½ PUBLIC HEALTH THEN AND NOW ½
Changing
Perceptions
of Pandemic Influenza and Public Health Responses
| Adam Kamradt-Scott, PhD, MAIS
According to the latest World Bank estimates, over the past decade
some US $4.3 billion has been pledged by governments to combat the
threat of pandemic influenza. Presidents, prime ministers, and even
dictators the world over have been keen to demonstrate their commitment to tackling this disease, but this has not always been the case.
Indeed, government-led intervention in responding to the threat of
pandemic influenza is a relatively recent phenomenon. I explore how
human understandings of influenza have altered over the past 500
years and how public policy responses have shifted accordingly. I trace
the progress in human understanding of causation from meteorological conditions to the microscopic, and how this has prompted
changes in public policy to mitigate the disease’s impact. I also examine the latest trend of viewing pandemic influenza as a security threat
and how this has changed contemporary governance structures and
power dynamics. (Am J Public Health. 2012;102:90–98. doi:10.2105/
AJPH.2011.300330)
90 | Public Health Then and Now | Peer Reviewed | Kamradt-Scott
OF ALL COMMUNICABLE
diseases, pandemic influenza
probably remains the most feared
by politicians, policymakers, and
health practitioners alike, and
with good cause. Unlike a variety
of other infectious diseases such
as HIV/AIDS, West Nile virus,
and severe acute respiratory syndrome (SARS), influenza has
infected and affected humanity
for centuries. Although seasonal
variations of this pathogen tend
to cause serious illness only in
the old, infirm, or very young,
periodically a new strain emerges
to which humans have little to no
immunity. These latter strains
have, on occasion, demonstrated
that even those in the prime of
life are vulnerable. There is no
better example than the 1918–
1919 Spanish Influenza pandemic, which spread around the
world approximately 3 times in
18 months and killed an estimated 40 million people. Over
time, however, the magnitude of
the 1918 pandemic faded from
memory. The 1958 and 1967
pandemics revealed that the
menace remained, yet for much
of the 20th century pandemic
influenza was generally viewed
as inconsequential in the face of
other potential threats such as
nuclear annihilation.
In more recent years, the international community has witnessed a lot of activity (often
accompanied by dire warnings)
directed against the threat of
pandemic influenza. Literally billions of dollars have been spent
on procuring and securing access
to pharmaceuticals, in drawing
up contingency plans and then
exercising them, in training critical personnel and first-line
responders, and in encouraging
the private sector to develop
business continuity plans, all
to better prepare societies for
dealing with the next pandemic.
Although the 2009 H1N1
pandemic was less severe than
originally feared, medical professionals and scientists continue to warn that another
pandemic of similar severity to
the 1918 pandemic remains a
distinct probability. The only
question that remains is not if,
but when.
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I examine how understandings
of influenza and attempts to mitigate its effects have developed
and evolved over the past 500
years and how the recent shift
toward framing the virus as a
threat to national and international security has shaped contemporary public health policy.
A BRIEF HISTORICAL
OVERVIEW
According to the Oxford English Dictionary, “influenza” is
from the Italian influenza, which
literally means “influence,”
although its origins can also be
traced to the medieval Latin
influere meaning “to flow in.”1
The official adoption in 1782 of
the term “influenza” by the British College of Physicians firmly
established its place in medical
parlance2 and displaced several
of the alternative names the disease was known by, such as the
French “la grippe,” the English
“catarrh,” and the Scottish
“rant.”3 Yet, although the name
may have changed over time, historical accounts of the symptoms
experienced by victims display a
striking commonality that leaves
little doubt that the disease has
been a persistent element of the
human condition for millennia.
