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Pandemic Flu Controversies: What Have We Learned?

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There's something slightly odd about the way in which pandemic flu preparations have unfolded in recent years. On the face of it, there appears to be a compelling and reasonable case for undertaking pandemic preparedness efforts. We know that pandemics are recurring events, with three registering in the past century alone. We also know that the viruses capable of causing pandemics continuously mutate in ways that make it hard for human immune systems to keep abreast of them. And we know that many socio-economic changes - including the rise of rapid international air travel and changes in farming systems - are creating new avenues for zoonotic infections to occur. And even if we did not already know it, there are always big movies like Outbreak and Contagion to act as graphic reminders. All in all, most influenza experts would thus agree it is not so much a question of if, but rather when, a new pandemic will arrive.

It is strange, then, that pandemic preparedness policy over the past decade has proven to be anything but straightforward. Rather than calmly putting the necessary plans into place, governments have - in many cases - had to be brought to the planning table kicking and screaming, with only the threat of an imminent H5N1 pandemic in 2005/06 kick-starting efforts in earnest.

But even then, and at pretty much every step of the way since, efforts to improve pandemic preparedness have been steeped in controversy. There have been controversies about the models we have developed for predicting how severe a future pandemic is likely to be (will it be on the scale of the Spanish Flu of 1918, for example?) There have been intense disputes - often carried out behind closed doors - around the naming of pandemics (should we call it 'swine' flu?) and indeed how to classify them (Phase 5, Phase 6, etc.).

Even the task of shoring up our medical defences has not escaped controversy - whether in the form of the continuing open data access saga surrounding Tamiflu, or the more recent concerns about rare, but significantly elevated, risk of side-effects of some pandemic vaccines. On the international stage, moreover, we have witnessed long and taxing diplomatic disputes about the sharing of H5N1 virus samples, prompted by concerns about inequitable access to medicines and other intellectual property issues. Even the carrying out of basic virology research on H5N1 viruses by highly trained scientists has provoked an international furore. Despite the prudent case for pandemic preparedness, our efforts to prepare have proved to be deeply controversial.

Stepping back for a moment, and looking collectively at all of these different controversies surrounding pandemic flu, two things become immediately clear. First, these controversies are themselves an integral part of how pandemic preparedness policies have unfolded over the past decade. We cannot tell the story of 21st century pandemic preparedness without taking this long string of controversies into account. Controversy has simply become part of the core business of pandemic preparedness.

Losing trust

But more than that, many of these controversies also have the potential to affect adversely future planning - most notably where they are perceived to undermine trust in decision-making and makers, where they lead to disruptions in international co-operation, or indeed culminate in the cessation of fundamental scientific research. Indeed, is the impasse we now face not itself simply the outcome of the biggest controversy of them all: namely that the most recent H1N1 pandemic did not turn out nearly as severe as many had warned, even though experts mostly think we have simply been very lucky in that regard? For global responses to influenza to continue to be effective in the long run, they must also learn to acknowledge and manage such controversies.

If that is true, then surely the one thing we cannot now afford to do is simply ignore these controversies. As tempting as it is to run for cover when controversies break out, and to hope that time will make them disappear, we know that this is unlikely to be the case. A rather more promising approach would be to develop a better understanding of why all these controversies have emerged around pandemic flu, learning lessons for the next time. It was in this spirit that the ESRC STEPS Centre and the Centre for Global Health Policy (CGHP) at the University of Sussex recently hosted a workshop in order to explore these controversies in much more depth, building on the work the Centres' researchers have carried out over recent years. More than fifty international experts drawn from the worlds of science, policy, the media and academic publishing - with both social and natural science expertise - explored the multiple facets of these pandemic flu controversies.

Lessons learned

So what have we learned? First of all, we learned from all of these controversies that preparing for flu is simply not just about flu; it is just as much - if not more so - about the interventions that we need to implement in order to manage a pandemic.

What provokes many of these controversies is not so much the flu itself; instead, they arise around questions of which public health measures to implement, what the effects of those interventions will be, and who they will affect. Here, political, moral, ethical and justice concerns come to the fore, as public health concerns are balanced against economic impacts in different parts of the world. A North-South politics is particularly evident, as health concerns in the North trump livelihood imperatives in the South. Equally, there is a global-local politics, as responses geared to international health and economic interests meet the often very different priorities of people in local settings.

Second, we learned that controversies are not only deeply infused with wider social, cultural and political dynamics, but are actually excellent entry points through which to understand these very same processes. Precisely because these controversies are sites where competing perspectives crystallize and clash in their starkest form, they are also revealing lenses through which to analyse pandemic flu politics, and its social and cultural dimensions. Controversies, in other words, are great opportunities to unearth the contested, contingent, and fractious nature of knowledge that shapes our ongoing quest to protect human lives - irrespective of which side of the controversies we come down on. Social science perspectives are therefore a critical complement to natural science-based understandings.

Finally, we were able to draw lessons about how some of these controversies could also be diminished and perhaps even avoided in future. This could be achieved by striving to assemble the best possible evidence for policies, by being open about where the evidence was not yet clear, by insisting on transparency and avoiding secrecy, by including diverse sources and forms of cross-disciplinary and local knowledge and expertise, and by ensuring that risk communication remains measured and proportionate, so that warnings do not end up backfiring.

As the world prepares for the inevitable next pandemic, these, surely, are good lessons to take forward, requiring new ways of working and new organizational mechanisms for assuring global health.

This article was co-written with Melissa Leach, STEPS Centre director, and Stefan Elbe, director of the Centre for Global Health Policy at the University of Sussex.