The H1N1 post-mortem

It's been a year since the height of swine flu frenzy - as good a time as any for a post-mortem.

Since the pandemic began last March, there have been 428 deaths and 8,678 hospitalizations in Canada due to influenza A/H1N1. The response has cost more than $2-billion.

In retrospect, it looks like a debacle: A massive amount of money spent on a minor threat.

But hindsight is no way to judge a potential public health disaster.

The real question that needs to be asked is: If the same situation were to arise again today - a novel influenza virus emerging in a country where Canadians travel in large numbers, an illness with a high mortality rate that is killing healthy young adults, spreading out-of-season, and a virus for which a vaccine can be manufactured relatively quickly - what would we do?

One would be hard-pressed to imagine how we could have responded differently, at least on the big-picture issues.

Ordering 50 million doses of vaccine, based on the information available at the time, was the right decision. Promoting universal vaccination and staging emergency flu shot clinics was appropriate. Purchasing additional ventilators because many people might become gravely ill was a smart investment. Calmly telling the public about the potential severity of the threat was a necessity.

Public health officials acquitted themselves pretty well given the scientific and political challenges posed by H1N1. And when you compare the response to H1N1 to that of SARS, it was night and day.

This time around, the response was not only appropriate, it was co-ordinated. Canada had a plan - a pandemic preparedness plan - and it was implemented fairly efficiently in every single province and territory.

With H1N1, unlike SARS, we don't need public inquiries to expose the failures; no one needs to be frog-marched to the guillotine. It's so refreshing to see lessons learned and applied in the health-care field.

Still, there is a lot of second-guessing.

The No. 1 complaint about H1N1 is that public health overreacted to the threat.

The principal argument used to demonstrate this is that swine flu didn't kill many people - only about 18,000 worldwide. Seasonal flu kills a lot more.

But when the most persistent complaint in the wake of a potential disaster is: "Shucks, there was hardly any death and destruction," then public health officials should feel good at the end of the day.

Everyone's vision is 20-20 in hindsight. Of course the $2-billion spent on pandemic flu could have been better spent - but there was no way of knowing that in advance.

And let's dispense with the conspiracy theories that this was all a ploy to enrich Big Pharma. Sure, drug companies made some money; in the grand scheme of things, it was a trifling amount.

The challenge that public health faced was trying to divine how the H1N1 virus would spread and its impact. The lag time of months needed for production of a vaccine created tremendous pressure to make a decision quickly.

Should we indict public health for being cautious? One would hope not. Had they waited, what would have been the appropriate trigger point for action? 100 dead? 1,000 dead? 10,000? Imagine the outrage.

The behaviour of H1N1 should lead us to rethink one fundamental bit of science, however: The assumption that a pandemic strain of influenza would be far more deadly than a seasonal flu strain.

We know now that isn't the case, and that reality needs to be incorporated into pandemic planning.

A related issue is that there needs to be a better definition of "pandemic" - not the bureaucratic one that exists now. And there needs to be a set of brakes built into the plan. Once governments committed to certain actions - vaccination, clinics, etc. - there seemed to be no easy way to scale back. There needs to be a continuous feedback loop that allows a pull-back when the threat lessens.

We need to recognize, too, that the biggest challenge for public health in the 21st century is communication. The "scandals" that arose were actually communications failures, notably the waffling on who should get vaccinated first (which created long lineups) and failure to explain clearly why an adjuvanted form of vaccine was purchased (which sparked confusion and fear).

H1N1 was the first pandemic of the Internet Age; the first pandemic with a 24-hour news cycle; the first pandemic with its own chat groups and listservs; the first pandemic where we could trace the spread of a virus around the globe in real time; the first pandemic influenza virus whose genome we could decode in the blink of an eye.

That changed public perceptions of risk - and ratcheted up expectations.

The fact is, despite advances in communications technology, the tools we have for responding to the threat of a potential pandemic remain rather primitive: Vaccines that take months to produce, antivirals of limited use, mucosal swabbing, and a lot of guesswork. And while sticking needles into people is easy, assuaging their fears and answering their questions is a lot more challenging.

The leaders in public health have reason to be proud of their response to H1N1. But their work is not done until they have done a thorough post-mortem. We need to reflect - publicly and insightfully - on what went wrong and what went right and then tweak the pandemic plan and public health responses more generally.

We need to arm ourselves with foresight, not wallow in hindsight.