Indeed, from the historical
accounts that have survived to
the present day, it is now generally held that the first truly worldwide influenza pandemic
occurred in the year 1510. Before
this, although evidence of localized influenza epidemics and
even regional epidemics dating
back to 1173 survives, none of
the accounts proffer sufficient
information to suggest that these
epidemics were worldwide in
scope. It is in this regard that Dr
Thomas Short’s account in his
work A General Chronological
History of the Air, Weather, Seasons, Meteors Etc., published in
1749, is unique. It describes an
epidemic that hit Britain in 1510,
while also noting its wider impact:
made in determining the nature
of the disease in large part
because of competing ideas over
causation. In fact, as Margaret
DeLacy relates,
The disease called Coccoluche,
or Coccolucio, (because the sick
wore a cap or covering close all
over their heads) came from the
island of Melite in Africa, into
Sicily; so into Spain and Italy,
from that over the Alps into Portugal, Hungary, and a great part
of Germany, even to the Baltic
Sea; every month shifting its situation with the wind from East
to West, so into France, Britain.
It attacked at once, and raged all
over Europe, not missing a family, and scarce a person.4
the depiction of influenza as a
distinct genus of disease only
first became common during
the eighteenth century. During
that period, physicians developed competing theories about
its etiology (causation) and
transmission, including the theory that influenza was contagious. Theories of contagion
were held by an increasing
number of physicians during
the course of the eighteenth
century, although the issue remained a contested one, as
symbolized by the publication
of two separate reports on the
epidemic of 1782 by the Royal
College of Physicians and the
Society for Promoting Medical
Knowledge: reports that differed on the question of transmission.7
Yet, although additional writings have contributed to our
overall understanding of the disease at this time,5 the intrinsic
flaw in both the early and contemporary accounts has been
their overreliance on a limited
pool of literature, as David
Patterson acknowledges that
[e]ighteenth- and nineteenthcentury information is geographically uneven, with data
most abundant by far for Western Europe, notably Britain,
Germany, France, and northern
Italy. Scandinavia, Russia, the
Iberian Peninsula, and especially the Balkans are more
sparsely documented in the
contemporary medical literature, but we can usually construct a fairly satisfactory picture of influenza activity in
Europe. Reports on Asia, the
Middle East, Africa, and South
America are sketchy at best and
usually supplied by European
observers. North American data
are better, but often quite disappointing.6
As a consequence, contemporary knowledge about influenza
epidemics and pandemics throughout earlier centuries tends to be
heavily skewed toward European
worldviews and those of a few
specific countries in particular.
Moreover, little progress was
January 2012, Vol 102, No. 1 | American Journal of Public Health
The debate over causation
continued into the early 20th
century, with some physicians
robustly defending the notion
that influenza was linked to meteorological conditions such as high
winds, sunshine, and relative
“
Of all communicable diseases, pandemic
influenza probably remains the most feared
by politicians, policymakers, and health
practitioners alike, and with good cause.
humidity.8 Generally speaking,
however, influenza did not rate
particularly high on medical and
political agendas even at the
beginning of the 20th century. As
late as 1837, there was a strong
view that governments had little
to no role in ensuring public
health9; although this sentiment
progressively began to change,
government intervention in the
form of large-scale public health
campaigns was rare, particularly
”
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any relating to influenza. Nonetheless, influenza epidemics and
pandemics occurred with almost
clockwork frequency throughout
the latter half of the 19th century.
Arguably, the frequency of these
events contributed to a measure
of acceptance and familiarity with
the disease; it is also easy to
appreciate that other diseases
such as typhoid and cholera
ranked higher because of their
comparatively high fatality rate
and impact on international
trade. That is, until the 1918
“Spanish Flu” pandemic forever
changed societal notions about
the disease.
Even by contemporary standards, the 1918 Spanish Flu pandemic continues to remain one
of the most devastating events in
recorded human history. As one
commentator reflected in 1978,
“The influenza pandemic of 1918
ranks with the plague of Justinian
and the black death as one of the
three most destructive human
epidemics.”10 Believed to have
begun in North America in early
1918, the pandemic traversed the
globe in 3 distinct waves over
approximately an 18-month
period. The speed of the disease
was therefore remarkable in that
it spread rapidly around the
world before the advent of international air travel. More disturbing, however, was the lethality of
the disease, which infected as
much as 50% of the population
in some areas before killing up
to 25% of the entire population.11 Furthermore, in contrast
to most influenza epidemics,
which affected the very old or
very young, some of the highest
fatality rates of the 1918 pandemic were for people in the
prime of life.
