Changing Perceptions of Pandemic Influenza and Public Health Responses

Adam Kamradt-Scott. American Journal of Public Health. Volume 102, Issue 1, January 2012.

Of all communicable diseases, pandemic influenza probably remains the most feared by politicians, policymakers, and health practitioners alike, and with good cause. Unlike a variety of other infectious diseases such as HIV/AIDS, West Nile virus, and severe acute respiratory syndrome (SARS), influenza has infected and affected humanity for centuries. Although seasonal variations of this pathogen tend to cause serious illness only in the old, infirm, or very young, periodically a new strain emerges to which humans have little to no immunity. These latter strains have, on occasion, demonstrated that even those in the prime of life are vulnerable. There is no better example than the 1918-1919 Spanish Influenza pandemic, which spread around the world approximately 3 times in 18 months and killed an estimated 40 million people. Over time, however, the magnitude of the 1918 pandemic faded from memory. The 1958 and 1967 pandemics revealed that the menace remained, yet for much of the 20th century pandemic influenza was generally viewed as inconsequential in the face of other potential threats such as nuclear annihilation.

In more recent years, the international community has witnessed a lot of activity (often accompanied by dire warnings) directed against the threat of pandemic influenza. Literally billions of dollars have been spent on procuring and securing access to pharmaceuticals, in drawing up contingency plans and then exercising them, in training critical personnel and first-line responders, and in encouraging the private sector to develop business continuity plans, all to better prepare societies for dealing with the next pandemic. Although the 2009 H1N1 pandemic was less severe than originally feared, medical professionals and scientists continue to warn that another pandemic of similar severity to the 1918 pandemic remains a distinct probability. The only question that remains is not if, but when.

I examine how understandings of influenza and attempts to mitigate its effects have developed and evolved over the past 500 years and how the recent shift toward framing the virus as a threat to national and international security has shaped contemporary public health policy.

A Brief Historical Overview

According to the Oxford English Dictionary, “influenza” is from the Italian influenza, which literally means “influence,” although its origins can also be traced to the medieval Latin influere meaning “to flow in.” The official adoption in 1782 of the term “influenza” by the British College of Physicians firmly established its place in medical parlance and displaced several of the alternative names the disease was known by, such as the French “la grippe,” the English “catarrh,” and the Scottish “rant.” Yet, although the name may have changed over time, historical accounts of the symptoms experienced by victims display a striking commonality that leaves little doubt that the disease has been a persistent element of the human condition for millennia.

Indeed, from the historical accounts that have survived to the present day, it is now generally held that the first truly worldwide influenza pandemic occurred in the year 1510. Before this, although evidence of localized influenza epidemics and even regional epidemics dating back to 1173 survives, none of the accounts proffer sufficient information to suggest that these epidemics were worldwide in scope. It is in this regard that Dr Thomas Short’s account in his work A General Chronological History of the Air, Weather, Seasons, Meteors Etc., published in 1749, is unique. It describes an epidemic that hit Britain in 1510, while also noting its wider impact:

The disease called Coccoluche, or Coccolucio, (because the sick wore a cap or covering close all over their heads) came from the island of Melite in Africa, into Sicily; so into Spain and Italy, from that over the Alps into Portugal, Hungary, and a great part of Germany, even to the Baltic Sea; every month shifting its situation with the wind from East to West, so into France, Britain. It attacked at once, and raged all over Europe, not missing a family, and scarce a person.

Yet, although additional writings have contributed to our overall understanding of the disease at this time, the intrinsic flaw in both the early and contemporary accounts has been their overreliance on a limited pool of literature, as David Patterson acknowledges that

[e]ighteenth- and nineteenth-century information is geographically uneven, with data most abundant by far for Western Europe, notably Britain, Germany, France, and northern Italy. Scandinavia, Russia, the Iberian Peninsula, and especially the Balkans are more sparsely documented in the contemporary medical literature, but we can usually construct a fairly satisfactory picture of influenza activity in Europe. Reports on Asia, the Middle East, Africa, and South America are sketchy at best and usually supplied by European observers. North American data are better, but often quite disappointing.

As a consequence, contemporary knowledge about influenza epidemics and pandemics through-out earlier centuries tends to be heavily skewed toward European worldviews and those of a few specific countries in particular. Moreover, little progress was made in determining the nature of the disease in large part because of competing ideas over causation. In fact, as Margaret DeLacy relates,

the depiction of influenza as a distinct genus of disease only first became common during the eighteenth century. During that period, physicians developed competing theories about its etiology (causation) and transmission, including the theory that influenza was contagious. Theories of contagion were held by an increasing number of physicians during the course of the eighteenth century, although the issue remained a contested one, as symbolized by the publication of two separate reports on the epidemic of 1782 by the Royal College of Physicians and the Society for Promoting Medical Knowledge: reports that differed on the question of transmission.

