Framing Post-Pandemic Preparedness: Comparing Eight European Plans
Martin Holmberg & Britta Lundgren. Global Public Health. Volume 13, Issue 1, 2018.
In the six years since the first influenza pandemic of the twenty-first century—the A(H1N1) pandemic of 2009—extensive research in the fields of epidemiology, social medicine, medical anthropology, and policy studies has been conducted along with a plethora of national and international evaluations of how the pandemic was managed. Most nations in the developed countries had worked for years to prepare for such an event and had produced pandemic preparedness plans at all levels. However, the pandemic did not turn out as expected in the planning, and this has led to some critical thinking about the anticipations resulting from this atmosphere of preparedness.
Framing has previously been studied in the field of pandemic preparedness and global health governance, and this paper was inspired among others by the project The Transformation of Global Health Governance: Competing World Views and Crises that was supported by the European Research Council (McInnes et al., 2012). The key findings in their project were that five 'visions' and their accompanying frames were present in contemporary global health governance—security, evidence-based medicine, economics, human rights and development. In the field of pandemic influenza the framing was found to be more restricted, mostly concerned with security and evidence-based medicine. In our review of the national preparedness plans, we are searching for signs of all of these visions, but with a special focus on the securitisation of pandemic influenza.
During the past decade, emerging infectious diseases, including pandemic influenza, have repeatedly been framed in terms of health security and 'securitisation' as the process of making a new field a security concern (Buzan, 1998). The securitisation of health, including pandemic influenza, has been studied from many perspectives (Elbe, 2010; Enemark, 2009; Kamradt-Scott & McInnes, 2012). Health security is still not a well-defined concept, and it is seen by many researchers as less of a one-time agenda-setting and more of a process where consensus can shift over time (Kamradt-Scott & McInnes, 2012). That security is only about existential threats has also been contested. The securitisation process influences the ways of preparing for an influenza pandemic, and it is now possible to ask how this has changed in light of the 2009 A(H1N1) pandemic.
The World Health Organization (WHO) has been instrumental in securitising pandemic influenza (WHO, 2007). Its 2009 guidance document referred to a six-phase structure of pandemics based on the extent of transmission—not the severity of a disease—and it harmonised recommended measures with the phases as well as with the 2005 International Health Regulation (IHR) legal framework. The updated guidelines of the WHO (2013) instead stress 'national risk assessments' where each WHO member state is encouraged to conduct its own risk assessments and to adopt a framework of 'Emergency risk management for health'. Many European countries have waited for the new WHO guidance before publishing their own revised preparedness plans.
The aim of this article is to examine how the preparedness planning of pandemic influenza has developed after the 2009 A(H1N1) pandemic in a comparative study of post-pandemic European national preparedness plans. We follow in the footsteps of the project The Transformation of Global Health Governance mentioned above (McInnes et al., 2012), using framing theory to analyse official documents concerned with global public health issues. We examine how the social construction of preparedness is structured through the themes of 'uncertainty', 'pandemic phases', 'risk management', 'vulnerability' and 'surveillance', using frame analysis and a narrative approach.
Explaining the historical motives and traditions of national preparedness thinking, or critically analysing the securitisation of influenza pandemics and the consequences of reframing the preparedness plans is not attempted in this initial exploration. We hope that this approach can give a broad overview of some problems in preparedness thinking and bring some new ideas to the planning processes.
As of October 2015, nine European post-pandemic national plans had been published (http://www.ecdc.europa.eu). Eight of these were in English or Scandinavian languages (the Dutch preparedness plan from 2011 was not available to us in translation). We examined the pandemic preparedness plans of the Czech Republic, Denmark, Finland, France, Norway, Sweden, Switzerland and the UK, that were published in the period after 2009. Neither Switzerland nor Norway are members in the EU but both take part in the coordinating of pandemic preparedness at the EU level. These documents varied in length (49 to 247 pages) and disposition, and totalled 838 pages of text altogether. The Scandinavian documents were read by us untranslated. (The Finnish plan had a Swedish language version). The Czech, French and Swiss plans all had official versions translated into English and these are used in referring to or quoting from these documents.
