Kang, Gagandeep

English

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to be made each year in most developed countries, so what 
was so special about this virus to induce a state of near panic? 
With all infectious diseases, the two key factors that determine 
how much damage is done are transmissibility, or the ability 
to spread, and virulence, or the ability to cause severe disease. 
A disease that is highly transmissible, like the common cold, 
spreads rapidly but is not considered an epidemic or pandemic 
because it is not a serious illness. It is annoying at most, and 
recovery is usually spontaneous. A disease that causes severe 
damage is much more of a concern. For example, gram negative 
septicaemia frequently results in death even when appropriate 
antibiotic treatment is attempted. But this is not considered an 
epidemic or a pandemic because of the low transmissibility of 
this infectious condition. 
So how does the WHO decide that influenza has become a 
pandemic? The WHO uses a six stage classification going from 
Phase 1 when no viruses circulating in animals have caused 
disease in humans, to Phase 2 where an animal virus causes 
disease in humans, to Phase 3 when animal or animal-human 
viruses cause small clusters of disease, but without human 
to human transmission, to Phase 4 where human to human 
transmission takes place in community-level outbreaks, to 
phase 5 where at least two countries in a WHO region are 
affected, and phase 6 where at least three countries in at 
least two WHO regions are affected (3). The purpose of this 
classification is for countries to be able to use a structure 
for communication with their own and world bodies, for 
organisation of response and for implementation of control 
and mitigation measures. Following this classification, the WHO 
responded appropriately in declaring the H1N1 outbreak a 
pandemic by June.
This resulted in measures similar to and beyond those taken 
for the Severe Acute Respiratory Syndrome (SARS) in 2003. 
SARS had appeared in southern China by February 2003, and 
was an atypical pneumonia that was highly transmissible and 
had about 10% overall mortality, with highest rates in the 
elderly. The ease with which SARS spread and the reported 
high mortality resulted in measures such as airport screening 
of passengers, contact tracing and quarantine. Very strict 
infection control and barrier nursing methods were adhered 
to in hospitals, particularly because of the early publicity 
surrounding transmission to healthcare personnel (4). With 
these measures in place, the incidence of SARS decreased 
rapidly and the epidemic ended by June 2003. As with SARS, 
airport screening, contact tracing and quarantine were 
introduced for passengers arriving from affected countries in 
Public health, preparedness and the World Health Organization response to 
swine flu in 2009
GAGANDEEP	KANG
Department	of	Gastrointestinal	Sciences,	Christian	Medical	College,		Vellore	Tamil	Nadu	632	004	INDIA	e-mail:	gkang@cmcvellore.ac.in
From March 1918 to June 1920, an influenza pandemic swept 
the world, spreading among the Inuit tribes in the Arctic and 
to remote Pacific Islanders, killing over 10 million people 
in the Indian subcontinent. It is estimated that about one 
in three people was infected and that between 50 and 100 
million people died worldwide. At the start of the epidemic, 
the medical profession believed that influenza was caused by 
Pfeiffer’s bacillus, but by the end, they were convinced that this 
was no bacterial disease, but a form of respiratory infection 
spread by secretions, spitting, coughs and sneezes. There was 
no cure and supportive therapies were limited, though quacks 
abounded and recommended strange potions to prevent 
disease. Unlike the seasonal flu, this new version, or “Spanish flu”, 
killed mainly young people, with between 2% and 20% of those 
infected dying. Bodies were buried without coffins in mass 
graves because there were not enough coffin makers or grave 
diggers to cope with the number of deaths. By some estimates, 
3-6% of the world’s population died in two years. In today’s 
world, that would mean wiping out the entire population of 
North America.
With no specific therapy, how did the epidemic stop? It is 
believed, but not proven, that the virus may have mutated to a 
less virulent form, or that the number of susceptible individuals 
declined to a point where transmission of the virus could no 
longer continue at high rates. Studies using tissue from bodies 
buried in permafrost in Alaska showed over 80 years later 
that the 1918 flu pandemic was caused by an H1N1 virus that 
probably resulted in a cytokine storm, causing severe disease 
and death in susceptible individuals (1).