The debate over causation continued into the early 20th century, with some physicians robustly defending the notion that influenza was linked to meteorological conditions such as high winds, sunshine, and relative humidity. Generally speaking, however, influenza did not rate particularly high on medical and political agendas even at the beginning of the 20th century. As late as 1837, there was a strong view that governments had little to no role in ensuring public health; although this sentiment progressively began to change, government intervention in the form of large-scale public health campaigns was rare, particularly any relating to influenza. Nonetheless, influenza epidemics and pandemics occurred with almost clockwork frequency throughout the latter half of the 19th century. Arguably, the frequency of these events contributed to a measure of acceptance and familiarity with the disease; it is also easy to appreciate that other diseases such as typhoid and cholera ranked higher because of their comparatively high fatality rate and impact on international trade. That is, until the 1918 “Spanish Flu” pandemic forever changed societal notions about the disease.

Even by contemporary standards, the 1918 Spanish Flu pandemic continues to remain one of the most devastating events in recorded human history. As one commentator reflected in 1978, “The influenza pandemic of 1918 ranks with the plague of Justinian and the black death as one of the three most destructive human epidemics.” Believed to have begun in North America in early 1918, the pandemic traversed the globe in 3 distinct waves over approximately an 18-month period. The speed of the disease was therefore remarkable in that it spread rapidly around the world before the advent of international air travel. More disturbing, however, was the lethality of the disease, which infected as much as 50% of the population in some areas before killing up to 25% of the entire population. Furthermore, in contrast to most influenza epidemics, which affected the very old or very young, some of the highest fatality rates of the 1918 pandemic were for people in the prime of life.

At the height of hostilities in World War I, information about the adverse impact of an epidemic on military forces was considered highly sensitive. It is believed that this reluctance to alert other countries to the impact on troop numbers aided the spread of the disease. Although the pandemic is suspected to have originated in the United States, it was inappropriately termed the Spanish Flu in 1918 only because the Spanish authorities were the first to declare that they were experiencing a nationwide epidemic; as W. I. B. Beveridge aptly noted, “this misleading name stuck.” Only once that point was reached did other countries finally begin to acknowledge that they too were recording significant numbers of human fatalities. Estimates vary considerably regarding the overall death toll of the 1918 pandemic, with most conservative estimates ranging between 20 million and 50 million deaths worldwide.

Because of the massive loss of human life, the 1918 pandemic did have one positive outcome in that it spurred considerable scientific research into influenza. One of the initial areas to be investigated was the connection to pigs, prompted by the observations of veterinarian J. S. Koen of the US Bureau of Animal Industry in 1918. Koen observed,

[t]he similarity of the epidemic among people and the epizootic among pigs was so close, the reports so frequent, that an outbreak in the family would be followed immediately by an outbreak among the hogs, and vice versa, as to present a most striking coincidence, if not suggesting a close relation between the two conditions. It looked like “flu,” it presented the identical symptoms of “flu,” and until proved it was not “flu” I shall stand by that diagnosis.

The cause of this porcine disease was subsequently confirmed as influenza in 1931, following the virus’s isolation and identification by Richard Shope and his colleague Paul Lewis. Following closely behind this discovery, three scientists—Wilson Smith, Christopher Andrewes, and Patrick Laidlaw—isolated and identified the virus from human tissue samples in 1933, naming this first virus influenza A. These discoveries and the subsequent development of a viable influenza vaccine in 1940s altered considerably the response of individuals and governments toward influenza, serving to usher in a new age of human interaction with the disease.

The 1918 pandemic had another interesting (albeit temporary) outcome: it instilled the notion that influenza was closely associated with war, with some scientists even explicitly referring to it as a “war disease.” Governments had been cognizant of influenza’s ability to decimate military forces since at least 1782, but the 1918 pandemic cemented military interest in the disease because of the considerable impact it had on armed services personnel. So convinced were some officials that influenza would appear with the outbreak of World War II that in 1941 the United States established the Commission on Influenza of the United States Army Epidemiological Board to provide technical advice and commence work on an effective vaccine. The preoccupation, though, was short-lived, and with the advent and mass production of antibiotics and new vaccines, many began to believe that the war against infectious diseases would soon be over.

