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Volume 758: debated on Thursday 8 January 2015

Question for Short Debate

Asked by

To ask Her Majesty’s Government what lessons they have learnt from the recent Ebola outbreak in West Africa.

My Lords, I welcome the opportunity of this short debate. First, I would like to pay tribute to the brave people who have gone from other countries, very much including the United Kingdom, to help tackle the outbreak of Ebola in west Africa. Obviously, I am thinking of Pauline Cafferkey, being treated at the Royal Free Hospital in London, and we all very much pray for her recovery. But I also pay tribute to all the others from different occupations and disciplines who have gone to help, including the 70 volunteers from the National Health Service. They have put their own health at risk and we should remember that, among the 680 healthcare workers who have contracted Ebola since the first outbreak of the disease, no fewer than 400 have died. These men and women have come from other countries in Africa and from around the world and have paid a terrible price for their altruism and selflessness.

Of course, the major casualties of the outbreak have been the 8,000 men, women and children who have died so far in countries such as Sierra Leone, Liberia and Guinea. There is perhaps a failure of imagination by us in the West about what a bare statistic such as that means for families on the ground—the individual tragedies that make up the total, with families torn apart and children left without one or both parents. The epidemic may have now reached a peak, I hope, but whether it has or not, one point is certain: we need to examine what measures should be taken to prevent further epidemics on this scale.

It is also worth remembering that any policy changes that may result from Ebola may also have the effect of helping in the fight against other diseases such as AIDS, TB and malaria, where the death toll is actually even greater. Around the world today there are 1.5 million deaths from AIDS each year, a further 1.5 million from TB and 600,000 from malaria—predominantly of children. The challenge must be to reduce radically this entirely unacceptable total of death.

What are the lessons that we can draw so far from the latest Ebola outbreak? I suggest that there are at least three. The first is that one of the reasons why the Ebola epidemic has spread so widely, so quickly and with such devastating effect is that in many parts of sub-Saharan Africa health systems are inadequate; the staff are under enormous pressure and their working conditions are often far below what any of us would consider acceptable in this country. Again, there is perhaps a failure to recognise the conditions in which medical staff have to struggle to make an impact. A few months ago I went not to west Africa but to Uganda and visited a hospital on the banks of Lake Victoria which had not received a budget increase for 10 years. Inadequate and underfinanced health systems remain the truth in so many African countries.

Sierra Leone is a prime example. The country lies 11th from bottom of the United Nations Human Development Index. The figures for infant, child and maternal mortality are bad even compared with neighbouring Liberia. Up until the crisis, Sierra Leone, with a population of around 6 million, had something like 136 doctors and 1,000 nurses to care for the population. The Health Secretary said in the other place on Monday that the Government,

“have committed more than £230 million to fight the disease in Sierra Leone”.—[Official Report, Commons, 5/1/15; col. 40.]

That is enormously welcome and makes Britain one of the biggest contributors in the world. However, my concern is not just what we are doing now but what we did before to strengthen the health system and what we will do in the future, because the whole need is for consistent policy applied year after year. My concern is that, once emergencies are over, there is a tendency for countries to fall off the agenda. We treat the casualties but we do not do enough to prevent those casualties taking place.

An excellent all-party report by the House of Commons International Development Committee, under the chairmanship of Sir Malcolm Bruce, found a strange lack of interest among the NGOs in even giving evidence on the position prior to the Ebola outbreak. The committee would have expected something like 100 pieces of evidence; it received 10. In passing, I pay tribute to Marie Stopes, Plan and Save the Children for being the exceptions to this trend. Unfortunately, the same view seems to have been taken by DfID. In paragraph 33 of its report, the committee found that bilateral programmes directly managed by DfID for Sierra Leone and Liberia were planned to reduce by £14.5 million in 2014-15 compared to the previous year, a reduction of around 19%. The committee commented that it was “appalled” that the budget was being cut in this way. Since then, policy has changed. Emergency money has been put in. A vast effort is being made to help. I welcome that, but my view remains that the priority of policy should be, above all, to provide consistent support for a country such as Sierra Leone, which is one of the poorest in the whole world.

My second point also concerns consistency. I declare an interest as a non-executive director of the International AIDS Vaccine Initiative, which is a non-profit organisation working to develop a vaccine for AIDS. My point today is a more general one about vaccines. If we can develop them successfully, this can have a dramatic effect, as we have seen in a number of countries in relation to the polio vaccine. But there is one point about vaccine development that is also absolutely certain. They take a long time to develop—sometimes a very long time. For example, the polio vaccine took 47 years to develop and the whooping cough vaccine took 42; with some of the diseases—malaria, for example—the search has been continuing for well over a century. The development time has a number of impacts. It means that the pharmaceutical industry is not always able or willing to invest what could be very substantial sums in development. The result is that, in my view, there is a particular responsibility on Governments to finance development here. The United States does a vast amount in this respect. I fear no one would claim that the United Kingdom proportionately does the same.

