Abstract
From the very moment that the first cases of swine flu reached Scotland last April, panic had already begun sweeping across the whole lengths and breadths of Britain. 1 During the early stages of the outbreak, there was a feeling of muted anxiety among a large proportion of the UK population, in anticipation of the impending threat. This was only compounded when Sir Liam Donaldson, Chief Medical Officer, warned seemingly prematurely that the new swine flu outbreak could outstrip the 1999–2000 flu mortality of 22,000 by ‘several times over’. 2, 3 Yet now in to 2010, we are still waiting. Such a statement was relatively mild compared to the many other predictions that followed, including economic forecasters who speculated on the impact that a swine flu epidemic could bring. Indeed, a World Bank report suggested a potential $3 trillion indentation to world GDP. 3 With most of the world and the UK in the midst of a terrible recession, negative speculation and panic was seemingly the least helpful of all actions, especially when many people were not even fully informed as to the exact nature of this new virus.
The term ‘swine flu’ itself is a controversial name; some scientists argue that it is more correctly termed H1N1/09. 4 The original reference to ‘swine flu’ was because initial laboratory testing of the virus showed that its genes were very similar to those found in pig influenza viruses. However, subsequent analysis showed a ‘quadruple reassortment’. 4,5 5 This can occur with segmented viruses, such as influenza, whereby variants of a virus that infect a single cell can result with progeny virions with mixed segments from each parent cell. 5 Indeed, further study demonstrated that H1N1/09 actually has six genetic segments from pig influenza viruses that circulate in Asia and Europe, coupled with two genetic segments from avian and human strains, respectively. 4 However, other scientists argued that the avian and human genes had existed within the swine influenza strain for the past decade, and should make no difference to its nomenclature: ‘swine flu’. Nomenclature, it seemed had wide-ranging political ramifications, on the farming industry, Jewish people and Mexico. 6 The new H1N1/09 virus also spread by coughing and sneezing, the same way as seasonal flu, and could not be transmitted via pork, as the name perhaps suggested. 4 The seemingly unnecessary controversy about the swine flu nomenclature, only added to the mystique and drama of the new virus. It further enhanced the belief that governments and world organizations did not know how to handle the situation. Was controversy being intentionally hyped?
The society we live in today can be characterized as a ‘politics of anxiety’. 7 Politicians and governments around the world are aware of this fact, and re-ignite its status regularly, wittingly or unwittingly. Even more disturbingly, it can be argued people are inherently at the mercy of these governmental experts. Within each of our own respective fields of expertise, we are well-equipped to formulate rational probability analysis to assess risks. 8 However, once we journey away from our respective fields, our probabilistic thinking capitulates; 8 the responsibility of risk perception analysis is deferred to judgement of the government.
This anxiety is also a creation of a modern world that has been described as a ‘risk society’. 9 There are constant murmurs of danger, be it terrorism, nuclear catastrophes and, indeed, flu pandemic outbreaks around every corner. Modernity creates risk by our increasingly busy and urbanized way of life, which includes working conditions, various modes of transport, pollution and infections. Although this is partly compensated by risk calculations and governmental regulation to quantify risks, there is no escape from the emergence of global catastrophes which have unquantifiable consequences. 7, 9, 10 Subsequently, the modern world is more susceptible to periods of moral panic than ever before. 11 Moral panic as is defined, ‘a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests’ 11 is at the forefront of the swine flu saga. By its very nature, moral panic has potentially long-term consequences that are dependent on how potent a threat the ‘folk devil’ 11 causing panic, in this case swine flu, exists in actuality. If the threat of the ‘folk devil’ is exaggerated, it will soon be forgotten, conceivably hindering the trust between the government and its people. However, if the threat proves itself to be catastrophic, society may be forced to review its foundations. So when the World Health Organization declared a global influenza pandemic on 11 June 2009, 12 it seemed on par with global catastrophes that have unimaginable outcomes. Even with the promise of antiviral medications and vaccinations in some countries such as Britain, there was the concern that globalization would rapidly lead to the spread of the new H1N1 virus. There seemed a need to panic. With such theories in mind, it is important to assess people's health behaviour in response to their anxiety. Does this panic trigger a health response and is it vital in health policy as it exists today?
In order to answer the question, analysis of public health response is necessary since successful health policy can only be evaluated by its effect on the people. Several studies in the past have shown that anxiety can influence health behaviours. 13, 14 15, 16 One study in particular 13 evaluated the change in protective behaviour and emotional status over the first week of the H1N1/09 outbreak in the United States of America. During this time the pandemic status changed from 4 to 5 on the WHO scale and so represents changes of risk perception and behaviour during a highly uncertain time. They found that people were most anxious within the first three days of the survey, which corresponded with an increase in protective health behaviours. However, after day 3, ‘calm status’ of respondents was very high and their health protective behaviours decreased correspondingly. 13 These findings suggested that the response of a population to the H1N1/09 is quite sensitive to media reports and that health protective behaviour is mediated not only by anxiety but the time-length of the risk. Further explanation of such responses can be given by an understanding of individual health protection. For any individual, one's own body is a resolute ground of control, and care of the body allows one to maintain stability despite any risks associated with the outside world. 7 It is no surprise that in light of mass media, government and health sector attention to the new H1N1/09 outbreak that individuals started to engage in more health protective behaviours such as hand-washing and avoidance of travel to affected areas.
