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Authorities must learn not to panic the public and take a measured response to pandemics

An illustration of hundres of people running away from a large pigPreparations by the Department of Health (DH) for a flu pandemic began years ago. In 2005, the Scientific Pandemic Influenza Advisory Group was created to advise on the scientific base for health-related influenza policies. It is currently chaired by the distinguished Professor Sir Gordon Duff.

A health minister recently, and correctly, told a parliamentary committee that the World Health Organisation (WHO) recognised the UK as "one of the best-prepared countries in the world". Stockpiled antivirals will enable treatment of around half of the population and advanced purchase agreements will enable the UK to buy up to 132 million doses of pandemic-specific vaccines, which is sufficient for everyone in the UK, when it becomes available.

If this was where the matter had rested, then all would have been well.

The DH should have been warned by what happened in the previous decade. The outbreak of mad cow disease in the 1990s led to the prediction that many thousands might die from vCJD. One government adviser was foolish enough to say in a television interview that 10,000 people a year might die and, over ten years, this could, logically, amount to 100,000 deaths. Unsurprisingly, the tabloid press ran headlines the next day that claimed the outbreak was: "Worse than AIDS".

Some ten years later, the death toll from vCJD stood at 160.The subsequent outbreaks of SARS and bird flu led to equally lurid headlines. Even the Guardian ran an article in October 2005 about the "bird flu that killed 40 million [people]", drawing on the much overused example of a virus that swept the world from 1918-1919. It stated that scientists believed the virus came from birds and that it bore “similarities to the avian flu at the centre of the current scare”. In another newspaper a picture of a gaggle of geese flying together appeared under the heading "The birds of death".

These overwrought examples should have been enough warning for the government to dampen down fears when the WHO declared a flu pandemic earlier this year and not to let the matter get out of control. Unfortunately this was not the case.

Government contradictions
The cautious approach was blown apart by the chief medical officer, Professor Sir Liam Donaldson, who warned that 65,000 people could die from swine flu, although he emphasised that this was a worst case scenario. The figure was based on 30 per cent of the population falling ill and 12 per cent of the working population being off sick.

The Yorkshire Evening Post reported that Leeds was drawing up plans for a worst case scenario, involving 10,000 deaths, which the executive director of public health at NHS Leeds said was based on a 2.5 per cent death rate (which, in turn, implied UK deaths of a remarkably high figure).

The media was now in full swing and the political parties got on board the rolling bandwagon, demanding – and getting – emergency statements in parliament. GPs reported a surge in visits, many from elderly people, which is ironic, given that this sector is among the least affected. NHS Direct had great difficulty in coping with calls. A new Pandemic Flu Service was set up and the DH added to the sense of alarm with its national advertisements about swine flu. The NHS website advised pregnant women to avoid inessential travel and to stay away from large groups of people, advice backed by the Royal College of Midwives, until it was decided, correctly, to drop such advice.

Employees who were suspected of having swine flu were sent home by businesses (but in most cases did not have it) and parents were withdrawing their children from schools, thereby forcing their closures. Individual comments on the internet referred to the panic that some parents felt. Even the churches were caught up in the over-reaction, with holy water withdrawn from the point of entry to many churches and people advised to avoid shaking hands.  

Some responsible ministers and officials sought to dampen down the debate. They pointed out that 3,000-4,000 people a year die from flu in the UK in normal circumstances, with many more in a bad year, and that these deaths are not confined to older people. By contrast, less than 100 have died from swine flu in the UK (61 at the latest count) and a number of these had existing health problems, such as cancer, that had already weakened their immune systems. It was pointed out that symptoms were generally mild and similar to those of a minor dose of flu. But this was all to no avail. They were standing in the way of a tsunami.  

Once such fear spreads, it can take unexpected twists, such as concern over the reliability of swine flu vaccines. Websites for mothers reveal that they have severe reservations, with one poll finding 48 per cent would probably or definitely not take the vaccination. This is a serious issue and carries shades of the MMR controversy.

There is also the real danger of "pandemic fatigue" and cynicism, which, in the event of a truly deadly outbreak, could cause responses to be delayed unnecessarily. 

In short, the reaction by the DH to the swine flu outbreak has been muddled, contradictory and confused, and the end results are thoroughly unsatisfactory.

Future actions
The first priority for a responsible government is to adopt a consistent, level-headed approach designed to fend off excessive fears. 

At an international level, there should be a re-examination of how the WHO classifies a pandemic. Phase 5 is characterised by human-to-human spread of the virus into at least two countries in one WHO region; phase 6, the pandemic phase, is characterised by community-level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in phase 5.

Rather than relying only on these criteria for defining a pandemic, with all the connotations that the word implies, there has been pressure, with some UK support, for the definition of a pandemic to be modified to take account of mortality rates. If, say, global recorded deaths had to reach 10,000 before a pandemic could be declared, this would not have applied to the current wave of swine flu, where such global deaths on August 23, 2009 were estimated as at least 2,185.

This would have eased the situation immediately and put what was happening into perspective. It would have made it easier for government to promote its own considered views in a less frantic environment.

Secondly, the DH should avoid making estimates of how many could die. It simply does not know, as has been proved on previous occasions. Indeed, it later cut its maximum mortality estimate from 65,000 to around 20,000. The aim should be to promote calmness, not to introduce, or to pander to, fears. A consistent and level-headed approach should be adopted towards the media. 

None of this means that the government should go to the other extreme of being complacent. The stockpiling of vaccines in the current situation is sensible, and, in a calmer atmosphere, patients are more likely to accept vaccinations for themselves and their children.

Even if the second wave of swine flu appears in a fairly mild form, there is no guarantee that some serious pandemic will not occur in the future.

Vaccines seem to be the obvious solution, given that they have led to the eradication of smallpox and polio, and could eliminate hepatitis B. But progress has been held back by the Joint Committee on Vaccination and Immunisation. It is cumbersome, less than transparent and its recommendations have resulted in prices that have discouraged the vaccines industry. An overhaul or replacement of the committee is long overdue, with incentives so that more companies enter the vaccines market and vaccines are produced in new and faster ways.

The Author
Chris Mockler is a senior policy adviser at Fleishman-Hillard

28th October 2009


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