The presentation of the content and the headings and subheadings are very different in the eight plans; there is no unified disposition of the content that could be used as a starting point for our framing study. We have instead tried to find key themes present in all the texts and compared the framing of these. We have found that all plans refer to themes of 'uncertainty', 'pandemic phases, 'risk management', 'vulnerability' and 'surveillance'. We summarise how these themes are framed and how the vision of pandemic influenza preparedness is related to security, evidence-based medicine, economy, human rights and development. Furthermore, narratives are powerful ways of framing and of making sense of complex phenomena, and we were interested to examine if any 'institutional' narratives could be discovered that could influence the framings.
Review of the Eight Plans
The first thing to consider regarding the plans in this study is who is responsible for them, at what level in the government they have been developed, and with what mandate they are published. The majority have been produced at a ministerial level and signed by the ministers of health in the respective countries. In Sweden and Denmark it is the Swedish National Board of Health and Welfare and the Danish Health and Medicines Authority, respectively, that publishes the preparedness plans, and this gives the Ministries of Health a seemingly more limited role in these two countries. The Swiss plan is published by the Federal Office of Public Health and signed by its director and the President of the Federal Commission for Pandemic Preparedness and Response. The responsibilities of the whole government are clearly outlined in the Czech, Finnish, French, Swiss and UK plans, making them the most inter-sectorial.
The second thing to note is how the respective documents are characterised by their titles. The Czech, Finnish, French, Norwegian, Swedish and Swiss documents are called 'plans', while the Danish and UK documents are called 'strategies'.
The Swiss, Finnish, French, Norwegian and UK plans describe themselves as complete revisions of earlier plans, while the Czech, Danish, and Swedish plans are described essentially as continuations of previously successful plans. Most European states have performed national evaluations of the management of the 2009 pandemic including how their plans were used. Evaluations at the EU level (WHO, 2010) and a global analysis commissioned by the WHO have also been published (WHO, 2011), but it is not within the scope of this paper to systematize the results of these evaluations. However, a general theme in most of these evaluations was that the preparedness was not really tested by the 2009 A(H1N1) pandemic and that the world is still not fully prepared for a new pandemic (Fineberg, 2014).
The Swiss, Norwegian and UK plans describe how stakeholders have been consulted in the making of the documents, the others do not comment on this. None of the plans describe any public or community consultations, although the Czech plan mentions that 'the issue of pandemic planning should be a responsibility of society as a whole' (Ministerstvo zdravotnictví, 2011, p. 1)
The Concept of Strategic Uncertainty
A common practice in planning for pandemics has been to refer to the uncertainty of influenza pandemics as a reason for the relatively weak evidence base for decisions. The uncertainties in pandemics have been attributed to biology as well as to epidemiology (MacPhail, 2010). The viral uncertainty involves the identity of the virus and the very concept of what constitutes a viral species. Knowledge about viral reproduction, recombination and reassortment also leads to an understanding of the inherent uncertainty that derives from the biology of the pandemic.
The epidemiological uncertainty depends on how the epidemic is framed. Epidemics can be articulated reductively, as isolated from social space and time, or in a more context-inclusive and trans-disciplinary manner. The uncertainty is constructed in different ways depending on whether social and cultural factors are weighed into the epidemiological process or not, which might lead to alternative pathways of preparedness and response actions.
Uncertainty has also been described in the categories of 'known unknowns' and 'unknown unknowns'. As has been suggested by Nicoll et al. (2010), there are some things that can be assumed about all influenza pandemics (the known knowns), and there are some important things that vary between pandemics where we cannot make assumptions beforehand. These have been called known unknowns. Inherent uncertainty and unpredictability are different concepts and have been called 'the unknown unknowns'. By declaring the unknown as certain or expected, the uncertainty can be put to strategic use (MacPhail, 2010). In some plans, the use of uncertainty strategically has taken a salient position in terms of the fundamental uncertainty of the disease and the course of events (DH Pandemic Influenza Preparedness Team, 2011). Or in the words of the French plan:
By their nature, crises involve uncertainty. While it is possible to reduce it, it can never be totally eliminated. This uncertainty is particularly high in health crises. During an epidemic, a mutation that makes the virus more virulent is always possible, for example. It is necessary to accept that there are many unknowns and to learn to deal with the crisis in a very uncertain context. (Ministère des Affaires sociales, de la Santé et des Droits des femmes, 2011, p. 5)
Other plans also highlight the unpredictable nature of pandemics, which motivate flexible plans, as well as what is presently unknown about future pandemic viruses (Federal Office of Public Health [FOPH], 2013; Socialstyrelsen 2012). This seems similar to the 'known unknowns' and also agrees with the view of influenza as a 'slippery disease', a phrase that was coined after the Fort Dix incident in 1976 (Neustadt & Fineberg, 1978). Still other plans, such as the Danish plan, refer to traditional public health risk assessments to support the management of a pandemic and are less concerned with uncertainties (Sundhedsstyrelsen, 2013). When uncertainty is used in a strategic way, it has been claimed to strengthen the position of evidence-based framing (MacPhail, 2010). However, we find that it is most obvious in the most securitised plans—the British and the French.
