Public Accounts Committee

Oral evidence: Oversight of UK spending to tackle Ebola in West Africa, HC 868

Thursday 11 December 2014

Ordered by the House of Commons to be published on 11 December 2014

Watch the meeting: http://www.parliamentlive.tv/Main/Player.aspx?meetingId=16785

Members present: Margaret Hodge (Chair); Stephen Hammond; Meg Hillier; Mrs Anne McGuire; and Stephen Phillips

Gabrielle Cohen, Assistant Auditor General, National Audit Office, Martin Sinclair, Assistant Auditor General, NAO, Tom McDonald, Director, NAO, and Marius Gallaher, Alternate Treasury Officer of Accounts, were in attendance.

Witnesses: Mark Lowcock CB, Permanent Secretary, Department for International Development, Professor Chris Whitty, Chief Scientific Adviser and Director of Research and Evidence, DFID, Fergus Drake, Director of Global Programmes, Save the Children, and Sanjayan Srikanthan, Emergency Field Director, International Rescue Committee, gave evidence. 

Chair: Welcome.

              Stephen Phillips: Just before we get going, I should formally declare, Chair, out of an abundance of caution, that my partner is an Overseas Development Institute fellow, previously theoretically employed by the Government of Sierra Leone, although obviously paid by the ODI and, in fact, although entitled to a salary from the Government of Sierra Leone, that was never paid.

              Q1 Chair: Just before we get into details, can we find out from Fergus Drake and Sanjayan—I hope I have pronounced that right; have I?—precisely the projects that you are carrying out on behalf of DFID on the Ebola issue, so we have a feel for what you are actually doing?

              Sanjayan Srikanthan: Thank you, Chair. The International Rescue Committee is working on a series of projects through DFID funding, including isolation centres in the Bo and Port Loko areas of Sierra Leone, and community mobilisation activities geared towards improving information about what Ebola is and how to prevent yourself from getting it at a community level. It is also supporting primary health care centres that are providing infection prevention and control treatments, so that doctors and nurses can work safely to treat non-Ebola conditions. These are our priority areas.

              Q2 Chair: How much money from DFID?

              Sanjayan Srikanthan: In total it is approximately £12 million.

              Q3 Chair: And then some through multilateral organisations that lands on you, where DFID will be a funder.

              Sanjayan Srikanthan: Correct. As well as US Government funding.

              Q4 Chair: Okay. And Save the Children?

              Fergus Drake: Thank you very much, Chair. Our main focus is our Kerry Town facility, which is an Ebola treatment centre, but like IRC, we are also working in community centres and on substantial amounts of public health education. Our relationship in terms of funding is mainly with DFID and Sierra Leone, but we also have extensive work in Liberia and Guinea.

              Q5 Chair: And quantums?

              Fergus Drake: The specific amount of funds so far is £5 million.

              Q6 Chair: Right, I am going to start, but Stephen is our great expert today, so he will do quite a lot of the questioning. I am not expert in this field, but it is interesting that if you look at Nigeria, with a massive population—much bigger—of 21 million, which is as large as the population of Guinea, Liberia and Sierra Leone combined, the main city is pretty unsanitary and there are lots of slums and all that, yet they have managed to control the outbreak. Why? What is the difference? We would like a feel for why the challenge is not emerging in that regard.

              Professor Whitty: What happened in Nigeria is that, because people are aware of the fact that this could rip away so quickly, all previous epidemics until this one had been controlled in a relatively short period of time. This demonstrated for the first time, really, what this disease can do once it is allowed properly to take hold. The Nigerian authorities got on top of the first two or three cases very quickly and followed up all the subsequent ones. The first wave of cases could not be predicted, because the first case was not identified until quite late on in the disease, but all the third wave—the people who caught it from the second wave—were identified very early and isolated, and then it died out.

              I think what this demonstrates is that if you get on top of Ebola quickly enough, in any country, you can snuff it out quite fast. The real failure of the international community was that between December and March we knew that there was an Ebola outbreak in Sierra Leone, but the expectation was that it could be brought under control, as all previous ones had been. Then there was really a delay between March and the end of July, for the sake of argument, when the whole international community did not move fast enough. That was the point at which it was allowed to take off. Had the kind of things that were done in Nigeria been done in Sierra Leone, it could have been headed off at a much earlier stage. 

              Q7 Chair: But the things that were done in Nigeria were done by the local community, so I assume—or I am asking you whether—there was a much stronger health infrastructure.

              Professor Whitty: It is important to understand that Nigeria is a very large country of multiple parts. There is a very big difference in the industrialised south, where these cases first appeared and where there is a good public health infrastructure—it is not a UK one, but it is a good one in local settings. If this had happened in, let’s say, the very challenged areas up north, where Boko Haram is, we might have seen a very different picture. Nigeria is a very complex and very large country. It is also important to note that Senegal also managed to get on top of an outbreak, as did the US and Spain, so when people are alert to it early enough, it has proved relatively easy to stop. It is once you have allowed the momentum to build up that things really get out of control.

              Q8 Chair: What happened in Sierra Leone—the one that we were taking the lead in? People did not identify it, or there were not the health professionals—what was it? You have said that the international community did not respond, and I know that Stephen wants to come in on that, but locally, is one of the lessons to be learned about investment in health infrastructure, rather than maybe some of the other programmes you have been running? I am guessing at that.

              Professor Whitty: That is absolutely right. There will be multiple lessons to learn, and there is no doubt that multiple bits of the system messed up over this, not in the first couple of months, when, in a sense, it was very early in the epidemic, but in that period up to about July. I do not think that we should blame others; I think the key thing is to say that we all own the international community, including the UK. When this is over—it is not the moment to start throwing stones at one another; it would be extremely unhelpful for the response—Margaret Chan, the director general of the WHO, and our chief medical officer have said that the WHO has some very serious lessons to learn from this, and I think others do as well. We should do that, although I think that all of us feel that this is probably not yet quite the right moment to do so.

              Q9 Stephen Phillips: I think we all agree with that. It is important to get the outbreak under control, but principally, this Committee is concerned with value for money—for the money that DFID spends on behalf of the UK taxpayer. I am quite interested in some of those answers. You say people were not aware that the disease could rip away so quickly initially, and you have just said that multiple bits of the system messed up. DFID was aware of the outbreak, Mr Lowcock, from almost the first moment—from December last year—wasn’t it?

              Mark Lowcock: I think the first identification in Sierra Leone that we needed to prepare was, as Tom’s note said, in about February. As I understand it, the first absolutely confirmed case was some time after that. The epidemic started in Guinea and then spread to Liberia, and a little bit after to Sierra Leone, but it is absolutely the case, as Chris has said, that the sort of expectation that was widely prevalent, not among everyone—MSF in particular was much better at identifying what was about to unfold—but among most people, was that the outbreak would be essentially quite like all the other known outbreaks, including the DRC cases: localised and relatively quickly brought under control. As Chris said, that was the planning assumption, which was wrong. As time passed, the gearing up happened, but it was too slow.

              Q10 Stephen Phillips: Let me stop you there. Why did MSF manage to predict that that planning assumption was wrong, but DFID did not?

              Professor Whitty: Can I be clear? The UK flags, including to the WHO and others, that we felt the epidemic was behaving oddly were from April. We were discussing them among the chief scientific advisers across Government—the chief medical officer and others—at an early stage. We have to think very carefully about the ability of one country to start declaring health emergencies in another country. The WHO has the right and technical capacity to do that, but a country is sovereign to do its own things. We need to be careful before we start saying, “DFID should have said there was a health emergency.”

              Q11 Stephen Phillips: No one is suggesting that you, unlike the WHO, can call a public health emergency of international concern. Obviously, DFID has a large presence in one of these countries—in Sierra Leone—and we must not forget that there are two others. You must, therefore, have been aware, given what you have just said, that this could rip away in the way it has. As a result, the UK taxpayer has now had to commit £230 million. If you had acted more speedily and with a smaller amount of money, that amount could perhaps have been much lower.

