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Preparing for the Pandemic: Universities and Public Health
Preparing for the Pandemic:
Universities and Public Health
Education session at BioScience2006, held at SECC Glasgow, U.K., 23–27 July 2006. Edited by K. Gartland (Glasgow Caledonian, U.K.).
Confronting an influenza pandemic: ethical and
scientific issues
U. Schuklenk* and K.M.A. Gartland†
1
*Centre for Ethics in Public Policy and Corporate Governance, Glasgow Caledonian University, Glasgow G4 0BA, Scotland, U.K., and †School of Life Sciences,
Glasgow Caledonian University, Glasgow G4 0BA, Scotland, U.K.
Abstract
The prolonged concern over the potential for a global influenza pandemic to cause perhaps many millions
of fatalities is a chilling one. After the SARS (severe acute respiratory syndrome) scares [1], attention
has turned towards the possibility of an avian influenza virus hybridizing with a human influenza virus to
create a highly virulent, as yet unknown, killer, on a scale unseen since the Spanish flu outbreak of 1918,
which produced more fatalities than the Great War. In deciding how countries should react to this potential
pandemic, individually and collectively, a reasonable and practical balance must be struck between the
rights and obligations of individual citizens and protection of the wider community and, indeed, society as a
whole. In this communication, ethical issues are discussed in the context of some of the scientific questions
relating to a potential influenza pandemic. Among these issues are the rights and obligations of healthcare
professionals, difficulties surrounding resource allocation, policies that have an impact on liberty and trade,
when and how to introduce any vaccine or other form of mass treatment, global governance questions and
the role of health policies in contemporary society. By considering these issues and questions in advance
of an influenza, or indeed any other, pandemic commencing, countries can be better prepared to deal with
the inevitably difficult decisions required during such events, rather than dusting down outdated previous
plans, or making and implementing policy in an ad hoc manner with a resultant higher risk of adverse
consequences.
Healthcare professionals’ obligations
Pandemic planning must include consideration of the risks
to which healthcare professionals, including medical practi-
tioners, nurses, dentists, optometrists and ancillary workers
in health facilities can reasonably and justifially be expected
to expose themselves [2]. An acceptance of serious risks of
infection or bodily harm was historically integral to being a
healthcare professional since time immemorial. Acceptance
of this is less obvious in the era of readily available antibiotic
treatment, vaccination against blood-borne infectious agents
such as hepatitis B and drug cocktails to control the
consequences of HIV infection [3]. Modern medical students
no longer consider their profession as particularly hazardous.
Key words: bird flu, health policy, influenza, pandemic, severe acute respiratory syndrome
(SARS), virus.
Abbreviations used: SARS, severe acute respiratory syndrome.
1
To whom correspondence should be addressed (Kevan.Gartland@gcal.ac.uk).
Instead, health professionals’ responses relate to the potential
transmissibility and consequences of exposure. This is
exemplified by the duty to treat felt by healthcare workers
dealing with HIV-infected patients, where the infection risk
is considered negligible if universal precautions are being
followed, in contrast with those dealing with SARS (severe
acute respiratory syndrome) patients [4]. Little or no debate
took place regarding the obligations expected of SARS–
care professionals, even though some staff became infected
and died as a result of such exposure [5]. In some cases,
however, at the height of the SARS scare, some Canadian
healthcare staff refused to treat SARS victims [6]. The
altruistic behaviour expected of professionally autonomous
care workers previously may no longer hold in contemporary
society with greater knowledge of risks and hazards.
Altruistic behaviour is no longer expected to the same degree
as has been the case historically [7], although some element of
risk could be considered a contractual obligation, since, for
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1152 Biochemical Society Transactions (2006) Volume 34, part 6
example, National Health Service workers do not routinely
choose which patients they attend to [8]. Although healthcare
professionals have a special obligation of beneficence to
patients, this is not an infinite obligation, since doctors are
not routinely asked, for instance, to donate a kidney to
their patients. There does not seem to be a clear boundary
to assist in determining what is a moral obligation and
what would constitute a superogatory action. The role of
contractual obligations in determining acceptable levels
of risk are also pertinent here, as risks tend to be determined
as either usual or extraordinary for a particular occupation.
At times of pandemic, what is accepted as usual may, however,
change, requiring infectious disease specialists, for example,
to accept higher risks than other healthcare workers [9].
