[Mb-civic] HOT TOPIC: Preparing for a pandemic - Heidi Larson - Boston Globe Op-Ed

[William Swiggard]

  Preparing for a pandemic

By Heidi Larson  |  January 20, 2006  |  The Boston Globe

LAST OCTOBER, a group of experts met in Geneva and acknowledged that, 
despite tremendous progress, the goal of eradicating polio by 2005 would 
not be realized. They also noted that the ''single greatest risk to a 
polio-free world" was Nigeria.

Why Nigeria? And, why does it matter to avian flu?

Today, the remaining polio is circulating in some of the world's 
poorest, most marginalized populations. Some of them are angry, 
frustrated, and distrustful of their own governments as well as foreign, 
particularly American, donors. They question why they should let their 
children be constantly vaccinated against polio when they are not 
getting vaccines and medicines to address diseases such as measles and 
malaria that they feel are their priority.

Distrust around the polio eradication campaign became so acute in a few 
states in northern Nigeria that they boycotted polio vaccination, some 
convinced that it was a sterilizing agent targeting Muslims. As one 
local leader said, ''We see the news. We see what America is doing in 
Iraq. And, you want us to take these vaccines?" Kano State sustained the 
boycott for 11 months, leading to polio outbreaks that spread beyond 
Nigeria as far as Indonesia, presumably via Mecca.

Nigeria was not the first country where vaccine refusals emerged. In 
2002, a polio outbreak in Northern India was partly fueled by similar 
rumors and vaccine refusals. In one year, the number of polio cases in 
India increased from 268 to 1,600.

What does this all have to do with avian flu?

One of the biggest lessons from the polio eradication effort is the 
importance of building trust with communities, particularly 
marginalized, underserved communities that are distrustful of the 
''powers that be." Many have not received the services they rightly 
need, and they are not going to easily collaborate with a state-driven 
agenda, unless there is clear understanding of why it matters to them. 
Not, why it matters to somebody else, but why it matters to them.

Isolation or ''social distancing" measures to minimize the spread of a 
lethal flu are not going to be easily adhered to in the current 
environment where many feel that their civil liberties are being 
over-impinged upon. Trust between health authorities, communities, and 
local businesses needs to be built through transparent, early, and 
candid information sharing. Trust is not built in a time of crisis or 
emergency.

In the polio eradication initiative, the importance of trust building 
was learned late in the game. The technical strategy was in order. The 
vaccines were available. There was financial and political commitment at 
the highest levels. What was missing at the end of the day, in some of 
the most difficult-to-reach areas, was social will. All of the 
''political" will in the world is not enough to achieve public health 
goals without the will of the public.

An investment in building public trust, before the vaccine delivery 
''push," might have saved the polio eradication effort millions of 
dollars. Some of the areas where the global effort hit stumbling blocks 
should have been no surprise. The problems arose among populations 
marginalized for political, religious, and socioeconomic reasons, where 
health service delivery is weak or nonexistent. An earlier effort was 
needed to understand the local sociocultural and political risks, and to 
look for opportunities for positive engagement with communities. Similar 
advance analysis could save resources and lives should a human avian flu 
pandemic occur.

We may or may not have a vaccine ready for H5N1 or any other lethal 
strain of the flu that may emerge. Even if there is a vaccine, it is 
unlikely that there will be enough for everyone. What we can have ready 
is an informed public that understands what they need to do in order to 
protect themselves and their community to whatever extent possible and 
to build community-resilience networks.

Now is the time to start considering the implications of reorganizing 
ourselves in the face of a pandemic. Who will we rely on if we cannot go 
to work, the schools are temporarily suspended, and the markets are 
running out of food and water? Who can we trust in a time of distress? 
We have time to assess where the weak points in the system will be and 
start to address them, to start community dialogues, and understand the 
fears as well as strengths of local communities to respond. Vaccine and 
drug strategies are essential, but are not enough.

This is not just about avian flu. This is about overall preparedness.

Heidi J. Larson is a research associate at the Harvard University Center 
for Population and Development where she is working on a book, ''Risk 
and Rumor in Public Health."  

http://www.boston.com/news/globe/editorial_opinion/oped/articles/2006/01/20/preparing_for_a_pandemic/
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