Pandemic Phases
At the core of pandemic framing is the construction of pandemic phases and what perspective to take on spatial and temporal developments of the pandemic. These phases can be defined and modelled in different ways depending on underlying theories. If they are constructed from epidemiological theory, they will include concepts such as pre- and post-outbreak, epidemic curve, peak and remission. If they are motivated by crisis-management theory, they will include concepts such as alarm, awareness, response and recovery. However, these theoretical stances do not provide the full story of how societies identify new diseases and how they respond to these threats. When examining the plans, we found that the framing of the pandemic phases is central to each plan and that the plans contain competing frames.
Originally, the WHO phases were modelled on the anticipated spread of the avian flu A(H5N1) with the first three phases involving the virus circulating in animals (in this case birds). The fourth phase involved a presumed sustained transmission among humans. This was followed by phases five and six that involved a widespread pandemic defined as sustained transmission among humans in two or more WHO regions. The phases were described as globally applicable and as a framework for aiding national preparedness planning.
In the new WHO (2013) guidelines, the global phases are made more generic than in the 2009 document—including the 'inter-pandemic', 'alert', 'pandemic' and 'transition' phases—and these phases allow for different processes of emergence and are more oriented towards management. The new document also states that countries and regions could experience different risks at different times thus making the global phases less applicable locally. Risk-management decisions are now expected, therefore, to be informed by the WHO global phases but based on local risk assessments. Five of the countries—Denmark, France, Norway, Switzerland and the UK—have changed their national pandemic stages, but the other three (The Czech Republic, Finland and Sweden) still adhere to the six WHO phases from 2009 (their national plans were all published before the new WHO phases were published).
In Switzerland, the WHO guidelines are still the foundation for pandemic preparedness planning. However, in the interests of flexible planning that more closely matches national needs, the national strategies and preventive measures are no longer linked to the WHO pandemic phases and now include 'normal influenza activity', a 'pandemic phase' and a 'post-pandemic phase'. There is also an escalation model based on situations defined by the new Epidemics Act as a 'normal situation', a 'particular situation' and an 'extraordinary situation'.
In Denmark, the six WHO phases have been simplified into four phases that are considered global: the 'inter-pandemic period', the 'pre-pandemic alarm period', the 'pandemic period' and the 'post-pandemic period'. The WHO still declares the global phases, and the national authority (Sundhetsstyrelsen) announces the Danish national phases in coordination with the WHO's declarations.
France does not consider the WHO phases necessarily corresponding to the situation within the country because the propagation of the virus and the pandemic waves are not simultaneous over the entire globe. The situation can also differ very substantially between mainland France and its overseas territories. Four national pandemic stages are declared in France, each with its own specific goal. The first is to slow down the introduction of the virus into the country. The second is to slow down the propagation of the virus once it is within the country. The third phase is to attenuate the effects of the epidemic wave. The fourth and final phase is to return to the former situation and prepare for the possible next wave of the epidemic.
The UK has developed a new approach to the indicators for action in future pandemic responses. This takes the form of a series of phases named 'Detection', 'Assessment', 'Treatment', 'Escalation' and 'Recovery' and incorporates indicators for moving from one phase to another. The phases are not numbered because they are not seen as linear, and it is possible to move back and forth or to skip over phases. There also might not be clear delineations between phases, particularly when considering regional variations.
These new national stagings of pandemics differ in an essential way. They either refer to an epidemiologically based staging as in Denmark and Switzerland or to a risk-based staging, as in France and the UK (The most recent WHO (2013) document represents a hybrid between these two). This distinction might seem insignificant because the epidemiological staging is closely tied to actions and to the emergency response. However, the risk-based staging adheres more closely to generic emergency management and moves the focus from public health actions on the ground to centralised emergency command centres and thus to a security-based framing.
