Last week, the Internet showed again its formidable rapidity: on Sunday night (May 19 2009), a prolonged but moderate earthquake shook the area of Los Angeles. Almost instantaneously, people started to flood Twitter with messages and the news of the earthquake was coursing through the world of microblogging long before the Internet press published the information. Rumours on the Internet can spread like pandemics and the way to control their nuisance could be equally employed to prevent pandemics.

As the main task of the World Health Organisation (WHO) is to be a worldwide health monitor, teams of the organization also dedicate themselves to track down the rumours of illnesses on the Internet in order to analyse them and evaluate the risks of pandemics. Nevertheless, the evolution of any flu virus is totally unpredictable, which makes it very difficult to foresee its extent of danger. In the case of the “swine flu”, the WHO has been very careful to prevent a repetition of the panic effect produced during the SARS epidemic. This time round, they have been more watchful with the terms used during informative campaigns. Recently, I heard on the radio a doctor working at the WHO insisting on the fact that the correct name of the flu is “A/H1N1 influenza”. Beyond what could seem to be an excess of pretentiousness, it is indeed important not to encourage false associations of ideas which could create paranoia and generate disastrous consequences such as the recent mass slaughtering of pigs in Egypt. Furthermore, the expression “swine flu” is inappropriate: despite its swine origin, the virus has not been yet isolated on animals and is only transmitted between humans. ’The Mexican flu’ or ’the North American flu” are different names used to define the A/H1N1 flu and they show how difficult it is to apprehend the pandemic, Le Monde even pinned the term “grey flu” (“grippe grise”) to underline the uncertainty experienced by organizations and States when it comes to taking decisions and measuring their efficiency.


The recent outbreak of A/H1N1 flu in Japan has caused the government to take special measures such as closing down more than 4000 schools while health officials called for calm, stressing that the virus had not caused any deaths in Japan and that most cases were relatively mild.

 

Drawing on his clinical experience, Professor Soebandrio demonstrated how communicating risk is similar to preparing medicine:
Must find an indicator – just as a patient demonstrates symptoms, so does a community. Considering the symptoms, the doctor decides on further action and in the same way a government will consider the need to communicate.
Ingredient – patients can have differing reactions to medicine and communities demonstrate the same variability to public health messages. The content of the message might need to vary from country to country.
Dose – how much information should we give? If too much medicine is administered the patient will not heal, if the public is bombarded with public health messages people will stop listening.
Method and route of administration – just as medicines and medical technology have evolved, so to have communication methods. This does not necessarily mean that traditional methods should be ignored at the expense of modern methods.
Duration – when to start and stop, when to follow up. The duration of a course of treatment is integral to a patient’s well being; too short a treatment and the illness will linger, too long a treatment and the effectiveness may be comprised. Medicine is administered to improve one’s condition, not to provide a new burden. This logic is transferable to risk communication.

 

Communication is part of the process of the revelation of truths. A truth is not a given fact as the reaction of the public influences what the truth is. This is the relationship between observed and the observation. The nature of a truth to be communicated can be changed. It is a systemic (that is, linguistic and symbolic) exchange in which dimensions of information, education, manipulation and public debate take place.
Communication in a time of crisis can only be understood when put in the context of one of the channels through which society today is able to be in identity and in solidarity and in submission in different spheres of time – the future and the crisis. Those dimensions must be considered together as the worst mistake is to concentrate on short time spans during the time of crisis without taking into account the long, slow and meaningful process through which civic societies and public actors today are willing to find a meaningful interaction that is creative of new solidarities and consensus.

Lessons for the Global Management of Health and Environmental Risks and Crises

The term “Avian Influenza” (AI) refers both to: 1/ the existing and related avian influenza epizooty and epidemic, and 2/ the possibility of an influenza pandemic, that would result from a mutation of the H5N1 virus.

The issue of AI therefore implies two necessities: 1/ the need to control the existing avian influenza virus and 2/ the need to prepare for the next pandemic.