Two subsequent pandemics revealed that such optimism was misplaced. The first pandemic, which commenced in 1957 and was named the Asian Flu after cases were first recorded in China and the surrounding region, contributed to the deaths of more than 2 million people worldwide. The first event of its kind to be observed with modern scientific techniques, the 1957 pandemic became one of the most widely described medical events of the 20th century. Contemporary medical professionals have even conceded that

[m]ost of the current understanding of influenza and its complications are derived from the 1957 pandemic experience.

The emerging practice of disease surveillance revealed what many had long suspected: that locations such as schools and military camps proved fertile grounds for spreading the disease because of crowded conditions and inadequate hygiene. The epidemiological data that were collected on the success of vaccination programs—which had been initiated in the United States by the US Department of Defense—and other campaigns that encouraged handwashing, facemask wearing, and general hygiene, also began to inform new public policy responses.

Arguably, why so much was written and recorded about the 1957 pandemic can be attributed to one organization in particular: the World Health Organization (WHO). In 1947, following a request by a respected group of scientists, the Interim Commission of the WHO agreed to establish the World Influenza Centre (WIC) to collect and distribute information, conduct and coordinate laboratory work on the virus, and train new laboratory workers. Officially established in London in 1947, the WIC marked the start of the broader WHO Influenza Program to (1) plan against the reoccurrence of future pandemics, (2) develop control methods to limit the impact when a pandemic did appear, and (3) limit as much as possible the economic impacts of influenza epidemics and pandemics. Behind all this activity loomed the specter of the 1918 pandemic and the massive loss of life it had inflicted. In 1952, the WHO also formed the Expert Committee on Influenza to provide technical advice and general oversight for the organization’s program of work. At the heart of the WHO Influenza Program, though, was an international network of laboratories and scientists that shared information on the latest influenza-related scientific discoveries—a network that continues to function to the present day and that forms the basis of international efforts to control and mitigate the health impacts of influenza. From the network’s inception, every member state of the organization was encouraged to establish a national influenza center to collaborate with the WIC; by 1968, when the next influenza pandemic commenced, the network had grown to include 79 national influenza centers in some 54 countries and 2 reference centers (later known as “collaborating centres”) in London and the United States.

The second pandemic to defy the notion that the battle against infectious diseases would soon be over was the 1968 “Hong Kong Flu” pandemic, which resulted in the deaths of approximately 1 million people worldwide. Named after the island where cases were first identified, the pandemic validated the critical importance of conducting regular disease surveillance. As it became increasingly evident that vaccination campaigns prevented the loss of human life and reduced the economic impacts on society, attention began to progressively shift to calculating the cost of such events—a trend that persisted well into the 1970s and 1980s in response to broader economic pressures and a desire by Western governments to ensure value for money in the face of economic rationalism.

By the mid-1980s, pandemic influenza had effectively fallen off the international agenda. Several geopolitical factors arguably contributed to this, such as political attention shifting more toward “hard” security considerations of nuclear proliferation, debt crises, and various conflicts throughout Central Asia and the Middle East. But even in health, the US “War on Drugs” and the rise of new diseases such as HIV/AIDS understandably shifted public attention away from influenza. Instead, influenza increasingly began to be viewed as an entirely preventable disease following the introduction and progressive refinement of viable vaccines.

In 1952, scientific consensus held that influenza vaccines remained “experimental.” By 1959, however, because of the considerable scientific evidence that had been collated from annual seasonal influenza epidemics and multiple clinical trials conducted in various countries throughout the 1950s, this view had shifted, with the WHO recording that

Experience in many countries has now established vaccination as the most efficient method for the prevention of influenza.

By 1969, the WHO, which by this time had become an “authoritative source of information on the occurrence of influenza and its spread from one country to another,” actively promoted the view that “[v]accination is the only established procedure for conferring protection against influenza.” Nonetheless, the organization became preoccupied with a number of global eradication initiatives, such as the Malaria Eradication Program and its now widely hailed successful campaign against smallpox. Added to this, in the aftermath of the comparatively mild 1968 pandemic and the 1976 Swine Flu vaccination debacle, public perceptions about the risk presented by this disease (and the need for protection from influenza) had altered perceptibly. The WHO, which is reliant on contributions from member states to support its work, reflected the downturn in interest to the extent that by 1997, the organization had progressively reduced the number of personnel employed to work on influenza to one individual.

