80.Throughout the Ebola outbreak, there has been sustained criticism of the World Health Organization (WHO). Reviews of its performance have concluded that it was far too slow in responding to the outbreak and that lives were lost as a consequence. It was not until 8 August 2014, nearly six months after a major Ebola outbreak in Guinea was reported by the WHO, that it declared a ‘public health emergency of international concern’ (PHEIC) and began to mobilise a coordinated, international response to tackle the epidemic. There has since been further discussion of the WHO’s responsibilities in global health governance and whether it should be more “operationally engaged”. Dr Ripley Ballou from GSK described how he contacted the WHO repeatedly in March, June and July 2014 about accelerating trials for an Ebola vaccine but was instead told that the WHO had “no policy that even contemplated the use of a vaccine in an Ebola outbreak”.
81.The Report of the Ebola Interim Assessment Panel (the Stocking Report), the Harvard-LSHTM Independent Panel on the Global Response to Ebola, and numerous other reviews have each identified reforms to strengthen the WHO’s leadership, restore its credibility, and help ensure that the international community can more effectively manage global disease outbreaks in the future. We were encouraged to hear from the Minister that she had spoken to both the Director-General of the WHO and the Chair of the WHO’s Ebola Interim Assessment Panel about the need for WHO reform. DFID and the Department of Health are, we were told, working with the WHO on a “blueprint for research and development for infectious diseases with epidemic potential”, which could improve the WHO’s capacity for managing future disease outbreaks.
82.Witnesses were careful not to lay blame solely at the WHO’s door for weaknesses in the international response to Ebola. Though acknowledging that the WHO was “extraordinarily slow” in tackling the outbreak, Professor Chris Whitty suggested that it was dangerous to assume that this was “someone else’s fault”. He stressed that we “all have to accept that WHO is owned by all of us; it is the international community and, if there is a problem with it, it is our problem as much as anyone else’s”. Professor Paul Cosford of Public Health England agreed adding that “the WHO is an organisation of member states, of which we are one, so we bear some joint responsibility” for failings in the way it responded.
83.Witnesses were clear, nevertheless, that the timing of the UK’s overseas response was hindered by the WHO’s delay in declaring a public health emergency. As Professor Tom Solomon of the University of Liverpool explained, “the response of individual countries, like ours, is limited if the WHO has not recognised [an outbreak] as an international emergency”. The UK could not, as Professor Whitty described it, “just march in and say, ‘You don’t think you’ve got a problem but you have got a problem, and we are going to sort it out’”. For Professor Solomon, one of the key challenges for the future was “how to get greater international recognition so that individual countries can embark on a response”.
84.We recommend that the Government supports the reforms proposed in the Stocking Report and the Harvard-LSHTM Independent Panel, as well as the WHO ‘Blueprint’ initiative, to ensure that the World Health Organization is fit for purpose and equipped to deliver international leadership when the next major disease emergency strikes.
85.Under the Civil Contingencies Act 2004, the Government has a duty “to assess, plan and advise” for emergencies. One way in which the Government exercises this duty is through its National Risk Assessment (NRA) process; a comprehensive, classified appraisal of the most significant emergencies (malicious and non-malicious) that people in the United Kingdom could face over the next five years. This information is then used to shape its plan for, and response to, such threats.
86.Since 2008, a National Risk Register (NRR), an unclassified version of the NRA, has been published to assist individuals, communities and local commercial organisations in their planning. Though the broad category of ‘emerging infectious diseases’ has featured on the NRR since it was first published in 2008, Ebola was not specifically referred to until the 2015 edition. We questioned whether such a broad category was appropriate, particularly since the UK failed to anticipate the extent and severity of the Ebola outbreak in West Africa. The Academy of Medical Sciences suggested that it might “be useful to have a more detailed technical appraisal of the risks posed by specific potential emerging infectious diseases”. Professor Adrian Hill from the Jenner Institute thought it would not “be difficult to get consensus about what the top five or 10 target diseases should be. […] That is not the difficult bit; you can get a committee to do that”.
87.The Chief Medical Officer and the Minister both disagreed with this approach. When asked about fleshing out the ‘emerging infectious disease’ category with the “top 10 risks” and designing “protocols for each of those”, the Minister replied that she was “a little worried” it could lead to “complacency”:
I would be a bit nervous about something as pinned down as a top 10, because if we had a plan for those we would be tempted to take our eye off surveillance and horizon scanning.