              Professor Whitty: All epidemiologists now have the benefit of hindsight and say, “Well, we could have predicted from March.” Actually, that was not the consensus view and, specifically, that was not the view of the WHO, which they were very explicit about.

              Q12 Stephen Phillips: There were epidemiologists who were saying very early on in this outbreak that the boat had already sailed, and that it was too late and it should burn itself out.

              Professor Whitty: I am trying to say that there was a range of opinion. At a certain point you do have to rely on the global expert body, which is WHO, for its opinion, given that there is a range of opinion.

              Let me take a different approach. At any given moment if you went on to a website called ProMED you would see multiple outbreaks around the world. There has just been a relatively quickly contained one in DRC where DFID is active. There is a plague outbreak in Madagascar at the moment, and so on. If every single time we responded as though there were going to be a global emergency we would also waste a huge amount of money. It is about getting the balance and responding very effectively to the ones that are there.

              I think now we are responding very effectively to the one that is there, and over-calling it so that we spend our entire time chasing around after things that are actually controllable. As you rightly say, it is about balancing the professional judgment—that is  the reason that I am answering, rather than anyone else—which was overall to assume that the international community would ultimately take all the different views. Some of them, such as MSF, said that it was a very major problem; some said it was not a major problem and that we have dealt with this before. We took the view of the international community. We are saying that in retrospect that was not necessarily what we would do again.

              Q13 Stephen Phillips: I think you also said, Professor Whitty, that that was not the view of MSF. In fact, as far as the UK Government scientific advisers, including yourself, were aware, you could see where MSF was coming from, if I could put it in those terms, and that this outbreak might not follow the patterns of the much more serious outbreaks in DRC in the past. Given that, the question to Mr Lowcock is why DFID did not have a different response, putting more money up front, which would have brought the outbreak under control in Sierra Leone and would lead to the UK taxpayer having to fund a lower level of spending.

              Mark Lowcock: We basically took the decisions we took on the basis of where we thought the consensus advice was at the time. In February we started some planning. In the March-April-May period we started allocating some funds. I think the first confirmed case in Sierra Leone came in 24 May. We then had discussions with WHO and others and allocated more funds. A few weeks after that we provided funding for MSF and others to open facilities in Kenama and Kailahun in eastern DRC.

              Stephen Phillips: Eastern Sierra Leone.

              Mark Lowcock: I beg your pardon, eastern Sierra Leone. Mr Phillips, I remember you raised the matter in the House in June.

              Q14 Stephen Phillips: I think I was the first person to raise it in June, and I was told that DFID had it under control, and that was plainly not the case.

              Mark Lowcock: Through that period, the numbers that WHO were using as an indicator of the scale of the problem, including through to early September, was that maybe there would be 20,000 cases. As you know, on 15 or 16 September, CDC, the US Centers for Disease Control, published the results of their modelling with much, much larger numbers. By that time—because WHO had declared the emergency in mid-August—it was clear that what had been done up to then had been completely insufficient.

              I agree with you 100%: had the world, the Government of Sierra Leone, WHO, we and others acted earlier, it would have been cheaper and easier to solve the problem. There is one big lesson to take away and learn. Maybe we should not just rely on WHO, although as Margaret Chan has said, there is a big WHO reform agenda. We should look at what other things we need to put in place in future to give us a greater degree of ability and confidence that we will catch these things earlier.

              Q15 Chair: Can I ask Mr Drake and Mr Srikanthan to comment on whether it was too little, too late?

              Fergus Drake: I would agree that MSF have been the real heroes, in terms of people on the ground and the scale of their response, as well as calling it early on. I would also agree with the comment from the World Health Organisation that the international community could have mobilised quicker.

              In terms of our response, back in April we were already doing community health education, which is absolutely vital, before the first patient was declared on 24 May. I have to say that since that time, and particularly since August and September, the amount of scale-up and the amount of willingness of agencies to work out of their comfort zone and to do something that is incredibly difficult has been very substantial.

              Sanjayan Srikanthan: I would just add that Ebola has picked probably one of the worst areas of Africa to have cases. Sierra Leone has suffered from a chronic lack of health services, which is part of the reason why this outbreak has got out of control. That should be acknowledged. Other countries, such as Uganda, now have sophisticated rapid-response mechanisms; they have had the luxury of smaller outbreaks from which they could learn. Sierra Leone, in particular, has been thrown in at the deep end. That is a contributing factor as to why we are seeing this.

              Q16 Chair: We have had you in front of us to talk about malaria funding, so you will put money into vaccine-type programmes like that. I just wonder why on earth we are not putting in more money out of our international aid to support health infrastructure, particularly for Sierra Leone, to which you have cut direct funding by 20%. I know your whole argument, and that you have gone through multilaterals, but goodness me, if we had more doctors and so on in there, we might have had a better response at one level.

              Mark Lowcock: First, on the overall level of funding, including in the health sector, we were doing about £50 million through the DFID bilateral programme in 2010-11. In 2013-14, it was £68 million.

              Q17 Chair: You have cut it, though.

              Mark Lowcock: No, we haven’t cut it. The 2014-15 funding will be lower in terms of the regular programme, as it has not been possible to pursue some of our activities because of Ebola.

              Q18 Chair: Just explain it to me. The International Development Committee’s report talked about a 20% cut to in-country funding.

              Mark Lowcock: There is a Westminster Hall debate on this subject this afternoon, at which the Minister will speak. For 2013-14, the DFID programme was £68 million, roughly 20% of which went on health—basically on system strengthening. At the same time, we take a strategic view that we want to put—in terms of commodities such as bed nets, antiretrovirals, immunisation and so on—more money, for value for money reasons, through the shared international vehicles, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2014, that institution will spend effectively £20 million of our money in Sierra Leone on its set of responsibilities.

              It is absolutely the case that, having come out of the civil war, which destroyed virtually every institution in the country, there was the massive challenge of rebuilding the health sector. If you look at the progress that was made before Ebola on some key health outcomes, such as child mortality, there has been good progress, but it has been overwhelmed and swamped by the Ebola outbreak. I completely agree with the proposition—the Secretary of State said this herself when she gave evidence recently to the International Development Committee—that we will need a much stronger focus, in terms of the bilateral programme, on system strengthening. That is absolutely right. We did what we could to build the system up over the past 15 years, and I am really sorry that it was just overwhelmed by this epidemic.

              Q19 Stephen Phillips: Mr Lowcock, you say that you did what you did over the last 15 years. The lack of a robust health care system, not just in Sierra Leone, but across west Africa, has made this outbreak much more difficult to deal with. I think we all agree on that. We were in there for 15 years as one of the largest donors—perhaps the largest donor in Sierra Leone—and yet when this outbreak comes along, the British taxpayer finds that there are only 120 doctors in the entirety of Sierra Leone. There is one virologist, notwithstanding that malaria, dengue and Lassa are all endemic across west Africa, and he dies early in the outbreak. It seems that it could be said that DFID has rather dropped the ball, which has had significant consequences during the course of the outbreak. You should have been spending much more on a robust health care system inside Sierra Leone and these other countries well before this outbreak occurred.

              Mark Lowcock: I agree with your fundamental point; we need to put more emphasis on this. To pick up your point on numbers of doctors, one of the problems to do with trained staff is that, unfortunately, lots of health workers trained in lots of extremely poor countries end up leaving.

              Q20 Stephen Phillips: Why don’t you have programmes to encourage them not to become part of the diaspora overseas, but to remain in their home countries?

              Mark Lowcock: That has been tried a lot over the decades, as you will know, and it has proved very difficult. Once people are trained, they tend to have freedom of movement. Health workers are very mobile internationally and it has proved a really difficult thing to tackle. If there was a magic bullet, we would love to have bought it, but we have not found it.

              Q21 Stephen Phillips: Isn’t the magic bullet for DFID and the international community to supplement terms and conditions in a way that encourages medically trained staff to remain in their home countries?

