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									European Policy Centre




                         COMMUNICATION TO MEMBERS S18/06

  PUBLIC HEALTH IN EMERGENCIES: TRANSATLANTIC EXPERIENCES
                                 Policy Dialogue - 31 March 2006


The European Policy Centre held a Policy Dialogue on Public health in emergencies: transatlantic
experiences. The speakers were Frank Rapoport, Partner, McKenna Long & Aldridge; Robert
Shotton, Director in the European Commission’s Directorate-General for Health and Consumer
Protection; Moya Wood-Heath, Civil Protection/Emergency Planning Adviser from the Red Cross
EU office in Brussels; Marc Ostfield, Senior Advisor on Bioterrorism, Biodefense and Health
Security, US Department of State; Steve Bice, a Senior Manager at Battelle Corp. and Former
Director of the National Stockpile Division, US Centers for Disease Control and Prevention (CDC);
Dan Gold, Senior Vice President, Pharmaceutical Operations, at Rockville, Md.-based Human
Genome Sciences Inc; John Martin, Director, World Health Organization at the EU; and Mark
Rhinard, Senior Researcher, Swedish Institute of International Affairs. EPC Senior Adviser
Eberhard Rhein chaired the meeting.
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Frank Rapoport said the outbreak of bird flu in some parts of the world had prompted the US
government to realise that it lacked the necessary countermeasures - specifically, medicines and
vaccines - to protect its population.

Last summer, US President George Bush signed into law Project BioShield, providing new tools to
protect Americans against a chemical, biological, radiological or nuclear attack. Among these is a
$6 billion fund allowing the government to enter into contracts with pharmaceutical manufacturers
for vaccines. Under such deals, if companies develop a drug accepted as part of the national
stockpile, the government will guarantee to purchase it. The law also allows the government to
accept a drug before it has been approved by the US Food and Drug Administration, albeit with
some restrictions.

Some progress has been made in purchasing and stockpiling the first cure for anthrax developed by
Human Genome Sciences, as well as a treatment for acute radiation sickness caused by a “dirty
bomb”. However, the US programme has been slow to get off the ground and the Bush
Administration has been criticised for not doing enough.

EU perspective

Robert Shotton outlined the preparations being made by the EU institutions to cope with a human
influenza pandemic.

First, the EU decided a few years ago to establish a Centre for Disease Control and Prevention in
Stockholm (which is not yet fully operational) to take charge of medical and scientific research in
communicable diseases; networking across the 25-nation bloc; building a consensus on medical and


            Part of the activities under the European Security & Global Governance programme
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non-medical responses to medical emergencies; and conducting a review of Member States’
preparedness plans.

The Commission is also working on contingency plans in case large numbers of staff are unable to
report for work, and seeking to establish accelerated budget and other decision-making procedures
to use in an emergency situation.

Mr Shotton said it was essential to define what a crisis is - and the difference between an
‘emergency’ and an ‘event’ - and who would activate these special procedures. There are also
templates of messages to go out to the media.

Important lessons came out of a series of “exercise” drills based on a human flu scenario. These
included the fact that all important phone numbers tend to be stored on computers, which would not
be available if information technology systems were down, underlining the need for communication
capabilities to be backed up.

As far as EU Member States’ are concerned, most have tried to identify a clear person - a so-called
‘flu czar’ - who would be in charge of coordinating the response to an emergency. This would
include dealing with both health and non-health aspects, such as police and security services. An
important part of this, said Mr Shotton, is getting the flu czars to work together.

EU governments are also discussing the production of vaccines with the pharmaceutical industry,
with both sides recognising that they would need to work together to stamp out the first signs of a
pandemic by dealing with ‘hot spots.’ However, some Member States are readier than others, with
some hoping to ‘free ride’ any EU distribution network.