The third and final lesson that I believe we should examine is the medical staffing position of some of the poorest countries in Africa to see whether the developed world is taking too many of the doctors and nurses who have been trained in Africa but then come to work and settle in countries of the West and the Middle East, including the United Kingdom, of course. Let me be absolutely clear: the doctors and nurses who have come here have made an invaluable contribution to the health service. There is no doubt about that. But that is not the end of the story. Seen from Africa, the problem is that many of the doctors and nurses who have been trained at some expense have left Africa, which is in vast need of their care, to go abroad. Taking Sierra Leone as an example, around 600 members of National Health Service staff received their primary medical qualification in Sierra Leone. That is small in our terms but absolutely massive in terms of Sierra Leone. Relatively few return.

I do not claim that it is going to be easy to reverse that trend. It is a question not just of salary but of the medical conditions to which doctors and nurses will return. What we should be aiming at is a situation where there is investment in inward migration but also in outward migration—a two-part thing. It is neither desirable nor possible to have a blanket ban on the immigration and emigration of medical staff. Ideally, it should be a two-way process, as an excellent report by VSO makes clear. But what is clear at the moment is that Africa appears to be a very heavy loser from this process and that we in the West would do well to mount an inquiry to see what can be done to correct that position.

These are just three questions that the Ebola crisis raises: whether we are doing enough to develop and produce vaccines; whether our policies in the West are taking away a disproportionate number of doctors and nurses from African countries which badly need them; and, above all, how we can further strengthen the health systems of countries such as Sierra Leone so that further human tragedies can be prevented. My hope is that the tragedy of the Ebola outbreak today may point the way to producing more permanent answers for the future.

My Lords, I thank the noble Lord, Lord Fowler, for initiating this debate and for his extremely thoughtful introduction to the subject, which made many of us think of the complexity of the issue.

After more than a year, the current outbreak of Ebola continues to destroy lives, livelihoods and communities. It impairs national economies and has damaged already fragile basic services. Ebola is a frequently recurring and fatal disease. Since its discovery in 1976, there have been several separate outbreaks with casualty rates as high as 90%. As Kofi Annan has said, it was only when the disease got to Europe and America that the international community really woke up to the crisis. This judgment was echoed by Dr Margaret Chan, the director-general of the World Health Organization. Speaking on the reason for the failure to produce a vaccine or a cure after 40 years, she said:

“Because Ebola has been, historically, geographically confined to poor African nations. The R&D incentive is virtually non-existent. A profit-driven industry does not invest in products for markets that cannot pay”.

She made that sombre statement in a world in which 38% of the population do not have access to essential medicines and 50,000 people die each day from largely avoidable causes. Governments and industries should by now have recognised the need for co-ordinated efforts to make registered medicines available at low cost or no cost. Surely Ebola has reminded everyone that, wherever a health crisis occurs, it affects us all. Professor Peter Piot, who first identified Ebola, has said that it would not have been difficult to contain the outbreak if those on the ground had acted quickly but he said that tragically,

“something that is easy to control got completely out of hand”.

Investments in healthcare as well as in drugs are essential everywhere. The unimaginable suffering endured in poor countries by poor people urgently needs and deserves a response. Liberia has 51 doctors to serve a country of 4.2 million people. Sierra Leone has 136 doctors for a population of more than 6 million, an average of 0.2 doctors per 10,000 people. There are too many similarly pitiful shortages. Clearly, the reason we do not have a vaccine against Ebola is that the likely victims of the disease are not wealthy enough to pay for the full cost of treatments and medicines.

The BBC reported this morning that the current epidemic has taken more than 8,000 lives in the three west African countries most affected. The mortality rate is estimated to be 70%. Around 75% of the sufferers in Liberia, for instance, are women who, obviously, are the primary carers and the ones with the responsibility for caring for sick and dying relatives. All three countries lack functioning health systems and access to clean water. They have poor hygiene practices and, generally, an absence of sanitation. According to the NGO WaterAid, such is the enormity of the current challenge that the costs of the emergency response to this crisis will amount to more than the total health and water and sanitation aid committed to Liberia and Sierra Leone over the past five years. That gives us an idea of the nature of the crisis. Lessons must be learnt from the fact that the effects of the response in Nigeria and Senegal have clearly shown that the virus can be contained with a functioning healthcare system and a rapid administrative response.

