Memorandum by the British Medical Association
Thank you for the opportunity to submit evidence
to the House of Lords Science and Technology Select Committee
on issues relating to human infections diseases in the UK. The
particular questions that the Select Committee is interested in
addressing have been considered by the BMA and our comments are
It is felt that many of the factors which change
a society's experiences of infectious disease may have their roots
in decisions some way removed from science or health or agriculture.
By way of a historical illustration, the Black Death, the plague,
caused by the bacillus Yersinia pestis killed 20-25 per cent of
Western Europe's 80 million population, between 1348 and 1352.
It is believed to have been introduced by the Mongols of the Golden
Horde who had swept westwards from Central Asia and laid siege
to Kaffa in the Crimea, a trading post established by the Genoese.
Plague broke out among the Mongols investing the city. It is believed
this was as a result of the Mongol's practice of killing marmots,
which carry the plague bacillus without getting disease, for their
furs. Contemporary accounts have them also throwing the corpses
of plague victims over the walls of the invested city. Plague
subsequently spread along the trade routes around Europe. This,
apart from illustrating that the emergence of infectious disease
is not a new phenomenon, also indicates a number of the categories
of factors that are repeatedly seen to contribute. It shows the
critical roles played by movements of peoples, in this case the
Mongols, and patterns of trade, particularly of fur and silk.
It shows the role of transportation whether medieval ships or
Tartar horsemen. It also indicates the ever-present threat of
biological warfare. These four aspects, changed in their detail,
are recognisable as key general problem areas in the prevention
of infection today.
The comparatively monolithic nature of health
services' organisation in the UK when compared with other developed
countries means that human health surveillance usually functions
at least adequately. It does of course rely on a cultural preparedness
to share information, in the public interest between health professionals.
This culture has received certain setbacks, of late.
Veterinary surveillance has been more problematic
but has been reviewed and is the subject of redevelopment by DEFRA.
A particular gap is the lack of surveillance for companion animals,
particularly with the relaxation of restrictions on their movements
brought about by the passports for pets scheme. A further issue
is the integration of surveillance data from human health, animal
health and food which in the UK, compared with a number of countries,
notably the Netherlands and Denmark, is very underdeveloped.
Problems arise when moving from surveillance
("information for action") to taking action whether
it be treatment or prevention or further investigation
in the field. This always requires a modicum of intelligence and
courage. Three things provide an additional handicap.
1. ResourceMuch of the fieldwork
capacity resided between health authorities and local authorities
(in their environmental health department or equivalent). As a
result of NHS reorganisation, health authorities have disappeared
in England and are due to disappear in Wales. This has left Consultants
in Communicable Disease Control housed temporarily in various
organisations and loss, particularly of support staff. Similarly
following the modernisation of local government, local authority
environmental health departments have enjoyed mixed fortunes.
Often they have lost status and resource to areas of local government
activity with a higher political profile such as education, social
services or housing.
2. The Research ParadigmFor a number
of reasons public health investigations have increasingly become
viewed not as public health practice (by analogy with clinical
medial practice) but research. Reasons for this, amongst others,
are the fact that public health investigations utilise similar
(usually epidemiological) techniques such as questionnaires and
surveys and an increasing involvement of academic bodies in research
in the field of public health (in itself welcome). When a public
health investigation becomes viewed as research it comes under
the research ethics committees. This inevitably adds the bureaucracy
of an application process, may introduce delay and sometimes effectively
prevent the work taking place at all.
3. The News MediaThe proliferation
of radio and TV channels as well as the internationalisation of
news means that the sheer volume of media inquiries can pose a
considerable obstacle to the efficient pursuit of an investigation
as well as diverting substantial skilled resource from solving
whatever is the problem. There is a potential compensation in
that this could result in greater public understanding and awareness.
Unfortunately, the narrow economic requirements of the News Media
as an industry determine coverage and if anything, often distort
public understanding. Issues with a complex technical background
and long gestation period fare particularly badly. Some examples
are HIV and AIDS where some newspapers expended a lot of energy
in denying that HIV caused AIDS, and the MMR controversy which
is substantially sustained by media coverage. These are sins of
commission. An example of sins of commission is the early years
of BSE, where sustained serious journalistic interest in the possible
relationship with CJD might have been beneficial but none was
This document contains a good synopsis of many
of the wider issues that can result in infectious disease problems.
The solutions proposed are, however, substantially of an administrative
nature, involving the reorganisation of existing services. Much
of the focus of the latter is, also, not infectious diseases but
wider aspects of health protection (particularly from chemicals
and radiation). If this is not to be, at best, neutral, much will
depend on the resource given to the new agency as well as the
energy and independence of its leadership.