At the height of hostilities in
World War I, information about
the adverse impact of an epidemic
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on military forces was considered
highly sensitive. It is believed
that this reluctance to alert other
countries to the impact on troop
numbers aided the spread of the
disease. Although the pandemic
is suspected to have originated in
the United States, it was inappropriately termed the Spanish Flu
in 1918 only because the Spanish
authorities were the first to
declare that they were experiencing a nationwide epidemic12; as
W. I. B. Beveridge aptly noted,
“this misleading name stuck.”13
Only once that point was
reached did other countries
finally begin to acknowledge that
they too were recording significant numbers of human fatalities.
Estimates vary considerably
regarding the overall death toll of
the 1918 pandemic, with most
conservative estimates ranging
between 20 million and 50 million deaths worldwide.14
Because of the massive loss of
human life, the 1918 pandemic
did have one positive outcome in
that it spurred considerable scientific research into influenza.
One of the initial areas to be
investigated was the connection
to pigs, prompted by the observations of veterinarian J. S. Koen of
the US Bureau of Animal Industry in 1918. Koen observed,
[t]he similarity of the epidemic
among people and the epizootic
among pigs was so close, the reports so frequent, that an outbreak in the family would be
followed immediately by an
outbreak among the hogs, and
vice versa, as to present a most
striking coincidence, if not suggesting a close relation between
the two conditions. It looked
like “flu,” it presented the identical symptoms of “flu,” and
until proved it was not “flu” I
shall stand by that diagnosis.15
The cause of this porcine disease was subsequently confirmed
as influenza in 1931, following
the virus’s isolation and identification by Richard Shope and his
colleague Paul Lewis. Following
closely behind this discovery,
three scientists—Wilson Smith,
Christopher Andrewes, and Patrick Laidlaw—isolated and identified the virus from human tissue
samples in 1933,16 naming this
first virus influenza A. These discoveries and the subsequent
development of a viable influenza vaccine in 1940s altered
considerably the response of
individuals and governments
toward influenza, serving to
usher in a new age of human
interaction with the disease.
The 1918 pandemic had
another interesting (albeit temporary) outcome: it instilled the
notion that influenza was closely
associated with war, with some
scientists even explicitly referring
to it as a “war disease.”17 Governments had been cognizant of
influenza’s ability to decimate military forces since at least 1782,18
but the 1918 pandemic cemented
military interest in the disease
because of the considerable
impact it had on armed services
personnel.19 So convinced were
some officials that influenza
would appear with the outbreak
of World War II that in 1941 the
United States established the
Commission on Influenza of the
United States Army Epidemiological Board to provide technical
advice and commence work on
an effective vaccine. The preoccupation, though, was short-lived,20
and with the advent and mass
production of antibiotics and
new vaccines, many began to
believe that the war against
infectious diseases would soon
be over.21
Two subsequent pandemics
revealed that such optimism was
misplaced. The first pandemic,
which commenced in 1957 and
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was named the Asian Flu after
cases were first recorded in
China and the surrounding
region, contributed to the deaths
of more than 2 million people
worldwide. The first event of its
kind to be observed with modern
scientific techniques,22 the 1957
pandemic became one of the
most widely described medical
events of the 20th century.23
Contemporary medical professionals have even conceded that
[m]ost of the current understanding of influenza and its
complications are derived from
the 1957 pandemic experience.24
The emerging practice of disease surveillance revealed what
many had long suspected: that
locations such as schools and
military camps proved fertile
grounds for spreading the disease
because of crowded conditions
and inadequate hygiene.25 The
epidemiological data that were
collected on the success of vaccination programs—which had
been initiated in the United
States by the US Department of
Defense26—and other campaigns
that encouraged handwashing,
facemask wearing, and general
hygiene, also began to inform
new public policy responses.