The reaction to the AI issue has thus articulated itself, over the years, in two movements: 1/ a strong solidarity drive, from the better prepared, to the less prepared and 2/ a “national preparedness drive”, as the majority of countries strove to strengthen their own capacity to respond to an AI outbreak/pandemic. The tension between those two dimensions of the management of AI contributed to the build-up of a strong mobilisation, from very different communities (animal health, human health, environmental health, security, media, private sector, etc.). This process of mobilisation resulted in the emergence of what appears to be, with the benefit of hindsight, a real “global fight against avian influenza”, which reaps significant results, as this report highlights. Such a dynamic may not last forever, however, as a lurking fatigue with the issue seems to be spreading amongst actors, and threatening past and current efforts. The new “One World One Health” agenda could, in this regard, prove to be a necessary option to remobilise actors, and consolidate the outcomes of the fight against AI.

Before highlighting some key lessons from the fight against AI, one should draw some key features of the architecture of the global governance of avian influenza.

Which Global Governance of AI?
- Governing AI at the global level has been a fluid process, as it took some time to structure the large range of actors that had mobilised. Today still, as the agenda One World One Health is gains momentum, the exact role played by the different institutions involved in this process
might start to shift again.
- States are the key actors, as they raise political momentum at the global level, and as no possible response/control/preparedness is possible without them.
- Intergovernmental Organisations are very important supporting actors in the fight against AI; it is important in this regard to understand their role and limits. If IOs are faced with some problems
i.e. bureaucratic problems, traditional aid issues), they also proved to be extremely innovative.
- The regional level can have a facilitating effect on the global fight against AI. However, strong discrepancies exist between the regional organisations.
- A strong mobilisation was possible thanks to yearly conferences at the high political level; high political support from the national level: continuity of leadership; simulations; a cautious use of the “security” agenda.
- Coordination, which is always a problem at the global level, appeared to be less of a problem her thanks to global, regional, national and institutional coordinators, who had both a high visibility and sufficient time, and used frequent meetings of all stakeholders to insure coordination worked. UNSIC was useful but not very present on the ground; the question of its persistence in 2009 is still open.
- The Global Governance of AI confirms that strengthening existing organisations and coordination mechanisms can prove more efficient than creating new institutions.

LESSONS from a Global Fight:
- One needs a blend of horizontal and vertical approaches to global health issues to ensure that both animal and human health systems and the specific realities of a given diseases are taken cared of.
- Communication is a key factor.
- Surveillance systems are now better, but they can still be improved, and this needs to be done.
- A rapid emergency response requires long term investment. Even fire brigades have structural costs.
- Decision-making in grey environments implying investing time and money in research, but one should accept the fact that there will never be enough knowledge, and that grey decisions will thus have to be taken.
- Global norms are essentials, but they need to be adapted to local settings. Furthermore, a robust system to check on implementation of global norms needs to be established.
- Controlling epizootic will always imply a risk for livelihoods and an increase in poverty levels. Sustainable financial solutions have to be found. Eradication will always be extremely difficult with complex ecologies and should therefore take place as soon as possible, before the virus spreads.
- The best options to respond to human cases is to strengthen [one] health systems. This implies an increase in the surveillance and response capacity, the distribution of pharmaceutical options, and the surge capacities. Non pharmaceutical options are important, but they cannot replace the medical response.
- Pandemic preparedness is a complex and constant effort. It requires both: 1/specific health efforts and multisectoral efforts to detect and solve gaps and vulnerabilities (importance of simulations); 2/ the recognition that there is no “zero risk”. Indeed, the real issue may be the resilience of the system and its capacity to survive to such a traumatic experience.
- Global Health and the virus-sharing issue would strongly benefit from a reformed WHO sharing system, and more widely a solution has to be found to improve access (included delivery) to drugs and vaccines against emerging diseases of global impact.

The future of AI
Prevention and preparedness efforts are difficult to evaluate. However in terms of surveillance and control, the effects of the fight are positive, and the world seem better prepared now than five years
ago to face an AI pandemic. Will this situation last? AI will remain a problem for some countries where the virus has become endemic and where, as soon as efforts diminish or falter, AI will re-emerge. People are still dying from H5N1. The pandemic risk will last. The fight is not over.