              Mark Lowcock: That is one of the things that has been tried and, unfortunately, so far it has not worked. Maybe Chris, who has quite a lot of experience in this, would like to add a bit.

              Professor Whitty: Getting people to stay against their will is clearly impossible. There are things we can do in the UK to ensure—the NHS is very committed to this—that we stop people from coming to the UK, but there is a larger world out there, and if people can command a very high salary in one country and they have been trained in a country where they cannot command a high salary, it is very difficult. You can try to encourage them by giving them salary supplementation as Mr Lowcock says, but that has been tried in Malawi, Tanzania and other places and that has a number of difficulties, not least of which is that you are committed indefinitely to supporting those salaries, because otherwise the minute you withdraw that support everybody leaves, so this is a high-risk option.

              Q22 Stephen Phillips: The trouble is, from the Committee’s point of view of trying to ensure value for money for the taxpayer, we are left with this dichotomy. We are helping to fund people to train, but once they have trained, they go overseas where they think they can enjoy a better quality of life. Then something happens in the countries from which they originally came and, essentially, we have funded them not to be there any longer, and that results in yet further costs to the British taxpayer.

              Professor Whitty: I do not know how often you have been to Sierra Leone—clearly you have local links to it—

              Stephen Phillips: Six times in the past year.

              Professor Whitty: Coming straight out of the civil war, which was not that long ago, it was one of the most destroyed communities in Africa. That was a horrendous civil war, and I think one of Britain’s great foreign policy triumphs—I am speaking not as a scientist, but as a citizen—was helping to end that civil war. The country was starting from an extraordinarily low base, and we have to have a certain degree of reality as to where we can get to.

              I do not think that anyone on this panel or anywhere in DFID would disagree with the fundamental points that you are making about the importance of building up the health care system. It is not a straightforward matter of just putting money in and the health care system strengthens; it is more complicated than that.

              Q23 Meg Hillier: On the staff front, I chair the all-party group on global health with Lord Crisp and we produced a report about DFID and the NHS supporting existing staff recruitment, which was accepted by Government. Mr Lowcock, could you give us an update on how that is working, particularly with the Ebola outbreak, in terms of NHS staff going overseas under normal conditions?

              Mark Lowcock: At the moment, there are about 1,000 public servants from the UK working on the outbreak in Sierra Leone. It goes up and down—people come in and out. A lot of them are in uniform, but a lot are not in uniform. They are mostly volunteers. I hope you do not mind me saying that I think we all owe them a debt of gratitude, as these people are heroes who are risking their lives doing difficult things.

              Q24 Meg Hillier: Yes, absolutely. On the volunteers, can I just check that this is not including the NHS?

              Mark Lowcock: This includes the NHS. I am just coming up to break down the NHS bit of it. Originally, early on, organisations such as MSF and the Red Cross, whom we were funding, were doing their own recruitment, including through the NHS. First, on 8 September we agreed to finance Kerry Town, and then on 17 September we agreed to finance the other five big treatment centres. One of the things that we did, with WHO and the organisations that run them, was put in place a plan to staff those centres. We, with the Department of Health, co-ordinated through the Cobra system, went out to the NHS for volunteers for that, and we got over 1,000. We have sent two waves so far: 30 in the first wave from the NHS around the UK, and 25 in the wave that has just gone, some of whom are in Kerry Town now. A third wave is coming. That is in addition to what we have been trying to do on international health work. As Tom’s note says—

              Q25 Chair: So what happened to the rest of the 1,000?

              Mark Lowcock: Well, they are in the rotation. As you will appreciate, one of the things is to get the right staffing mix. We have had lots of offers—

              Q26 Chair: What did you want? What were you aiming for? I accept that you want to rotate, but what was the number you were aiming for?

              Mark Lowcock: It is different by category. There are two critical skills gaps that we have been struggling with. We still do not have enough people, and it remains one of the big constraints. The first is on people who can run the labs. One of the ways in which you get ahead of the disease is to do the testing faster to find out whether people have got it or not. Lab testing has been a constraint. We have just opened two more labs this week, but it has been difficult to get them all staffed up to the level we need.

              The second gap, which is the biggest remaining constraint—this again speaks to your point—is one on which the NHS has been fantastic, but it remains a challenge: the senior people who can be the clinical leads. They have to be experienced in these dangerous facilities, and the world does not have many of those people. We have had a lot of volunteers, and we are taking them up as fast as we sensibly can, but in some critical areas we do not have enough.

              Q27 Chair: Can I dig down on that? Out of 1,000, 55 have gone. There is a shortage of people to do the labs, and a shortage of clinical leads, but within that 1,000, why on earth is it so low? Eventually, we will come back to Fergus Drake and the ability to open his beds.

              Mark Lowcock: Obviously the staff are one of the inputs for the total package of the beds. The facilities and isolation centres need a whole bunch of things. In the chart I sent you yesterday I set out the planned numbers and the actual numbers for how we are doing the scale-up. The easiest place to start is figure 4. The light blue line was the level of beds and people to staff them, the facilities for them to be in, and labs, logistics, consumables, drugs and all those things. The dark blue line shows where we are at the moment against our planned scale-up. We have 1,539 total beds and spaces in Sierra Leone, of which 750 are currently provided by the UK. All of those are staffed. We are opening another suite of these facilities and centres imminently over the next few days. For each organisation that we have agreed will run them, there is a populated staffing plan from the UK, Sierra Leone—as you know, we have trained 4,000 Sierra Leonean health workers—and internationally. The issue is to make sure that from all those sources, which includes the NHS, the available facilities are properly staffed. At the moment, that is okay, except for the critical areas that I have talked about.

              We will be coming back to more of those fantastic volunteers from the NHS. We have 1,000 public servants there at the moment, but we need to take the people as we need them for particular rotations and facilities, rather than in a more random way.

              Q28 Mrs McGuire: Could you comment on the information we have that Cuba has committed 165 health professionals at various grades to work in the UK treatment centres? Where does that quite significant number, for a country that is quite small, fit into the overall plan?

              Mark Lowcock: The Cubans were one of the first countries off the blocks. They came to the London conference on defeating Ebola on 2 October. I talked to the Secretary of State and the Minister. Their staff are in Kerry Town and in lots of other facilities. They deserve a lot of credit for being fast to do actual things on this. That has certainly helped us a lot in our facilities. We work well with them.

              Q29 Mrs McGuire: I suppose that then begs a question; by your own words they have had a very fast response, and we appear—I am not denigrating in any way whatsoever the volunteers who are out there—not to have even reached the numbers that Cuba has delivered to assist with UK treatment centres. It would be helpful if we got a bit of an explanation.

              Mark Lowcock: The point is, we have a staffing model for each facility, and we have an open mind about exactly the nationality of who does what where. It was from our point of view a very good thing that the Cubans made the offer they did. We have the same critical skills gaps, even with the Cuban offer, so I regard it as a positive thing that we could deploy them because they were available. There are quality control checking issues—people have to be released by their trusts, and so on. It is a complicated system.

              Chair: I think the criticism is, why has Cuba done better, why have we not done as well, and are we using the volunteers as best we can?

              Q30 Mrs McGuire: And actually engaging with the real commitment that volunteers have made; having come from a sector where I was working with volunteers, when I was a real person, before I became a Member of Parliament, one of the things that you have to harness is the enthusiasm and the commitment of volunteers. You do not just leave those people lying around waiting for somebody to give them a phone call. That is all I am asking.

              Professor Whitty: Can I swap hats? As a jobbing NHS consultant physician, many of whose junior staff are currently out there or are deploying to go, I feel quite strongly about this. Many of my friends are out there. At the point when we started this deployment, the estimate varies; my calculation was 10%; the CDC’s calculation was 8% per annum per person—

              Chair: 10%?