The pre-2009 preparedness plans have been described as schemata of pre-made strategic and tactical decisions rather than flexible plans for action. They were tightly linked to pre-defined phases of a 'generic' global pandemic, and different steps in organising and managing were supposed to be triggered automatically. In an emergency such as a pandemic, it was thought that there would be little time to deliberate on what actions to take and that having well-defined stages of the pandemic were essential to the decision process. Batteries of pre-made decisions and checklists to control events and coordinate the different actors were recommended by the WHO and implemented in the national plans—an approach that has been called 'the bureaucratic reflex' (Barker, 2012, p. 703).
Following evaluations by the European member states and the Fineberg (2014) report to the WHO (WHO, 2011), a more flexible approach has been advocated and a concept of 'emergency risk management for health' has been introduced. This is part of a new framing of pandemics as generic emergencies that can be understood in the light of knowledge and practices from disaster or crisis management, and such a framing has been adopted in all of the plans studied here. However, how the continual and flexible risk assessments are to be organised is not clear in all plans.
Is the emphasis of the response to a pandemic on containment of the threat, delaying or reducing its spread or adapting to it by mitigating actions? Depending on the state of beliefs and knowledge about the threatening infectious agent, the emphasis might be placed on one or the other of these basic strategies. But choice of strategy also depends on what the prevailing views are on governmental ability and societal resilience.
The possibility to contain a pandemic early in its spread has been devalued by the WHO in the new guidelines (WHO, 2013) and this is also reflected in the different national plans. It is only the Czech, French and Swiss plans that discuss this strategy at all and give it a limited role, basically as a possible international task. When it comes to delaying and reducing the spread of the infectious agent in a country, there are several distinct framings, either trusting antivirals as crucial for restricting spread or 'social distancing' as effective, sometimes these in combination. The countries that are in the most optimistic end of the spectrum regarding the possibilities to delay and restrict the spread nationally are Finland, Sweden and France; the most pessimistic are Denmark and the UK.
In Finland, the view is that there are several ways to reduce or even deflect a pandemic at the border that are not based on vaccination or pharmaceuticals, including travel restrictions, vetting of passengers, isolation and treatment of the ill, surveillance and quarantine of the exposed, closure of educational facilities, education about using good hand hygiene, and informing the public about risks and ways of protecting themselves. Some of these measures are seen as no longer possible during a full-blown pandemic due to lack of resources. The countermeasures can be changed or terminated when deemed ineffective or too disruptive.
The French strategy is to first identify the virus and to limit the epidemic at the source as much as possible through international assistance. This is followed by attempts to slow the dissemination of the pandemic through measures such as isolation, treatment, prophylaxis, managing transport and border controls. The plan also calls for attenuating the health impact by limiting contacts in places of high human concentration such as schools.
In the UK, a principled response based on precaution, proportionality and flexibility is advocated in order to minimise the harm caused by the pandemic as a whole.
This means that it almost certainly will not be possible to contain or eradicate a new virus in its country of origin or on arrival in the UK. The expectation must be that the virus will inevitably spread and that any local measures taken to disrupt or reduce the spread are likely to have very limited or partial success at a national level and cannot be relied on as a way to 'buy time'. (DH Pandemic Influenza Preparedness Team, 2011, p. 11)
The Swiss and Danish plans make the protection of life and health of the population their main strategic goal and all other goals are seen as secondary to this. In the other plans, protection of health and societal functions are equally prioritised. In the words of the French plan:
In addition to its health impact, an influenza pandemic can cause disorganization of the health system, and also disturbances in social and economic life. The response to it involves not simply a health care approach, but also an inter-sector approach. (Ministère des Affaires sociales, de la Santé et des Droits des femmes, 2011, p. 4)
While the Danish, Swedish, Swiss, Norwegian and UK plans place an emphasis on general principles, strategic goals, and co-ordination, the Finnish, Czech, and French plans place their emphasis on organisation, preparedness for contingencies, and support for decision-making.