These risks would include potential transmission to family
and friends. Toronto doctors and nurses refusing to treat
SARS patients suffered no disciplinary sanction as a result
of their withdrawal of treatment, in an eerie reflection of
Roman plague doctors remaining in their homes and refusing
to attend the sick to protect themselves and their families
[1]. Thankfully, however, such instances are rare. Managers
of healthcare systems have a duty of care towards their
staff to minimize such risks and hazards, but also have
a responsibility to determine, justify and make clear in
advance of a pandemic their understanding of health pro-
fessionals’ roles and the reasonable limits of their exposure.
In developing such an understanding, consensus should
be encouraged, including the involvement of professional
associations such as the British Medical Association (or
equivalent) and statutory bodies should be fully engaged and
encouraged to issue their own guidelines.
Resource allocation
As recently noted by Sir Liam Donaldson, England’s Chief
Medical Officer, healthcare facilities and staff will be placed
under enormous pressure during an influenza pandemic, and
access to facilities will need to be targeted to those most
in need [10]. Primary care staff themselves will also fall ill
until any vaccination campaign becomes effective, and local
hospital trusts and strategic health authorities must consider,
plan and regularly test how they would respond to the diffi-
cult ethical issues likely to arise. Who will be given priority
access to primary care facilities? Will healthcare staff, local
planners, politicians, police or armed forces personnel receive
priority, to the disadvantage of more severely ill others? The
importance of a home-based care strategy and communicat-
ing the benefits of frequent hand-washing are considered
crucial, as is the establishment of a national group to
consider ethical questions such as whether it is appropriate
to prioritize younger over older patients and family carers
over single citizens in any primary-care-rationing strategy
[2,10]. Identifying the likely total resource demands during a
pandemic, considering different clinical attack and mortality
rates is essential if reasonable attempts at allocation justice
are to be made ([2], and FluPlanner modeller). Clinical attack
rates of 5–25% and mortality rates of 0.5–5% appear possible.
Better still to have sufficient resources in place before a
pandemic strikes, as is being contemplated for antivirals such
as Tamiflu, in the absence of an effective vaccine. Balancing
the need to maximize quality additional life years (QUALYS)
or disability-adjusted life years (DALYS) with the economic
value of particular occupations and skills to society is likely
to be a difficult task, resting on a utilitarian problem-solving
strategy [11]. In practice, however, implementing such an
approach may be highly demanding on arbitrage staff and
health decision-makers. Consideration must be given not just
to which types of people should receive care or vaccine access
but also to prioritizing the types of other illnesses receiving
primary care treatment. Torontonian cancer and heart-disease
patients, for example, endured surgery postponements during
the 2003 SARS outbreak. The level of collateral and con-
sequential damage extended to several patients dying before
receiving what would in other circumstances have been
priority hospital treatment [1].
Policy impact on liberty
Historical experience suggests that restrictions on individual
liberty are likely to be invoked during a pandemic. In deciding
upon the nature and extent of such restrictions, there is a
need to weigh individual liberty against public health-related
concerns. T he proportionality of any restrictive r esponse
and the desirability of avoiding undue stigmatization must
also be considered. Two types of autonomy restriction are
likely, with different aims. Quarantine is intended to separate
from the general population exposed or potentially exposed
individuals who are not yet symptomatic for long enough to
determine whether they will develop symptoms. This allows
for surveillance and the identification of appropriate care
strategies before the development of symptoms. Isolation, on
the other hand, is intended to confine and physically separate
symptomatic individuals from distributing infectious agents
to the populace [12]. Ethical questions relating to the
limiting of autonomy include whether the restrictions are
justifiable and likely to be effective [13]. In determining
whether restrictions are justifiable, the need for transparent
communication with the public cannot be underestimated
if goodwill and solidarity are to be maintained [1]. The
scale of restrictions must be shown to be the minimum
to be effective and applied equitably to all sections of the
community. The nature, scale, enforcability and effectiveness
of autonomy restrictions are likely to vary during a pandemic
between different societies. Both Toronto and Beijing, for
example, quarantined or isolated approx. 30 000 citizens
during SARS outbreaks. Ontario authorities needed to issue
only 22 compulsory quarantine orders within this, in contrast
with the sealing of buildings, electronic surveillance and
potential use of execution orders as enforcement devices in
Beijing [6]. Potential U.K. measures restricting liberty may
include the closure of sports stadia, theatres, universities,
schools and shopping centres. Serious consideration must be
given to severe limitations of national and international air
travel. The sensitive use of restriction orders in justifiable
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Preparing for the Pandemic: Universities and Public Health 1153
circumstances can also include ‘work quarantine’ orders pre-
venting healthcare workers from breaking journeys, donning
masks and limiting contact with family or visitors [6,14].
