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Wednesday, May 13, 2009

What the flu has taught us

To prepare for a pandemic is to prepare for surprises

05:55 AM May 12, 2009

AS THE Influenza A (H1N1) outbreak backstory seeps out, there are some vitally important lessons that can be learned. Huge investment in pandemic preparedness and contingency plans, improvements in surveillance and response systems and stockpiling of drugs and vaccines have followed recent avian influenza outbreaks. But do we have effective global disease surveillance and control systems that can prevent a disaster?

In the face of a potential pandemic, huge numbers of potential deaths are bandied about, based on highly suspect data and assumptions and resulting in wild speculation and panic. The counter move is to keep quiet, cover up and assure the populace. Neither approach helps, as we don't know what will happen, when and to whom. This acceptance of uncertainty and ignorance in a public debate is tough. But it is also vital. Otherwise, inappropriate public policy arises and misguided signals are given.

Preparing for a pandemic means preparing for surprises - and being ready to respond rapidly and flexibly under conditions of uncertainty requires a new set of skills, bureaucratic routines and incentive systems in the public agencies charged with protecting the world from emerging infectious diseases.

As Emery Roe and Paul Schulman argue in their recent book High Reliability Management, reliability must be a feature of any system operating in a complex, uncertain world. This requires, they argue, high reliability professionals who can track between local understandings of what is happening on the ground and the broader policy situation, liaising between agencies and across scales.

These professionals are currently absent from the international effort - creating a vacuum at the heart of the response - because authoritative knowledge consists of accepted expertise that does not acknowledge uncertainty, ignorance or complexity.

In a potentially global pandemic situation, global assessments are also based on global statistics, but in reality major structural inequalities affect the likely outcomes of rapid disease spread. We don't know why disease virulence and mortalities are high in Mexico, but apparently lower elsewhere. This may have a complex medical, viral cause. But it also may be to do with access to healthcare and effectiveness of response.

The swine flu story is also revealing how poor surveillance and reporting systems mean an outbreak can quickly get out of control - there were big gaps in detection and reporting that date back to February. But local people knew of the disease, and have strong hypotheses about its origins. Anselma Amador from La Gloria, the village where the first known case of swine flu occurred told The Guardian: "We are not doctors, but it is hard for us not to think the pig farms around here don't have something to do with it ... The flu has pig material in it and we are humans, not pigs."

These explanations are dismissed by the health minister and pig farming company, but why are such leads not being followed up? And why are such early-warning approaches, based on local knowledge about disease incidence and its dynamics, not part of the standard surveillance system?

In South-east Asia local understandings of avian flu and its spread have been vitally important. Medical doctors, epidemiologists, virologists, veterinarians and other specialists need to work hand in hand with local people for surveillance to be effective.

Another strong lesson from the avian flu experience is that attention to the changing structure of the livestock industry is essential to understanding how diseases emerge and spread. While it is easy to blame big agribusiness and industrial farming techniques, the situation is more complex.

While the "livestock revolution" is celebrated as a source of economic growth in the developing world, rapid restructuring of the livestock sector has major downsides and implications for how industries are regulated and diseases managed. As the details begin to emerge on the swine flu outbreaks, a more comprehensive assessment of the political economy of agriculture - and the pig industry in particular - in Mexico will be essential in learning lessons for the future.

Right now, of course, the spotlight is focused on the international public health response. Preparing for a pandemic means preparing for surprises - and being ready to respond rapidly and flexibly under conditions of uncertainty. As the experience with avian influenza has shown, this may require more than simply the top-down, "active and aggressive" technocratic responses being urged. The Guardian

From TODAY, Comments – Tuesday, 12-May-2009



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