There are now signs of some progress, but the epidemic is far from over and experts are urging caution. Infection rates, they advise, could oscillate and reinfection could occur. The WHO assistant director-general has warned against claiming that this very dangerous disease is under control. He said that a few mishandled burials could,

“start a whole new set of transmission chains”,

and the incidence of the disease could increase again.

A report published in last week’s Lancet Global Health by three specialist professors from leading British universities made it clear that IMF conditionalities have required Governments receiving aid to adopt policies that prioritise,

“short-term economic objectives over investment in health and education”.

Using IMF archive detail, they came to a view on the effects on the health systems in Sierra Leone, Guinea and Liberia. IMF economic reform programmes,

“required reductions in government spending, prioritisation of debt service, and bolstering of foreign exchange reserves. Such policies have often been extremely strict, absorbing funds that could be directed to meeting pressing health challenges”,

with the result that all the countries “failed to meet” the very modest IMF “targets for social spending”, and,

“to keep government spending low, the IMF often requires caps on the public-sector wage bill—and … funds to … adequately remunerate doctors, nurses and other health professionals … ‘often … without consideration of the impact on priority areas’”.

Such caps,

“have been linked to emigration of health personnel”,

and massive reductions in community health workers.

The article states that,

“the IMF has long advocated decentralisation of health-care systems”,


“in practice … can make it difficult to mobilise coordinated, central responses to disease outbreaks”,

and led to a deterioration in the quality of health service delivery. The professors concluded that:

“All these effects are cumulative, contributing to the lack of preparedness of health systems to cope with infectious disease outbreaks and other emergencies … Although Lagarde’s comment on prioritising public health instead of fiscal discipline is welcome, similar comments have been made by her predecessors. Will the result be different this time?”.

That is a fundamental question, a matter of life and death. The UK Chancellor and Secretary of State for International Development have governor status in the IMF.

My Lords, I, too, add my congratulations to the noble Lord, Lord Fowler, on bringing this debate to us today and on the eloquent way in which he set it out, for which I am very grateful.

There are clearly some fundamental lessons to be learnt from the Ebola catastrophe in west Africa, which can be summarised in terms of healthcare practice and provision, public health resources and general infrastructure. The year-long epidemic has now claimed more than 8,000 lives and infected more than 20,000 people. While the number of new cases in Liberia is falling, it continues to rise in Sierra Leone. The data from Guinea continue to be inconclusive, underlining the remoteness and inaccessibility of the mountainous forest region through Guéckédou, Macenta and Seredou.

Apparently the Ebola virus was discovered as long ago as 1976. I can vouch for the fact that in the mid-1980s, while I was working in the Guinea interior along the borders with Sierra Leone and Liberia, villagers would speak to me of their terror of a killer disease that they believed was caught by eating bush meat from monkeys, which may well have been Ebola. At the time, we were doubling the water supply of the capital city, Conakry, but nothing was being done for the remote villages scattered throughout the interior of the country.

A primary lesson is that by not developing a vaccine to tackle Ebola in the intervening 40-odd years, the pharmaceutical establishment bears witness to the eventual deaths of probably tens of thousands and the infection of many more. The reasoning is unclear, but seems to be associated with concerns over cost recovery from desperately poor communities. However, the cost to the regional economies of decimated and crippled communities does not seem to have been taken into account.

The decision by the board of Gavi, the Vaccine Alliance to support large-scale vaccination efforts with $300 million procurement funding as soon as a safe and effective vaccine is recommended by the World Health Organisation is very welcome. However, the WHO has been strongly criticised for its slow response to the Ebola outbreak, which to date has affected more than 20,000 people and caused more than 8,000 deaths. There are clearly lessons to be learnt on the effectiveness of the mobilisation, distribution and administration of global health relief.

The Ebola outbreak has underlined the need for a fresh approach to strengthening health systems in Africa. Strengthening must be community led. Donors need to prioritise and support community ownership of health systems. The top-down approach does not fully appreciate the spiritual, cultural and political undertones to health that exist among many communities and groups.

The NEPAD organisation of African countries has agreed that each should allocate 15% of GNI to the provision of state-funded universal healthcare, but, so far, there has been little progress. In this context, it seems bizarre that some donors are promoting USA-style healthcare models, based on the principle of private healthcare being purchased by the user, in communities where abject poverty is the norm.

