it is three-quarters—of new infections which come from animals by jumping the species. This is not new knowledge; it was only new to me. Most of us know that most of our common, communicable diseases began when the human race went in for agriculture and close proximity to farmed animals. Your Lordships might think, therefore, that those organisations which were set up to deal with animal health and those for human health would be aligned to share information and control measures most efficaciously. That is not what we found, as our report shows in some detail, yet the danger is greater now that animals are moved so far and so often for farming, hunting, food, laboratory and pet trades and on an increasingly globalised scale. People penetrate into the depths of the forest and the jungle more than before, and use its products more exhaustively.
As my noble friend Lord Soley said, there is no set of international health regulations to deal with animal infections, and we recommended that there should be. I regret that the Government, in this case, did not agree with us. While there are, for instance, EU directives on some of these zoonotic diseases and some general directives for agriculture and food safety, there is none to oblige disease monitoring for nature and biodiversity. Some think that the UK does not match its DfID investment in research on avian flu with full enough assessment of all future risks posed by wildlife in general. Then there is the whole area of which animal viruses, among the myriad which infect animals, will make the jump and which will turn into lethal diseases. This science, too, is in its infancy, not least because the places where these jumps happen most often are the poorest countries, in the tropics, with fewest scientific resources to identify them.
When we looked at the management of serious infections that had reached humans, we did see change and progress. Rationalisation of the complex web of organisations was being addressed by the international
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The word “poor” keeps cropping up in any discussion of the control of infectious diseases. It is no accident that their toll is so infinitely less in rich countries. The best way to stop the devastating mortality of AIDS, malaria and tuberculosis and the other life-threatening plagues is to eradicate the poverty, poor living conditions, malnutrition and lack of clean water which are the daily lot of those who die before their time in such large numbers. These, the non-health determinants of health, are now analysed by the WHO. They also need on-the-ground analysis by the local and national governments concerned. This is where the redistribution of resources, which is intrinsic to democratic politics, saves lives. Inequality breeds disease and early death.
Professor Sir Michael Marmot told us that if the WHO had health equity as a core value, it would be institutionally natural for the WHO to bring in the non-health causes of ill health such as education, poverty, trade, habitat and migration and to promote measures that alleviated their adverse effects. The new report of the WHO’s Commission on Social Determinants of Health, which Professor Marmot chaired, bears eloquent witness to the relationship between social justice and health. However, in our output-driven funding habits, it is hard to measure the impact of any non-health measure on any particular disease, unlike, say, immunisation, so there is a disproportionate incentive towards vertical programmes rather than improvements of the whole system. We have made recommendations to improve the focus, as well as the accountability, of both international and national health organisations through UK action.
It is important, we thought, that the World Bank’s new strategy put health in the context of its overall strategy for poverty alleviation. Perhaps the clearest lesson from our seminars was that in devising mechanisms to protect our own populations from deadly diseases from distant places, we should remember that we will do this best if we join in removing their fundamental basis: the soil of poverty in which they flourish.
Finally, as my noble friend Lord Soley said, the UK contributes sizeably to the intergovernmental organisations that we have been considering and many others. This
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3.41 pm
Lord Crisp: My Lords, as the first speaker who has not been a member of the committee, I congratulate it on a very good report that dissected the issues, drew out the key points, and finished quite rightly on the sobering note that a pandemic is likely at some point.
I very much agree with the noble Lord, Lord Soley, that the UK’s reputation in this field is very good indeed, and it is against that background that I make some comments about how more could be done. The first point that I was going to make was made by the noble Baroness, Lady Whitaker. I therefore merely echo her remarks, with which I agree completely, about the non-health issues—the determinants of health—and the importance in that context of the World Bank playing a full role alongside the World Health Organisation and others.
Two points arise from the report and are crucial to the success in controlling the spread of communicable diseases; they are, if you like, about our vulnerability. The first point is about the UK’s interdepartmental collaboration. The report calls for more collaboration, the Government acknowledge it, and the big policy statement, Health is Global, is as good as any such broad policy document that I have ever seen on this.
How good are the Government in practice at using the strengths of the departments to reinforce each other? This is a universal issue. Three years ago, on behalf of the previous Prime Minister, I called a meeting of a number of countries to look at health and development globally. I found that every country sent two representatives—one from its equivalent of DfID and one from its equivalent of the Department of Health—apart from France, which sent three. It also sent someone from its Foreign Office. The fact that government is not totally joined up is not unique to the UK.
The important point is that the globalisation of health has implications. There is the potential for pandemics and a huge movement of staff. There is trade, drugs are sold all over the world, and above all there is an enormous movement of people around the world. We need to have a real understanding of the linkages between first-world health and development issues. The health service in the UK must act as a global player and in a global context, and when DfID deals with health it must do so with the best health knowledge available. I still do not think that I see this in practice. I know that there is good co-operation at the policy level, but is it happening in practice? The test question for the Minister is: when DfID is dealing with the development of a health system in a country, how often does it ask the Department of Health for help from its experts or ask for help from the best health experts in this country, or does it simply use its own parallel systems, processes and structures?
I am not asking this question naively. I understand that there is a difference in health issues in different countries and I absolutely recognise the expertise in
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The parallel test question is: when the Department of Health or the Health Protection Agency is dealing with a problem originating outside this country, how often does it call on DfID for advice to make sure that it has a real understanding of what is happening in that country? This co-operation is getting better, but it is still a weak point. While I know about the relationship around health, I suspect that the same thing must be true in other areas, such as education.
My second point concerns staffing. There is a huge shortfall of health workers around the world, which is the vulnerability that underpins all others. We globally are as vulnerable as the most vulnerable point, and the most vulnerable point is likely to be in a poor country with poor health and social conditions, with very few health workers and with people who may not be able to recognise the problems as they arise. That is our big vulnerability.
