Five lessons from past global influenza outbreaks for COVID-19

The COVID-19 pandemic is a rare event in its scale and spread. But in responding to it, people have been looking at lessons from other outbreaks of infectious disease. What are the patterns in the ways that governments and people respond, and why have some widely-known lessons been ignored again and again?

One source of insight is the global outbreak of avian influenza (H5N1) in 2004-2006. In 2007, Paul Forster and I, with support from the FAO/DFID and the ESRC STEPS Centre, set out to explore the implications of that outbreak. We were joined by Sophal Ear, Rachel Safman and Tuong Vu, and together we looked at the national responses in Cambodia, Indonesia, Thailand and Vietnam, alongside the array of global initiatives.

In 2009, in the midst of another global pandemic – this time of swine flu (H1N1) – we wrote it all up as a book, Avian Influenza: Science, Policy and Politics, aiming to draw lessons for the future. Many saw the avian and then swine influenza as the ‘dress rehearsal’ for the major pandemic that everyone knew would come sometime. In the midst of the COVID-19 pandemic, we are now at that point. I re-read the book recently in preparation for an IDS Between the Lines podcast. The parallels with today are striking.

Back then, thankfully, the avian flu outbreaks did not turn out to be the long-expected ‘big one’, and in the end only a few hundred deaths were recorded. But, as the H5N1 virus began to spread between people in 2004, people’s minds turned to the spectre of the 1918 flu pandemic – as they are doing today. During the avian influenza outbreak, dire warnings were spelled out of the potential death tolls: up to 150 million people, according to one estimate from WHO. The interventions to stop spread, particularly through poultry populations, were extreme, combined with major movement restrictions on animals and people.

Avian flu was highly virulent among poultry and wild bird populations, but it did not catch hold in the human population. Although it spread further, the later H1N1 swine flu virus similarly failed to take hold among people. But, as biologists reminded us, we were only one genetic reassortment away from the lethal, fast-spreading flu virus. Today we are confronting a different virus – a coronavirus, SARS-CoV-2 – which has just these qualities. This virus comes from a different source, with different epidemiological dynamics, but also causes respiratory disease.

The final sentence of the 2010 avian influenza book is telling. We urged the world to “waste no time” in learning the lessons. In the intervening decade since the book was published, did the world take heed? The short answer is, no. In the closing chapter, we outline the important challenges for policy and practice. Of course every epidemic is distinct, with different contests over science, different policies and different politics, as the country cases in the book show. But there were some striking common themes that emerged from across our studies.

Lessons from the past

Five lessons are startlingly relevant to what also needs to happen after COVID-19, and they are summarised here.

1) Go beyond a focus on outbreaks to address changing disease ecologies

We only wake up to disease threats when there is a big outbreak. Most recently for influenza, this was in 1968, 1976 in the US, 1997 in Hong Kong, and then 2004-6 and 2009 for avian and swine flu respectively. During these periods, funds are mobilised (usually late), experts are consulted (usually selectively) and governments invest (if they can afford it). The international machinery grinds slowly into action, and encourages global action. Then, when it’s over, things stop and go back to normal.

But it’s the intervening years between outbreaks that are actually the important ones. This is the period when viruses that might jump from wild animal populations are circulating. Most diseases that become epidemic (subject to outbreaks) start out as endemic (just part of the normal disease environment). Unless we know more about disease ecologies, by tracking viruses, examining their genetics and phylogenies and exploring vectors and hosts, we will not be able to spot pending outbreaks.

Over the past three decades or so, over 30 new human pathogens have been detected, three-quarters of which have originated in animals. This means zoonotic spillover is very common, and sometimes the consequences are serious for human populations. Just as with influenza viruses, coronaviruses can cause human disease – SARS (Severe Acute Respiratory Syndrome) was one and COVID-19 is another. But there are plenty more, and viruses change fast under selection pressure, so there are always possibilities of new ones.

As environments alter – through climate change, intensification of agriculture or rapid urbanisation, for example – we need to be on top of the game. For COVID-19, we weren’t; just as we weren’t for avian and swine flu.

2) Address the political economy and ecology of food systems

Most transfers from wild populations to humans occur in the context of agriculture and food production. For avian influenza, it was most likely due to the rapid industrialisation of poultry production in parts of southeast Asia and China, spurred by the growing demand for meat. Poultry products were increasingly being supplied by medium-scale industrial units, frequently with poor biosecurity. For swine flu, it was pig farms in the southern US and Mexico owned by large corporates that were the source of outbreaks. For COVID-19, the initial transfer seems to have been traced to a so-called ‘wet market’ in Wuhan that sold wild animal products.

In each case, however, there is a wider story of changing agri-food systems behind the outbreak.

As Rob Wallace argues, big farms create big flu and the increasing concentration of animal production, and the role of powerful corporate players in the food chain, is important. For COVID-19 the story is a bit different. Many are now blaming Chinese ‘wet markets’, but simply banning them will simply drive markets underground, with even less biosecurity and greater risk, and would be a ‘terrible mistake’.

In exploring the disease history of COVID-19, we have to look at the wider political ecology of production, and how wild animals are increasingly harvested further and further into still-remaining forest areas. Here, viruses circulating in wild populations may come into contact with humans for the first time, causing infections. So it is disturbance of the wider ecosystem and its consequences for agri-food systems that is important; not just the market where – following a long chain – the outbreak started.