There is now a thing called “Ebolanomics”, or the role of the pharmaceutical sector, which raises many questions about the interaction between market economies and the pharmaceutical sector. That needs to be analysed, understood and reworked into a modern model that responds to the needs of the global population. Barriers that have prevented earlier development of treatment need to be overcome, with more support being focused on the growth of the African pharmaceutical industry. The current business model needs to be redesigned. What would that model look like? Should there be a legally binding framework to guarantee funds to research and to produce and stockpile vaccines for diseases that would otherwise be neglected?

An unforeseen effect of the Ebola epidemic is its impact on programmes to tackle other pandemics, in particular malaria. The Ebola virus is distracting attention from other diseases that still ravage west Africa. Malaria patients in Sierra Leone, Liberia and Guinea—the countries worst effected by Ebola—are now so terrified of the impact of the virus that they will not attend their local hospitals where their malaria could be easily treated with a package of available drugs. Fatoumata Nafo-Traoré, head of the UN’s Roll Back Malaria Partnership, says that without the necessary treatment, malaria patients are going to die.

The economic impact of Ebola on the sub-Saharan region as a whole will be significant, according to Roger Nord, deputy director for Africa at the IMF, who spoke at an Africa All-Party Group meeting recently. He reported that if it takes another nine months to get the outbreak under control, it is expected to reduce growth in Guinea by 1.5% and by around 3.5% in Liberia and Sierra Leone. Neighbouring countries such as Senegal and the Gambia are also starting to see tourism activities decline.

Margaret Chan of the WHO, while recognising the delayed international response and the need for increased international funds, has said that more important than anything else is the need for community funding and support. In this regard, community-level media and radio have an essential role to play, and I pay tribute to the work of the BBC World Service and BBC Media Action, which work with local FM stations that are trusted by their communities. In particular, I pay tribute to BBC reporters in the field who have overcome formidable physical obstacles to reach the most isolated communities in the grip of the Ebola virus.

Much of the work to defeat Ebola is being done by local people. Nigeria and Uganda have sent hundreds of health workers and South Africa has contributed significant funds. The media have a responsibility also to report what African people and Governments are doing to fight Ebola.

My Lords, I, too, thank the noble Lord, Lord Fowler, for initiating this debate. I thank him also for his brilliant speech and for his great concern for those who volunteer to do this work. I associate myself with the comments that he made about Pauline Cafferkey and I wish her a speedy and complete recovery.

I want to speak on four issues as far as the lessons learnt are concerned. Could the crisis have been spotted earlier? Was the UK’s response timely and appropriate both in scale and support? What needs to happen to cope with future pandemics? Did the UK have appropriate safeguards for NHS and other volunteers who went to Sierra Leone, including on their return?

Peter Piot, in his book No Time to Lose, described the dramatic effects of Ebola infection since its outbreak in 1976 and warned us to be prepared. Previous outbreaks were controlled by prompt notification, deployment of specialist teams, quarantining of exposed individuals and isolation of patients, but the lessons were not learnt. The current outbreak started in Guinea at the end of 2013. Despite hundreds of deaths, neighbouring countries did not take any notice. Surveillance systems were not effective and warnings from organisations such as Médecins Sans Frontières were ignored. Official agencies were either complacent or did not have the resources or personnel in place to monitor the outbreak. Hundreds died. Worse, in countries where health workers were in poor supply, several hundred health workers died.

Did the WHO botch its response to the developing crisis in Sierra Leone and Liberia? The answer is most likely yes, but the question is why. Africa office representatives were not filing Ebola reports to the head office. There are lessons here as to how the WHO, the only global health agency, should operate in the future and how its performance could be improved. There is no doubt that its effectiveness was weakened by decades of policy failures and budget cuts by wealthy nations trying to fund their deficits. Wealthy nations need to restore their funding of the WHO. The Ebola crisis has confirmed a new reality: that we live in a shrinking world. To cope with future pandemics—which are sure to come and might be worse than the current pandemic—strong international organisations working with national organisations is absolutely necessary.

My second point relates to the UK response. Here I can do nothing but congratulate the UK Government on the speed with which they responded, with both personnel and finances—the second-highest donor nation after to the United States—and commend the continuing effort that DfID and WHO are making to bring this crisis to an end. We need to learn lessons as to whether we could have done better—it is always possible to have done better—but, hitherto, I have nothing but praise for our Government.

