Singapore’s communication strategy on the Pandemic A/H1N1 has been quite country and culture-specific. Singapore’s response system, the DORSCON (Disease Outbreak Response System), evaluated pandemic severity using a classification distinct from that of the WHO, integrating the parameters of transmissibility and virulence of a disease.

Singapore’s communication strategy was also remarkable for its directive style. In the words of Dr MENON, “soft warnings and reassurances do not work”, whilst “fear can be a constructive emotion.” Thus rather directive measures, in place of incentive ones, were communicated to the public – Home Quarantine Orders for travellers returning from Mexico and voluntary quarantine for those returning from other affected areas, travel restrictions through “strong” advise to postpone or avoid non-essential travel – travellers which had stayed at the Metropark Hotel Wanchai, in Honk-Kong, were requested to call the hotline of the Ministry of Health, deployment of thermal scanning in air, sea and land checkpoints.

Such measures, which were well accepted by the Singaporean population, could have been difficult to implement in a number of other countries. The position of the Singaporean government, which is endorsed by its population, is that “it is better to err on the side of over-reaction that under-reaction.”

Dr MENON’s presentation also illustrated the difficulties that may arise from the articulation of local and global governance levels. For instance, it would seem that Singapore, despite its independent system for evaluating the severity of the pandemic, dovetailed the progressive step-up of WHO phases, only to reverse this progression and retrograde shortly after, when it appeared that the disease was less serious than expected. This “evident confusion in the responses of Government Ministries and organisations having to amend processes mid-stream” was caused by the perceived “loophole in WHO’s pandemic alert system”, or more generally by the friction that can arise between global (WHO) and local standards.

The importance of local/national specificities in elaborating an adequate communication strategy does not preclude however the existence of a global framework actively shaping it. Dr MENON underlined that the specific content of Singapore’s management of the Pandemic A/H1N1 outbreak took place under the umbrella of the WHO. Information between both levels circulated, and was either adapted at the local/national level from the global one, or compatible with it. Specific communication styles did not send contradictory signals.

(Summarized by E. Broughton)
Download here Dr. Menon’s PPT

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The speaker talked about the challenges of facing the H1N1 in the Taipei region and how drawing upon previous pandemic experiences helped ensure a successful outcome.

The SARS epidemic of 2003 highlighted the communication difficulties between local government and central government. The command structure was changed in the aftermath of SARS. Under the revised system, the central government operated the command center and local governments executed these commands. This ensured that messages delivered during H1N1 were more consistent.

The government had two phases of dealing with H1N1:
1.Stage of containment – June 2009. Many foreign tourists so hotels used as checkpoints; and
2.Stage of mitigation – September 2009. Coincided with the Deaf Olympics in Taipei. This was at the height of the pandemic. Letters sent to guests.

The 2009 H1N1 campaign was successful because it was simplicity (message was easy to understand), credibility and delivered in a unified voice.

Lessons for the Global Management of Health and Environmental Risks and Crises

The term “Avian Influenza” (AI) refers both to: 1/ the existing and related avian influenza epizooty and epidemic, and 2/ the possibility of an influenza pandemic, that would result from a mutation of the H5N1 virus.

The issue of AI therefore implies two necessities: 1/ the need to control the existing avian influenza virus and 2/ the need to prepare for the next pandemic.

The reaction to the AI issue has thus articulated itself, over the years, in two movements: 1/ a strong solidarity drive, from the better prepared, to the less prepared and 2/ a “national preparedness drive”, as the majority of countries strove to strengthen their own capacity to respond to an AI outbreak/pandemic. The tension between those two dimensions of the management of AI contributed to the build-up of a strong mobilisation, from very different communities (animal health, human health, environmental health, security, media, private sector, etc.). This process of mobilisation resulted in the emergence of what appears to be, with the benefit of hindsight, a real “global fight against avian influenza”, which reaps significant results, as this report highlights. Such a dynamic may not last forever, however, as a lurking fatigue with the issue seems to be spreading amongst actors, and threatening past and current efforts. The new “One World One Health” agenda could, in this regard, prove to be a necessary option to remobilise actors, and consolidate the outcomes of the fight against AI.