              Professor Whitty: There was going to be a situation—there was a situation three months ago, when we were doing this planning—where the rate of infection of health care workers was somewhere between 8% and 10% per person per year, and over 70% of those would die. Throwing people, half-trained, into systems not yet tested was incredibly dangerous and in my view—I think most people would agree with this—a totally unacceptable thing to do for these volunteers who have put themselves on the line. It is still dangerous to do this, but systems are now much better tested and they have actually got proper training behind them. That has been one of the delays.

              The other delay is all of these people have had to come out of an NHS system that is in many areas quite stretched, and where NHS trusts have recently had to balance their own needs for the UK population against the ability to re-staff. There have been many situations where they have been quite nervous about that. I have had a lot of phone calls with senior executives in NHS hospitals who have been nervous, and reasonably so. It is about balancing those.

              Q31 Mrs McGuire: For fear of being misunderstood, I do not think you meant to imply that somehow anybody on this Committee was suggesting that NHS volunteers, or any volunteers from the UK, should be put into a situation that threatened either their health or their lives. I just want to make that clear, because I think you sort of implied that that was where we were going with our questioning.

              Professor Whitty: I did not mean to imply that. I was trying to explain why it was slow.

              Q32 Mrs McGuire: I just want that clarified. I think the second part of your answer may well have clarified why there has been a slowness in putting volunteers in. It is not to do with either the commitment of the volunteers, the commitment of DFID or anybody else; it is actually that there are pressures on the NHS. But can I clarify the situation with the Cuban volunteers or health workers? Surely they, in UK treatment centres, would not be put into a situation where their lives or their health would be endangered. So I think the first part of your answer, dare I say, maybe muddied the water slightly. The second part I accept.

              Professor Whitty: I will give an answer ,and then Mr Lowcock will give a much better one, I am sure. Cuba, as I think everyone in the Committee will know, has always had a tradition of having a group of people who they send over to emergencies. They are much better set up for this kind of situation. What then happened was that the Cuban doctors essentially took up the places that we considered safe. More places were being built behind that, and that is what the NHS doctors are now beginning to fill in, as they come on-line in a phased way, to make the introduction safe for everyone. We absolutely want the same level of safety for Cuban doctors and Sierra Leonean doctors as for any health care workers. The key is to do this in a structured and safe way.

              Q33 Meg Hillier: There is an existing agreement about NHS workers volunteering to work abroad, how long they do it for, how the trusts fund that and so on. Has there been any discussion about enhanced compensation for the NHS to encourage and support volunteers to go out? At the moment, trusts have to backfill that. That agreement has been in place for a long time. Where have we got to on that issue? Will it make a difference?

              Mark Lowcock: What we have tried to say is that the Department will underwrite the finances. We try to make sure that the problem is not a financial problem. The problem is backfilling the actual trained people. The International Emergency Medical Register has worked quite well. UK-Med have done a really good job. They have played a really important role in making sure that the standards of the facilities where we can appropriately put Cuban, UK and other health workers are met. There are lots of other bits of the system that have been struggling, but that bit of the system has worked okay, I think.

              Tom McDonald: I just wonder whether there might be an analogy with another part of Government, which is the Stabilisation Unit, where we have a process to put together a register of people ready to go—in that case, it is to conflict or post-conflict environments, but you could have a similar register for medical emergencies. You could be dealing with all of these issues in advance, such that when an outbreak becomes very serious, we are in a position that is more akin to the Cuban one, where we could send people more rapidly and deal with all of the domestic issues, if you like, that arise as a result.

              Q34 Chair: Do you agree with that?

              Professor Whitty: I absolutely agree that we should look at that as part of the wrap-up. The one thing I want to add to the last answer is—I am sure that everyone in the Committee would agree—that one of the fantastic things about the NHS is people’s sense of public service. When people have been deployed and have not been able to find someone to do it with them, there is camaraderie—I would really like to pay great tribute to the junior staff who have accepted that there are gaps in their rotas which they have to fill as their contribution in the NHS to this being done. As the permanent secretary said, money is not the issue. Finding staff, particularly at this time of year, can be challenging. Other staff have really stepped up to try to make it possible for their very brave colleagues who are volunteering to go.

              Q35 Meg Hillier: I want to move on to where the money that has been spent by DFID has gone. It was originally estimated to be £100 million and has gone up to £230 million. I think that a large amount has gone on the Kerry Town treatment centre. I wondered if you could give us an update on that. When will it be fully operative? How much is being spent on that, out of that money? I do not have a figure for that and have not found one. I know that you are working with other partners on that. How much is being spent by the UK on Kerry Town? You mentioned £5 million, Mr Drake, in the context of that.

              Mark Lowcock: Can I start and then pass it to Fergus? We have announced a total payment so far of £230 million, of which we had spent £125 million as of yesterday. Of that £230 million, £38 million was allocated to Kerry Town, which has two elements. There is the MOD-run facility, which is for both international and Sierra Leonean health workers. That is a 12 to 20-bed facility. Then there is the Save the Children facility, which will have 80 beds over time.

              Fergus can give you the detail about exactly where we are at the moment. Our commitment to Kerry Town, with both elements, is £38 million. We have obviously continued to work up other plans for things that we will need to do, not all of which have been announced yet. Over the financial year as a whole, I think that we are expecting to spend probably about £270 million. Given what we are already planning to do to guard against the possibility that a significant problem remains into the second quarter of next year, we have planned and organised a set of activities which could take the total bill to £330 million. Tom’s note gives you some breakdown, but I would be very happy to give you a lot more of the breakdown if you would like.

              Q36 Meg Hillier: We are the value for money Committee, so while there is an acceptance about a lot of the international development side—we can lay that to one side—it is also about the cost per bed and the ongoing costs; what is temporary, what is permanent and what is there for the Sierra Leoneans to take over and maybe convert into something long-standing once the Ebola crisis is gone. I know that it is all very fast, but I would hope and presume that that planning is in place. Could you and Mr Drake just give a bit more information about that? These are British tax pounds going in, and we want to make sure that it is not eventually going to run into the sand.

              Mark Lowcock: Yes, exactly. Just before Fergus completes the answer on Kerry Town, a lot of the facilities we have built or converted have been done to meet an immediate need, so the expected lifespan is not the same as if we were building the health system in the way we talked about earlier. They will have a lifespan and be maintainable, updateable and so on, and some of them will be highly useful as part of rebuilding the overall public—especially primary—health system. There is a very heavy concentration on the western area, the reddest bit of the map, where we knew there would be a surge and planned for that, so what we might well find is that we have built more facilities there because of the Ebola crisis than are needed in steady state. Then there will be a question about what these things can be used for. They are facilities that have got power, water and are properly secure, so there will be something useful that can be done with them.

              Q37 Meg Hillier: Was there any thought of building them as prefabs that could be relocated to areas of greater need?

              Mark Lowcock: Some of them are that. There are bits and pieces for Kerry Town.

              Professor Whitty: We had quite a debate about this right at the beginning. The problem that we faced epidemiologically was that the doubling time at that point was every 30 days. Every 30 days it was ticking up. The choice was building something that could be repurposed—but that might have taken several weeks or months longer—or going very fast because we could see that there was a real risk by this stage of the epidemic. We had over 1,000 cases a week, which had overwhelmed us, and we had to get ahead of that curve or we would have been lost. That decision was taken quite deliberately and, clearly, in an ideal world, it would have been better to have been able to do something that was not that, but that would have delayed us.

              Q38 Chair: Let’s bring Fergus Drake in because there has been stuff in the UK press about all this. Charles Mambu has been critical of you and said “It’s very, very, very slow” and Paolo Conte from the Ebola response centre said that they have expertise and the Brits got it wrong by handing over the facility in Kerry Town to Save the Children, which has never run an Ebola facility. That is a flavour of what I have picked up.

              Fergus Drake: Indeed, and you can imagine that for our staff, particularly NHS and Ministry of Defence staff, those comments really sting. In terms of the facility itself, I have gone back there since, a couple of weeks ago. I rang the team this morning just to give you an update, and I think it would be useful to just tell you how far we have come with the scale-up. So far we have treated 91 patients. We have 50 beds open as of now—

              Chair: Sorry, 15 or 50?