When pressed to identify ways to strengthen the detail on emerging infectious diseases in the NRR, Dame Sally stated that considering the “transmission” mechanism was key: “Is it respiratory, blood-borne, vector-borne or food-borne?” She told us that:
we try to have, and we do have, protocols in place for those groupings that we can fine-tune if something comes: “There we are, Ebola blood-borne.” We have had cases of Lassa fever and Crimean Congo haemorrhagic fever before, but the basic protocols are there for different things.
The CMO’s transmission ‘groupings’ do not appear in the 2015 edition of the NRR.
88.We appreciate the Chief Medical Officer’s reassurance that protocols are in place to respond to different types of disease emergencies, according to their transmission mechanism. However, the groupings she described do not feature in the 2015 edition of the National Risk Register: Instead, the broad category of ‘emerging infectious diseases’ is used. This is the same broad category which has been in place since 2008, yet it did not prepare our research, science advice or political response systems for a public health crisis on the scale or time-frame of the Ebola outbreak. We are not convinced that this wide-ranging category is sufficiently detailed to enable responders without clearance to view the National Risk Assessment to prepare adequately for the next disease outbreak. Furthermore, given the far reaching lessons learnt from the Ebola outbreak, it seems extraordinary that the Government does not appear to accept the case for refining its emerging infectious disease risk assessment and protocols.
89.In its response to this report, we ask the Government to set out with which responders it shares its respiratory, blood-borne, vector-borne and food-borne emergency response protocols. These groupings should be used to structure the ‘human diseases’ section of the next edition of the National Risk Register.
90.In an era of ever increasing globalisation, the health of UK citizens is inextricably linked to events taking place hundreds, sometimes thousands, of miles away. There is a growing recognition that while action can be taken in the UK to protect its citizens from outbreaks in other countries, it may need to be matched by the deployment of its skilled personnel and resources overseas to contain major disease outbreaks at source.
91.Public Health England (PHE) confirmed that its “bread and butter work” was “controlling outbreaks in the UK” and acknowledged that it was not as well equipped to respond overseas. It was unclear how strong its mandate from Government was, prior to the Ebola outbreak, to establish an international epidemic response capability, and the extent to which this would become a key function of the organisation. The cross-Government Health is Global Plan 2011-15 and PHE’s Global Health Strategy 2014-19 both support the principle that diseases do not respect national borders. Yet the Epidemic Diseases Research Group of the University of Oxford reported that “operationalization” of this concept had “been limited”. We were repeatedly told, for example, that some of the UK’s interventions overseas during the Ebola outbreak were ad-hoc. As a result, it appears that they were not necessarily as effective, or as targeted, as they could have been.
92.Dr Oliver Johnson from the King’s Sierra Leone Partnership commented that “at times there were not senior public health officials as part of the leadership team in Freetown [in Sierra Leone] who could help to understand what was happening. A colleague out there described the British response as a bit deaf and blind as a result”. The lack of British epidemiologists in Sierra Leone was particularly singled out:
From my perspective, there was not the same epidemiological footprint from Public Health England on the ground [...] To compare it with the US Centres for Disease Control, they had perhaps 70 people on the ground; at every meeting I went to, a senior public health specialist from the US would be present informing US decision making.
Professor Paul Cosford from PHE recognised that “myriad CDC personnel [were] present all across the world”, but added that this level of “capacity is not the sort of numbers we have”. In the case of epidemiologists, he clarified that PHE had “one person” in Sierra Leone “leading our epidemiology and other work at the moment; we have had people plugged into some of the district emergency response centres, but it has been ad hoc”.
93.Dr Johnson maintained that a decision needed to be taken by the Government as to whether the UK needs a domestic capacity that can be deployed overseas or whether, as a country, we are content to rely on the WHO and US Centres for Disease Control. The Minister suggested that a more international outlook to disease control was being contemplated:
One of the big lessons we learned within the Government and as a nation is that our best protection at home is helping to fight disease abroad. Thinking of it like that was quite a turning point for the nation […] We will look back on that as the moment we really understood that our world is so interconnected that our best defence at home is by making sure we invest in and support work abroad effectively.
