Lessons from the H1N1 Ordeal: Truth-Telling, WHO Guidance and Quarantine Measures in Singapore

Introduction

On 10 August 2010, the WHO finally declared the H1N1 pandemic to be over,¹ but questions about the roles and responses of state governments and the WHO need to be addressed for us to emerge better prepared for future outbreaks.

In this essay, I will first consider the relevance of Fischhoff ’s proposal in the context of Singapore, to “tell people the truth, even if it is worrisome”.² Second, I will discuss the role of the WHO in providing guidance to governments during pandemics and how the involvement of industry representatives can interfere with its organisational image and objectivity. Finally, I will describe some ethical issues pertaining to quarantine measures and suggest how to make such bitter imposition on individual liberty more palatable through community engagement.

Should we always tell it as it is? In communicating risks during a pandemic, it is important to consider the polarity of responses ranging from panic in the overly-anxious to the dangerous indifference in the complacent. Fischhoff rightly asserts that officials should use communication methods empirically demonstrated to be most effective.³ However, a strategy proven effective in one population may be unsuitable in another where cultures and societal norms are different.⁴ The issue of truth-telling, in terms of how much to tell and whom to tell, has been the subject of longstanding bioethical debate.⁵ Doctors often find themselves in a dilemma when the prognosis of patients is poor and informing the patient directly goes against the wishes of the family.⁶ Consideration of the social and cultural circumstances then becomes important for the attending physician.⁷ In the case of risk communication amidst a pandemic, the factors which health officials need to consider in a multicultural setting like Singapore are far more complex. This warrants diligence on the part of officials and requires good understanding of Singapore’s multi-cultural dynamics.

While individualistic communities favour personal decision-making in matters pertaining to their own health, Mahmut (2006) suggests that the “Asian” culture grounded in collectivist ideas in which individual liberties often come secondary to the collective well-being of the population.⁸ This favouring of the collective good, together with the prescriptive regulatory attitude of the Singaporean government (herein termed “government”), create an expectation that instructions will be relayed from government officials to guide the population effectively in society’s best interests.

The Singapore population (termed “population”) is generally well-versed in disease management in the wake of past outbreaks of dengue, SARS, H5N1 and H1N1, and most have easy access to healthcare information.⁹ However, there continues to be an expectation for the government to direct pandemic responses since past outbreaks have been managed effectively.

Telling the entire “truth” insensitively, including how much remains unknown about the novel pathogen,¹⁰ how difficult it is to contain the spread of disease¹¹ or how little can be done to treat infected persons, might only increase anxiety. Perceived hesitation on the part of the government to manage the disease would heighten insecurity and possibly lead to inappropriate responses including hoarding of important medical supplies and straining the healthcare system.

This abrupt change in leadership style would shift the burden of pandemic management to citizens and may be misinterpreted as a shirking of responsibilities by the government. Such negative public perception could potentially exacerbate an already tense situation.

To avoid unwarranted extrapolation, Fischhoff rightly limits his advice to the United States since this is the research population in his studies. For the Singapore government to communicate risk in a way which maximises benefit and minimises harm, further studies need to be conducted in the local context to determine which methods are most suitable. Consideration of existing leadership styles and the expectations of the population will be of particular importance.

The Legitimacy and Relevance of WHO Guidelines

In deciding which healthcare policies to implement, it is necessary for the Singapore government to have the best available scientific information at hand. Especially when outbreaks traverse national boundaries, there needs to be an appointed organisation, such...