The UK plan sees the impact of a pandemic as being determined not only by the characteristics of the disease and the capacities of health care and emergency services, but also by the public response. In this plan, the public's response reflexively can have a mitigating effect on a pandemic's impact (DH Pandemic Influenza Preparedness Team, 2011), but it could also act as a hindrance to implementing countermeasures:
… behavioural science indicates that communication should not rely upon an overly linear or 'rational' model of human behaviour, where information is provided and people judiciously weigh up the pros and cons of acting on that information. Awareness is not always correlated with action … (DH Pandemic Influenza Preparedness Team, 2011, p. 47)
The other plans frame the impact as dependent on the vulnerability or defencelessness of the population in addition to the characteristics of the disease. They construct a much more passive role for the public—basically they are to 'do as they are told'. However, the French plan also assigns a restricted active role for the public outside government actions:
The actions of the Government and of various public and private organizations are insufficient in and of themselves. A mobilization of the population is also indispensable. This involves participation in solidarity with family and neighbours … (Ministère des Affaires sociales, de la Santé et des Droits des femmes, 2011, p. 22)
There are thus differing opinions about the possibilities to delay or restrict a pandemic once it has started to spread in a country outside its origin. Within a framing of pandemic influenza as a security issue, the opinions on how we best secure ourselves differ. The recommended measures are generally framed in terms of evidence-based medicine in a way that also strengthens the security framing. Denmark, the Czech Republic and the UK are more sceptical about the possibility of altering the course of a pandemic even with available antivirals and vaccines, and have not included mass vaccination of all citizens in their plans, while Switzerland, Finland, Norway and Sweden see this as a possibility. In the case of Sweden, there is an argument that a vaccine could be available before the pandemic has reached its borders, which would increase the chances of delaying or reducing the spread (maybe a convincing argument in countries who believe they will be in the periphery of a pandemic). France views measures to delay the spread as important, but it does not aim for mass vaccination to achieve this. However, all plans include vaccination of groups of people as an important countermeasure to mitigate the effects of a pandemic.
Antivirals are seen as variably important, especially in the period before a pandemic vaccine is available. Some countries will deploy them widely, relying on them to help delaying the spread of disease; others will mainly use them for treatment of serious disease and protection for special risk groups. The different policies regarding use of antivirals were obvious during the 2009 pandemic and they seem not to have changed much since then.
Finally, different non-medical interventions are discussed in all plans. There is no controversy regarding hygienic measures, but for other interventions, notably school closures, different policies are adopted. Some countries seem more willing to use school closures early in the course of a pandemic, while other are more hesitant.
In influenza pandemic preparedness, attention has been directed toward identifying and protecting groups with chronic diseases or other conditions that put them at increased risk for medical complications from influenza (WHO, 2009). Vulnerability has also been described more universally as a lack of immunity, information and resilience (Stephenson et al., 2014). Furthermore, it is possible to see vulnerability in terms of social structures through the lens of the social determinants of health, which could influence daily resilience and lead to disproportionate impact from a pandemic (O'Sullivan & Bourgoin, 2010). An important question to ask, therefore, is whether the national preparedness plans articulate a general vulnerability as a form of insecurity (a security framing), a 'social determinants of health' framework (a development framing), or a framing of groups at risk for medical complications (an evidence-based medicine framing).
In most plans there is no trace of a 'social determinants of health' framing (Ministerstvo zdravotnictví, 2011; Socialstyrelsen, 2012; Sundhedsstyrelsen, 2013). In some plans there are paragraphs on the continuity of social services (DH Pandemic Influenza Preparedness Team, 2011; Social-och hälsovårdsministeriet, 2012) that are still framed as an emergency response, but recognise social vulnerability as such. One plan, the French, mentions socioeconomically vulnerable groups as a special concern and describes a need for community solidarity to help isolated and excluded persons. However, this is not seen as a fundamental state responsibility (Ministère des Affaires sociales, de la Santé et des Droits des femmes, 2011).
The medically at-risk groups are described similarly in most plans and form the basis for prioritising vaccines in the case of a shortage. However, in the Finnish plan the priorities for protection are strictly by age groups regardless of chronic medical conditions or social status. The reasoning behind this is to save the maximum amount of potential life years by weighing the expected remaining years to live with the age-related mortality of the pandemic (Social- och hälsovårdsministeriet, 2012). Several plans also discuss the protections of certain professional groups by arguing that certain occupations are of special importance to society and are particularly vulnerable to disruptions. This protection could be achieved through targeted prophylactic antiviral treatment or through prioritised vaccination when a vaccine is available. There is a consensus in all the plans to protect health care workers. Only the Czech and the Danish plans mention the protection of other employees that have 'essential' functions. In the Danish case this seems somewhat contradictory considering their overall strategy to prioritise the protection of health.