In the late 1990s, public perceptions of and political interest in pandemic influenza changed markedly yet again. The confirmation in 1997 that 6 of 18 people infected with a novel strain of H5N1 “bird flu” died as a result of their exposure reawakened international concern for the disease. This event also coincided with a wider growing recognition among Western developed nations that several infectious diseases, once previously eliminated in their territories, had begun to resurface alongside new diseases to threaten populations. Pandemic influenza came to be seen as a particular threat; with several prominent medical professionals, academics, and policymakers warning against a repeat of a 1918 Spanish Flu-like event, pandemic planning began to be increasingly viewed as a critical measure that governments needed to undertake. Reflecting the change in political interest, the WHO immediately began to enlarge its pandemic influenza portfolio, increasing the number of dedicated staff and releasing several guidance documents on pandemic preparedness.

By the turn of the century, the way in which developed countries viewed some infectious diseases had entered a new paradigm—that of (inter)national security. The release of such documents as the US Central Intelligence Agency’s national intelligence estimate confirmed that “threat” arguments had found purchase among policymakers and politicians concerned about the potential societal impacts that some infectious diseases such as pandemic influenza could generate. The passage of United Nations Security Council Resolution 1308 on the threat of HIV/AIDS epitomized this change in perception; as Stephen Collier and Andrew Lakoff have summarized,

[r]evelations during the 1990s about Soviet and Iraqi bioweapons programs, along with the Aum Shinrikyo subway attack in 1995 and the anthrax letters of 2001, lent a sense of credibility and urgency to calls for biodefense measures focused on bioterrorism.

By 2005, a select few diseases had become “securitized” in the sense that they were perceived (and openly discussed) as a threat to national and international peace and security. The corresponding effect of this securitizing move was to reemphasize the central role of government in mitigating the impacts of these diseases; Western governments increasingly found themselves under pressure to develop strategies ranging from generic pandemic planning to more specific interventions.

In the context of pandemic influenza, the cornerstone of pandemic planning and preparedness was widely promoted as ensuring ready access to influenza vaccines. The advent of influenza antiviral medications in the 1990s added to the pharmacological arsenal; however, despite limited clinical trials demonstrating their efficacy, on the advice of medical practitioners antivirals were soon identified alongside vaccines as “the two most important medical interventions for reducing illness and deaths during a pandemic.” Correspondingly, governments embarked on new programs aimed at stockpiling these drugs and were encouraged to develop plans that took into account a range of additional measures—such as the practice of encouraging physical distancing between individuals in multiple social settings (otherwise known as social distancing), legal considerations and regulation, the application of social justice principles, and the ethical considerations of pandemics—to protect their respective populations.

Further compounding the pressure on governments was the realization that policies that focused on the domestic sphere alone were insufficient. As David L. Heymann and Guenael Rodier summarized,

[p]opulation movement is only part of the globalization fallout. Expansion in international travel and commerce in food and medicinal biologic products provides another potential source of communicable diseases such as hepatitis and other bloodborne infections. Social and environmental changes linked to urbanization, mobility, and deforestation have created new opportunities for infection, while rapid adaptation of microorganisms has facilitated the return of old communicable diseases and the emergence of new ones. With the rapid evolution of antimicrobial resistance, treatments for a wide range of parasitic, bacterial, and viral infections have become less effective. Today, a communicable disease in one country is a global concern.

A series of disease-related incidents early in the first decade of the 21st century—which notably included the 2001 anthrax letter attacks in the United States, the 2003 SARS outbreak, and the emergence and progressive international spread of avian influenza from late 2003 onwards—validated these concerns.

By 2005, convinced of the growing threat presented by avian influenza to the whole of society, governments the world over embarked on new programs of pandemic planning and preparation. The Secretary-General of the United Nations, at the urging of several Southeast Asian countries, established a new department—the United Nations System Influenza Coordinator (UNSIC)—to help coordinate the multiple UN agencies engaged in activities related to preventing avian influenza. The creation of this supra-organizational body coincided with the establishment of the International Partnership on Avian and Pandemic Influenza announced by US President George W. Bush; it was accompanied by considerable US government funds for strengthening international surveillance, detection, and response. In addition, multiple fora for coordinating pandemic-related work were either newly created or subsumed into existing mandates with all manner of intergovernmental organizations, ranging from regional (e.g., Asia-Pacific Economic Cooperation [APEC] and the Association of Southeast Asian Nations [ASEAN]) to international (e.g., the WHO); these fora received new financial investment and support to enhance pandemic influenza preparedness and response capabilities. Various local, national, regional, and international plans were developed and in a number of instances exercised. New laws and regulations were passed, and contracts worth billions of dollars were agreed to between national governments and pharmaceutical companies to ensure access to vaccines and antivirals. In short, the international community went into pandemic overdrive, pledging approximately US $4.3 billion between 2005 and 2009.

