By Mark Chataway
When Dr Margaret Chan, the Director General of the World Health Organization, speaks in private to industry leaders, she reassures them about the desire of the WHO to work with them on health issues. Away from those meetings, she often sounds like an anti-private sector ideologue. There are now signs that the more sensible senior staff at the WHO are rebelling at the anti-industry rhetoric.
Dr Chan can be vitriolic and unfair. Last week, she said that the pharmaceutical industry had failed to develop a vaccine against Ebola because “Ebola has historically been confined to poor African nations.” According to TIME magazine, “she lambasted drug manufacturers for not taking an interest in an Ebola vaccine until the disease became a threat to non-African countries, including the U.S.” This ignores several key elements of the story.
There are, in fact, several vaccines in development; there was just no way to test them outside a laboratory. The vaccines were mostly developed with US government funding so the incentives existed to develop them further: the problem was how. Tests of vaccines on animals are often pointless and always inadequate. These vaccines had been tested on so many monkeys that not even the most avaricious vaccine researcher could ask for more pre-clinical funding. How were they to be tested on humans? The classic pathway calls for phase I safety studies to be followed by phase II and phase III studies in populations at risk for the disease. The phase I studies can only receive ethics approval if they are in communities that may benefit from the vaccine to be tested. So, before the CNN cameras started flying over Dallas, it would not have been ethical to run a phase I trial of an Ebola vaccine in a country that had never had a case of the disease. Even had a phase I been possible, there was no way to run the phase II or III trials of efficacy because Ebola had — until early this year– broken out only in isolated rural African communities where, in the absence of a health system or reliable monitoring, no principled researcher would run a test of an unproven vaccine.
There was only one way to break this logjam: the WHO had to declare that the usual rules did not apply and that an Ebola vaccine could be approved based on safety trials alone. There was a precedent: this is what happened with vaccines against the H1N1 flu virus. It is, in the end, just what the WHO did with Ebola vaccines but not until September 2014 when the West African epidemic had already been ignored by WHO staff for six months — as Dr Chan herself pointed out.
The industry baiting may have gone too far for the more grounded members of the WHO staff such as Dr Marie Paul Kieney, the widely-respected Assistant Director-General for Health Systems and Innovation at WHO. Welcoming the start of human trials of a second Ebola vaccine this week, she said, “these trials show an almost unprecedented mobilisation on the part of countries, health agencies and industry to pitch in and help to curb the Ebola epidemic … If the vaccines prove to be safe and effective and we move to production and distribution scale-up, this will be the fastest vaccine roll-out we have had in response to a public health emergency to date.” Dr Kieney made a point of saying the fastest vaccine roll-out ever just a few days after her boss’s outburst. A coincidence maybe or could it be the start of a fight back by experts sick of the politicisation of the WHO?
Let’s hope so because Dr Chan’s dislike is not limited to the pharma industry. She launched a broadside against the food and drinks industry in February 2013. “Few governments prioritize health over big business. As we learned from experience with the tobacco industry, a powerful corporation can sell the public just about anything … When industry is involved in policy-making, rest assured that the most effective control measures will be downplayed or left out entirely. This … is well documented, and dangerous,” she said in talking about businesses and non-communicable diseases. As we said at the time, Dr Chan may be right about the baleful influence of some big food companies but she is wrong to say that there is a straight fight between the forces of good (the public health community) and those of evil (commercial interests). If good wins, she suggested, regulation and WHO guidelines will overcome “front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt … [and] gifts, grants, and contributions to worthy causes that cast these industries as respectable corporate citizens in the eyes of politicians and the public.”
I wonder what Dr David Nabarro thinks about this view of food industries which “fear regulation, and protect themselves by using the same tactics”[as tobacco companies]? He is the one pictured alongside her in the TIME photograph. Until he took over as the UN System Coordinator for Ebola, Dr Nabarro was (maybe still is) co-ordinator of the Scaling Up Nutrition network. In 2012 he said, “members of the SUN Movement believe that change happens when everyone works together to scale up nutrition policies, programmes and investment. Business has a vital role to play, and I therefore congratulate the SUN Business Network on its launch and inaugural workshop.” Maybe that’s why he looks so awkward sitting next to Dr Chan?
Will the Nabarro vision prevail over a failed, statist model of public health?
Mark Chataway is principal consultant Hyderus, a Wales (UK) based company which works in all areas of public health.
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