This leads to my third, and important, point—already mentioned by the noble Lord, Lord Fowler, and other noble Lords: what should we do about future pandemics? Why were countries such as Guinea, Sierra Leone and Liberia not able to cope with the crisis, when countries such as Nigeria curtailed it very quickly? The answer is very poor health systems, as has been mentioned: lack of facilities or equipment, deficit of a health workforce, lack of appropriate public health measures, and lack of surveillance and controls. Both Larry Summers, the previous Treasury Secretary of the US, and Bill Gates, when he spoke in the Robing Room, asked for help in developing health systems in those countries.

Larry Summers’s report, Global Health 2035, published in the Lancet, identifies that we will need some $30 billion a year for the next decade. Building health systems requires time and money, and the richer nations of the world need to come up to the plate to develop that. Otherwise, we will continue to have such crises, which will begin to affect us even more than they do now. The UK can take a lead in building health systems. We are the right country to do so because we have demonstrated that we can have effective influence.

My fourth point relates to whether the UK’s support for our NHS volunteers has been appropriate. It is important that we make sure that people who volunteer to go to affected countries are in a safe environment, are able to work safely and can return home safely afterwards. Comments that we have seen in some of the media, particularly social media, demonising those who return from such work, are unacceptable. Sarah Wollaston, MP for Totnes and chair of the Health Select Committee wrote a very good article about this in the Telegraph. I was disappointed to learn—if accurate—that some BBC staff feel that they can no longer interview in person people who come back from west Africa, and therefore that a telephone interview would be more appropriate. Brave BBC workers have reported from there, but such comments from the media—if correct—are also inappropriate.

My Lords, I also thank the noble Lord, Lord Fowler, for securing this debate and introducing it in such compelling fashion. I join noble Lords in paying tribute to Pauline Cafferkey as she struggles for life in a hospital not far from where we are today. The latest report on healthcare workers who have died from Ebola puts the number at 500 rather than 400, which shows the awful toll it is taking in so many different areas.

I will concentrate on the economic consequences of the epidemic, to which the noble Lord, Lord Fowler, alluded. There is another tragedy unfolding alongside those of a medical and humanitarian kind. Prior to the Ebola episode, all three main states involved experienced strong economic growth following years of war and inept or tyrannical rule. Growth rates have already halved in Sierra Leone and Liberia and could even turn negative in Guinea. Tourism has come to a halt, as the noble Lord mentioned. Restrictions on mobility severely hamper trade. Agricultural production—a key area in all three countries—is way down. Rising food prices have helped create steep inflation—a very unpleasant economic scenario—which was running at more than 13% in Liberia in 2014. That situation could quite easily get completely out of hand. Meanwhile, investors are running scared and there is a serious risk of capital flight from these countries. Economically, this has the makings of a truly tragic situation.

The emancipation of women is a key aspect of economic development in emerging economies. Many women in the labour market have turned instead to the care of sick family members or others in the community. In Sierra Leone, for example, women were heavily represented in cash crop production, local trade and microenterprises. Many had to quit and most are highly unlikely to re-enter the labour force at any time soon.

As a result of this, I have three basic questions for the Minister to comment on. Like the noble Lord, Lord Fowler, and other noble Lords, my great fear is that if and when Ebola is effectively contained in west Africa, the international community will lose interest in the countries affected. Can we avoid them sinking back into despair and perhaps fragmentation? The possibility is very real that these countries could be worse than back to the point zero of some years ago when they were racked by war. These are, as every noble Lord knows, among the poorest societies on the face of the Earth. We must ensure that the international community does not lose interest if it appears that the epidemic can be contained—although some medical specialists now say that it could become endemic, which is an additional worry.

Secondly, how will the Government assess the success or otherwise of the World Bank in the budget support it pledged to facilitate trade, investment and employment in the three countries involved? The World Bank promised substantial sums of money. Does the Minister have any information about whether any of that money has been forthcoming? As we know, promises are easy to make. The sums involved were very large and it would be good to be updated on that if the Minister has that information.

Thirdly, it is clear that regional aid and investment will be crucial, coming from surrounding African states. How much progress has been made with the fund for renewal set up by the Economic Community of West African States? Any western intervention concentrated on the three principal countries must also seek to involve other African countries, and perhaps fund them in addition so that they can help the three countries most affected.

My Lords, like other speakers I congratulate the noble Lord, Lord Fowler, on introducing this debate and his consistent commitment to health in the developing world. I am delighted to be able to take part in the debate but fear my contribution would probably be more useful in five weeks’ time, when I will have returned—I hope—from a visit to Sierra Leone to see for myself the work of some of the agencies with which I am associated. I declare my interests in those, recorded in the register.