In 2009, another H1N1 virus emerged in Mexico, again causing 
disease in younger individuals, and spreading rapidly to 
neighbouring countries. The virus was first officially recognised 
in April 2009 in Veracruz, Mexico and spread within a few weeks 
to the United States of America. Initially, each case was reported 
and counts maintained of persons affected. Persons rapidly 
became states and then countries, and in June 2009, most 
countries stopped counting as the World Health Organization 
(WHO) issued a statement declaring the influenza epidemic, 
now known as “swine flu”, a pandemic (2). By this stage, intensive 
efforts by scientists applying genome sequencing and analysis 
showed that the virus was a new variant of H1N1, a triple re-
assortant virus which had further combined with a Eurasian pig 
flu virus to result in a virus with a shuffled set of swine, human 
and avian sequences.
From seasonal influenza, we know well that influenza viruses 
change their genetic code rapidly enough for new vaccines 
Indian Journal of Medical Ethics Vol VII No 3 July - September 2010
[ 168 ]
almost all parts of the world, but it rapidly became clear that 
although the initial cases of H1N1 in each country may have 
been from travellers, the increasing count of cases and the lack 
of travel history showed that H1N1 very rapidly established 
domestic transmission in many parts of the world.
In a few months, swine flu had overtaken seasonal influenza 
strains, and public health practitioners were engaged in 
both decision making regarding the use or futility of control 
measures and the evaluation of excess morbidity of H1N1 
disease. All through this period, media reports recorded 
each case, trumpeted each death and conducted their own 
investigations into the adequacy of diagnostic testing, 
monitoring of new cases and medical management of the 
disease and its complications, as well as the limited supplies 
of anti-viral drugs. As children were reported positive, schools 
were closed, neighbourhoods shunned families of quarantined 
residents and hospitals worried about their ability to cope with 
increasing patient loads. All through this period, there were 
epidemiologists and others saying that the instituted control 
measures were of limited use and that the epidemic should be 
allowed to take its course, so that it would settle rapidly into a 
similar pattern as seasonal flu. 
Within a few months, this appeared to be happening, and by 
January 2010, Dr Margaret Chan of the WHO announced that 
the peak appeared to be over in the northern hemisphere but 
vigilance needed to be maintained in the southern hemisphere 
where winter was yet to come. Shortly after the announcement, 
health professionals and the public began to ask whether the 
labelling of the H1N1 outbreak had been appropriate, whether 
the management by the WHO had lead to unnecessary panic 
and how such situations should be handled in the future. There 
was also a perception that the threat of disease had been 
exaggerated by pharmaceutical companies hoping to make 
a profit on anti-viral drugs and vaccines. This has now led to a 
wider discussion on the issues of conflict of interest, and the 
relationships of experts advising the WHO with pharmaceutical 
companies (5).
From the categorisation of phases by the WHO, the H1N1 
outbreak was called a pandemic when it fit the definition. 
However, the response of screening, contact tracing, the use of 
oseltamavir or zanamavir, social distancing, hand hygiene and 
quarantining may have delayed, but did not succeed in limiting, 
spread of disease, resulting in a use of resources that is now 
being deemed wasteful. 
Certainly, during the early phase, governments and individuals 
were engaged in a desperate scramble for drugs and vaccines, 
and predictions were being made that people were going 
to get sick and die because of unavailability and stock-
piling by hoarders. As drug and vaccine companies ramped 
up production, their products sold quickly, with the result 
that most major vaccine manufacturers began reporting 
substantially increased profits in late 2009 and 2010 (6).
It can be argued that the WHO was basing its actions on a plan 
that had been laid down based on the experience with SARS 
and avian influenza caused by H5N1, both of which result in 
high mortality, and in the case of H1N1, it was not clear initially 
what the clinical spectrum of disease was going to be. To take 
an example from another recent natural phenomenon, when 
a volcano erupted and governments closed air space resulting 
in 750,000 stranded passengers, the pressure built up rapidly. 
Airlines lost millions of dollars a day and began to ask, “Isn’t 
this an over-reaction?” Opposition parties in affected countries 
called the incumbent government over-cautious and accused 
them of actions leading to significant economic losses. 