In April 2009, the hyperactivity initially appeared to have been substantiated following the announcement that a novel strain of H1N1 influenza had managed to infect humans. Within a matter of weeks, the virus had been detected in multiple countries around the world, and the WHO moved to declare a full-scale pandemic. Fortunately, the virus responsible for the pandemic was more akin to the 1977 Russian Flu than the 1918 Spanish Flu in terms of severity, and the dire warnings about the number of possible fatalities and widespread societal impacts were thus revealed to be excessive—the threat had proved nominal. Nonetheless, in anticipation of a disastrous event, contingency plans were invoked, emergency committees were convened, and billions of dollars were spent procuring antivirals and pandemic-specific vaccines. The legitimacy of the WHO, once viewed as the vanguard of human health, was questioned over accusations the organization had been unduly influenced by pharmaceutical manufacturers into changing its definition of a pandemic. A number of independent inquiries were subsequently launched, and although they exonerated the WHO of any inappropriate or unethical behavior, the organization did agree to review its processes for declaring a pandemic.

Challenges Associated with Changing Perceptions

It is clear from this summary that human understandings about pandemic influenza, and how best to mitigate its effects, has altered markedly over time. In centuries past, the disease was viewed as a meteorological phenomenon, the result of foul-smelling air, or even condemnation by the gods. The response by individuals to try and prevent contracting the disease, however, was somewhat limited. As time progressed and scientific advances were made, the cause of the disease was identified to be a virus. This revelation prompted the creation of vaccines and, eventually, antiviral medications to counteract its effects. Over the past century, the role of government has ebbed and waned as politicians, policymakers, and health practitioners alike have weighed the hazards associated with responding to this disease. But, as Western societies have become increasingly risk averse, the need for government-led interventions and protection from influenza has grown. Although the change has been reflected in government responses to a select few other infectious diseases as well, the latest clearly identifiable shift in public policy responses to pandemic influenza has been to securitize the disease, but this too has had both positive and negative outcomes.

Indeed, securitizing pandemic influenza appears to have been a double-edged sword in many respects. Certainly, the framing of pandemic influenza as a security threat illustrates deeper changes in global health governance, which some have argued is closely tied to US economic and security interests. Whether such claims are accurate or not, this framing has served to elevate the disease above other health concerns that are arguably more pressing for a larger percentage of the world’s population (e.g., maternal and child mortality, malaria). Furthermore, at least in the short term, securitizing pandemic influenza has ensured that governments have accorded significant political attention to the disease. This has had the corollary effect of substantial resources being allocated to strengthen health systems to enhance disease surveillance, detection, and outbreak response capacities for pandemic influenza—approximately US $4.3 billion in monetary pledges or in-kind technical support to date. Not surprisingly, communities have benefited from this investment—if for no other reason than because strengthening health systems in one area (i.e., pandemic preparedness) can also lead to gains in other health areas more generally (i.e., improving communicable disease prevention and control).

At the same time, by securitizing the disease advocates of this approach have also reinforced the message that the threat is both serious and imminent—a message that was not borne out by the latest influenza-related event. Of course, had the 2009 H1N1 pandemic proven more severe, it is likely that influenza would have been further embedded in our collective consciousness as a legitimate threat, and reinforced the broader view that infectious diseases do threaten (inter)national security. Given, however, that the 2009 pandemic has been portrayed as comparatively mild (compared with 1918), it is currently unclear whether depicting influenza as a security threat will endure. Certainly, what has become apparent is that just as significant political attention and resources were accorded to pandemic influenza in 2005, by 2010 there had been an equally substantial and rapid scaling back of resources now that the threat was perceived to have passed. Whether this assessment is entirely correct is not certain, with human H5N1 infections continuing to occur; with widespread “pandemic fatigue” having set in among international donors, however, it is unlikely that the former level of activity will now be sustained.

Securitizing infectious diseases like pandemic influenza has also had an unsettling effect on national and global governance structures and, accordingly, on public policy. The heightened political attention accorded to the threat of infectious diseases has, for instance, prompted the passage of new legislation that grants governments extended powers, given greater impetus for intervention (and ownership) by central governments in health care services, and resulted in millions (and in some instances billions) of dollars worth of investment in civil and military biodefense initiatives. Within all these arrangements, vaccines have continued to remain the much-sought-after magic bullet in the war against infectious diseases.