The Joint Committee on Vaccination and Immunisation
has a mechanism for addressing decisions on vaccination that has
substantially stood the test of time. The improvement in the organisation
of the vaccine programme and in uptake of most vaccines since
the early 1980s could be considered a considerable success. Nevertheless
although in "the Green Book" and similar publications,
doctors and other health professionals have an accessible source
of advice, many only have a hazy notion of the scientific and
epidemiological basis of this official advice and how it is arrived
at. This may be a handicap in giving the vaccination programme
the support and professional commitment all such programmes need
to sustain success. More open government, as reflected in documents
such as the government's code of conduct for scientific committees,
may potentially bring unanticipated benefits by remedying this
and building trust.
It is clear that there are a number of quite
disparate threats, even without considering biological warfare
about which much has been written, which must not be lost sight
of. HIV is proving difficult to contain and despite success with
treatment will remain a heath burden until a vaccine is successfully
developed. Verotoxin producing E.coli O157 remains a relatively
rare disease in the UK, with the exception of parts of Scotland.
Nevertheless infections result in a high burden of illness, often
in children and there is an ever-present threat of outbreaks.
Containment requires action by a number of agencies at a number
of levels which may prove difficult to sustain.
The scale of the variant CJD epidemic remains
unclear even though there are some grounds for cautious optimism.
Preventing potential human to human spread via surgery and blood
transfusion is proving a complex and sometimes costly exercise.
The development of a vaccine for group B meningococci
remains a priority. It will become an even more pressing issue
if any transfer of virulence genes form group C strains, a plausible
consequence of the welcome and successful vaccination campaign,
were to take place.
Finally experience with Foot and Mouth Disease
(FMD) and Classical Swine Fever (CSF), which are not zoonotic,
should alert us to the risk of the introduction of zoonotic animal
diseases. Had Nipah virus rather than CSF or FMD been introduced
from the Far East, the consequences for human health, particularly
in occupations dealing with pigs or pork would have been much
greater. The steady expansion of the Pets Travel Scheme, although
welcomed by the public, may well have disease introduction consequences
which are difficult to predict.
As well as addressing the provision of structures
that directly address infectious disease there is also a need
to consider more widely those policies which may, as a by product,
either make infectious disease problems more or less likely. With
national and international policies a formalised approach to assessing
the infectious diseases impact, such as microbiological risk assessment,
may be helpful. Internationally, a policy framework might be an
overall review of the International Health Regulations to take
into account the more diffuse nature of human contacts through
globalisation of markets. They were last subject to major revision
in 1969 and cover only plague, cholera and yellow fever. They
do not reflect the modern day nature of a number of markets with
an impact on health such as food, tourism and health care. They
are being revised and modernised by WHO and will move away from
reporting of three specific diseases towards reporting of syndromes
of international public health significance. Although WHO will
consult WTO in this process there is a case for considering the
development of a wider role for WTO in a broader regulation, on
health grounds, of the movement of peoples, animals and goods.
The latter body is influential on national a governments in a
way WHO is not. Further, as a recent joint WHO/WTO report, "WTO
Agreements and Public Health" acknowledged (BMJ 31 August
2002, page 460), "governments may put aside WTO commitments
in order to protect human life". Thus any new regulations
may be a legitimate restriction of trade.
Where people and goods move quickly, information
to contain infectious diseases must move quickly as well. Electronic
communication has facilitated this. However the legal framework
around the transmission of information has become progressively
more complex and restrictive. The Health and Social Care Act 2001
has qualified the justifications of "medical purpose"
and "public interest" which allowed patient identifiable
information to be shared, without necessarily obtaining the patient's
consent, under the Data Protection Acts and the common law. Although
the Health Service (Control of Patient Information) Regulations
2002 now provide a mechanism for the Secretary of State to give
permission for patient identifiable information to be shared without
consent, that mechanism is cumbersome and bureaucratic and the
permission has to be renewed at least annually. Simplification
of these regulations or how they are administered would be welcome.
Quite apart from the energies that such processes use up, they
foster a culture inimical to the sharing of information of all
kinds, on which surveillance and disease control are ultimately
based. An alternative approach might be a new public health act
actively requiring modern system of disease reporting.
Finally the News Media represent a well organised
and well capitalised industry whose actions have a demonstrable
impact on health, sometimes for the worse. Arguably they have,
just as any other industry, a duty of care which may be enforceable
under the Health and Safety at Work 1974. This, or other mechanisms
which might promote the reporting of health topics in such a way
as not to diminish the health of the population, could be explored.