Arguably, why so much was
written and recorded about the
1957 pandemic can be attributed
to one organization in particular:
the World Health Organization
(WHO). In 1947, following a
request by a respected group of
scientists, the Interim Commission
of the WHO agreed to establish
the World Influenza Centre
(WIC) to collect and distribute
information, conduct and coordinate laboratory work on the
virus, and train new laboratory
workers.27 Officially established
in London in 1947, the WIC
marked the start of the broader
WHO Influenza Program to (1)
plan against the reoccurrence of
future pandemics, (2) develop
control methods to limit the
impact when a pandemic did
appear, and (3) limit as much as
possible the economic impacts of
influenza epidemics and pandemics. Behind all this activity
loomed the specter of the 1918
pandemic and the massive loss of
life it had inflicted.28 In 1952, the
WHO also formed the Expert
Committee on Influenza to provide technical advice and general
oversight for the organization’s
program of work.29 At the heart
of the WHO Influenza Program,
though, was an international network of laboratories and scientists that shared information on
the latest influenza-related scientific discoveries—a network that
continues to function to the present day and that forms the basis
of international efforts to control
and mitigate the health impacts
of influenza. From the network’s
inception, every member state of
the organization was encouraged
to establish a national influenza
center to collaborate with the
WIC; by 1968, when the next
influenza pandemic commenced,
the network had grown to
include 79 national influenza
centers in some 54 countries and
2 reference centers (later known
as “collaborating centres”) in London and the United States.30
The second pandemic to defy
the notion that the battle against
infectious diseases would soon be
over was the 1968 “Hong Kong
Flu” pandemic, which resulted in
the deaths of approximately 1
million people worldwide.
Named after the island where
cases were first identified, the
pandemic validated the critical
importance of conducting regular
disease surveillance.31 As it
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became increasingly evident that
vaccination campaigns prevented
the loss of human life and
reduced the economic impacts on
society, attention began to progressively shift to calculating the
cost of such events32—a trend
that persisted well into the 1970s
and 1980s in response to
broader economic pressures and
a desire by Western governments
to ensure value for money in the
face of economic rationalism.33
By the mid-1980s, pandemic
influenza had effectively fallen off
the international agenda. Several
geopolitical factors arguably contributed to this, such as political
attention shifting more toward
“hard” security considerations of
nuclear proliferation, debt crises,
and various conflicts throughout
Central Asia and the Middle East.
But even in health, the US “War
on Drugs” and the rise of new
diseases such as HIV/AIDS
understandably shifted public
attention away from influenza.
Instead, influenza increasingly
began to be viewed as an entirely
preventable disease following the
introduction and progressive
refinement of viable vaccines.
In 1952, scientific consensus
held that influenza vaccines
remained “experimental.”34 By
1959, however, because of the
considerable scientific evidence
that had been collated from
annual seasonal influenza epidemics and multiple clinical trials
conducted in various countries
throughout the 1950s,35 this
view had shifted, with the WHO
recording that
Experience in many countries
has now established vaccination
as the most efficient method for
the prevention of influenza.36
By 1969, the WHO, which by
this time had become an “authoritative source of information on
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the occurrence of influenza and
its spread from one country to
another,” actively promoted the
view that “[v]accination is the
only established procedure for
conferring protection against
influenza.”37 Nonetheless, the
organization became preoccupied with a number of global
eradication initiatives, such as the
Malaria Eradication Program and
its now widely hailed successful
campaign against smallpox.
Added to this, in the aftermath of
the comparatively mild 1968
pandemic and the 1976 Swine
Flu vaccination debacle,38 public
perceptions about the risk presented by this disease (and the
need for protection from influenza) had altered perceptibly.