In the specific context of pandemic influenza, the fixation on vaccines, combined with the recent policy shift toward securitizing the disease, has served to distort the existing governance arrangements, granting pharmaceutical manufacturers a disproportionate amount of political power and influence. Some public health experts have been complicit in this, arguing that

School closure, quarantine, travel restrictions and so on are unlikely to be more effective than a garden hose in a forest fire.

Accordingly, less attention has been given to building the evidence base for alternative measures such as the use of personal protective equipment, personal hygiene, and social distancing principles—measures that would arguably benefit a larger proportion of the world’s population that currently do not have access to these essential medicines. Indeed, in the majority of pandemic plans, governments have only tended to consider these measures as a means to limit virus transmission until a viable vaccine becomes available. This imbalance was perhaps most clearly demonstrated in the context of the 2009 H1N1 pandemic, with the World Bank noting that of the estimated US $1.48 billion required to counteract the pandemic’s effects in 95 of the least-resourced countries, some US $1.14 billion (or 77% of the funds) was identified as being necessary to purchase vaccines and related medicines.

The contemporary imbalance was also reflected in Indonesia’s decision to stop sharing virus samples with the WHO’s Global Influenza Surveillance Network (GISN). This decision, which transpired in January 2007, was taken in part to force the international community’s hand to improve access to vaccines. After some 4 years of diplomatic negotiations, a new agreement—the Pandemic Influenza Preparedness Framework—was endorsed by the 64th World Health Assembly in May 2011. The new agreement outlines a series of recommendations, norms, oversight procedures, and governance arrangements to facilitate the sharing of influenza virus samples with human pandemic potential. Through new obligations placed on pharmaceutical companies that are part of the GISN to contribute 50% of the network’s operating costs, the agreement transforms what was previously a largely publicly funded network (supported principally by funds from Japan, Australia, the United Kingdom, and the United States) into a new public-private partnership. At the same time, those companies that are not members of the network (and thereby exempt from contributing to the network’s operating costs) are required to agree to a package of measures intended to improve access to medicines and diagnostics for low-income countries. In this regard, the agreement may begin to address the power imbalance between pharmaceutical companies and governments that has arisen in the wake of the global dissemination of avian influenza, although it remains to be seen whether equity in access between governments will be achieved under the terms of the agreement.

Perhaps the most intriguing aspect of the recent shift to securitizing diseases such as pandemic influenza has been the fact that Indonesia—a relatively small geopolitical power—successfully used the perceived threat of a disease to force some of the world’s most powerful countries to the negotiating table. What this reveals is that the concept of health security has gained a measure of traction within contemporary international politics. One could overplay the significance of the case; however, that a country like Indonesia can command global attention and require changes to existing influenza governance arrangements by withholding virus samples represents a notable shift in contemporary global governance. What this trend portends for the future remains to be seen, but it is likely that in the current risk-averse environment the importance of government involvement in preventing and controlling infectious disease outbreaks such as pandemic influenza will continue to grow rather than lessen. Accordingly, there is likely to be a greater willingness on behalf of governments of all resource persuasions to be willing to challenge existing governance mechanisms and arrangements if they perceive that their security and the legitimacy they derive from protecting their population are being compromised.


This overview has provided a brief summary of the way in which humanity has sought to contend with and respond to the constant hazard of influenza pandemics over the past 500 years. In deciding what to name this common threat, 18th-century physicians selected an apt title, for influenza has certainly demonstrated its ability to influence human society in profound ways. Indeed, aside from the Justinian Plague of the 6th century and the Black Death of the 14th century that wreaked so much human suffering and death, it must be concluded that the 1918 Spanish Flu, which caused an estimated 40 million deaths worldwide, was one of the most devastating medical catastrophes of recorded human existence. The chance that another influenza pandemic of equivalent lethality may arise has spurred tremendous advances in medical science and public policy, and continues to do so. At the same time, the erosion of geospatial boundaries by globalizing processes ensures that the threat to human populations is as great as ever. In response to this trend, the role and importance of government-led interventions to counteract disease outbreaks has grown tremendously, as has the need for more effective coordination at the international level. Correspondingly, international organizations, governments, local authorities, industry, and even individuals all have a role to play in planning and preparing for the next pandemic. What remains to be seen, however, is how our contemporary understandings of this disease, and the measures we use to counteract its potential devastating effects, will serve to assist or hinder attempts to prevent a future pandemic.