              Fergus Drake: Fifty.

              Stephen Phillips: From 87, is that right?

              Fergus Drake: From 80. We have 17 survivors—there was an 8 and 9-year-old brother and sister as of Monday—and we have 35 people who have died. In terms of our planned scale-up, that is on track. We had always planned, as per MSF protocols, to not open the facility immediately; that would be wrong in terms of all the training and vector control that we have talked about. It has been very challenging, and I can come on to some of the challenges, but we are on track to reach 80 beds by the end of this month.

              Q39 Chair: Take us through some of the challenges, because clearly people out there—and I am no expert—thought that you should have gone faster.

              Stephen Phillips: And particularly in this context. We know there have been 8,000 cases declared by the Sierra Leonean Government to the WHO, which is probably under-reported by, let’s say, 50%. That is 12,000, maybe as many as 16,000, in Sierra Leone. You have an 80-bed facility, of which 50 have been used. Two weeks ago, the Prime Minister was asked by Sir Edward Garnier at PMQs why only five beds were being used. It does seem to be very slow. We all make clear that it is not a criticism of the staff on the ground, who are heroes, but Save the Children seems to have been very slow off the mark in getting the facility up and running.

              Fergus Drake: I think for the first two or three weeks, that is a very fair response. It was a result of the speed of build. We have basically built a field hospital from a muddy field in eight or nine weeks. Obviously, there is only so much training you can do with regard to staff in facility for the first four and five days, which is absolutely vital. The first duty of care is obviously to our own staff, be that Department of Health staff, NHS staff or Ministry of Defence staff, because if we were to jeopardise the health of that facility we would not have any beds there at all. We have always been very specific and plain, both to DFID and others, that we were going to grow the facility in line with MSF protocols.

              Q40 Chair: And have you had experience? There was criticism that you were on a learning curve as well as growing the facility. Is that a fair criticism?

              Fergus Drake: It is a fair criticism. We have had a steep learning curve. Everyone involved in Ebola, apart from MSF—the world-renowned experts in this—has had to work out of their comfort zone. It has been an incredible group effort, not just between staff of the NHS, MOD and Department of Health, to get to a point where we have over 450 individuals working in that facility at the moment.

              Of the 450 staff, a lot of them only speak Krio, and the Cubans only speak Spanish, so everything has to be translated. There is about 1,000 metric tonnes of procurement and 2,574 individual line items. We were specific on scaling up as quickly as we could, but ensuring that some of the issues that Professor Whitty talked about were lock-tight to ensure the safety and security of our staff was paramount, as well as responding as quickly as we could to the needing country. 

              Mark Lowcock: I would like, if you don’t mind, to make a point about this. In July or August, everybody was saying that the existing institutions and facilities would not be able to cope. MSF—the leaders in this space—said, “You need to bring in new institutions, including military and state institutions.” By definition, none of those had ever run an Ebola facility before. It is extremely dangerous, as you have been appreciating. We had a series of conversations with a range of potential organisations.

              The first organisation that we thought had some ability to run such a thing and was willing to take on the risk, and do it safely but at a speed, was Save the Children. We pay tribute to them for being willing to do that. The scale-up is on track, as Fergus said. Nobody should be surprised, if you have never done this before, that you face lots of problems. We do not think that this has been badly handled. There have been lots of problems to fix. We would love to have done it faster—of course we would—but overall, as figure 4 on my chart shows, and partly through the contribution of the fantastic work that Save the Children has done, the provision of facilities is a bit ahead at the moment of where we planned it to be on the modelling.

              Q41 Stephen Phillips: You’d love to have done it faster. How long was it between the moment that you told Save the Children to go and that you were grateful to them—we all are as well—and the first bed opening?

              Mark Lowcock: I will have to refresh my memory.

              Stephen Phillips: Roughly.

              Mark Lowcock: Yes, I will give you that. During the course of the second half of August, after the declaring of the emergency, the senior team at Save the Children had a series of discussions with us. I was closely involved, and we were discussing it with lots of other people as well. Save the Children, of course, had to do a lot of its own due diligence. They said to us, repeatedly, “We have never done this before. We don’t know if we can do it.” I think that the decision, when we all agreed that we would do it, was on 8 September. The facility opened and took in its first patient on 5 November, so there was an eight-week period. As Fergus said, they were starting with a muddy field. That period of time is not people hanging around and kicking their heels; it is people working from 6 o’clock in the morning until 10 o’clock at night, seven days a week, trying to get the thing up and running.

              Q42 Stephen Phillips: Given that MSF was complaining, fairly vociferously, about the response of the international community as early as late June or the beginning of July, why did it take until 8 September for the Department to find a partner with which it could work? Obviously, it would take a while thereafter to build the facility.

              Mark Lowcock: The core reason is because there are not many institutions that have the capability.

              Q43 Stephen Phillips: That should shorten the time, because there are fewer people to speak to.

              Mark Lowcock: In fairness to them, we had a series of conversations with them before they were willing to take it on. We had the same set of conversations with the military. It is not a trivial thing for the UK to deploy its military capability. That takes some time to think through.

              Q44 Stephen Phillips: No, but we could have done that, couldn’t we? RFA Argus, which is essentially a hospital ship, could have been out there by the beginning of September if the action had been taking in July or August.

              Professor Whitty: Can I just add something? To be clear, it is not that nothing happened before Kerry Town. The key thing in all these responses is to build on what is already there. A lot of the UK response was about bolstering existing things in Sierra Leone, including MSF.

              Q45 Stephen Phillips: The trouble with that answer, Professor Whitty, at least according to the press reports that we read, is that there was not very much there at all, and what was there was completely overwhelmed by the scale of the outbreak—indeed, to the detriment of the treatment of any other endemic condition at all.

              Professor Whitty: You have made multiple points there. I will respond to the last one, and I think that the permanent secretary might want to address the others.

              On the other diseases, that is absolutely the case. There is a high chance that when we look back on this epidemic more people who did not have Ebola will have died as a result of the Ebola epidemic.

              There are two big problems with the Ebola epidemic. First, it chews up the health service by panicking people, quite reasonably, and killing health care workers in what is already a challenging situation. Malaria, issues in childbirth—all those things will almost certainly have gone up significantly over this period of time. We have done what we can to support that, but we all recognise that it is a very major issue.

              The second problem is that it is a disease of panic. It has led to some very irrational responses that compound things, because people stop having economic activity with the affected countries, which has an impact on the poorest people. There are a whole series of knock-on effects—I totally accept that point.

              Stephen Phillips: I think we will want to come back to that with Mr Lowcock.

              Q46 Chair: What I do not understand is this: we are sitting here in the comfort of the Palace of Westminster, but the criticisms have come from people on the ground, so you sort of feel like something is happening there. Perhaps you can take us through the challenges that you have faced that may have been frustrating and made the delivery tougher than you originally thought it would be.

              Stephen Phillips: You should feel free in this Committee to talk about corruption as well, because you enjoy immunity. You can do so as freely as you want.

              Professor Whitty: Shall I give an epidemiological answer, and then the people on the ground can give their answer? There was a delay with the international community between March and July, which we have talked about, but once the scale-up started, there was inevitably a delay while that was actually happening. During that time, people saw a lot of activity, but not many beds opening and the disease continuing to go up. It has continued to go up. In Sierra Leone, because of all the activity now, it is likely to hit its plateau some time between now and the middle of January. I cannot guarantee that—forward projections on any disease are very dangerous—but all the modelling suggests that.

