Dr David Nabarro was appointed in September to co-ordinate the UN response to avian influenza and the threat of a human pandemic. This means bringing together the strategies of the animal and human health organisations which work at international level and reviewing national plans. Jane Corbin spoke to him on 2 November 2005.
Jane Corbin: Where are we now in terms of the risk of a global flu pandemic, and how bad could such a pandemic be?
David Nabarro: There is a certainty that sooner or later there will be another global flu pandemic, and there is a certainty that that pandemic has the potential to cause widespread death and at the same time to damage the social, the economic trading and travel systems on which our world depends for continued operation.
So if we start with those certainties, we then have to go into the uncertainties, we don't know when it will start, we don't know where it will start, we don't know how severe it will be, we don't even know for certain from where the causative virus will come.
Handling that uncertainty is critical for all of us involved in preparedness planning. As long as we recognise that however big or small the pandemic will be, it will have a very major impact on the functioning of our world, then at least we know what we've got to be prepared for and we know some of the work that we've got to do over the next few weeks and months as we do get preparation into gear.
We've additionally got the problem that we are being affected by a really virulent bird flu virus right now, H5N1, and were that to mutate or undergo some other genetic modification and become the virus that is capable of sustaining transmission between humans, then we would be facing a very nasty pandemic and we would need to be acting very rapidly to try to delay it or even contain it.
Jane Corbin: If the pandemic was to start, given what we know about modern society, modern communications, could we contain it? How long would it take to spread?
David Nabarro: The estimate that I've been told on the basis of fairly precise modelling is that from the start of the pandemic which means the first appearance of the changed virus, through to it getting out of control, becoming like a forest fire, that's about 3-4 weeks. It depends of course on the circumstances with which it happens, the location where it starts, it also depends on the degree of crowding that there is, but that's the sort of time interval that we have.
So you can see from that, that if we're going to contain that pandemic by distancing the people who are either infected or at risk, so that it becomes an isolated outbreak, we will need to move very, very quickly in that time interval. We have to also recognise that it will take possibly about a week to get the identity of the virus confirmed, so we may well have an even shorter time frame in which we can actually get mobilised.
Jane Corbin: You've recently returned from a trip to the Far East, to China and Vietnam, other countries, what's your overwhelming impression having been there?
David Nabarro: In my visit to Vietnam, China, Thailand and other countries in the region, I was primarily talking to officials of government, officials from the United Nations System, the World Bank and other organisations. So I was really getting second-hand information on what is actually going on. But that's quite useful when you're having to do things quickly, because at least people will give you their differing perspectives. I've noticed the following:
Firstly that there has been a great increase in the degree to which influenza issues are getting political prominence at the highest levels of government. No longer in Vietnam or in China are the Ministries in Health and Agriculture being expected to deal with this on their own. Instead, it's gone up to Premier, Vice Premier level and a number of other parts of government are being brought in, and this is as it should be.
Secondly, I've also noticed that all the countries in the region are recognising that they do have to start being as open as they can about what they're experiencing both on the Avian influenza side, and also on how their health services are getting ready to cope with large numbers of cases of human influenza, and, particularly in China, they've recognised that it's going to require a joined up response between countries if we're going to be able to get on top of it, and that's now accepted much more.
Thirdly, I felt, more confidently than I might otherwise have thought, that the United Nations System and other development agencies are tackling this in a very integrated way and that will, I think, give us much more chance of being able to respond more effectively to the bird flu and deal with the pandemic when it does come.
Jane Corbin: Are you confident that you're being told the whole story, particularly in a country like China, where there's a lot of official secrecy and a fear of the economic repercussions of admitting to a problem with bird flu?
David Nabarro: I can never be sure when I'm talking to representatives of government or of other organisations, whether they're telling me everything that's happening in their countries. Perhaps even they can't be sure because in some of the countries that I visited, there is quite a strong decentralisation of health and agricultural services, and information doesn't always flow to the centre in a timely fashion, not least because sometimes there are disincentives for information to move. So I have to agree that it's not always possible for me or any other international person involved in this work to be able to ascertain that they have certainly been told everything that's happening. That is one of the reasons why we have to continue to engage with the governments to get them to recognise that we're wanting to work with them in a coordinated response.