The reactions would be expected to be similar in any potential 
disaster that does not happen, or with any response that 
changes routine practices or uses significant resources. The 
WHO applied its experience to a situation that did not turn 
out as severe as expected because the virus spread more 
rapidly and caused less excess morbidity than anticipated. A 
recent study in PLoS Currents: Influenza based on a estimation 
of years of life lost (yLL) states that the 2009 epidemic resulted 
in a much lower mean age of mortality with the lower end of 
their yLL estimate comparable to the estimate for an H3N2-
dominated, or more severe flu season, while the upper end is 
greater than that for the 1968 pandemic (7). Given that “swine 
flu” has been seen before in the 20th Century, resulting in the 
pandemic of 1918 and outbreaks in 1976, and given that the 
entire genome of the 2009 H1N1 virus was sequenced by 
June 2009, was it really possible to have handled the outbreak 
differently? The revised International Health Regulations 
(IHR) came into force in 2007, and the pandemic H1N1 is the 
first public health emergency of international concern since 
then. The IHR played a central role in the global response to 
the pandemic and in April 2010, an external review process 
was initiated to investigate the global handling of the H1N1 
pandemic and to make recommendations for the future (8). 
Today we have sophisticated methods of diagnosis, the ability 
to rapidly characterise new infectious agents using genomic 
sequencing, and the potential to use these tools to make 
vaccines, but we have limited availability of effective anti-viral 
drugs. In hindsight it is always possible to have 20:20 vision, 
but in the throes of an evolving situation, it is difficult to make 
a call that is the perfect response. All we can hope for is to be 
aware of the circumstances that influence decision making, 
particularly those driven by media and commerce, to learn 
from history and not repeat it.
References
1. Kobasa D, Jones SM, Shinya K, Kash JC, Copps J, Ebihara H, Hatta y, 
Kim JH, Halfmann P, Hatta M, Feldmann F, Alimonti JB, Fernando L, Li y, 
Katze MG, Feldmann H, Kawaoka y. Aberrant innate immune response 
in lethal infection of macaques with the 1918 influenza virus. Nature. 
2007:445(7125):319-23.
2. Chan M. World now at the start of 2009 influenza pandemic. World 
Health Organization [Internet]. 2009 Jun 11[cited 2010 Jun 11]. Available 
from: http://www.who.int/mediacentre/news/statements/2009/h1n1_
pandemic_phase6_20090611/en/index.html
3. World Health Organization. Current WHO phase of pandemic 
alert[Internet]. Undated [cited 2010 Jun 11]. Available from: http://www.
who.int/csr/disease/avian_influenza/phase/
4. Smith RD. Responding to global infectious disease outbreaks: Lessons 
from SARS on the role of risk perception, communication and 
management. Social Sci Med. 2006 Dec; 63(12): 3113-23. 
Indian Journal of Medical Ethics Vol VII No 3 July - September 2010
[ 169 ]
5. Cohen D, Carter P. WHO and the pandemic flu” conspiracies”. BMJ. 2010 
Jun 3; 340:c2912.
6. GlaxoSmithKline ups dividend after return to sales growth. 
IBTimes[Internet]. 2010 Feb 4[cited 2010 Jun 11]. Available from: http://
www.ibtimes.co.uk/articles/20100204/glaxosmithkline-ups-dividend-
after-return-to-sales-growth.html
7. Viboud C, Miller M, Olson D, Osterholm M, Simonsen L. Preliminary 
estimates of mortality and years of life lost associated with the 2009 A/
H1N1 pandemic in the US and comparison with past influenza seasons. 
PLoS Curr Influenza. 2010 Mar 20;RRN1153. 
8. World Health Organization. How will the global response to the 
pandemic H1N1 be reviewed? [Internet]. 2010 Apr 12[cited 2010 Jun 11]. 
Available from: http://www.who.int/csr/disease/swineflu/frequently_
asked_questions/review_committee/en/index.htmlWhile India today is in the forefront of healthcare, and we often 
hear of health tourism being a great revenue generator, the 
vast majority of Indians, especially in the rural areas, today lack 
even the basic health amenities. 
