Outbreak policy narratives
Public and policy reactions to H5N1 and H1N1 have been guided by the prospect of the devastating impacts of an outbreak. ‘Outbreak narratives’ have guided policymaking, with the building of drug stockpiles, the development of contingency plans and so on. Draconian measures for containment have often been devised, including restrictions on movement, travel bans and closures of public spaces. How have these ‘outbreak narratives’ arisen – what are the roles of policy-makers, scientists, media and other actors in creating and sustaining them? If ‘the big one’ really came, would the recommended measures be of any use? What would really happen? And why is less being invested in catching signs early through more effective surveillance? Most commentators recognise that surveillance systems failed. The world was caught unawares, but what incentives are there for investment in long-term systemic surveillance to spot new viruses or combinations? What alternative policy narratives exist that might counter the dominant outbreak narrative?
Modelling for policy
Global public policy has been deeply informed by epidemiological models of influenza outbreak and spread. These have had huge influence on thinking about the potential speed and scales of impact and the forms of response required (particularly the prophylactic use of anti-viral drugs). With a particular type of modelling thus dominating policymaking, what other perspectives are excluded? What other types of modelling – for example pattern based macro-ecological models or participatory epidemiological models – offer alternative insights? And what about other sources of knowledge, informed by anthropological and sociological insights or the perspectives of disease-affected people themselves? Do these other perspectives tell a different story, one with very different policy implications? What would be a more effective way of combining insights from multiple sources of knowledge and expertise in policymaking?
The political economy of virus control
Much policy response has involved a politics of blame: it’s the fault of someone else, somewhere else, threatening ‘our’ health and economic wellbeing. There is sometimes a north-south dimension to this, as the industrialised north blames others in the south for lack of virus control, as well as one that blames the back-yard chicken or pig rearers rather than the larger scale industrial producers with poor biosafety. Power and politics are central, with international geopolitics intersecting with national politics and the politics within animal production sectors. The result often is misdirected attempts at control. Backyard chicken producers were targeted in South East Asia before it was realised that the greatest risks lay in medium scale peri-urban poultry units. In Egypt small scale pig producers were required to slaughter their animals en masse for political and religious reasons, masquerading as veterinary and public health ones. And when H1N1 was discovered in Mexico, the links to US farms and the role of migratory workers was not fully investigated. Even the naming of viruses becomes contentious. Avian flu blamed birds, swine flu blamed pigs, but they could have been Chinese or Mexican (perhaps even Californian) flus under a different nomenclature. What are the key dimensions of a political economy of control that, at times, involves both high politics and hard cash? Who is gaining and who is losing – and what might be done?
Pharmaceuticals and health security
Pharmaceutical products – especially anti-virals – play a central role in pandemic preparedness planning and control. In the United Kingdom, government policy sought the creation of an anti-viral stockpile of Tamiflu and Relenza large enough to cover 80 percent of the UK population. Around the world many other countries similarly created sizeable precautionary stockpiles of antiviral medications as part of their pandemic preparedness planning, collectively spending billions of dollars on these medicines. Pharmaceutical companies have thus emerged as prominent partners in strengthening health security, and have worked with governments to make sure the products are available in sufficient quantities, and that these products can get to the right people at the right time in the event of pandemic. Yet pharmaceutical companies also have strong commercial interests in pandemic preparedness planning as a new market for their products. Reviews of the handling of the swine flu pandemic in Europe have thus expressed concern about the close role of pharmaceutical companies in these policy processes. The Cochrane Collaboration, BMJ and investigative journalists have added their voices to these concerns. So what do we know about the role of pharmaceutical companies in pandemic preparedness planning? How can this tension between ‘industry as partner’ and ‘industry as lobbyist’ be responsibly managed?
Intellectual property and virus sharing
Effective infectious disease control requires the sharing of virus samples between countries – a task traditionally facilitated by the Global Influenza Surveillance Network (GISN). Whilst this system of international virus exchange works well in inter-pandemic periods, recent experience has shown that when concerns about a impending pandemic rise, the virus sharing system comes under increased diplomatic and political pressure. Of particular concern for developing countries is that although they share these virus samples readily with the international community, they face challenges when it comes to accessing the benefits that arise from working with these virus samples – whether this is the advancement of scientific knowledge, the development of new medicines for public health, or indeed the commercial benefits accruing from new medical products that are developed on the basis of these virus samples – like the creation of new vaccines. As a way of drawing attention to these issues, Indonesia controversially ceased to share its virus samples with the international community from 2006 onwards, despite the fact that Indonesia was widely perceived to be at the ‘forefront’ of H5N1. What pressures does pandemic planning put on international virus sharing practices? How have different countries sought to resolve this difficult standoff diplomatically? What legal and policy instruments should govern this area of pandemic preparedness planning in future?
Researching deadly viruses
According to the World Health Organization, more than 50% of people infected with highly pathogenic bird flu (H5N1) have died. So why did two publicly funded university research teams (in Holland and the USA) try to develop new H5N1 viruses that could transmit more easily between humans? And why do they want to publish the findings of how they did it in leading scientific journals? The high risk to human health involved, combined with the risk of bioterrorism, has prompted calls for deeper reflection on the implications of such ‘dangerous’ research. The U.S. National Science Advisory Board for Biosecurity (NSABB) even took the unprecedented step of requesting that the journals Science and Nature withhold key information when publishing the results. With the UK Cabinet Office risk register listing influenza pandemic as the number one civil emergency risk, should scientists researching viruses be censored? What are the ethics of developing deadly virus strains in the lab? How should governments balance security issues with those of health?
Organising for global public health
At the centre of the global response to influenza viruses are a number of international organisations, notably the WHO (but also the FAO and OIE on animal health issues). Each of these organisations was established with particular mandates in the post-War period. How have they fared? Certainly there has been greater coordination and interaction and newer UN units such as UNSIC have played an important role. But given the challenges, and the particular controversies discussed in the previous sessions, are these organisations, as currently organised, fit for purpose? How different would they look if they were to be more effective in overseeing, facilitating and guiding the international response to influenza viruses? What would a global architecture for a ‘One Health’ look like, for example?