The WHO, which is reliant on
contributions from member
states to support its work,
reflected the downturn in interest to the extent that by 1997,
the organization had progressively reduced the number of
personnel employed to work on
influenza to one individual.39
In the late 1990s, public perceptions of and political interest
in pandemic influenza changed
markedly yet again. The confirmation in 1997 that 6 of 18 people infected with a novel strain of
H5N1 “bird flu” died as a result
of their exposure reawakened
international concern for the disease. This event also coincided
with a wider growing recognition
among Western developed
nations that several infectious diseases, once previously eliminated
in their territories, had begun to
resurface alongside new diseases
to threaten populations.40 Pandemic influenza came to be seen
as a particular threat; with several
prominent medical professionals,
academics, and policymakers
warning against a repeat of a
1918 Spanish Flu–like event,
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pandemic planning began to be
increasingly viewed as a critical
measure that governments
needed to undertake.41 Reflecting
the change in political interest,
the WHO immediately began to
enlarge its pandemic influenza
portfolio, increasing the number
of dedicated staff and releasing
several guidance documents on
pandemic preparedness.
By the turn of the century, the
way in which developed countries
viewed some infectious diseases
had entered a new paradigm—
that of (inter)national security.
The release of such documents as
the US Central Intelligence Agency’s national intelligence estimate
confirmed that “threat” arguments
had found purchase among policymakers and politicians concerned about the potential
societal impacts that some infectious diseases such as pandemic
influenza could generate. The
passage of United Nations Security Council Resolution 1308 on
the threat of HIV/AIDS epitomized this change in perception42; as Stephen Collier and
Andrew Lakoff have summarized,
[r]evelations during the 1990s
about Soviet and Iraqi bioweapons programs, along with the
Aum Shinrikyo subway attack
in 1995 and the anthrax letters
of 2001, lent a sense of credibility and urgency to calls for
biodefense measures focused
on bioterrorism.43
By 2005, a select few diseases
had become “securitized” in the
sense that they were perceived
(and openly discussed) as a
threat to national and international peace and security. The
corresponding effect of this securitizing move was to reemphasize
the central role of government in
mitigating the impacts of these
diseases; Western governments
increasingly found themselves
under pressure to develop strategies ranging from generic pandemic planning to more specific
interventions.44
In the context of pandemic
influenza, the cornerstone of pandemic planning and preparedness
was widely promoted as ensuring ready access to influenza vaccines.45 The advent of influenza
antiviral medications in the
1990s added to the pharmacological arsenal; however, despite
limited clinical trials demonstrating their efficacy,46 on the advice
of medical practitioners antivirals
were soon identified alongside
vaccines as “the two most important medical interventions for
reducing illness and deaths during a pandemic.”47 Correspondingly, governments embarked
on new programs aimed at stockpiling these drugs48 and were
encouraged to develop plans that
took into account a range of
additional measures—such as the
practice of encouraging physical
distancing between individuals in
multiple social settings (otherwise
known as social distancing),49
legal considerations and regulation,50 the application of social
justice principles,51 and the ethical considerations of pandemics52—to protect their respective
populations.
Further compounding the
pressure on governments was
the realization that policies that
focused on the domestic sphere
alone were insufficient. As David
L. Heymann and Guenael Rodier
summarized,
[p]opulation movement is only
part of the globalization fallout.
Expansion in international
travel and commerce in food
and medicinal biologic products
provides another potential
source of communicable diseases such as hepatitis and
other bloodborne infections. Social and environmental changes
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linked to urbanization, mobility,
and deforestation have created
new opportunities for infection,
while rapid adaptation of microorganisms has facilitated the return of old communicable diseases and the emergence of
new ones. With the rapid evolution of antimicrobial resistance,
treatments for a wide range of
parasitic, bacterial, and viral infections have become less effective. Today, a communicable
disease in one country is a
global concern.53
A series of disease-related incidents early in the first decade of
the 21st century—which notably
included the 2001 anthrax letter
attacks in the United States, the
2003 SARS outbreak, and the
emergence and progressive international spread of avian influenza
from late 2003 onwards—validated these concerns.