Vulnerability could also be framed as an exposure to adverse effects caused by countermeasures, whether medical or non-medical. A critical adverse effect would be side effects of pandemic vaccines because vaccination takes centre stage in all of the plans. This was precisely what happened in the 2009 pandemic when vaccine-associated cases of narcolepsy emerged in several countries (Ahmed et al., 2014). The two countries with the most cases were Sweden and Finland, but France, the UK, Ireland and Norway also had documented cases. In light of this, one would expect the plans to mention narcolepsy cases and the possibility of these or other unexpected adverse effects when using a new pandemic vaccine. A strategy for post-vaccination surveillance and plans for compensation for those affected by following government recommendations would also be expected. The plans of Denmark and Finland mention the narcolepsy cases, but none of the others do. This is remarkable, especially for Sweden, which had the highest coverage with pandemic vaccine and the highest number of vaccine-associated narcolepsy cases.
Significant ethical considerations come into play when deciding how to protect the vulnerable, avoid harm, and be fair and transparent. These would also be considerations for a human rights framework. Solidarity has been seen by some philosophers as an essential requirement for the possibility of ethical decision-making (Dawson & Jennings, 2013), thus it is relevant to examine how the plans frame solidarity. All the plans state that ethical considerations are necessary, but some of them defer the ethical considerations to special ethics committees or to separately published frameworks. Solidarity is mentioned only in three of the plans, and each of these has a different understanding of the term. In the Finnish plan, it is expressed as international solidarity with less fortunate countries and as placing a value on global health. In France, solidarity is framed as a value for local governance where authorities and organisations should encourage the citizens to act with solidarity. It is only in the Swiss plan that the concept of solidarity is discussed at length and with a similar meaning as that understood by Dawson and Jennings (2013) as a collective relation between people that is essential for social coherence. Framing preparedness in terms of solidarity is in line with a human rights framing, but possibly wider as it includes moral obligation and not only rights.
Surveillance and Monitoring
An important consideration is the logic behind surveillance in the plans and whether such surveillance is seen as gathering public health knowledge for public health action (an evidence-based policy framing) or as intelligence gathering for crisis management (a security framing). The plans differ in how surveillance is framed. Those that base their view of the pandemic phases in epidemiological terms place surveillance at the head of their plans. They stress the routine seasonal influenza surveillance as the backbone structure in a pandemic situation supported by monitoring the burden on health care resources and monitoring vaccination coverage. Some countries also have mortality monitoring as part of their routine surveillance, and others will include it during a pandemic. In some plans there is a mention of surveillance of animals (birds, poultry, pigs, etc.). The two plans with an emergency-based staging of the pandemic (France and the UK) do not include surveillance as a pillar of preparedness in the same way as the others. In the early stages, their emphasis is on the initial detection of the pandemic and on assessing the severity of the illness, the age groups and populations that are the most affected, and how transmissible the virus is (DH Pandemic Influenza Preparedness Team, 2011). In France, surveillance is seen as a part of the multi-sectorial response and is closely linked to the stages of crisis management (Ministère des Affaires sociales, de la Santé et des Droits des femmes, 2011).
Pandemic Narratives
The framing processes through the different themes describe important aspects of the mind-set and propensity for action in these countries. Viewing the pandemic more holistically as narratives, as strategic, functional and purposeful (Riessman, 2008, p. 8) and not just as a list of framings of categories or themes adds another dimension to the picture. Leach and Dry (2010) have pointed out how disease and epidemics 'are constructed through different narratives that justify and shape different pathways of response' (p. 6). Following Scoones (2010) in his research on the avian influenza, the international response during the last decade is shaped by three overlapping outbreak narratives. The first links veterinary concerns with agriculture and livelihood issues (Scoones, 2010, p. 139). This narrative can be traced to a limited extent in the plans. Several of the plans mention influenza in animals (mainly in birds, almost never are pigs mentioned). The popular name 'the Swine flu' for the latest pandemic is mentioned only in the Scandinavian plans (except in the Danish plan, Denmark being a big pork producer). Only two plans want to call influenza a zoonosis (an infection that can be transmitted between humans and animals), and only one, the Norwegian, discuss measures to decrease contacts between humans and animals. The second narrative, which is more commonly represented in the plans, is about the human public health where 'human-human spread is the real risk, and could be catastrophic'. This narrative invokes the use of epidemiological success stories such as vaccination interventions, antivirals, hygiene measures etc. The third narrative, which is at the core of the plans, is the narrative focused on pandemic preparedness: 'a major economic and humanitarian disaster is around the corner and we must be prepared' (Scoones, 2010, p. 140).