On this evidence, it seems easy to argue that panic could play a pivotal role in successful modern health policy. However, the main difficulty is to instill a high level of anxiety and panic for a sustained period of time, as demonstrated by the finding 13 that the time-length exposure of risk is linked to anxiety. Indeed, risk perception research has shown that people are more afraid of risks when they are brand new than after they have lived with it for some time, seen its progression and gained their own personal, as opposed to an institutional perspective. 10, 13 14 Another study, 14 also looked at anxiety and behavioural changes during the H1N1/09 outbreak. They found that responders with increased anxiety carried out recommended health behaviours. However, their study – conducted during the second week of the outbreak – discovered that the number of responders anxious about the pandemic was very low (24%), with only 2% being very anxious. These findings further suggest that anxiety is important in stimulating a ‘healthy’ response to policy but does not explain why it is so fleeting. An analysis of risk perception can perhaps elucidate one possible explanation. Initially, knowledge and consent of the novel risk is both uncertain and contested, respectively. 17 However, especially in the case of H1N1/09, a not so completely unknown risk, progress moved smoothly. As a result, knowledge and consent of the risk quickly became more known and complete, which culminated in the rather swift development of a vaccine. 17 Therefore, the panic created by the risk can only last as long as knowledge of the risk is limited and being contested. As this knowledge expands, it becomes increasingly difficult to maintain a sense of panic. Even so, 10–14 days seems too short a period for anxiety to dwindle. In combination, it is perhaps reflective of a deeper social attitude, apathy. A large proportion of the population in Britain during this time had misgivings about the government due to the economic situation and there is no reason to suggest that this disillusionment would disappear due to claims of another ‘flu catastrophe’. The trust had simply gone. 16, 18 Were there not similar warnings about SARS and ‘bird flu’? Perhaps then, panic is only a short-lived albeit important response, a call to action, but its effect can only be sustained on more consistent groundings.
The necessity of reducing uncertainty and providing well-informed and consistent advice during an emerging health threat has proved to be important before. 14, 16 Yet, during the early stages of the H1N1/09 outbreak, the most used source of information was the media, or more specifically the Internet, far ahead of the healthcare sector. 13, 16, 17 In essence, the Internet is not a forum open to consistency but does this denote it as a negative source? Media coverage has traditionally been seen as troublesome by governmental health policymakers. 20 Often, the media and its journalists are accused of being ‘irrational’ and addicted to covering stories rather than facts. 20 Rather than simply dismissing the media, it is necessary to understand the reasoning behind their perceived sensationalism. The primary aim of any media source is of course to attract and maintain reader interest. However, it may also been seen to have a moral responsibility. 20 Often, this is representative of its particular demographic of followers, to cover certain issues, uncover scandals or ironically, to reveal governmental sensationalism. Indeed, despite accusations of sensationalism, a few studies have shown that the media tend to publish more reassuring than alarming news. 20, 21 Although this may not always be the case, it is generally not helpful to dismiss all media coverage.
If healthcare authorities, including doctors, could become more forthright and prominent in their advice, there is no reason to suggest why they could not utilize any initial panic generated by the media. However, such advice and health promotion must be given quickly and truthfully, for public levels of anxiety are unsustainable on media hype alone. Although trust in authorities is higher than the media, they must do more to make sure that they have a more significant impact, based on evidence and without making perceived ‘exaggerated’ claims. 20
Unfortunately, this is not as clear cut as it may seem. On an interpersonal level, trust between an individual doctor and their patient can have direct therapeutic benefits. 22 In modern society, it can be argued that the patient–doctor relationship continues to move away from the traditional paternalistic style, towards a more holistic, patient-centred approach. Such an approach openly acknowledges the expertise that the patient, or ‘lay-expert’, brings to an appointment with their doctor. 7 Why then, is trust on an interpersonal level seemingly not being replicated on a larger, organizational scale? 22 Institutionally, health organizations are viewed by many in the public to focus on targets and cost saving. 22 The perceived business-like approach to modern healthcare within the NHS does not lend itself to the human care of each patient that a doctor can provide on an individual basis. This is further compounded by research that suggests a decline in trust of healthcare is reflective of a deeper, more widespread lack of confidence in the government as a whole. 22, 23 Due to an increase in the already intense budgetary pressures facing the economy this is a problem that is exceedingly difficult to solve. Nonetheless, it is a highly important problem that must be addressed in the near future. If it is ignored, there is a chance that it may even threaten trust on an interpersonal level. In light of this, while taking heed of the current economic climate, health policy must concentrate on consistent, rational guidelines that consider the concerns of the public; the media will create the interest and panic. If not, further inconsistent claims may further diminish their already fragile public confidence during a time of ‘real’ catastrophe.
Panic, important as it is in successful modern health policy, is not the key. It provides access to concerns and anxieties of the population, but only for a limited period. Generating further hype without evidence is counter-productive, and will diminish concern and anxiety rapidly. Instead, the traditional theory of trust, based on clear and consistent advice is the real key to health policy. In this modern world, it is somewhat easy to create a stir but infinitely more difficult to maintain it, with the endless sources of information that make even serious, seemingly imminent issues yesterday's news. It is imperative that the various authorities involved during a public health response, including the healthcare profession, take heed of this fact. For during the next pandemic, there is the danger that the public may decree ‘the boy who cried cry wolf’ and no one, least of all the authorities, could blame them.
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