94.The Chief Medical Officer also pointed to a proposal for establishing a ‘rapid response force’ which would be on permanent standby, ready to deploy to countries with disease outbreaks. Professor Cosford told us that the proposal was a “key part” of PHE strengthening its international public health functions and would be “good for the UK reputationally”, while helping “to protect our own health as well”. The Head of the Civil Contingencies Secretariat, Campbell McCafferty, told us that the “rapid response team [was] about identifying that we did not have capability that could deploy quickly and looking to fill that gap as we move forward”. He also highlighted additional provisions announced in the National Security Strategy and Strategic Defence and Security Review 2015. The Review stressed that the UK has learned lessons from major incidents overseas, including Ebola, and promised the publication of “a national bio-security strategy in 2016”. This, it stated, would address the “threat of natural disease outbreaks, as well as the less likely threat of biological materials being used in a deliberate attack”.
95.The Government’s ‘Health is Global’ plan states that the Government will “protect the health of the UK proactively by tackling health challenges that begin outside our borders”. It is not clear, however, what would prompt the UK to intervene overseas, or what level of capability and capacity the UK should be able to deploy in such situations.
96.We recommend that the forthcoming National Bio-security Strategy sets out what would trigger an in-theatre response by the UK to a disease outbreak overseas. In addition, the Strategy should make clear what level of capability and capacity the UK should be readily able to deploy overseas in the event of a disease epidemic or pandemic. This should include details of the roles and responsibilities of relevant Government departments and how they would deploy sufficient resources.
97.In addition to Public Health England staff being deployed overseas, we also heard about the NHS staff, including GPs, nurses, clinicians, psychiatrists and consultants in emergency medicine, who volunteered to assist in Sierra Leone during the height of the Ebola outbreak. By November 2014, over “1000 NHS staff and 185 staff from Public Health England [had] put their names forward” to volunteer. Our evidence, however, suggests that the call from the Government for volunteers came late and was poorly communicated. The Pirbright Institute stated that the request was “not well publicised or co-ordinated” which, in turn, “resulted in difficulty in the rapid recruitment of appropriately skilled scientists for deployment”. The Microbiology Society agreed that “the initial call for volunteers from the wider microbiology community could have been made earlier and advertised more widely”. The Society went on to recount some of the difficulties faced by volunteers both in negotiating a period of absence from their ‘day job’ as well as reacclimatising on their return. It thought that a much clearer framework for volunteering in future disease emergencies was needed.
98.We can only admire the courageous and selfless actions of UK volunteers, and their West African counterparts, throughout the Ebola outbreak. However, some employers lacked the capacity to release their staff or to manage their return. Some individuals were left on their own to negotiate a leave of absence from full-time clinical roles and research to assist in West Africa. We are concerned that the ad hoc nature of these arrangements made our clinical response more fragile than it needed to be. This is a structural weakness that should be addressed.
99.In some situations, Public Health England’s capacity may need to be augmented by volunteers drawn from across the NHS, public sector, universities and beyond. We recommend that a clear framework facilitating the timely deployment of volunteers overseas, in response to an epidemic, is agreed and put in place now, ready for use in the future. We encourage the Government to consider the model used by NHS Trusts when employing staff with Reserve Forces commitments who may be subject to short notice mobilisation in conflict zones.
141 World Health Organization, Final Report of the Ebola Interim Assessment Panel, July 2015 (“the Stocking Report”); Suerie Moon et al, “Will Ebola change the game? Ten essential reforms before the next pandemic. The report on the Harvard-LSHTM Independent Panel on the Global Response to Ebola”, The Lancet, volume 368, (2015), pp 2117-2226
142 Colin McInnes, “Changing authority in global health governance after Ebola”, International Affairs, Vol 91 (2015), pp 1299-1316
145 Supplementary written evidence submitted by Jane Ellison MP, Parliamentary Under Secretary of State for Public Health ()
146 Q80 [Professor Whitty]
147 Q80 [Professor Whitty]
149 Q16 [Professor Solomon]
150 Q80 [Professor Whitty]
151 Q16 [Professor Solomon]
152 Civil Contingencies Act 2004,
153 Cabinet Office, , March 2015
154 The Academy of Medical Sciences and The Royal Society () para 12
155 Q57 [Professor Hill]
157 Q186 [Dame Sally Davies]
159 Q145; Q138; Public Health England ()
160 Epidemic Disease Research Group, University of Oxford () para 3.6
161 Qq137-137, Qq173-174
167 Q186 [Minister]
170 Q186 [Campbell McCafferty]
171 HM Government, National Security Strategy and Strategic Defence and Security Review 2015. A Secure and Prosperous United Kingdom, , November 2015, para 4.131
173 - 212924, answered on 10 November 2014
174 The Pirbright Institute () para 5.iii
175 The Microbiology Society and the Society for Applied Microbiology () para 22
Prepared 21 January 2016