Before highlighting some key lessons from the fight against AI, one should draw some key features of the architecture of the global governance of avian influenza.

Which Global Governance of AI?
- Governing AI at the global level has been a fluid process, as it took some time to structure the large range of actors that had mobilised. Today still, as the agenda One World One Health is gains momentum, the exact role played by the different institutions involved in this process
might start to shift again.
- States are the key actors, as they raise political momentum at the global level, and as no possible response/control/preparedness is possible without them.
- Intergovernmental Organisations are very important supporting actors in the fight against AI; it is important in this regard to understand their role and limits. If IOs are faced with some problems
i.e. bureaucratic problems, traditional aid issues), they also proved to be extremely innovative.
- The regional level can have a facilitating effect on the global fight against AI. However, strong discrepancies exist between the regional organisations.
- A strong mobilisation was possible thanks to yearly conferences at the high political level; high political support from the national level: continuity of leadership; simulations; a cautious use of the “security” agenda.
- Coordination, which is always a problem at the global level, appeared to be less of a problem her thanks to global, regional, national and institutional coordinators, who had both a high visibility and sufficient time, and used frequent meetings of all stakeholders to insure coordination worked. UNSIC was useful but not very present on the ground; the question of its persistence in 2009 is still open.
- The Global Governance of AI confirms that strengthening existing organisations and coordination mechanisms can prove more efficient than creating new institutions.

LESSONS from a Global Fight:
- One needs a blend of horizontal and vertical approaches to global health issues to ensure that both animal and human health systems and the specific realities of a given diseases are taken cared of.
- Communication is a key factor.
- Surveillance systems are now better, but they can still be improved, and this needs to be done.
- A rapid emergency response requires long term investment. Even fire brigades have structural costs.
- Decision-making in grey environments implying investing time and money in research, but one should accept the fact that there will never be enough knowledge, and that grey decisions will thus have to be taken.
- Global norms are essentials, but they need to be adapted to local settings. Furthermore, a robust system to check on implementation of global norms needs to be established.
- Controlling epizootic will always imply a risk for livelihoods and an increase in poverty levels. Sustainable financial solutions have to be found. Eradication will always be extremely difficult with complex ecologies and should therefore take place as soon as possible, before the virus spreads.
- The best options to respond to human cases is to strengthen [one] health systems. This implies an increase in the surveillance and response capacity, the distribution of pharmaceutical options, and the surge capacities. Non pharmaceutical options are important, but they cannot replace the medical response.
- Pandemic preparedness is a complex and constant effort. It requires both: 1/specific health efforts and multisectoral efforts to detect and solve gaps and vulnerabilities (importance of simulations); 2/ the recognition that there is no “zero risk”. Indeed, the real issue may be the resilience of the system and its capacity to survive to such a traumatic experience.
- Global Health and the virus-sharing issue would strongly benefit from a reformed WHO sharing system, and more widely a solution has to be found to improve access (included delivery) to drugs and vaccines against emerging diseases of global impact.

The future of AI
Prevention and preparedness efforts are difficult to evaluate. However in terms of surveillance and control, the effects of the fight are positive, and the world seem better prepared now than five years
ago to face an AI pandemic. Will this situation last? AI will remain a problem for some countries where the virus has become endemic and where, as soon as efforts diminish or falter, AI will re-emerge. People are still dying from H5N1. The pandemic risk will last. The fight is not over.

In July 2008, several persons interviewed in Washington D. C. were positive that if Senator Obama were to be elected, more funding would be dedicated for the management of global health issues and health systems. However, the advent of the financial crisis may make health issues appear like less of a priority for many decision-makers.

A new momentum has to be raised, for global health, for “One World One Health”, and for AI.
Read here the complete report