Public forebearance in accepting autonomy limitations
should be matched by government acceptance of the need to
promulgate the benefits of these measures and endeavour
to care for and compensate affected individuals. The majority
of Toronto paramedics voluntarily accepted 10-day home
quarantine measures in the knowledge of Ontario legislation
preventing loss of employment and providing generous
compensation measures [6,15]. Where justifiable and likely
to be effective, autonomy restricting measures can reinforce
the individual’s moral obligation of not infecting others [16].
Vaccination timing
Vaccination and the use of antiviral drugs before symptom
onset are currently seen as the most effective precautions
against an influenza pandemic. Demand for antivirals
currently outstrips supply and can only increase with the
arrival of such a pandemic. Scientific issues surrounding a
vaccination strategy include the precise nature of the viral
agent against which protection is to be gained, the scale,
timing and cost of vaccination needed. At this time, while the
H5N1 avian flu strain has caused fatalities, and has recently
shown human–human transmission in Indonesia [17], the
real concern comes from a hybrid between H5N1 and a
highly virulent human influenza strain, of the type which
routinely infects 10–20% of the population annually [10].
Ethical questions include whether it is appropriate to im-
munize with potentially suboptimal early versions of vac-
cines, and how best to deal with an anticipated surge of
risk behaviour once vaccinated. Communicating the need to
limit movements for up to 2 weeks after vaccination is also
necessary, before any protection takes effect. A difficult trade-
off must be made between protection from early vaccine
release and losses due to therapeutic misconception [18].
Recent improvements in adjuvants for influenza vaccines
developed by GlaxoSmithKline may enhance our response.
Resource allocation issues will remain, however, no matter
how effective novel vaccines may be, while Ferguson et al. [19]
have recently suggested that as little as a 3-week window will
exist to quarantine, identify carriers and treat symptomatic
citizens with antivirals in an affected country before infection
spreads out of control.
Global governance
As shown by the ease with which SARS spread across
Asia and on to Canada, epidemics do not respect national
boundaries. Should a pandemic arise, global governance issues
will become as important as local arrangements. The role of
the WHO (World Health Organization) in communicating
information on disease status, travel-advisory warnings and
regional information will be very important. In this regard,
recent events in Indonesia including the deaths of seven
members of the same family from avian flu in Sumatra,
are concerning. Speed of response, sharing of viral sequence
information and data sharing have all been shown to be key
matters where improvements are desirable. WHO and the
governments involved face several dilemmas, including
the ownership of and when to share viral sequence infor-
mation with others, and the economic and social implications
of issuing travel advisories for international air travel, tourism
and other forms of commerce. Differences of opinion
between WHO and affected governments appear to be
inevitable, and the ethical dimension of these differences
should not be ignored. As yet, no clearly communicated de-
cision support tool to decide whether the national economic
interests or global concerns should take priority exists. In
the recent Indonesian avian flu clusters, the first acknow-
ledgement of likely extended human–human transmission
caused stock market panic. The understandable protective-
ness of national governments towards their own economy
must, however, be weighed against delaying release of scienti-
fic data. A mutation found in Turkish and apparently at least
one Indonesian sample substituting glutamic acid with lysine
at position 627 in the PB2 domain of the polymerase gene may
be associated with an increased viral ability to survive and be
distributed from the cooler regions of the upper respiratory
tract, including the throat and nose compared with previous
H5N1 strains [17]. Other governments, including China have
also been slow to release avian flu viral sequence information,
and this reticence to share biological data internationally must
be overcome if effective and ethical preparations are to be
made [20].
Policy responses, society and preparedness
Considering important ethical issues before setting pandemic
policy will help to ensure that appropriate responses are
developed [10]. Levels of preparedness will be lower if
questions of healthcare workers’ obligations [21], resource
allocation prioritization, restricting autonomy, treatment
timing and global governance have not been addressed.
Ethical policy responses in a just society should be the
product of transparent decision-making processes, involving,
as far as is reasonable, public participation. Measures for
dealing with an influenza pandemic should be published and
be easily accessible in advance and related to the analytical
framework guiding the decision making [22]. It is only by
incorporating consideration of ethical issues such as these,
alongside scientific, sociological and economic issues, that
society can be fully prepared for the pandemic.
References
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2 Kotalik, J. (2005) Bioethics 19, 422–431
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4 Schuklenk, U. (2003) New Rev. Bioethics 1, 127–144
5 Reid, L. (2005) Bioethics 19, 348–361
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Received 14 August 2006
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