3) Take livelihoods, equity and access seriously

Very often, measures to stop a disease can be highly damaging to vulnerable populations. In the avian influenza outbreak, control efforts focused on so-called ‘backyard chicken’ producers, and their poultry was slaughtered compulsorily in huge numbers. This caused devastating impacts on livelihoods across southeast Asia, with governments insisting that producers ‘upgrade’ to biosecure facilities. This was of course out of reach of many people, and the opportunity of the disaster was captured by those with capital and political influence.

Just as with the quarantine measures for COVID-19, it was poor and marginal groups that were the worst hit by disease control efforts. These were the same groups who had least access to healthcare support if they got the disease. While viruses can affect everyone, their impacts – both of the disease and the control measures that follow an outbreak – are unevenly felt across diverse and unequal societies.

The rhetoric that ‘we are all in this together’ in a global outbreak forgets issues of equity, and the ‘structural violence’ that diseases deliver. In the avian influenza case, the focus on ‘at source’ extermination of poultry flocks to protect ‘global’ business and western populations illustrated the uneven nature of what was portrayed as a unified international response.

4) Embrace uncertainty and surprise and rethink approaches to policy advice

Despite the experience of previous major influenza outbreaks, the spread of avian influenza from 2004 took the world by surprise. It did again in 2009 with H1N1, and it has today with COVID-19. We will never know when a new disease will emerge, and how it will spread, but it will certainly happen.

After the avian influenza outbreaks, much effort was focused on poultry in southeast Asia, but the next outbreak came from the Americas and was in pigs. Despite the vast investment in pandemic preparedness and epidemiological disease modelling, we can never predict what will happen and when. Even when an outbreak occurs, there are so many uncertain parameters in any model that predictions of what will happen is simply guesswork, even if well-informed.

The warning that perhaps 150 million could die from H5N1 in the mid-2000s was thankfully way off the mark. The influential models published in Nature and Science in 2005 – including by modellers now heavily engaged with the COVID-19 response – were subsequently found wanting. They tried to offer certainty where there was none, and misled policy-makers by giving a false sense of predictive security.

As we argued in the 2010 book (and many times since), embracing uncertainty and surprise requires a different approach: a more plural perspective on modelling and sources of knowledge, including linking to local understandings and experiences. The COVID-19 experience shows a similarly dangerous reliance on necessarily imperfect models, and thus an unhealthy reliance in science-policy circles on inevitably limited epidemiological information, without this being complemented by other sources of more diverse and locally-rooted expertise.

5) Develop institutions and organisations that foster adaptation, innovation and reliability

In our reflections on avian influenza, we concluded that the existing institutional and organisational architecture, constructed after the Second World War through the United Nations system, was not fit-for-purpose. It was top-down, cumbersome, lacked flexibility and was organised in disciplinary/sectoral siloes. This remains the case today.

The avian influenza episode prompted useful debate about a ‘One Health’ approach, which encouraged cross-working between medics, vets and ecologists, together (sometimes) with social scientists. But the incentives, funding flows and capacities to institutionalise this were absent, despite the flurry of interest. Subsequent work highlighted just how segmented networks of expertise were, and how challenging a One Health approach is for current systems in the UN and beyond.

To generate reliability in the face of uncertainty and ignorance and to offset damaging surprises, a totally different set of skills, capacities and organisational arrangements are required.

Where is the capacity in large organisations to learn from the ground, share innovations and shift course? Frequently missing. Where are the reliability professionals in health systems who can track between local contexts and wider scenarios, and facilitate real-time responses? Largely absent, or at least not recognised. Where is the built-in redundancy, system flexibility and adaptive capacity for facing times of crisis? Again, not evident – too often these are the first elements in any organisation to be cut due to ‘efficiency’ measures under austerity financing.

In top-down, crisis and emergency planning, such flexibility is usually eliminated, and people are left to innovate on their own, embedding their own practical knowledges into cultural repertoires and forms of collective action. This is what happened amongst poultry farmers in southeast Asia in the 2000s, as it is across the world in response to COVID-19. As we learned from Ebola in West Africa, it is these culturally- and socially-embedded responses that are key to ‘flattening the curve’ in any outbreak, but are only rarely incorporated into wider responses.

* * * *

These five lessons summarise what we learned from the avian influenza outbreaks in the mid-2000s. As you can see, they are all relevant to what we are facing now. Once the worst of the COVID-19 pandemic is over, let’s hope that the lessons – adapted to the particular conditions of different places – will be learned this time, and the same mistakes will not be made in the future. COVID-19 will not be the last pandemic to confront humanity.


Find out more

COVID-19: Resources and research on epidemics and pandemics
Compilation of 13 years of work on epidemics and disease under the ESRC STEPS Centre, and its links to COVID-19.

Books on epidemics and One Health

You can buy the book on the avian influenza response and two companion volumes from the publisher, Routledge, at a 50% reduction using the code IDS50 until the end of May 2020.


Podcast: The Social Dynamics of Pandemics

Melissa Leach, Hayley MacGregor, Annie Wilkinson and Ian Scoones discuss how we should learn from past epidemics and outbreaks and the need to understand social dynamics in order to respond to Covid-19.

Listen/subscribe (IDS website)

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