Even today “quacks” or “Docsaab”, who are former compounders 
of doctors or even the compounder’s assistants, rule the roost 
in such areas. Those in the government setup largely ignore 
such “quacks” as they are regularly paid off to turn a blind eye 
to their activities. It is common to have a person walking into a 
clinic and asking for a drip because of “weakness”. In a matter of 
30-45 minutes, dextrose is pumped into that person alongwith 
injections of Avil and dexamethasone, he or she ends up paying 
some Rs 250 to 300 and leaves satisfied at having been treated 
well. Even the auxiliary nurse midwives (ANMs) and “dais” who 
are the “Doctorani” have well educated persons utilising their 
services for ante-natal services and deliveries. 
Against this background of grassroots realities, the National 
Rural Health Mission may have been launched to remove the 
dichotomy in healthcare. As it stands even today, the NRHM 
could have revolutionised healthcare delivery in India and 
been a role model for all the Third World to emulate. But this is 
not the case.
The NRHM mission document states that “The goal of the 
mission is to improve the availability of and access to quality 
health care by people, especially for those residing in rural area, 
the poor, women and children.” (1) It primarily aims to improve 
the following parameters: health, sanitation and hygiene, 
nutrition and safe drinking water. It seeks to provide to rural 
people equitable, affordable, accountable and effective primary 
healthcare. 
Along with other national programmes like the Janani Suraksha 
yojana, the NRHM can go a long way to improve the mother 
and child welfare parameters in the country. While the concept 
is utopian, given the ground realities in the country, it has 
become a milch cow for many to siphon off funds.
The NRHM workforce comprises accredited social health activists 
National Rural Health Mission: a failing mission 
ATUL	S	BAHADUR
Vardan	Health	Care	Clinic,	MDKV	Road,	Najibabad	246	763	Uttar	Pradesh,	INDIA	e-mail:	atulbs@gmail.com
(ASHAs), auxiliary nurse midwives (ANMs), and multipurpose 
workers (MPWs) along with contract or “samvida” staff nurses, 
AyUSH (ayurveda, yoga, unani, siddha and homoeopathy) and 
allopathic doctors. There is a great emphasis on reviving the 
AyUSH system of medical treatment for which various measures 
have been incorporated into the mission.
The ASHAs form the backbone of the NRHM and are meant 
to be selected by and be accountable to the panchayat. There 
is no fixed remuneration provided for the ASHAs but it is 
assumed that they will be suitably compensated for their work 
through various schemes. They are to act as a bridge between 
ANMs and the village. They are to be provided with a drug kit 
including Ayush drugs for common ailments, worth Rs 1,000, 
which are to be replenished from time to time. The government 
has also allocated “total support of up to Rs 10,000 per ASHA for 
initial training, monthly orientation, drug kit, support material, 
travel expenses, etc. Rs 5,000 permanent advance may be made 
available to every gram panchayat as a permanent advance 
for performance based incentive for ASHAs and anganwadi 
workers(2). 
In fact the ASHAs were selected by the government’s provincial 
medical service doctors for a consideration and legalised later 
by getting the panchayats to appoint them. yet, even today no 
ASHA has a drug kit and so there is no question of these kits 
being replenished. Finally, funds are provided to the panchayats 
to transport patients to primary health centres (PHCs) but 
again these are siphoned off as most of the population is not 
aware of this and other facilities under the NRHM.
Bringing AyUSH into the mainstream is a major thrust area 
of the NRHM. AyUSH doctors were to be appointed at PHCs 
and sub centres, and pharmacists and drugs were to be made 
available to them(1). However, on appointment they are 
being posted to allopathic hospitals. They are not provided 
with AyUSH drugs and pharmacists. They are prescribing 
allopathic drugs to patients and the unfortunate patient does 
not know that the treating physician is a homeopath or hakim 
or vaidya prescribing allopathic medicines. As the salary of 
Indian Journal of Medical Ethics Vol VII No 3 July - September 2010
[ 170 ]


Public health, preparedness and the World Health Organization response to swine flu in 2009

http://repository.ias.ac.in/93298/1/93298.pdf

Public health, preparedness and the World Health Organization response to swine flu in 2009

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