On the international front, the EU has pledged to help the countries most at risk, such as China and
Vietnam. However, many issues remain to be tackled, such as what kind of travel advice should be
issued to EU nationals in parts of the world where there was a flu outbreak should they be ordered
or advised to return home or stay where they are to contain the crisis?

Another difficult but important task is to prepare the media to provide sound health advice and
minimise panic. “We can prepare but this is going to be a difficult thing to manage,” admitted Mr
Shotton.

Human versus animal health

An important distinction must be made between the EU’s powers in human health and animal
health. In the former, the Union does not have strict legal or budgetary instructions to act if Member
States are unwilling to work together. However, when it comes to animal health, the EU has very
extensive powers and can, for example, order Member States to cull birds.

Avian flu is currently a serious problem, “totally disastrous” for the poultry industry, with reported
cases in some 13 Member States. “We expect many more outbreaks,” said Mr Shotton, adding that
the first priority should be to protect the health of poultry workers and the rural population living in
affected areas. Although there have been no proven human cases so far, there is a “real risk” of one
or two isolated cases.
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NGO perspective

Moya Wood-Heath addressed the role to be played by non-governmental organisations (NGOs)
and specifically the Red Cross/Red Crescent during health emergencies.

NGOs have a different status in different countries: in some, they play a role in the health
infrastructure, while in others they have a purely support role. Because a flu pandemic or other
health emergency would overstretch any country’s resources, many would be dependent on
volunteer organisations for additional help. “Massive events require a massive response,” said Ms
Wood-Heath, especially in local communities.

Key considerations include whether or not to evacuate and where evacuees should go; identifying
those who need help (such as the elderly and those living alone) and communicating with them; and
deciding what kind of shelters to set up (short term or long term) and where.

Rather than deal with these problems as they arise, it is advisable to plan as much as possible in
advance. Providing a framework for action is the responsibility of governments and EU institutions,
but all actors - including NGOs - have different contributions to make.

The Red Cross/Red Crescent is the world’s largest independent humanitarian network with more
than 100 million members and 183 million national societies, each of which is independent but
works on a common set of principles. It performs different roles in different countries but, as a
general rule, does not differentiate between responding to emergencies and development; in other
words, it remains in countries once emergencies are over.

Ms Wood-Heath said that during an emergency, it is important to focus on citizens’ ability to cope,
rather than perpetuate the myth of the helpless victim. This means assessing local strengths and
priorities, and helping societies to become more resilient.

The International Federation of Red Cross and Red Crescent Societies (IFRC) influenza initiative
has set up a task force to lead preparations and provide guidance on what to do in the event of a
human or avian flu pandemic. Among other things, the task force is examining what key messages
to get out during an emergency, medicines and vaccines, communication strategies and ethical
issues. The initiative aims to involve all elements of society in the planning process in every
country.

Governments should also involve NGOs in emergency planning and response. “If you don’t make
use of them, you will waste them and you won’t provide an effective response,” warned Ms Wood-
Heath. The Red Cross/Red Crescent in turn works together with other groups including the EU’s
humanitarian aid arm, ECHO, the private sector, and even the military, which is likely to play a
greater role in dealing with future emergencies.

US perspective

Steve Bice explained why stockpiling and preparedness are important.
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While preparing for emergencies was unpopular in economic terms (why, for example, should the
government spend billions of dollars on a future vaccine which may or may not work?), Mr Bice
argued that it was a cost-effective mechanism - not just for the US but for the rest of the world.
Currently, medicines/vaccines are “just in time" inventions, but, as the situation following
Hurricane Katrina showed, it is the chronically ill who most at risk during emergencies (with, for
example, diabetes patients not having access to their medicines). A synergy between the public and
private sector was essential, with the private sector often proving the best partner for governments
in such situations.

In terms of when countries should start stockpiling vaccines etc., Mr Bice said it was “already too
late”. This was not meant to discourage efforts, but merely to emphasise the importance of starting
now. He suggested that the EU consider stockpiling, although he acknowledged that it was already
far ahead of the US in interacting with private-sector partners.