Many lessons of the Ebola outbreak are already emerging. The speed of response is one that others referred to. The need for the international community to have a plan that is both flexible—because not every emergency is the same—and already funded is tremendously important. We all have a responsibility to look at how the international community could prepare for further outbreaks. As others said, not only will they occur but we cannot consider them to be someone else’s problem. Ebola is not an airborne disease, for which we all throughout the world must be extremely grateful, but other diseases are airborne. The interconnectedness of health in our global world is a lesson we must learn.

Another lesson that no one will quarrel with is that, however much international aid and however many volunteers—I, too, pay tribute to them—we parachute into a situation such as the one we have seen in west Africa, there can never be enough to replicate a basic health system that reaches into every village and community and is the absolute foundation not only of public health in normal times but of dealing with disease outbreaks. What we as a world do post-2015 in terms of the objectives for health and providing support for health systems will be tremendously important.

That will be shown in Sierra Leone because, as others pointed out, once Ebola is, we hope, no longer rampant—the noble Lord, Lord Giddens, rightly pointed out there is a possibility of it becoming endemic in the country—there will still be a tremendous specific health need left behind by the effects of the crisis. There will be the patients with malaria. We have seen a terrible spike in malaria deaths. There will be the women who died in childbirth because they were not able to get to attended facilities. There will be the health of the orphans left behind. There will be the vaccination programmes that have been interrupted. There will be a tremendous health need. As the noble Lord, Lord Giddens, said, it will be a test of us all that we do not walk away from that at the end of this process.

The other lesson that we can learn is that we can rightly be proud of the response of professionals in this country who have volunteered, of the British public, who have given more than £30 million to the Disasters Emergency Committee, of which I am a trustee, and the work of the agencies funded by that money, which goes far beyond medical treatment to provision of food and latrines for people who are in isolation, the care of Ebola orphans and safe burials. That is a tremendously important contribution.

We should also pay tribute to those in the affected countries in Africa. I will also be considering the work of Restless Development, the charity that my husband chairs, which has about 2,000 community volunteers in the field working on social mobilisation. The trust and behaviour change of communities that is needed is on a tremendous scale and does not come from lecturing by people from outside; it comes from the mobilisation of community leaders, religious leaders and individuals who are connected to their communities, who are trusted and who give the right messages and support people to change behaviours to protect themselves.

An understanding of the need to marry the command and control and international response with the grass-roots, culturally sensitive response of those on the ground, is something that we hope we can learn from this outbreak. I cannot finish without endorsing what the noble Lord, Lord Fowler, said about vaccines, to which the noble Baroness, Lady Kinnock, also referred. We have a market failure in vaccines and medicines for the poor. We cannot simply shrug our shoulders and say that the pharmaceutical industry as currently constructed cannot and will never produce the goods. We need to ensure, through government, philanthropy and voluntary organisations, that those goods are produced for the poor.

My Lords, I, too, thank the noble Lord, Lord Fowler, for ensuring that this vital issue remains high on the political agenda. Last November, my noble friend Lady Kinnock initiated a similar debate, and many of the concerns raised then remain relevant today. The Government’s response on the ground has been positive, so far providing more than £200 million for treatment, facilities, expediting NHS staff who heroically volunteer and helping to finance trials and develop new treatments and vaccines for Ebola.

The UK medical workers who have volunteered in their hundreds to join the fight against Ebola in Sierra Leone are playing a critical role in the front-line response. The tragic case of nurse Pauline Cafferkey highlights their exceptional bravery and compassion. My thoughts—and, I know, those of everyone here and all noble Lords—are very much with Pauline and her family during this very difficult time.

As we heard from the Statement in the other place on Monday, Save the Children is conducting an urgent review, which I understand will involve representatives from Public Health England. Clearly, the sooner we know the results, the better. Can the Minister update the House on the review? When are the results likely to be published? As the next group of NHS volunteers leave for west Africa in the coming weeks, they will want to know whether procedures and guidance will be changed in the light of that case. Will the noble Baroness also liaise with the Department of Health to ensure that the employment and careers of volunteers who show their compassion are not adversely affected by any further quarantine restrictions that may be introduced following the review?

The role of British volunteers has been significant in the campaign against Ebola. What plans do the UK Government have to establish a standing roster of medical workers for possible deployment in future health emergencies? As we have heard in this debate, this crisis underscores the importance of investing in a strong system of research and development for global health. In Justine Greening’s own words, new technologies are,

“vital if we are to improve the health of the poorest people through better treatment and prevention”.

The UK Government have shown leadership in supporting solutions, including product development partnerships. PDPs have been instrumental in bringing through 37 new therapeutic products for poverty-related diseases registered over the past decade. Will the Minister commit to prioritising within DfID, and promoting among other key donors, the need properly to fund and support R&D for global health?

