Stephen Leahy

BROOKLIN, Canada, Nov 29 2005 (IPS) — Coping with a future influenza pandemic will require more than new drugs and good infection control – shared ethical values will also be needed, experts say.

The predicted flu pandemic threatens to affect the health of millions worldwide and overwhelm health care systems. To cope, public health officials need an agreed-on ethical framework to help make difficult decisions and to obtain public cooperation, according to a new study of the Severe Acute Respiratory Syndrome (SARS) crisis of 2003.

“When the SARS outbreak hit, ethical issues came fast and furious,” says Peter Singer, director of the University of Toronto Joint Centre for Bioethics (JBC) and the report’s co-author. Included in the report is a 15-point framework for ethical decision-making during a pandemic.

“SARS showed us that ethics are important because they inform many health care decisions,” Singer told IPS. “If a flu pandemic becomes an international health tsunami, it would be useful for every head of state to have this guide.”

While 120 countries have prepared plans to cope with a flu pandemic, none contain an ethical framework for decision-making at this time, he said.

The World Health Organisation (WHO) has said that if the H5N1 strain of avian flu mutates so that it is transmitted among humans, it could spread to all continents in less than three months. Should that happen, the World Bank estimates that based on the SARS experience, world gross domestic product would drop by two percent or more. That would amount to about 800 billion dollars in losses over the course of a year.

An outbreak would force health authorities, including the WHO to impose travel bans, and prompt the closing of schools, churches, mosques and other public buildings.

During the SARS outbreak, the WHO imposed its first-ever travel ban, which cost Canada millions of dollars in lost revenues from travel and tourism.

“That ban was based on poor information and the WHO’s criteria for imposing it were unclear,” said Kumanan Wilson, an Associate Professor at the University of Toronto and co-author.

This led to confusion among the public and sniping in the media between Canadian officials and the WHO. Many of those issues have been addressed under a new set of international guidelines.

“Decisions about travel restrictions need to be clearly justified and the process must be transparent and equitable between all countries,” Wilson said in an interview.

Ultimately, trust is the key to gaining public cooperation for other restrictions on movement like quarantines. Officials must advise the public of the procedures and the rationale, explaining the risks and benefits of non-compliance, said Singer.

This approach contrasts with U.S. President George W. Bush’s idea of using the military to enforce quarantines in the event of an avian flu outbreak.

“Sending soldiers to quarantine large numbers of people will most likely create panic, and cause people to flee and spread disease,” writes George Annas, chairman of the Department of Health Law, Bioethics and Human Rights at Boston University.

A rumor during the SARS epidemic that Beijing would be quarantined led to 250,000 people to flee the city that same night, Annas noted in an editorial in the Boston Globe.

“Effective public health policy must be based on trust, not fear of the public,” he writes.

An explicit ethical framework makes it much easier to talk about and clarify rationales for who receives scarce resources like vaccines first, or how much risk health care workers should take, says Alison Thompson, a researcher at St. Michael’s Hospital in Toronto and a report co-author.

Some health care workers refused to care for people infected with SARS, and a few were fired for failing to report for duty because there were inadequate measures to protect their health. A flu pandemic could be even worse, with workers fearing personal infection or infecting their families.

“Society must recognise the greater risks health care workers face and ensure their safety with appropriate masks, gloves and vaccinations,” Thompson told IPS.

Beyond direct protection, there should be support for their families should workers need to put in extended hours or be placed in quarantine. Health insurance should also be in place, she said.

The exact details of this support should be discussed and agreed by all involved and in advance of any outbreak, Thompson said.

“During a pandemic, countries will greatly depend on the willingness of healthcare and other workers to take very high personal risks,” said Singer. “Society needs to strongly support them – otherwise they won’t take those risks.”

The report also acknowledged that many developing countries lack the resources to fight a pandemic or are poorly equipped to monitor outbreaks. Developed countries need to make investments in the surveillance capacity of developing countries to detect outbreaks of disease early, said Wilson.

However, countries dealing with ongoing public health crisis like malaria or HIV/AIDS also need additional investments to improve the overall public health infrastructure of developing countries, he said.

“Helping to build strong public health networks in developing countries will mean better disease reporting,” Wilson said. “There’s an element of self-interest here for developed countries.”