              The R0, the reproductive number, which started off probably somewhere around about 1.6, has gradually drifted down in Sierra Leone, little by little, because of this activity, and it is probably going to cross the 1 line, which is basically where it is stable in the population, sometime in the next few weeks. In that period, people are understandably incredibly frustrated. They see the money going in and the activity, yet the number is still going up. They say, “What on earth is going on here?” A lot of quite understandable emotion is being thrown at people—what’s going on? Now that we have reached this point, from now on the number of beds exceeds what we projected we would need to get on top of the epidemic, and from now on we hope that things will begin to plateau. This has been a very bumpy period. We were expecting it to be, and it certainly has been.

              Stephen Phillips: Can we hear something about the challenges and corruption?

              Q47 Stephen Hammond: Can I ask a question? Mr Phillips previously talked about reported and unreported numbers; does that plateauing number that you mentioned take into account an estimate of the unreported number?

              Professor Whitty: All the way through, there has clearly been a gap between the number of cases that are actually there and the number that are reported. Initially in the epidemic we thought it was roughly 2.5 times, although it is obviously difficult to tell. As time has gone on, that gap has probably narrowed, but it is very difficult to estimate. I would therefore assume that, because of that, if anything the trajectory would do the opposite of flattering the numbers. Our expectation is that it will plateau, and although we accept that even now we are not picking up all cases, we still think that the trajectory is gradually beginning to level off and should reach a plateau and begin to go down, although I do not want to put exact numbers on it, because that would be very dangerous in a very dynamic epidemic.

              Of course, there will be some areas in which that will not happen. In many areas it is already clearly getting better, but there are clearly still some hotspots. I am really talking about the overall picture, because it is clearly still going up in at least two of the districts in Sierra Leone, but in quite a lot of the others it has gone quite a long way down as a result of the activities undertaken.

              Q48 Stephen Phillips: I want to come back to Kono at some point, but first I really want to hear from the NGOs and the Department about the challenges faced.

              Fergus Drake: From our perspective there are three key challenges. I have spoken about the first, which is the speed of building the facility, being able to take it over as quickly as possible and then providing adequate and efficient training. Obviously, it is only when you are beginning to use a facility that you stress-test everything from septic tanks to water sources and the speed at which more than 331 sacks of personal protective equipment—the yellow suits that you see—can be burnt a day.

              There is then the staff build-up. When we get up to 80 beds there will be approximately 750 staff involved. At the moment we are up to 450 staff. The third challenge is training the people who spray down the health workers coming out of the red zone. It takes about 20 minutes to take off your PPE, and spraying people down is absolutely vital. The water is heavily chlorinated, and it is one of the key times of vector control at which you can catch the disease. We have had to train about 200 of those people, many of whom have not been to school. Therefore, giving them an overview of what they are doing, taking them through a mock facility and then taking them through into the red zone—all of that is specific.

              One area where we could have done a better job is in our communication to the Sierra Leone people, because we talked a lot about the opening of this 80-bed facility and about the very strong UK aid effort. We should have done far better at saying that the facility would not be open with 80 beds from week one and that we would need to scale up safety for our staff, as per MSF protocols.

              Q49 Stephen Phillips: Because you had patients, potentially with Ebola, showing up at the front door and nowhere to put them?

              Fergus Drake: That is right. The Kerry Town facility has always been a referral centre. It has been a place where we can care for and respond to people who have had a blood test and been told that they are Ebola positive. Obviously, if President Koroma and others have been on television talking about this facility being open, people will turn up. We are now working very closely with NERC to make sure that the systems are in place so that every morning we are saying, “We have this number of open operational beds. As of today, we are asking for 10 new patients to come from the various holding centres. They will be taken by our staff and will go through that process.” Unfortunately, because we are a referral centre, many of those people who are coming to us have had Ebola for quite some time, so we are seeing about three or four deaths a day, as well as two to three survivors. At any one time, our staff have an incredible feeling of elation to be working in that environment and to see people coming through it, but some of the levels of trauma that staff are seeing are analogous to those in 1994 and the first 100 days in Rwanda.

              Sanjayan Srikanthan: I agree with everything that Fergus Drake has said, but I have a few other points to make. We are involved with isolation centres, which take the strain off treatment centres by putting suspected cases in a safe location where they can be monitored, observed and tested quickly. If they are confirmed, they can be moved into a treatment centre. One of the challenges that we face is the movement of the virus. As you have seen, the virus has spread from the east, and there are now concentrations in the north and west of Sierra Leone. In remote areas, it surges in certain places. We are trying to keep up with the virus by opening small 20-bed isolation units at village level so that people can get immediate treatment, but we need always to map out whether the location is right and whether the virus is moving somewhere else. We have to be ahead of the virus, which is a challenge. Underpinning the problem is the challenge of staffing. We are an organisation that is predominantly, more than 95%, Sierra Leonean. Our country director is Sierra Leonean, and Sierra Leonean staff are scared. One of the reasons they come to work for an NGO is that they feel there is a higher level of safety and risk management in working with us. We need to continue attracting the best staff at a time when we are still hearing about Sierra Leonean doctors who are dying of the virus.

              Q50 Stephen Phillips: I read yesterday that junior doctors have just gone on strike. Is that right?

              Sanjayan Srikanthan: Yes.

              Q51 Stephen Phillips: Because they are not being adequately protected and are not receiving their hardship payments.

              Mark Lowcock: Can I just add one point before coming on to your corruption point?

              Stephen Phillips: Well, it is the corruption that Mrs Hodge and I are both very interested in.

              Mark Lowcock: Yes. Just to reiterate what Fergus said, the mistake that we collectively made was not being clear with people that the scale-up would be slow and gradual. I don’t know whether you have read—you probably have, Mr Phillips—the evidence that MSF gave to the Select Committee on International Development three weeks ago. They made it absolutely clear that their scale-up in these facilities is just the same, so we should have been clearer about that, which might have helped with one or two things.

              As you know, everything that the Department is financing in terms of the delivery effort is being done outside of government. Governments co-ordinate, help set priorities and set the framework, but we have brought in delivery partners. We have done that because the Sierra Leoneans’ own system is under so much strain that it is not sensible to be putting more money through that system. Of course, Sierra Leone’s own health system is doing the best it can in these circumstances. There is a really big problem about making sure that people are properly paid and get their hazard pay, and we have seen some graphic examples of what people will do if those things do not come through.

              The World Bank has lead responsibility for helping to make the financing set of arrangements and salary payments work properly. The president of the World Bank was there last week. He acknowledges there are some really difficult problems. There is corruption in the health system and in lots of other institutions, and he is clear that they have not solved the problems yet. He asked for our advice on some things that they could do, and we gave him some advice, so they are absolutely determined to get on top of it.

              Q52 Chair: There was a figure in my papers—was it in your document?—about the amount of money that went in on health and the amount that reached the front line.

              Tom McDonald: I do not think so, no.

              Chair: I have it somewhere. I just cannot put my hands on it.

              Mark Lowcock: There is a big problem, Chair. At one of my appearances before you a year or so ago, Mr Bacon asked about the health sector in Sierra Leone. He made the point that we had suffered a loss, which we fully recovered, from commodity provision through the health system. It is a characteristic of a country whose institutions were completely destroyed in the civil war and faces the difficulty of rebuilding them. There is weak capacity and less than perfect behaviour by some people in key positions of authority, and that is the environment we are operating in. It does add to the challenge. I think the Sierra Leoneans are doing the best they can. It is difficult. We are supplementing them by the directly commissioned delivery, but that does not mean that we do not want their own system to work as well as it can.

              Q53 Meg Hillier: On the infection rates, I do not know whether you have the same note that we have got, but it states: “Case incidence continues to increase in Sierra Leone and transmission rates remain high in Guinea and Liberia.” Doing the rough maths, about half of the cases are dying in Guinea and Liberia, but only slightly less than a quarter in Sierra Leone. I am not an expert on Sierra Leone. I know about west Africa, but not Guinea and Liberia. Perhaps you could tell me why that is and what the risk is? If there is progress in Sierra Leone, and if that is the death rate in Guinea and Liberia, what is being done to prevent further spread from there?