The three countries facing the largest burden of Ebola are among the poorest countries in the world and, as we have heard, have some of the most fragile health systems. They have had insufficient investment in infrastructure, the healthcare workforce, health information systems and medical supplies and equipment over decades. What is the Minister’s assessment of the state of preparedness for Ebola in neighbouring countries? What plans do the Government have to provide specific support to the high-risk countries on the WHO watch list to reduce the risk of further outbreaks? What is the Minister’s assessment of the factors contributing to the decline of cases in Liberia? What lessons from Liberia are being applied to the UK response to Ebola in Sierra Leone?

As we have heard in this debate, the main issue has been health systems not being resourced or strong enough to deal with the issue. That is a key factor. Universal health coverage, whereby there is access for all without people having to suffer financial hardship when accessing it, is a key way that we can make countries more resilient to health concerns such as Ebola before they become widespread emergencies. Universal health coverage is a clear and quantifiable goal, and 2015 is the year when international development will be high on the international agenda. On 19 January, negotiations start in New York on the replacement of the millennium development goals. I know that I have asked this before, but I ask the noble Baroness to support universal health coverage in the language of the health goal in the successor to the MDGs, the SDGs. I ask her to back that strongly because, as we have heard in this debate, universal health coverage is the key to avoiding such catastrophes in the future.

My Lords, I start by thanking my noble friend Lord Fowler for securing this important debate and all noble Lords who have contributed for their considered responses. As my noble friend Lord Fowler and others have made clear, this epidemic has terrible individual consequences, as well as wider social and economic consequences.

I join noble Lords in my extremely deep concern for Pauline Cafferkey. The Royal Free has just issued a statement, and I understand that her condition remains critical and is unchanged. The bravery and compassion shown by Pauline and her colleagues have helped to save thousands of lives in Africa. Like my noble friend Lord Fowler, I pay tribute to all those who have volunteered to help in that dreadful crisis. I here commend the son of the noble Lord, Lord Patel, Dr Neil Patel, as he undertakes his own challenging tasks in Sierra Leone, leaving shortly. It is vital that we never compromise the safety of such extremely brave volunteers and I can give the Government’s unequivocal commitment on that. Clearly, Save the Children and Public Health England keep this under constant review. They are reviewing the situation at the moment and we will update noble Lords as soon as possible.

I note what the noble Lord, Lord Collins, said on that and what he said about standing rosters. We have taken forward quite considerable amounts of development to ensure that those who wish to volunteer are properly trained before such a crisis and are able to be deployed in humanitarian disasters. There is new training offered by the Royal College of Surgeons to ensure that those who volunteer are safe and effective in dealing with the need in question, so I hope that the noble Lord will be encouraged to hear that. Guidelines on this particular crisis are kept under review all the time.

Noble Lords will appreciate that DfID is still focused on containing and eliminating the Ebola virus in Sierra Leone, where the UK has the leading international response. I thank the noble Lord, Lord Patel, for his tribute and I will pass it on to my outstanding colleagues in DfID. So far, we have committed more than £230 million to combat Ebola in Sierra Leone, and have already delivered more than 1,200 treatment and isolation beds and three new Ebola testing laboratories. We are also working closely with the Government of Sierra Leone to train and equip burial teams to ensure safe burial practices.

The noble Lord, Lord Collins, mentioned differences in Liberia. I am sure he will know that there are all sorts of cultural differences between the two countries—different social norms and so on—which underpin what has happened in them in this epidemic. I am quite happy to go into further detail outside as to why there have been differences here.

As the noble Baronesses, Lady Kinnock and Lady Hayman, indicated, there are tentative signs that we may have reached the peak of the disease in Sierra Leone. But as both were saying, we should not be complacent; the response is far from over. Like my noble friend Lord Chidgey, I pay tribute to the response that has come from African countries.

The economic impact of this should not be underestimated. Various noble Lords, including the noble Lord, Lord Giddens, made reference to that but I think we are all aware of it. The noble Lord also flagged the financial commitments of the World Bank. We are acutely aware that promises do not necessarily get delivered and we are working very hard to ensure that, where promises have been made, they are duly delivered.

We agree that a long-term interest in affected countries is essential to ensure recovery. The EU is convening a meeting in early March to look at resources for this and the WHO has a special session in late January to agree reforms, so a number of things are under way.

