The Asia Medical Forum, The Lancet 2006: "Preparing For Pandemic Influenza The Avian Dimension and Other Emerging Diseases"

03 May 2006

By Mr Khaw Boon Wan, Minister for Health

Venue: Suntec City, Singapore

Distinguished guests, ladies and gentlemen.

Introduction

I am very honoured to have been invited to the opening of the Lancet Asia Medical Forum. I understand that this Forum is being held in Asia for the first time.  We are delighted that The Lancet has selected Singapore as the conference venue and I wish all our overseas guests and delegates a very warm welcome to Singapore.

Preparing for Pandemic Influenza

The theme of your forum, "Preparing for Pandemic Influenza", could not have been more apt.  History has shown us the potential devastation of influenza pandemics.  All of us should be concerned that we are not caught unprepared when it hits us.

On our part, Singapore has been studying, planning and implementing what we think needs to be done.  We have been preparing our population, government, healthcare system and other sectors of our society and economy for the pandemic. We are getting our hospitals prepared, stockpiling critical items like anti-virals and personal protective equipment.  Government agencies have been drawing up business continuity plans, and we have been encouraging private sector companies to do so as well.  But it is work in progress, as we practice and refine our plans as our understanding of the flu virus and its characteristic deepens. 

More importantly, we have so far based our planning assumptions on the relatively milder 1957 and 1968 pandemics.  We know that it is not impossible that the next influenza pandemic could have mortality and morbidity rates similar or even exceeding that in 1918 - the most severe one.

Moving forward, therefore, we are thinking through the "what if" scenarios and actively planning for them.  For example, the impact on the healthcare sector will be severe. The number of patients requiring hospitalization will overwhelm our hospitals. The number of outpatient flu visits will exceed the capacity of our healthcare delivery system. It would be impractical and unrealistic to simply contemplate building more capacity, training more personnel and stockpiling more supplies. Given the magnitude of the surge under a worst case scenario, we need to find new and innovative ways to deliver care, including delivering healthcare outside of traditional establishments, using different modalities.

Beyond the healthcare system, we have to deal with equally critical questions.  How do we deal with the impact on our open, externally-dependent economy?  Can we ensure continued and adequate food supply?  How will we deal with society's response in the face of such a calamity?  Should schools continue to operate? What about life after the pandemic? How do we quickly pick up the pieces and move on?

There are no easy answers to these questions.  But we must all spare no efforts in preparing ourselves for the unthinkable. 

Amidst the gloom, a silver lining

Even as we contemplate the worst, however, we must not let the gloom overwhelm us.  A repeat of 1918 fundamentally assumes that mankind and science have stayed stagnant.  That is clearly not the case.  Medicine and science have made great strides over the years, particularly in the last few decades, in important areas like genomics. Although we rely on some tried and tested tools since the 14th Century like contact tracing and quarantine, we now have an much expanded toolbox including better capabilities to develop anti-virals and vaccines, and a whole new understanding of the way the influenza virus behaves and mutates.

I see a parallel in the realm of economics. After the 1929 Great Depression, which unleashed unheard of devastation and hardship globally, the emergence of seminal work by economists like Keynes and the monetarists gave policy makers a better understanding of macroeconomics - how fiscal and monetary policies can be employed to counter cyclical economic downturns, how policy coordination between countries, including on exchange rate policies, can help us avoid a global economic meltdown, and how "Beggar-thy-neighbour", protectionist trade policies, far from being the panacea, will deepen the crisis.  We have not been spared subsequent visitations of economic shocks.  Indeed, we have experienced several since the Great Depression, including the 1997 Asian financial crisis.  But we have not seen a repeat of 1929.

To be sure, there is no guarantee that we can bring the same to bear in our fight against a flu pandemic.  We may not be able to outguess and outrun the microbe.  But I believe we must try and focus our research efforts to ensure that we have at least a decent chance of winning the battle.

Toward greater research collaboration

For our research efforts to bear fruit, several factors are key. 

Closer Cooperation

First, closer cooperation among the scientific community.

We each have different strengths and capabilities. We have to think through how we could combine our efforts and complement each other in order to make sure all grounds are covered in our attempt to find out how to defeat this virus. 

