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David Heymann began by highlighting the UK’s Global Health Strategy as a world leading, and precedent setting, approach to managing the impact of global health on a single country. The strategy, whose first instance ran from 2014 to 2019, is remarkable both for its engagement in the relationship between global efforts to achieve health security and public health in the UK and for taking a cross government approach, with every single government department contributing something to its development and implementation.

 

The strategy arose from lessons learned from two recent pandemics that were handled far less well. The first of these came from Variant CJD, caused by BSE in the British Beef cow population. This was seen to have been poorly managed by the government and had very significant impacts on the economy of the UK. The second was the SARS outbreak of 2003, which emerged in Guangdong and Hong Kong. The spread of this disease was traced back to a single doctor who fell ill in an international hotel in Hong Kong, infecting other guests who spread it around the world. The government of China was heavily criticised for not taking this outbreak seriously enough at first. However, following a change in policy and aggressive international efforts, it was later effectively contained.

 

Other recent disease outbreaks, including MERS, Ebola and Human Monkeypox, highlight the important role that poor biosecurity and infection control, especially in hospitals, often plays in initiating pandemics, and thus the significant opportunity that governments have to prevent them by investing in global health. They also highlight how international cooperation is key to detecting and fighting pandemics. Sometimes this has been achieved via intergovernmental cooperation. For instance, UK-Nigeria Health Service cooperation enabled the early detection of two cases of Human Monkeypox in the UK. However, in other cases, international cooperation has had to be achieved without government assistance, or even in the face of government opposition.

 

The UK has played a leading role in improving global health, especially in the field of fighting antibiotic resistant pathogens. Partially, this has been made possible by our involvement in International partnerships such as the Global Health Security Initiative. However, it has also been facilitated by the fact that we continue to invest in International Development via our legal commitment to spend 0.7% of our GDP on Aid.

 

Piers Millett began his presentation by pointing out that biosecurity was inherently intergenerational. Large scale global pandemics do not, thankfully, occur on a regular basis but can be expected every 50-100 years, with the last major event being the 1918 ‘Spanish Flu’.

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For instance, since smallpox immunization largely stopped half a century ago, most of the world’s population would have no protection against the disease were it to remerge.

 

However new technologies are giving us more powerful means of securing ourselves against dangerous pathogens. For instance, it is no longer necessary for everyone working at the front-line in fighting a virulent epidemic to wear full body protection suits anymore, while much more of the work of studying emerging pathogens can now be undertaken in the field rather than in the lab. Researchers at Novartis were recently able to use digital sequencing and synthetic biology to create a vaccine for a new strain of influenza in a week, far faster than traditional lab-based methods.

 

The UK should thus support a proactive strategy of supporting research and development in biosecurity to make use of its expertise and the massive data coming out of the NHS.

 

Yet, such research and development initiatives can only ‘pre-position’ medical interventions, in that they must still be taken through medical testing and regulatory approval. This means that there are a growing number of unlicensed vaccines and other experimental treatments that are now available but as yet unregulated. These create a challenge for policy makers who need to respond in these situations. In the USA there is a general legal indemnity for companies whose treatments are used in emergencies; however, no equivalent provision exists in the UK or EU at present. This may be one area in which the UK could use its greater regulatory freedom post Brexit to improve biosecurity if it chooses, by providing similar indemnities to those offered in the US.

 

Many emerging biotechnologies are also dual use, in that they can be used to construct bioweapons, and other biohazards, more easily and efficiently. One of the reasons why the international ban on bioweapons has been, generally, more effective than that similar bans on other weapons of mass destruction is that it is widely acknowledged that bioweapons are either too ineffective or too dangerous to use in battle. However, this consensus is now shifting and that may have a knock-on effect in making these weapons harder to control.

 

Another potential risk with these new technologies is that they open up new vulnerabilities in the biosecurity system. Because biological data is now being digitized and transmitted over the internet, it is increasingly possible for it to be hacked, and for people to cause biological damage via cyberattacks alone. Nor can potentially dangerous pathogens be contained any more merely by securely storing the biological material itself, since if one knows enough about these organisms it is possible to synthesise them elsewhere. This is making international biosecurity increasingly difficult, especially as governments have different approaches to the regulation of information sharing.

 

At present, the main people who are considering and addressing the risks of information sharing are those who are actively involved in producing potentially dangerous information, but they clearly have a vested interest in the subject. Dr Millett and other researchers at The Future of Humanity Institute have worked to produce a set of guidelines for managing potential information hazards, which they hope could form the basis for a more objective approach to the issue.

 

While a growing number of organizations involving in developing biotechnologies  are aware of these risks, recent surveys suggest that only half have any idea where to obtain support in how to manage them and the only examples of anything even close to best practice are to be found in the USA. Even when people are not doing anything illegal, they can still be acting dangerously and anyone who has suspicions about someone with the knowledge or access to cause harm should be able to contact somebody who they can easily communicate their concerns to. The lack of any clear UK based person or agency who can address these concerns and bring together the security and engineering communities means that there is nobody building relationships of trust and best practice.

 

Catherine Rhodes argued that while future generations would like us to take steps to prevent pandemics from occurring, they would also like us more broadly to take steps to boost social resilience to pandemics, including those that would allow us to recover more quickly, since sooner or later our biosecurity will surely be breached. A key theme in shaping how we can go about doing this is trust. 

 

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 For instance, Indonesia stopped sharing samples with the international system for monitoring influenza because it felt that it was not receiving an equitable share of the benefits from this scheme. The WHO were able to take steps to rebuild this trust, such as centralizing the sharing of vaccines and other benefits to ensure that it remained equitable across all member states. However, often individual states act in ways that significantly undermine these efforts.

 

For instance, at the time of the 2009 Swine Flu outbreak, 7 industrial states were found to have advanced contracts with vaccine manufacturers and thus came to dominate the international supply of vaccines - these were not the states that one would expect to be worst affected by such a pandemic. This is not an easy thing to talk about as states desire to put their own citizens first. However, governments could still take real trust building actions to promote international cooperation, such as issuing assurances that they will not act in the same way in the future.

 

Trust is also important between states and the international biomedical research community. The community is worried that governments may limit the activities of researchers in ways which threaten research efforts that rely on international sharing of sequencing and other resources. Governments do not seem to be responding to these concerns.

 

Within states, trust is also important between people and their governments. To this end, there are issues about people receiving conflicting advice from different agencies. We need to carefully think about how and why governments may provide differential recommendations to different people should a disease outbreak occur, as this can create a powerful sense of mistrust and inequity and thus hamper cooperation.

 

At the moment, most people are not even aware that there is a national pandemic preparedness strategy, let alone interested in engaging with it. Some key concerns that this raises are that people are not aware of the burden that a pandemic is likely to place on healthcare infrastructure, and how we can manage the ‘worried well,’ or at least people who are not sick enough to require hospital treatment. There is also insufficient awareness of the impact of an increased number of deaths over a relatively short period, such as using community facilities to expand mortuary capacity. These things will greatly undermine trust if they are a surprise to people, and could be seen as a sign of a lack of preparedness rather than of a well-developed strategy being put into action.

 

In the UK, there are Local Resilience Forums but people do not know about them and they are not aware of where we can go and who we can look to for advice and guidance in an emergency situation. Many people do not even know who their neighbours are and whether they will need additional support. On the other hand, Dr Rhodes concluded, knowing in advance what you might contribute in the event of a national emergency like a pandemic, is something that could really help to build trust and resilience.