While our principal focus must continue to be on the ongoing response, it is essential, as my noble friend Lord Fowler pointed out, that we learn lessons from these actions both here in the United Kingdom and internationally. This Ebola outbreak has been unprecedented. More than 8,000 people have died and it is crucial that we make changes to ensure that this never happens again—and that lessons are carried over for other potential epidemics, as was pointed out by noble Lords, in particular my noble friends Lord Fowler and Lord Chidgey.

It is evident that international reform is required. The World Health Organization and the wider international system did not respond quickly enough to this threat before it got out of control. While progress has been made in efforts to strengthen global health security following SARS and avian flu outbreaks, the Ebola outbreak demonstrates that there is still much to do in responding efficiently to public health emergencies. As I have mentioned, the WHO executive board is convening a special session later this month to examine some of these issues, and I am sure that the points made by noble Lords, including the noble Lord, Lord Patel, must be considered. In particular, we need to look at surveillance, stronger early warning and response mechanisms, and how the global community identifies and responds to potential crises in the future. Like the noble Baroness, Lady Kinnock, I noted that Nigeria managed to check cases in the initial stages and it should be commended for that. Lessons needs to be learnt from how that was achieved, even though, again, we cannot be complacent.

The international community needs to be ready to respond rapidly and deploy public health experts immediately. The noble Baroness, Lady Hayman, had a number of important perceptions here as to changes that might be needed and the way in which the international system needs to link to what happens within a particular country and be sensitive to the arrangements and the views, beliefs and practices within those countries. This was a point which my noble friend Lord Chidgey also made.

In linking to national systems, a number of noble Lords emphasised the importance of strengthening health systems. We have been investing heavily in strengthening health systems in Sierra Leone through our bilateral aid programme but, barely 10 years after the end of a devastating civil war, health systems are still fragile and unable to cope with a crisis of this scale. My noble friend Lord Fowler made it crystal clear that the weakness of health systems is fundamental in this case. International support from DfID, but also from the World Bank, IMF and UN, will be critical in supporting Sierra Leone and the wider region to recover from this devastating crisis. Supporting the health sector ravaged by Ebola will be a priority, as well as supporting vulnerable groups such as orphans, children, women and girls.

I heard what my noble friend Lord Fowler said about consistency in support. That seemed to me to be an argument for the 0.7% Bill, which will come before this House on 23 January. I hope that noble Lords will support it. The aid budget has often been subject to easy battering in the past. Consistency and predictability are vital, which is why it is important to legislate for that level of aid. I welcome the support of the party opposite on this. Investment in human development is vital to the elimination of poverty and the growth of developing countries. I can assure noble Lords that we fully recognise that. In DfID, 20% of our budget in Sierra Leone has been spent on health programmes, and that will continue to be the case when this crisis is over as well. We agree that weak health systems in the affected countries have contributed to the rapid spread of Ebola.

We also agree that there has been a significant drop in the utilisation of health services, a point made by my noble friend Lord Chidgey and others, including the noble Baroness, Lady Hayman. We are therefore working with experts to determine strategies to decrease malaria deaths, including using new drugs and making sure that there are adequate stocks in Sierra Leone to try to address this. We recognise that it is vital to prepare the health sector for future shocks and have started to consider this challenge. National institutions are crucial but we also recognise that it will take time to build up health systems capable of dealing with major epidemics. That is why we focus on poorer developing countries; that is where the need is greatest.

To improve response to infectious disease outbreaks we need to ensure that, as far as possible, we have proactively identified potential diseases and developed technologies such as vaccines and treatments to address them. A number of noble Lords made this point. We need to be able to deliver rapidly clinical trials of promising candidates, resolve intellectual property disputes over them, scale up production, put in place adequate delivery capacity and manage the increased liability risks, while securing financing for all this.

I would dispute what my noble friend Lord Fowler said about reducing our aid spend in Sierra Leone. In 2010-11, we spent £51 million; in 2013-14, it was £69 million.

Our support for vaccines has been a major move by DfID under this Government. My right honourable friend Stephen O’Brien was quite remarkable in the way that he brought forward the proposals on support for what were called neglected tropical diseases, and I think that people will pay tribute to him and DfID for the work that was done. I think that we have a strong record in this regard, and that is something that we will continue to focus on and to regard as very important.

Our focus remains on ridding Sierra Leone and the surrounding region of Ebola. It is critical that we learn the lessons from this crisis to ensure that it never happens again. We realise how a crisis like this affects us all and how it has devastating consequences, both individually and more widely on societies and economies. We understand that, and we all need to see what lessons need to be learnt and then—most importantly, as the noble Lord, Lord Giddens, indicated—acted upon.