Jane Corbin: Migratory birds are another route that the bird flu.. the current bird flu virus can spread and indeed has done, what do we know about its movements so far and where might it end up?
David Nabarro: I, like many, have been looking at the patterns that the migrating birds tend to fly in as they're moving from wetland to wetland, from North to South and South to North, and it was quite clear that there is a fairly strong migrating route that goes from Asia north-westwards toward Europe, and then there's another one that goes from Europe South across the Middle East to Africa, and it does look as though that Asia to Europe route may well have been the responsible agent for bringing H5N1 virus into some of the countries that are in Asia and in Eastern Europe. Now nobody can be 100% certain that the virus did appear in Eastern Europe as a result of the birds, but what I am hearing from the groups who have been studying it, suggests that it is indeed likely. So then what I'm suspecting is that the next migrating bird flu transmission will be from Europe moving South to the Middle East, and then into Africa and that is a really serious danger and one that we've got to be looking out for in the next few months.
Jane Corbin: Why are you so concerned about what might happen if it reaches Africa?
David Nabarro: I worked for many years in different parts of Africa. I have seen how African health services, and - though I don't know them so well - African veterinary services are really nothing like as strong as is needed either to detect outbreaks of Avian influenza so that they can then be controlled at source or to be prepared for the emergence of pandemic human influenza. So therefore we could easily get a situation where the influenza in birds or the possible pandemic in humans becomes very pronounced, very extreme, long before it's properly detected, and that could have not only consequences for the countries and communities concerned, but severe consequences for elsewhere if that's where the pandemic starts.
Jane Corbin: What is going on in terms of a global response to this? Is there a satisfactory level of cooperation between governments?
David Nabarro: My role as coordinator has me wanting to get countries, their governments and their civil societies, their scientists and their private sector companies, working together as never before because both the bird flu problem and the potential pandemic are issues that require the most joined up response that the world can possibly mount. Any fracturing between different institutions within countries or between countries will create space through which the flu can move and will affect our global health and our human security. So for me, joined up cooperative work between countries is the ultimate requirement, and I don't think yet we've got that level of inter-country working that is needed to really be confident that we as a world are fully prepared.
Much of what I'm going to be doing over the next few months, and I really hope we don't get a pandemic starting within the next few months, is working with governments, with countries, with different parts of the United Nations, to try to stimulate the trust that is needed for a truly joined up response.
Jane Corbin: If a pandemic was to break out this winter, are we ready for it? Is the world ready for it?
David Nabarro: No, no, no, we're not. I really do hope that the pandemic will not break out this winter because we have not gone through in our planning machinery that we've got in the world at the moment. We've not gone through the contingency planning that is necessary to consider how we might deal with the kinds of changes in the way the world works that would be provoked by the pandemic itself and by the reaction of our different global institutions to the arrival of pandemic influenza.
Jane Corbin: Realistically, if this was to break out, it would be every country for themselves, wouldn't it, that's what's going to happen.
David Nabarro: I'm absolutely certain that individual countries will initially be wanting to look at ensuring their own people are as protected as possible against an influenza pandemic. But what I'm also beginning to see in my discussions with governments all over, not just in one or other part of the world, what I'm beginning to see is a recognition that it's not going to be what's done inside the country that determines the security and survival of that country's population, but what's done throughout the world that will have an impact on national survival. And so I'm not as concerned as you might be from the way you've asked the question, about the potential for joined up action that will lead countries, even at the beginning of a pandemic, to look beyond their shores as well as inside their shores - let's see.
Jane Corbin: Now vaccines of course are the answer long-term but we're in a difficult area here, both in terms of capacity, the technology to make them and deciding which strain that you actually use as the basis. Where are we on vaccines and what realistically can countries do to prepare long-term for this?