By 2005, convinced of the
growing threat presented by
avian influenza to the whole of
society, governments the world
over embarked on new programs
of pandemic planning and preparation. The Secretary-General of
the United Nations, at the urging
of several Southeast Asian countries, established a new department—the United Nations System
Influenza Coordinator (UNSIC)—
to help coordinate the multiple
UN agencies engaged in activities
related to preventing avian influenza. The creation of this supraorganizational body coincided
with the establishment of the
International Partnership on
Avian and Pandemic Influenza
announced by US President
George W. Bush; it was accompanied by considerable US government funds for strengthening
international surveillance, detection, and response. In addition,
multiple fora for coordinating
pandemic-related work were
either newly created or subsumed
into existing mandates with all
manner of intergovernmental
organizations, ranging from
regional (e.g., Asia-Pacific Economic Cooperation [APEC] and
the Association of Southeast
Asian Nations [ASEAN]) to
international (e.g., the WHO);
these fora received new financial
investment and support to
enhance pandemic influenza preparedness and response capabilities. Various local, national,
regional, and international plans
were developed and in a number
of instances exercised. New laws
and regulations were passed, and
contracts worth billions of dollars
were agreed to between national
governments and pharmaceutical
companies to ensure access to
vaccines and antivirals. In short,
the international community went
into pandemic overdrive, pledging
approximately US $4.3 billion
between 2005 and 2009.54
In April 2009, the hyperactivity initially appeared to have
been substantiated following the
announcement that a novel strain
of H1N1 influenza had managed
to infect humans. Within a matter of weeks, the virus had been
detected in multiple countries
around the world, and the WHO
moved to declare a full-scale pandemic. Fortunately, the virus
responsible for the pandemic was
more akin to the 1977 Russian
Flu than the 1918 Spanish Flu in
terms of severity, and the dire
warnings about the number of
possible fatalities and widespread
societal impacts were thus
revealed to be excessive—the
threat had proved nominal.
Nonetheless, in anticipation of
a disastrous event, contingency
plans were invoked, emergency
committees were convened, and
billions of dollars were spent
procuring antivirals and pandemic-specific vaccines. The
legitimacy of the WHO, once
viewed as the vanguard of
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human health, was questioned
over accusations the organization
had been unduly influenced by
pharmaceutical manufacturers
into changing its definition of a
pandemic. A number of independent inquiries were subsequently
launched, and although they
exonerated the WHO of any
inappropriate or unethical behavior, the organization did agree to
review its processes for declaring
a pandemic.
CHALLENGES ASSOCIATED
WITH CHANGING
PERCEPTIONS
It is clear from this summary
that human understandings about
pandemic influenza, and how best
to mitigate its effects, has altered
markedly over time. In centuries
past, the disease was viewed as a
meteorological phenomenon, the
result of foul-smelling air, or even
condemnation by the gods. The
response by individuals to try and
prevent contracting the disease,
however, was somewhat limited.
As time progressed and scientific
advances were made, the cause of
the disease was identified to be a
virus. This revelation prompted
the creation of vaccines and,
eventually, antiviral medications
to counteract its effects. Over the
past century, the role of government has ebbed and waned as
politicians, policymakers, and
health practitioners alike have
weighed the hazards associated
with responding to this disease.
But, as Western societies have
become increasingly risk averse,
the need for government-led
interventions and protection from
influenza has grown. Although
the change has been reflected in
government responses to a select
few other infectious diseases as
well, the latest clearly identifiable
shift in public policy responses to
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pandemic influenza has been to
securitize the disease, but this too
has had both positive and negative outcomes.