              Professor Whitty: To some extent, this is an artefact of the fact that in Sierra Leone the numbers are still going up, and, because there is a lag, it artificially looks better, sadly, than it is. In Liberia, the numbers are going down, and that reverses. In fact, what we will see, we hope, when we get on top of the epidemic in Sierra Leone, is that, paradoxically, it will look as if the mortality rate is increasing significantly because we have got on top of the epidemic. So it just to do with the dynamic of the epidemic.

              Meg Hillier: Okay, so there is not a risk of spread.

              Stephen Phillips: What is the actual mortality for this particular strain? It looks to be around 70%. Does that sound about right?

              Professor Whitty: It is around 70% up to the point where we have got reasonably reliable data. Probably, as people are getting better at managing it and getting better with fluids, it is beginning to come down, but it does not seem to fall below 50% with current treatment in most centres. That seems to be the base. Clearly, we are trying to bring on new treatments that we hope in due course will take it down further, but they are not yet there.

              Q54 Meg Hillier: May I ask about vaccines? I represent one of the largest west African diaspora communities in the country. I know that a lot of west Africans support it. We have not heard much about that today, so it would be good to get that on the record. There is also the issue of education—I will wrap them all into one, if that is all right—within Sierra Leone. I think Mr Drake mentioned the role of education earlier, so it would be interesting to know a bit more about that, but there is also the issue of education in the UK. People I have spoken to in the UK are afraid to tell their families, or certainly their colleagues, that they are visiting even Nigeria, because they are worried about how people will react when they come back. That brings me to the issue of what happens to volunteers on return, and the duty of care and what happens there.

                            Mark Lowcock: There is a set of questions there. First, on education, public awareness, information and so on, I think Tom’s note sets out some of the things we have been doing. We have trained 2,000 community volunteers; we are supporting 40 radio stations broadcasting public information messages; crucially, we are engaging with about 600 religious leaders, because one of the big problems is transmission of the virus at funerals and meeting the need for safe burials.

              We are also doing anthropological research to understand better what people in Sierra Leone know, how that is changing their behaviour and what the constraints to behaviour change and risky behaviour continue to be. As time passes, we are seeing that knowledge levels are rising. Most people have quite good knowledge; most people are willing to change very entrenched culturally, societally, religiously important rituals to protect themselves at funerals and so on. But a proportion of people, because there is a not unreasonable suspicion of authority, continue to place primacy on the rituals that have been intrinsic to their culture. So there is a continuing issue there, although we are making progress.

              On the diaspora, Lindsay Northover, the Under-Secretary, met a big group from the Sierra Leonean diaspora earlier in the week. We are engaging with them in lots of different ways in how they can help. One thing that is helping to manage the epidemic is the 117 call centre, which you have probably heard about. That is a national and district centre. What people say when they ring the number is a bit like what people say to NHS Direct: “I think I am ill. What am I going to do and where do I get help?” Members of the diaspora have been very helpful in thinking through the protocols for making that system work as well as possible.

              Q55 Meg Hillier: And what about the west African support in region? Can you give us a flavour of that?

              Mark Lowcock: Other countries?

              Meg Hillier: Other countries in Africa. We are talking about aid from all sorts of countries outside Africa, but I would like to know your interpretation of what is going on.

              Mark Lowcock: I don’t know what the numbers are; Chris probably should supplement this. A number of African countries have offered to send health workers to the three most affected countries. The African Union is running a programme to do that. There are certainly lots of international staff of African origin who have volunteered and are working, some of whom have lost their lives in doing so. You will probably have read about the Sudanese doctor in the press.

              We are also involved in preparedness across the region. We have a £25 million allocation to help, first, in the countries bordering the three affected ones: Côte d’Ivoire, Guinea Bissau, Mali, Senegal. That is obviously the first ring of risk, if you like. There is then a bigger exercise that the UN is doing, looking at 15 other high-risk countries. That was completed this week.

              In that wider region, the UK is focusing on the countries where we have the strongest links. We have been working closely with the Nigerians and are doing the same with the Ghanaians. For many of the other countries, because they are francophone and we do not have the history, others will be better placed than us.

              Q56 Chair: I want to put on the record the shocking figure I have for Liberia, not Sierra Leone. Only $3.9 million out of a $60 million EU programme reached the front line. That is less than 7%, and it is shocking.

              Mark Lowcock: There is a really big problem to do with the fact that this is not one of those emergencies where you can write a cheque and something good automatically happens. Overall, what the UN is telling us is that something like $4 billion has been committed, but it can’t actually do anything until you turn it into people on the ground or facilities or programmes.

              One of the other big learning points from this crisis is that we do not have enough institutions that can be put instantly to work in these countries where their own institutions cannot be expected to solve the problem. That is why we have been scrabbling around. Some of that $4 billion will be put to very good use during the course of next year, because there will be an economic recovery and there are a lot of fiscal problems to deal with. The EU, the World Bank and so on should help with that. But you are exactly right to say that the problem is not the money; it is what you are going to do with the money. That is the point that Mr Phillips made, in fairness, in the debate on 5 November. It is not a new point.

              Q57 Stephen Hammond: I just want to ask two very quick questions which are broadly related to that. Earlier on, we talked about the problem of doctors leaving. In hindsight, accepting that it was after a civil war, are there things you could have done in terms of public health interventions or other capacity building in country that would have helped? You started to talk about your preparedness, which is one of your strategic aims. What have you directly learnt from this that might change how you look at preparedness for the next epidemic of whatever it may be, while making sure that it does not happen?

              Stephen Phillips: And wherever it may be.

              Professor Whitty: On the first of those questions, it is important to remember that health has been improving really very rapidly in Sierra Leone since the civil war. The idea that nothing has happened is, I think, wrong. It has started from an incredibly low base and got up to a low base. If you look at the numbers, they have actually gone down quite significantly. If you look at child mortality figures, for example—if you wish, I can send you a note after this which tracks them down in terms of the MDG figures over that time.

              You can see that there has been a substantial improvement. That does not mean that there is not a huge amount more that needs to be done in terms of strengthening the system. Strengthening the system overall—I think that this is Mr Phillips’s point and your point—is the biggest thing we can do to prevent epidemics such as this from not being picked up early enough. We can try to put together fancy epidemiological systems in Europe and the States; those are probably useful things to do. But much more important, really, is to get the front line to work more effectively.

              Mark Lowcock: On lessons, the first thing that is important to say is that we are still putting the fire out. The time to do a serious job on the lessons is when we have time to think about it. That also applies to causes, early warnings and so on. The Development Secretary, when she was giving evidence to the IDC the other day, said that she thought it would be good for Parliament to be engaged in helping with this lesson learning exercise.

              There are three things to flag that we will be thinking about. The first, obviously, is early warning surveillance, epidemiology and all those kinds of thing. Clearly, as the director general has acknowledged, the world will want WHO to do a much better job on that. There is a special session with the WHO executive board on 25 January which will start to get into that. But there is a very important question about what other things should complement WHO. The US, as you know, has a lot of institutions in this space. The CDC, for example, has played an important role. For us it is a question of what use we want to make of our own scientific and technological capability, which the Prime Minister has been asking about and talked about at the G20. That is a first set of issues.

              The second issue is response institutions—national institutions are crucial, but we must also recognise that you cannot build a health system that is going to deal with major epidemics in 10 years or 15 years. We must do all we can to build up the systems in these weak countries, but we also have to ask ourselves how we will know next time that we have a larger set of institutions to go to that will be ready much earlier to deploy.

              The third area is technology and research and development, which you alluded to. We are financing with others the development of a vaccine. The first-phase trials of the three candidates are all under way and largely finished. There are then phase two and three trials. That is all being fast-tracked. There are other technologies as well. I talked earlier about how labs and testing have been a big constraint. We have a research programme at the moment which is testing a new rapid diagnostic tool for use in the field, a bit like the one you are probably familiar with for malaria. You don’t have to send the blood to the lab any more.