David Nabarro: We need to make sure that all the vaccine manufacturers with capacity for doing human flu vaccine development are organised so they're going to be able to start the moment that we've got the pandemic virus, that means that they need to be managed as a group and I think that the World Health Organisation is going to do that. I just want to make sure that the governments concerned really do focus on this and make sure their vaccine manufacturers are in line. Secondly, there are other vaccine manufacturers who are not necessarily tooled up to do influenza vaccine work, who may well be potential extra source of manufacturing capacity and we need to get them brought into the fold. The Minister of Health in Mexico, Julio Frenk, is particularly keen on this and I'd like to find ways of linking that second tier of manufacturers with the primary vaccine manufacturers. Thirdly there are a lot of new technologies that are potentially going to be useful for vaccine manufacture that the United States are proposing to bring on stream. That's very important, the quicker we do that the better. This needs concerted attention from all governments.
Jane Corbin: We are now relying, while we wait for a vaccine to be developed and for the strain to be identified, on one or two antiviral drugs. Is there a danger that if governments concentrate on these antivirals, and the strategy around them, that we become too reliant on one thing?
David Nabarro: The right preparedness strategy goes down a number of different approaches, it's not just going to be using one i.e. antiviral medicine. We have to be sure that we've got personnel trained, particularly frontline workers, communities informed, health services primed and facilities ready, plus the extra medicines that are going to be necessary to deal with pneumonia and other conditions. This is absolutely key and therefore to simply be judging preparedness on the basis of the amount of antivirals that are in the stockpile is not satisfactory.
Jane Corbin: But realistically, that's all we've got until we get a vaccine and we can't do that until we know the shape of what we're facing, we've got to depend on antivirals. There's not a lot more we can do right now.
David Nabarro: I'm not going to agree with that because as well as the antivirals there are going to be other approaches that are necessary. I have seen in dealing with outbreaks in my previous work, that it's as much the organisation, training, discipline of frontline response personnel and the degree to which communities are primed and ready to respond to the problem they face as the administration of a particular medicine.
In addition, we have to remember that these antivirals, if they're going to be effective, have to be given within 48 hours of the onset of any symptoms at all. They have to be got to people who need them. There are going to be a lot of logistic and other challenges with dealing with antivirals, and so let us try, as much as possible, to be working on the whole range of preparedness activities and not concentrating just on antiviral stockpiles, so of course they are an important part of the whole.
Jane Corbin: Is containment realistic, when we talk about trying to help countries in the Far East to keep the virus within their own borders, can we actually do that, is that the right strategy?
David Nabarro: I think that it is possible, if the disease starts in a location where the geography is helpful, if the citizens of the country have been well primed as to the importance of containment and if the first line workers have been trained.
I've heard accounts from Hong Kong of how it was the organisation of local community services that was key in SARS and in other outbreaks. In other countries as well, when I've seen cholera or other conditions emerging, I have noticed that it's not so much the nature and the organisation of the medical personnel that makes a difference, it's the other parts of society, Red Cross, Police and the like who are key to making sure that we've got a good response.
Jane Corbin: Vietnam is a country we've studied quite closely in the making of this programme. You've recently been in Vietnam yourself. What's your view of the situation in Vietnam? They're pretty much at the front line on this, they're the ones who've had the most deaths. How serious is the situation there?
David Nabarro: I believe that the situation with regard to Avian Influenza in Vietnam is very serious indeed. Everything I've been told by different specialists in country, suggests to me that we really do have to work hard to diminish the intensity of the Avian Flu outbreak there and to try to reduce the amount of virus that there is in the community. This is an environment in which a mutation or a re-assortment of the genetic material in the H5N1 virus is quite probable and it therefore seems to me important that we not only do our best to help control the influenza but also we try to reduce contact between humans and birds which is very difficult given the role of backyard birds in local society.
The Vietnamese government does seem to be seized of the issue and I was very impressed by the attention being given to dealing with Avian Influenza by all parts of government, particularly at the highest level but it's going to be a huge and continuing battle and one that we must all support, all of us.