Indeed, securitizing pandemic
influenza appears to have been a
double-edged sword in many
respects. Certainly, the framing of
pandemic influenza as a security
threat illustrates deeper changes
in global health governance,
which some have argued is
closely tied to US economic and
security interests.55 Whether such
claims are accurate or not, this
framing has served to elevate the
disease above other health concerns that are arguably more
pressing for a larger percentage of
the world’s population (e.g.,
maternal and child mortality,
malaria). Furthermore, at least in
the short term, securitizing pandemic influenza has ensured that
governments have accorded significant political attention to the
disease. This has had the corollary effect of substantial resources
being allocated to strengthen
health systems to enhance disease
surveillance, detection, and outbreak response capacities for pandemic influenza—approximately
US $4.3 billion in monetary
pledges or in-kind technical support to date. Not surprisingly,
communities have benefited from
this investment—if for no other
reason than because strengthening health systems in one area
(i.e., pandemic preparedness) can
also lead to gains in other health
areas more generally (i.e., improving communicable disease prevention and control).
At the same time, by securitizing the disease advocates of this
approach have also reinforced the
message that the threat is both
serious and imminent—a message
that was not borne out by the latest influenza-related event. Of
course, had the 2009 H1N1
pandemic proven more severe, it
is likely that influenza would
have been further embedded in
our collective consciousness as a
legitimate threat, and reinforced
the broader view that infectious
diseases do threaten (inter)
national security. Given, however,
that the 2009 pandemic has
been portrayed as comparatively
mild (compared with 1918), it is
currently unclear whether depicting influenza as a security threat
will endure. Certainly, what has
become apparent is that just as
significant political attention and
resources were accorded to pandemic influenza in 2005, by
2010 there had been an equally
substantial and rapid scaling back
of resources now that the threat
was perceived to have passed.56
Whether this assessment is
entirely correct is not certain,
with human H5N1 infections
continuing to occur; with widespread “pandemic fatigue” having
set in among international
donors, however, it is unlikely
that the former level of activity
will now be sustained.
Securitizing infectious diseases
like pandemic influenza has also
had an unsettling effect on
national and global governance
structures and, accordingly, on
public policy. The heightened
political attention accorded to the
threat of infectious diseases has,
for instance, prompted the passage of new legislation that
grants governments extended
powers,57 given greater impetus
for intervention (and ownership)
by central governments in health
care services,58 and resulted in
millions (and in some instances
billions) of dollars worth of
investment in civil and military
biodefense initiatives.59 Within
all these arrangements, vaccines
have continued to remain the
much-sought-after magic bullet
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in the war against infectious
diseases.60
In the specific context of pandemic influenza, the fixation on
vaccines, combined with the
recent policy shift toward securitizing the disease, has served to
distort the existing governance
arrangements, granting pharmaceutical manufacturers a disproportionate amount of political
power and influence. Some public health experts have been complicit in this, arguing that
School closure, quarantine,
travel restrictions and so on are
unlikely to be more effective than
a garden hose in a forest fire.61
Accordingly, less attention has
been given to building the evidence base for alternative measures such as the use of personal
protective equipment, personal
hygiene, and social distancing
principles62—measures that
would arguably benefit a larger
proportion of the world’s population that currently do not have
access to these essential medicines. Indeed, in the majority of
pandemic plans, governments
have only tended to consider
these measures as a means to
limit virus transmission until a
viable vaccine becomes available.
This imbalance was perhaps most
clearly demonstrated in the context of the 2009 H1N1 pandemic, with the World Bank
noting that of the estimated
US $1.48 billion required to
counteract the pandemic’s effects
in 95 of the least-resourced
countries, some US $1.14 billion
(or 77% of the funds) was identified as being necessary to purchase vaccines and related
medicines.63
The contemporary imbalance
was also reflected in Indonesia’s
decision to stop sharing virus
samples with the WHO’s Global
Influenza Surveillance Network
(GISN). This decision, which
transpired in January 2007, was
taken in part to force the international community’s hand to
improve access to vaccines. After
some 4 years of diplomatic negotiations, a new agreement—the
Pandemic Influenza Preparedness
Framework—was endorsed by
the 64th World Health Assembly
in May 2011. The new agreement outlines a series of recommendations, norms, oversight
procedures, and governance
arrangements to facilitate the
sharing of influenza virus samples
with human pandemic potential.