Overstretched military forces mean that governments will be even more dependent on NGOs in
responding to public health emergencies in future. “I don’t think you can count fully on the
military,” said Mr Bice.

Unfortunately, governments are not very good at identifying out their requirements. They may, for
example, order a number of doses of a vaccine, but forget about ordering syringes or other
equipment needed to dispense it.

Marc Ostfield suggested thinking about public-health emergencies in terms of three boundaries: 1)
international (“we need to be working across borders”); 2) across disciplines; and 3) public-private
partnerships, which he sees as the most challenging (“I rarely talk to people outside government,”
he admitted).

Responses to public health emergencies mirror the four pillars of biodefence; namely: 1) threat
awareness; 2) prevention and protection; 3) surveillance and detection; and 4) response and
reaction. All four require working across borders, disciplines - from agriculture, public health and
science and technology to the military, among others - and the public and private sector. Arguing
that the public-private dialogue needs to go beyond the pharmaceutical industry, Mr Ostfield asked
where transportation and energy suppliers had been during discussions on public health
emergencies, since both would play a critical role.

He lamented the fact that the private sector was missing from some of the exercises to plan for
emergencies, so government “pretended” that it knew the sector’s wants or needs. “We need those
players in the room and at the table,” he insisted. For example, the US Department of Health and
Human Services has no trucks of its own, so would depend on the private sector during
emergencies.

Getting medicines to areas in need is also an important international consideration. On an
international level, the US and other G8 countries have formed a bioterrorism expert group.

To improve preparedness, Mr Ostfield suggested buttressing national and international efforts to
identify outbreaks; boosting interaction and cooperation across the public and private sector and
different disciplines; and increasing military and civilian interaction. It is in the explicit interest of
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nations to help one another, and to develop and test their communication strategies. The anthrax
outbreak in the US was an example of “risk communication gone bad.”

Dan Gold said the US anthrax outbreak had demonstrated that pharma companies need a “market
pull,” or incentive, to develop drugs for stockpiles; in other words, they need to have a well-defined
market and to know what kind of timeline they are working under.

The need for stockpiling was made clear in the anthrax outbreak in Washington, D.C. in 2001, when
several grams of anthrax were released through the mail, necessitating a clean-up costing more than
$1 billion.

The disease is spread by spores, and the most fatal version of which is the rare pulmonary version
(which killed half of the 11 that were infected in 2001); in the late stages, antibiotics and vaccines
are no longer effective. Although it is relatively easy to develop vaccines, by the time many patients
presented themselves to health authorities it was too late. In addition, some patients did not take the
antibiotic for long enough to wipe out dormant spores, which germinate for about 40 days.

Human Genome Sciences, a biopharmaceutical firm with a number of products in clinical
development, has the capacity to produce hundreds of thousands of doses annually, but the factories
themselves take five to six years to develop, making it impossible to create additional capacity once
an outbreak has begun. In conclusion, Mr Gold emphasised that national stockpiles should include
anthrax countermeasures.

The big picture

Setting out the global picture, John Martin said the United Nations’ systems were about to be
“quite radically upgraded”. This will include revising international health regulations in 2007
following substantial negotiations between governments. The UN National Assembly has also
passed a resolution recommending that members upgrade security and safety measures in public
health laboratories. The WHO has a system in place designed to pick up and verify information on
potential problem areas 24 hours a day.

WHO is also working closely with the pharmaceutical industry, with more than 600 public-private
partnerships. Mr Martin said preparing for public health emergencies required a global approach,
adding: “Unless all countries are safe, no country is safe.”

Mark Rhinard said societies around the globe face a huge challenge in dealing with an increasing
number of threats, and neither side of the Atlantic had all the right answers. Crisis management, he
concluded, its not just something you do, but an entire way of thinking.




                                                                                        18/JD/mv04.04.06

								
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