I know that the UK and others are part of the innovative financing task force, which is co-chaired by the Prime Minister and the president of the World Bank. Again, I would ask the Minister for reassurances that in looking at its work, attention will be given not only to innovative funding for staffing, which is part of its terms of reference, but also to innovative approaches to staffing. My point is simple: staffing is not just about doctors and nurses. It is about all those public health professionals, public health local community workers and mid-level workers—they are called a number of names in different countries—who work in the most difficult conditions and are therefore most likely to see where the problems are. Therefore, the issue is not just about making sure that the UK supports innovative funding mechanisms in order to increase the levels of staffing in health services around the world but also about increasing the innovative structures. You do not want to have the same grades and types of staff as we have in the UK in many of these countries. We will miss an opportunity if we raise money to increase staffing, but do not use it to have the most impact on issues such as communicable diseases, which will tend to be at the most local level often with the staff who have had the least training.
Incidentally, in parenthesis, the UK has the most tremendous tradition of health education, and throughout the world it has played its part in the education of doctors, nurses and others. It has, I believe, a great opportunity, if the appropriate arrangements can be made, to support training and education internationally. That would be a very positive contribution to the globalisation of health education and would help to support poor people globally.
In summary, this excellent report has laid out the ground very well and has expressed our vulnerabilities. I believe that these two areas require more attention and more action.
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3.49 pm
Lord Desai: My Lords, it is a great privilege to thank my noble friend Lord Soley for having initiated and having led this inquiry in a most efficient and charming manner. We finally got to grips with what is really an enormously complex subject. Before I turn to the topic of the report itself, let me reflect that today we are going through another global pandemic, a financial one. If only there were as many institutions around the world talking to each other about disease control as there are talking about financial problems, the situation might not be as bad as this. I can put it no more strongly than that. As my noble friend said, while in the report we concentrated on four major diseases, many others are no less important. We just did not have the time to deal with them. In poor countries especially, these other diseases are just as important as the four we looked at. We were also as much concerned with globalisation on the health front as with the role played by intergovernmental organisations in combating global diseases.
I want to make some points that have not yet been made because the report has been welcomed by my noble friend Lord Soley and others. We thought that we would encounter a jungle out there of overlapping jurisdictions all interfering with each other in trying to deal with the problems of the four global diseases, but instead we found a much greater degree of clarity among the people involved, especially those at the WHO. They know what they are doing and have ways of co-ordinating with other players in the field, so that while from the outside it may look messy, it is not as untidy as we thought it would be.
On the nature of structures, there is a contrast between vertical and horizontal health issues. In my view, the vertical structures are not in a sense co-ordinated enough because we have institutions like the WHO, to which DfID contributes in a vital way, and many other similar organisations. Poor countries find themselves receiving visits from unco-ordinated groups from different nations, each bringing their own agenda and each wanting a return from the recipient country on the buck they have given. We were told that in countries like Tanzania and Malawi, officials in the health ministries have to host as many as 340 delegations a year. I do not know when they find the time to do any proper work. We ought to worry about whether there is a way of co-ordinating this stuff so that fewer delegations visit individual countries, and those that do, do not just push their own little angle. Rather they should ask about outcomes on the ground as a result of donations and worry less about whether a particular country’s dollars have resulted in a particular cure. The question should be: has a cure been achieved? Given the fragility of staffing levels both in terms of organisation and health needs in poor countries, devising some sort of co-ordinating mechanism would make a tremendous contribution. This requires on the part of taxpayers in the rich countries a bit of trust that, although we do not quite know where the DfID dollar has actually gone, we can take it that their dollar has been properly utilised and that outcomes will show how that has been the case. The global structure needs to become slightly more co-ordinated and less nationalistic and protectionist over individual donations and the return on them.
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I turn now to one or two other problems. In the case of pandemic flu, we face a problem that is not unknown in international relations: countries are often unwilling to share evidence of the occurrence of an outbreak. That happened famously in Indonesia. Countries are very often afraid of the economic impact it will have on investment, business and tourism if they admit to a problem. Again, we have to find mechanisms of compensating countries which are honest and come up with a warning that will benefit all of us. We have to tell them that if there are problems and if costs are incurred, the World Bank or some other agency such as the International Monetary Fund will compensate them, but the importance for the world at large is that they share this information and share it as quickly as possible.
Problems of sovereignty in terms of both the recipient and donor countries often get in the way of efficiently tackling the problems of disease. The matter may not be the specific responsibility of a particular government department but one about which the global leadership should think carefully what to do.
One of the lessons we would obviously like to learn from what we have done is the tremendous importance not only of the need for more resources at the vertical structures but also, as my noble friend Lady Whitaker said, of the horizontal parts of the health problem, which is the general problem of tackling poverty. It is extremely important, at a time when we are all feeling rather hard up in terms of the financial meltdown, that the global leadership—the G8 especially, and the G20—does not resile from the task of keeping up international aid so that the flow of international resources which is most needed by the poorest countries continues. Yes, we are slightly worse off, maybe by 10 per cent or 15 per cent, but even so we are still 20 to 30 times better off than those people who are really at the front line of suffering from some of these diseases. It behoves us not to fall back but to keep our commitment to helping tackle health problems in the poorest countries as far as possible.
3.57 pm
Baroness Barker: My Lords, it is a true delight to take part in this debate. I thank the noble Lord, Lord Soley, the committee and the staff with whom he worked for producing a really excellent and interesting report. I thank him for the informative and engaging way in which he introduced a very complex report examining quite deep seated issues. It is a very timely analysis of a really complex set of organisations with overlapping roles, multiple areas of expertise and fragmented funding streams. That is a recipe for disaster if ever there was one.
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