In July 2008, several persons interviewed in Washington D. C. were positive that if Senator Obama were to be elected, more funding would be dedicated for the management of global health issues and health systems. However, the advent of the financial crisis may make health issues appear like less of a priority for many decision-makers.

A new momentum has to be raised, for global health, for “One World One Health”, and for AI.
Read here the complete report
Distributing contraception to Pakistan’s large rural population has been a challenge for Glaxo Smith Kline. Rather than utilise the increasingly popular social networking sites and other digital media, the company has successfully resorted to less technologically sophisticated methods. Glaxo Smith Kline has utilised radio advertising to reach and mobilise the rural sector. Radio is part of an integrated communication model that also includes interpersonal and community mobilization through activities such as marketplace interviews and roadshows.
Glaxo Smith Kline was particularly successful in distributing and encouraging use of contraception. Realising that the information provided with contraception medication was in small print and hard to read, serving no purpose other than “basically to frighten the consumer”, the company began circulating cassettes, recorded in local dialects, that answered frequently asked questions about the medication.

Download here the complete presentation in PDF

From the Global response to Avian Influenza through Pandemic A/H1N1, towards "One Health"

How much information should governments communicate to the public? How transparent should they be? Should they communicate all the information that they have, or rather leave aside information that could run the risk of being misinterpreted? And should honesty be preferred to transparency?
This question, which characterises all policy-making, is made even more complex here by the existence of what Dr. VANDERSMISSEN called the “scientific dilemma”. Science on the emergence, development and evolution of a pandemic is not fixed – this was clearly exemplified by the emergence of a pandemic of porcine origin in the South American continent, when a pandemic of avian origin was expected to develop in the Southeast Asian region. The pandemic A/H1N1 also turned out to be, until now, far less lethal than originally predicted.
As summarised by Dr VANDERSMISSEN, we have entered an era of “infectious uncertainty”. How much of this uncertainty should be communicated to the public? Would trust/serenity/obedience of an audience, depending on the primary objective of the communication strategy, be best established by a self-confident government who might need to change its message following the evolutions of science? Or by an executive acknowledging the gaps in its information and advising to “keep listening” to possible evolutions in its recommendations?

Dr Vandersmissen's PPT

[inset side="left" title="Alain Vandersmissen"] has been the Coordinator of the External Response of the European Commission to the Avian Influenza Crisis since January 2006. In this capacity, he has strongly contributed to the orientations and achievements of the global AI response. He is one of the promoters of the evolution of the AI response towards a “One Health” approach addressing all major risks at the interface between animals, humans and ecosystems. [/inset]

Ms Leboeuf wove previous speakers themes together to sharply illustrate two recent examples in France during the H1N1 outbreak.
An apparently arbitrary decision to not close infants’ schools even if cases of H1N1 were reported, reversing a previous decree that schools must be closed if three cases are detected, indicated the importance of ensuring that relevant information is communicated and that bureaucracies must be flexible enough to deal with new crises rather than rely on previous models of action.
Her second example described a situation whereby H1N1 vaccines were initially available to strictly defined groups and then later to broader groups. While this change in process was not official, people seeking vaccination still had to present a case as to why they should be vaccinated. This meant the boundary was no longer strictly medical and bureaucratic, but had expanded to be negotiable, thereby introducing additional layers of complexity and power.
Ms Leboeuf noted that medical professionals now must remind patients that although what they have been advised is true for today, it might not be true for tomorrow. This is a departure from established patterns of medical advice.

The speaker talked about the challenges of facing the H1N1 in the Taipei region and how drawing upon previous pandemic experiences helped ensure a successful outcome.

The SARS epidemic of 2003 highlighted the communication difficulties between local government and central government. The command structure was changed in the aftermath of SARS. Under the revised system, the central government operated the command center and local governments executed these commands. This ensured that messages delivered during H1N1 were more consistent.

The government had two phases of dealing with H1N1:
1.Stage of containment – June 2009. Many foreign tourists so hotels used as checkpoints; and
2.Stage of mitigation – September 2009. Coincided with the Deaf Olympics in Taipei. This was at the height of the pandemic. Letters sent to guests.

The 2009 H1N1 campaign was successful because it was simplicity (message was easy to understand), credibility and delivered in a unified voice.

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