Some research areas are more glamorous, promising greater potential for economic reward than others. They naturally attract more funds, attention and competition. This is not inherently bad; it produces rapid progress. But we must make sure that other important areas are not neglected. 

Indeed, there are still many gaps in our knowledge. The nature of H5N1 influenza infection in humans, its clinical course and optimal management strategies are still not fully understood. Issues of vaccine development and how to rapidly scale up their production to enable them to act as meaningful tools have to be dealt with. New anti-virals must be discovered for we cannot be sure that our current arsenal will be effective against the eventual pandemic strain.  Let us leave no stone unturned. In the larger scheme of things, there is no single winner in our fight against the microbe. If anyone of us succeeds, we will be able to save millions of lives.  Mankind will be the winner.

Transparency and Openness

Second, and linked to greater cooperation, is greater transparency and openness.

One key area to facilitate research is the sharing of samples. Countries affected by avian influenza have their concerns. The economic impact of being put on a global travel advisory, for example, is not insignificant, particularly at a time when economic resources are most needed as part of the arsenal to fight an outbreak.  Some countries are reluctant to share samples because they worry about intellectual property rights or not receiving a fair share of the scientific credit.  There is also concern that information from samples shared will be used to develop diagnostic kits and vaccines which will, in turn, be sold back to the affected country at inflated prices.

Some may think that these concerns are unfounded.  But we cannot trivialise them, in so far as they stymie the flow of samples critical for scientific research to push the boundaries of our battle against the virus.  Real or perceived, we must address such concerns.   

At the most fundamental level, there is a need to build relationships of sincerity and trust.  We face a common enemy which disregards national politics and boundaries, and our response must be a united, global one.  While politically, each government will need to take care of the interests of its citizens and keep them informed of infectious disease threats, this must be balanced carefully so as not to make the situation more difficult than it already is for countries grappling with an outbreak.  At the same time, each of us must humbly acknowledge that on our own, we lack the resources and capabilities to fight such a formidable foe.  If we can forge a common understanding that as we help others we help ourselves, and make progress in our understanding of how to avert or deal with an influenza pandemic, mankind as a whole will benefit.

In parallel with facilitating research with better flow of samples, we must ensure complete transparency of information and knowledge gained. Nobody disputes the general principle of transparency.  Yet, according to an article in the 3 March 2006 issue of Science, holding back of information by scientific agencies is prevalent, even as some quarters of the scientific community call for the release of more data on the H5N1 virus.  Real or perceived, we must also address this issue.  If key research institutions and international organisations are not or are perceived to be less than transparent and open, then the fundamental relationship of sincerity and trust between all parties cannot be built. 

It is therefore critical that we develop a system that engages every member of the international community, encourages transparency and openness, and at the same time, takes care of the rights of the affected countries and others. Ultimately, the greater good should triumph over our own parochial individual interests. We can collectively move faster if information is shared and we do not end up re-inventing the wheel all the time.  As in the case of economics, closed, protectionist, "beggar-thy-neighbour" approaches will only deepen the crisis.

Inter-Sectoral Cooperation

Finally, the need for inter-sectoral cooperation.  Human and animal health authorities, researchers and government officials, clinicians and epidemiologists, et al (using your research lingo) must collaborate in our campaign against an influenza pandemic.  Again, we must humbly acknowledge that no one single group can do the job alone. The more we engage each other, the more coordinated we are, and the better equipped we will be in facing the challenges ahead.  Critical information can be shared and all relevant stakeholders can respond together in a coherent manner.

I am therefore extremely encouraged that participants in this Lancet Forum include clinicians, researchers, epidemiologists and policy makers, among others. I understand that an equally diverse range of topics will be discussed.  It is when we harness the collective wisdom of all stakeholders that the sum of our efforts is greater than the individual parts. 

Conclusion

Influenza pandemics are natural events.  We cannot predict when and what will actually happen. History has shown that nature has its way of reminding us how unpredictable and devastating its forces can be.  But history has also shown us that if we work together and better prepare ourselves, we have a fighting chance of mitigating the impact and averting the worst.   We have no choice but to give it our best shot. 

I wish you all a fruitful conference.