Flu: From Uncertainty to Illusion...

The term "flu pandemic" corresponds to the global spread of a new virus against which immune defences are weak, or even non-existent. Individual and collective protection measurements (vaccine, medicines, wearing of protective clothes, limiting of meetings, travel and other measures) have never been tested against this new pathogen. In spite of uncertainties, the still vivid memory of the catastrophic nature of previous episodes, notably the Spanish flu epidemic of 1918-19, necessitates the planning and co-ordination of a response to the threat. While the H1N1 influenza epidemic is spreading, its extent is most probably underestimated due to its often- weak clinical sign, and the need for confirmation by a laboratory test.

In the Northern Hemisphere, the dominant approach is to delay the spread of the virus until a vaccine becomes available in the autumn. However, this is not a sure-fire solution, and vaccinating too late in the day means lost effectiveness In the interim, the approach consists in isolating and treating the first patients, to prevent their transmitting of the illness. With the majority of cases being quite unsymptomatic, the exercise is no doubt reassuring from a media perspective, but hardy convincing in medical terms. Certain might consider it favourable, on the contrary, for the virus to be transmitted before it becomes more virulent... However, health authorities oppose this approach, underlining the dangerousness of a virus able to kill slightly over four people per thousand cases. Notwithstanding, as mentioned previously, the cited mortality rates are based on an underestimated total number of cases, in turn resulting in an overestimated death rate. Another argument employed is a reminder of the obligation, in the common interest, not to encourage the transmission of illnesses whereas the illness is still benign. Actually, the virus is already spreading very rapidly, and individual initiatives to contract it are currently unlikely to amplify its overall transmission. Similarly, the benefit of administering antiviral treatments to a patient and his immediate environment is compromised by the speed of propagation of the virus. UK health authorities estimate 100,000 new cases per day during August. Apart from in serious clinical cases, the prescribing of antiviral's is aimed essentially and somewhat unrealistically at delaying the epidemic rather than treating the individual patients in question, and the latter, moreover, risk suffering side effects. Additionally, the basically unjustified prescribing of antiviral's as monotherapy risks encouraging the appearance of resistant strains. In reality, such a health policy influenced by mathematical modelling comprises too may unknowns to allow guaranteeing that we are effectively and rapidly modifying the course of the spread of the virus

In traditional terms, reaction to declared epidemics takes two avenues, conditioned by the epidemiological profile of the illness, and the available means. The first category of measures aims, by preventive action, to limit the total number of cases or serious cases. This assumes a rapid start of operations after confirmation of the existence of an epidemic, and before the latter reaches its peak. In today's context, this takes the form of temporary isolation of patients, administering of antiviral's to limit transmission, and preparations for a mass vaccination in the autumn. The second series of measures consists in identifying and treating serious cases. In summary, the ambition of reducing the number of deaths rests on two types of measures, with which French public health institutions are basically unfamiliar: vaccinating provided that the vaccine is available in time of several tens of millions of people in a short period, and treating outside of hospital premises a large number of seriously ill patients. Succeeding in such a venture necessitates intense preparation in order to align the practices of a multitude of professionals. The action of nurses and doctors operating outwith institutional walls on a freelance basis, therefore will be a driving factor if the virus acquires greater virulence and results in greater numbers of serious cases than can be dealt with by hospital admissions. The risk is that illusory attempts to delay the growth of the epidemic may divert energies from the efforts required to organise the treatment of large numbers of patients Having reacted to a large variety of epidemics over several decades, Doctors Without Borders has acquired sufficient experience also to understand the risk, namely, that the hope of influencing the course of an epidemic hides the efforts required to reduce death rates, by underestimating the need for sound therapeutic management of victims.

Lastly, there is a genuine risk of seeing states applying series of measures to limit public freedoms (movement and assembly of individuals), thus introducing discrimination between individuals and populations, with no serious discussion as to the relevance of the associated decisions. The only existing certainty is the shortfall between available resources and potential demand. Who will get the privilege of timely vaccination? Who will get access to curative care? It must be added that the considered measures represent in themselves enormous economic stakes. And finally it will be necessary to better understand who will be favoured (or neglected) and who will be enriched (or ruined) in this extraordinary and extremely ambitious enterprise, whose results, it must be stated, are only hypothetical after all... The situation merits a public debate, underscoring the factor of uncertainty and highlighting the human and economic effects of the various options.