To Taipei this week, to give the plenary speech at the 2006 Global Health Leaders Forum. This is the second year that the Taiwanese government have organised a major conference on health. My involvement with Taiwan came about in a very roundabout way. Last year I was Armenia, at a time when a gamily just across the border in Turkey was infected with avian flu. Turkey has an effective surveillance system, appropriate measures were taken, and the international community was soon alerted.
Yet the occurrence of a bird-borne disease in this part of the world raised important questions. Few people can be unaware of the war in Chechnya yet this was only one of a number of local conflicts that took place in the aftermath of the collapse of the USSR. The result has been that, in the Caucasus and Moldova, a number of territories broke away from the then newly independent republics. During our discussions in Armenia we were focusing on Nagorno-Karabach, an area populated by Armenians but entirely surrounded by Azerbaijan. Our question was what would have happened if an outbreak of avian flu had occurred there, or in one of the other enclaves in this region. This set us thinking because, of course, there are a number of places across the world that are not recognised as independent states but are not fully under the control of a government recognised by the international community. Other examples include Western Sahara, the Republic of Northern Cyprus, Kosovo, and the Palestinian Territories.
With my colleague Rifat Atun, from Imperial College, we set out to discover what arrangements were in place in these territories. The picture was very variable. In some, reporting channels of varying degrees of formality existed. For example, the Palestinian Authority works closely with the Eastern Mediterranean Regional Office of WHO. In others, such as the Trans-Dniestr republic that has declared its independence from Moldova, any information flows were intermittent at best. In most of these cases there were problems with both surveillance infrastructure within the territories and communication channels to the outside world.
There was, however, one exception among the places we were looking at. After the Chinese civil war at the end of the 1940s the government of China withdrew to the island of Taiwan, leaving the mainland under the control of Mao’s communist party, which declared itself the government of the new People’s Republic of China (PRC). [see Wikipedia for fuller description]. Until 1971 the government in Taiwan was recognised by most countries as the legitimate government of China but following the Richard Nixon’s rapprochement with China, this recognition was shifted to the government in Beijing. For reasons too complicated to go into here, Taiwan is considered as a province of China and the government of the People’s Republic is considered to represent it in international affairs. Why is this relevant to avian flu, you ask? Because the international surveillance system, co-ordinated by the WHO, is based on communications between WHO and the governments of its member states. Although the PRC government claims to be able to speak for Taiwan, it has no formal means of communicating with Taiwan and the WHO was unable to contact the Taiwanese authorities without getting permission from Beijing.
In the course of our research on these areas outside the global surveillance system we obtained a copy of a memorandum of understanding between the WHO and the PRC that set out the circumstances in which contact with Taiwan could take place. While it was an honest attempt by the WHO to make things work, the guidance was totally inappropriate for dealing with an emergency. Permission had to be sought from the Chinese contact point in Geneva 5 weeks in advance of making contact. The PRC contact point could decide which Taiwanese experts should be contacted. If Taiwanese experts were invited to technical meetings an expert of similar status should be included. Taiwanese citizens were not permitted to attend WHO meetings as members of NGO delegations. Most bizarrely, because writing “Taiwan” on an envelope (necessary if it was to reach its destination) would imply recognition of its independence in the view of the PRC, all paper communications had to be faxed.
This system was put to the test during the SARS outbreak, when e-mails from the Taiwanese authorities to the WHO went unanswered for weeks. This is a ludicrous state of affairs, not only because of the consequences in cases of emergency but also because it denies the very considerable Taiwanese expertise to the WHO.
So that is how I became involved with Taiwan….
Anyway, the conference was excellent, with some really thought provoking presentations. Among the most noteworthy were a set of presentations on migration of health workers, a huge challenge for many countries especially in sub-Saharan Africa. Yet there is some hope, and we heard about the integrated approach being taken by the government of Malawi to stem what has been a haemorrhage of skilled staff, so that this country of over 12 million people does not have a single cardiologist or urologist. The strategy described was multi-faceted; a core element was to raise salaries of health professionals and to improve their working conditions. Early results suggest that it may be working.
Others looked at a range of complex ethical issues. Barry Pakes, from the University of Toronto, discussed the many ethical challenges posed by pandemics, especially those arising from limited stocks of vaccine, while Alireza Bagheri, also from Toronto, discussed the challenges posed by the market for organ transplants in Asia. All in all, much to think about on the long flight home.