              Q58 Stephen Phillips: That is great, but it does raise a question about why there was no proper funding for what appears to be a relatively simple vaccine to engineer at a much earlier stage. Also, what is the next thing? We think that we are going to have a vaccine for Ebola pretty soon; excellent. But what are we doing about Marburg? How do you know that there is not going to be a Marburg outbreak?

              Professor Whitty: Those are very important questions. On the first question about why we do not have a vaccine now, you are absolutely right. There are actually three vaccines that were at advanced stages of pre-clinical development—already, in a sense, on the shelf. The reason that they have not been deployed is that all previous epidemics have been turned around so quickly using conventional public health methods.

              Q59 Stephen Phillips: But they have all been in rural parts of the DRC, they have been much more severe and lethal, and have basically burnt themselves out.

              Professor Whitty: Yes, but when you come to testing a vaccine in trials, you have to have enough people with the disease properly to be able to test it. We have not had any epidemics to date where you would have been able to get out there, design a trial and get it out there before the thing was over. People say that it is only because it is in poor countries, and I am sure that is a part of it. However, until now, those have been small, and quick in medical terms, epidemics that have been got on top of very quickly. This puts us in a different situation. As a result of this, there will be a big push, as you rightly imply, not just for Zaire strain Ebola but for the four or five other strains—one of the five is not so much an issue for humans—and for Marburg. We also need to look at other diseases that could do this. Our Secretary of State has set us a task to find out what the other diseases are that could do this and, therefore, what we should be looking at. That is an important question for us to address.

              Q60 Stephen Phillips: Mr Lowcock, obviously you are going to have to look at it with Ministers, but it looks as though that is a useful use of taxpayer spend, which prevents a large cost when we have an outbreak.

              Mark Lowcock: I completely agree with that. As you will know, research on neglected tropical diseases has been a big thing that the Department has been doing over the past 10 years or so. We have helped to develop a lot of technologies. A challenge is the order in which you do them. As Chris said, it was difficult previously to contemplate testing an Ebola vaccine, but it was in lots of people’s minds that maybe there were higher priorities. There has been a massive effort, for example—not yet completely successful—on HIV; there is malaria, dengue, and Marburg. The order in which you do those presents a difficult set of judgments, but the one big takeaway is that faster-developed technology is going to help deal with epidemics in future. H1N1 is clearly another massive thing to worry about. On one level, we have been lucky with Ebola in the sense that it is not as transmissible as some airborne infections.

              Stephen Phillips: It is very difficult to get.

              Mark Lowcock: Yes.

              Q61 Stephen Phillips: I wish that message would go out through the press, but there we are.

              Professor Whitty: Just to pick up on that and a question that we did not answer from Ms Hillier about how people are treated in the UK when they return—that comes very much to the point that you are making. The UK politicians and the press have been extremely responsible in the way that this has been reported, by and large. The hysteria that other countries have had about people returning—

              Stephen Phillips: The United States in particular, Professor Whitty; you can name them.

              Professor Whitty: I wouldn’t wish to point fingers, but there are a number of them. The UK has been very good. For example, there are NHS workers who have recently come back from Sierra Leone. They are doing a very good job. They are completely safe and are monitored by Public Health England. That is a rational, science-based system that Ministers have signed off on. That is the way that it should be done. 

              Mark Lowcock: May I add one point, very quickly? That approach makes it easier for us to get people to go to help tackle the problem. Some 100 staff in the Department are part of the response. They are volunteers like all the other public servants. The fact that we have not had the kinds of problems that you allude to in other countries has made it easier for us to get all the people we need to help tackle the problem where it is best tackled and, therefore, avoid spread, not least in the region but potentially to other places.

              Q62 Chair: Can I ask about the MOD? I understand that you are having to fund its effort. Is that right?

              Mark Lowcock: It is not quite right.

              Chair: Good.

              Mark Lowcock: The situation is that there is a standing cost met by the MOD for the existence of all the assets: the folk running Kerry Town; the trainers who have trained the 4,000; the RFA Argus, to which you have referred; the people who are doing the helicopters and the logistics; the military engineers who are building the facilities; and the information people on the joint inter-agency task force. They all exist and are paid for as a standing capacity by the taxpayer through the MOD. We have a long-standing arrangement with the MOD such that when we ask them to take on additional cost to help us deal with an emergency, there is a protocol that has us pay those costs. So far, the bill for that is £35 million and is included in the £230 million. I think that is a very good arrangement. That is all ODA-able, by the way, so it counts against the 0.7%.

              Q63 Chair: Well, it goes to the Treasury. I can’t remember what the fund is called, but anything you do in Afghanistan is picked up by the Treasury.

              Mark Lowcock: The UOR.

              Chair: Yes. I cannot for the life me understand why we are asking—we might have different views around the table on this—

              Stephen Phillips: We do.

              Q64 Chair: Okay, well, from my point of view, I cannot understand for the life of me why what I still see as a pretty small contribution to world poverty is being asked to pay for MOD activities. I am not sure what else they would be doing if they were not helping you.

              Mark Lowcock: May I make one comment? If every time we wanted to, say, ask for the aircraft carrier to help in the Philippines or ask for more to deploy, we had to have an argument about who was going to pay for what, the whole thing would slow down. The system we have enables us to deploy these resources faster than would otherwise be the case. Without those hundreds of service people, we would be in a much worse position.

              Q65 Stephen Phillips: There is one final point that I want to touch on, which I know is important to the NGOs, and to your staff as well, and that is direct flights. Obviously, we need to look at that from a value for money perspective, but it has a number of impacts. First, the lack of competition on the route and having to go via either Brussels or Casablanca increases costs. Secondly, it discourages people from going and volunteering, is a disincentive for people to travel and also affects the morale of people who do travel. There is no justification, according to the WHO or, indeed, anyone else, for the absence of direct flights. Why was Gambia Bird’s licence restored? Why are you not beating down British Airways’ door to get them to restart direct flights?

              Mark Lowcock: As you know, the Government took the view that as part of a whole set of measures to avoid the risk of spreading the epidemic, it would be better to not have direct flights. I completely accept that it is inconvenient, but it is not—

              Q66 Stephen Phillips: Well, can I ask Professor Whitty, as the chief scientific officer in DFID, is there any risk at all from direct flights? You will answer that “Yes,” but is the risk absolutely negligible, which is what the WHO says?

              Professor Whitty: I do not think that this was a decision purely driven by science.

              Q67 Stephen Phillips: It was a political decision?

              Professor Whitty: It was a political decision.

              Q68 Stephen Phillips: Which has had costs for the taxpayer, Mr Lowcock?

              Mark Lowcock: I do accept that it is inconvenient. On the other hand, the system is functional. In addition to the—

              Q69 Stephen Phillips: When did you last take a long layover in Casablanca?

              Mark Lowcock: But we also have the UN humanitarian air services flight, which is operating now between Accra and the three countries. We have thought about whether we should charter flights—

              Q70 Stephen Phillips: That was going to be next question. Why do you not just get the RAF to fly direct flights and charge the NGOs?

              Mark Lowcock: The reason we are not doing that is because we think the current system is sufficiently functional. There are other better things for us to do with our resources, such as get the facilities up and running faster.

              Q71 Stephen Phillips: Mr Drake, do you have a view on whether or not that would be a good use for DFID money?

              Fergus Drake: I would agree that in order of priority, I would still very much be focused on getting Ebola under control and, with response to your question, on some of the medium-term things that we need to be focused on now, such as strengthening the education and health systems. That is vital.

              I flew in on SN Brussels two weeks ago and flew out on Royal Air Maroc, and the four hours sat in Casablanca was not ideal having just come back from that environment.

              Stephen Phillips: Or the three hours in Brussels airport.

              Fergus Drake: Indeed. However, it is functional and it is working, but it is not ideal.

              Chair: Thank you all very much indeed.

              Oral evidence: Oversight of UK spending to tackle Ebola in West Africa, HC 868                            1