More than three years ago, an editorial of this newsletter (No. 102) stressed the multisectoral dimension of pandemic preparedness and the need for serious contingency planning. At the time, the perceived threat was the avian influenza A (H5N1) virus, for which no human-to-human transmission had been reported (defined at that time as WHO Pandemic Phase 3).
Early this year, the pandemic (H1N1) 2009 virus rapidly developed the capacity to infect humans and to transmit from person to person, leading WHO to use a more precise definition of pandemic Phase 6 than was originally adopted.
Phase 6 is characterized by community-level outbreaks in at least one other country in a different WHO region. Designation of this phase indicates that a global pandemic is underway.
In the end, the rather ominous scenarios forecast for an avian influenza pandemic did not materialize. The pandemic that was expected to reach the Americas from Asia, carrying with it a highly lethal avian strain, ultimately originated in the Americas with a rather mild porcine variant; there was neither a high mortality rate, nor did social disturbances occur. The response remained predominantly a health matter, under the competent leadership of public health experts, and in particular epidemiologists, rather than disaster managers.
What broader lessons can and should disaster managers learn from three years of intensive awareness and planning for an avian pandemic at national and international levels?
- Detailed scenarios rarely are accurate. Many countries prepared detailed pandemic plans based on an analysis of the past three pandemics, which were, by and large, poorly documented. Specific attack and fatality rates were selected for planning purposes. Potential consequences, including serious social and institutional disruptions were identified, and concrete measures pre-selected. However, the dramatic health, social, and economic consequences did not materialize as anticipated in the scenarios. In the case of pandemic preparedness, is this a failure?
This reality is not unique to pandemic preparedness. The World Food Program (WFP) recently completed a global evaluation of its extensive contingency planning for food insecurity worldwide. One striking conclusion reached was that few, if any, of the detailed plans based on precise scenarios were actually implemented (or needed to be implemented) because what actually occurred was distinct from what was forecast. Our ability to anticipate the future (what, where, and when) is remarkably inaccurate! The experience with pandemic planning only confirms an observation that applies to all types of hazards.
- What matters most is the planning process, not the written plan. Does a failure to construct accurate scenarios mean that this planning effort was in vain? Definitely not. WFP’s evaluation concluded that the collective planning process itself was very useful and led to a better response, even if the characteristics of the crisis differed from what was anticipated. The fact that ministries of health have worked with other actors to address vulnerabilities, discuss potential corrective measures and identify institutional weaknesses almost certainly improved the response to the pandemic (H1N1) 2009 virus. Coordination and the exchange of information were improved and ad hoc changes were made to pre-established measures. Perhaps, the disaster management community attaches too much importance to the output—a detailed written plan—rather than to the outcome: greater institutional awareness and ongoing dialogue and preparedness among actors.
- A lead role for technical experts. In most countries in the Americas, experts in communicable diseases from the ministry of health carried out the response to the pandemic (H1N1) 2009 rather than professionals from the civil protection system or health disaster managers (as was contemplated in some of the original scenarios). The success of response to the actual pandemic reflects the institutional flexibility and technical competence of public health experts in the Region. This being said, it is also true that only a small percentage of the costs resulting from a pandemic are health related expenditures; the majority of the costs (>99%) are due to measures taken to allay fears, whether justified or not.
- Generating excessive fear may backfire. For years, the public has been reminded of the potential catastrophic consequences of a repeat of the pandemic of 1918. In fact, in some cases, raising the public’s level of concern and fear was seen as necessary to stimulating political support and funding. As a result, pandemic readiness at the global level often has been better funded than similar efforts for multi-hazard preparedness—an imbalance noted by many developing countries. In Latin America the public response tended to be highly emotional and led to pressure for measures of questionable cost-effectiveness. The health sector’s role is important to allay or mitigate fear and to reassure the population that measures are in place and accurate information is available. Countries may wish to examine whether or not the credibility of the health forecasters was affected by the public’s overemphasis on the most dramatic scenarios, and whether generating what is now perceived to have been an excessive amount of concern and fear may not have been ultimately counterproductive.
- Worst-case scenarios will occur… one day. The 1918 pandemic is proof enough that a new pandemic, with fatality rates up to 2% or more, remains a possibility. The pandemic (H1N1) 2009 virus’ capacity to mutate means that we cannot exclude any scenario. If we should refrain from overemphasizing or singling out the worst-case scenarios in our communication with the public, they should, nevertheless, remain in the minds of disaster and health planners. How to secure support for planning for the worst-case scenario without over-alarming the public or jeopardizing our credibility is an issue that warrants debate.
- Lessons learned. Now that the first wave of the pandemic (H1N1) 2009 has followed its rather benign course, it is easy to reflect back on whether the measures taken were justified and cost effective. Estimating the effectiveness of prevention measures against a hazard that was ill-defined and potentially variable is, at best, a difficult endeavor. Judgments made in hindsight, with the benefit of information and perspective, are of little help to understanding and improving actual decision-making processes that take place in a climate of uncertainty. Nevertheless, there is much to learn. We cannot merely turn the page on one of the greatest public health efforts to prepare for a severe crisis. An evaluation for educational purposes, at both regional and national levels, should be carried out and the results discussed and saved for future pandemic threats.