Through new obligations placed
on pharmaceutical companies
that are part of the GISN to contribute 50% of the network’s
operating costs, the agreement
transforms what was previously a
largely publicly funded network
(supported principally by funds
from Japan, Australia, the United
Kingdom, and the United States)
into a new public–private partnership. At the same time, those
companies that are not members
of the network (and thereby
exempt from contributing to the
network’s operating costs) are
required to agree to a package of
measures intended to improve
access to medicines and diagnostics for low-income countries. In
this regard, the agreement may
begin to address the power imbalance between pharmaceutical
companies and governments that
has arisen in the wake of the
global dissemination of avian
influenza, although it remains to
be seen whether equity in access
between governments will be
achieved under the terms of the
agreement.
Perhaps the most intriguing
aspect of the recent shift to securitizing diseases such as pandemic
influenza has been the fact that
Indonesia—a relatively small
American Journal of Public Health | January 2012, Vol 102, No. 1
~ PUBLIC HEALTH THEN AND NOW ~
geopolitical power—successfully
used the perceived threat of a
disease to force some of the
world’s most powerful countries
to the negotiating table. What
this reveals is that the concept of
health security has gained a measure of traction within contemporary international politics. One
could overplay the significance of
the case; however, that a country
like Indonesia can command
global attention and require
changes to existing influenza governance arrangements by withholding virus samples represents
a notable shift in contemporary
global governance. What this
trend portends for the future
remains to be seen,64 but it is
likely that in the current riskaverse environment the importance of government involvement
in preventing and controlling
infectious disease outbreaks such
as pandemic influenza will continue to grow rather than lessen.
Accordingly, there is likely to be
a greater willingness on behalf of
governments of all resource persuasions to be willing to challenge existing governance
mechanisms and arrangements if
they perceive that their security
and the legitimacy they derive
from protecting their population
are being compromised.
CONCLUSIONS
This overview has provided a
brief summary of the way in
which humanity has sought to
contend with and respond to the
constant hazard of influenza pandemics over the past 500 years.
In deciding what to name this
common threat, 18th-century
physicians selected an apt title,
for influenza has certainly demonstrated its ability to influence
human society in profound ways.
Indeed, aside from the Justinian
Plague of the 6th century and
the Black Death of the 14th century that wreaked so much
human suffering and death, it
must be concluded that the 1918
Spanish Flu, which caused an
estimated 40 million deaths
worldwide, was one of the most
devastating medical catastrophes
of recorded human existence.
The chance that another influenza pandemic of equivalent
lethality may arise has spurred
tremendous advances in medical
science and public policy, and
continues to do so. At the same
time, the erosion of geospatial
boundaries by globalizing processes ensures that the threat to
human populations is as great as
ever. In response to this trend,
the role and importance of government-led interventions to
counteract disease outbreaks has
grown tremendously, as has the
need for more effective coordination at the international level.
Correspondingly, international
organizations, governments, local
authorities, industry, and even
individuals all have a role to play
in planning and preparing for the
next pandemic. What remains to
be seen, however, is how our
contemporary understandings of
this disease, and the measures
we use to counteract its potential
devastating effects, will serve to
assist or hinder attempts to prevent a future pandemic. Q
Acknowledgments
This research was made possible
through funding from the European Research Council under the European
Community’s Seventh Framework Programme, Ideas Grant 230489 GHG.
I thank the 3 anonymous reviewers
from the American Journal of Public
Health.
Note. All views expressed remain
those of the author.
Human Participant Protection
Adam Kamradt-Scott is with the Department of Global Health and Development, Faculty of Public Health Policy, London School of Hygiene and Tropical
Medicine, London, UK.
Correspondence should be sent to
Adam Kamradt-Scott, Department of
Global Health and Development, 15-17
Tavistock Place, London WC1H 9SH, UK
(e-mail: Adam.Kamradt-Scott@lshtm.
ac.uk). Reprints can be ordered at http://
www.ajph.org by clicking the “Reprints/
Eprints” link.
This article was accepted June 8, 2011.
January 2012, Vol 102, No. 1 | American Journal of Public Health
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