The temporal dimensions of narratives, their origins, sequences and phases, and their ways of 'remembering the past' (Riessman, 2008, p. 8) are evident in the plans. The origins of influenza pandemics, how they evolve over time and space, what we can do about them and what transformative powers pandemics might have, are framed in different ways in the documents.
Most plans describe influenza pandemics by the four pandemics of the past 100 years, starting with the Spanish flu. Not much is said about geographic origins, only that they can never be predicted. This gives the readers an impression that influenza pandemics are emergent, modern phenomena. Only three plans mention a longer history; the Danish plan mentioning the 'Russian flu', the Czech trace influenza pandemics back to the sixteenth century and the Swedish plan characterise them as thousands of years old. A second and possibly a third wave of a pandemic are seen as almost a natural law and not as a contingent phenomenon. In several plans the second wave is also described as the 'strongest'.
None of the plans describe any social or political factors, or convergence between these and biological and physical factors that could have influenced the emergence of the pandemics. Although the past 100 year period has seen one of the greatest health transitions of all time in the industrialised nations, this is not reflected upon or how this could influence the impact of influenza pandemics.
Regarding the course of pandemics and their threats to security, we have seen some of the similarities and differences in framing in the previous sections. The influence that the WHO pandemic narrative has had is obvious. One paradoxical part of this story is how the post-pandemic (or inter-pandemic) period is described. Almost without exception this is said to be a return to 'normalcy' or the 'way it was before'. In light of the envisioned threats to social order and even basic values such as democracy or rule-of-law, it is perhaps surprising that long-term effects are not seen as a possibility. Actually there is one plan, the Czech, stating that a pandemic can have 'negative impact on the social and economic activities of communities, which may persist long after the pandemic period has passed' (Ministerstvo zdravotnictvi, 2011, p. 3).
Discussion and Conclusions
Even though the 2009 A(H1N1) influenza led to a state of emergency and substantial morbidity and mortality that burdened health care systems in many countries and was costly to health care budgets, most evaluators have claimed that the 2009 pandemic was mild and that the WHO definition of a pandemic was unstable (Abeysinghe, 2015; Doshi, 2011). However, no official evaluations have explicitly judged it not to have been a threat to national or global security. This is in line with security research since the 1990s that considers security a speech act and a social construct and not something that can be quantified, while severity of a pandemic could be measured in several different ways. This creates a tension between securitisation and severity judgements about pandemics.
From our review of how different themes are presented in the plans, it becomes evident that there are variations in the processes of framing in the different countries. Uncertainty is sometimes emphasised, sometimes not. There are alternative formulations of pandemic phases. The views on risk management, vulnerability and surveillance are different, sometimes in very fundamental ways. Regarding the five visions in global health governance that McInnes et al. (2012) describe, we find that a security framing takes centre stage in all the plans. The strategic use of uncertainty, in our view, strengthens the security framing more than the framing of evidence-based policy. Framing pandemic threats in economic terms does appear in some of the plans, but tightly coupled to security and only in the Czech plan as a possible long-term effects on the economic system. The framing of pandemic preparedness in development terms is absent; there is, for example, no discussion of how developing public health or health care systems generally could increase resilience to a pandemic. There are traces of framing preparedness in terms of solidarity in some plans. These differences and alternative framings could serve as a platform for further discussions about possible re-framings of plans.
The current plans analysed here contain two main referent objects of security concerns—public health and vital systems as previously observed by Lakoff (2008). In addition, the Swedish and UK plans also mention basic values such as democracy, rule-of-law, and human rights, implying that these values can be threatened by a severe pandemic and thus be a matter of political security. The French plan mentions disturbance of public order but adds that this type of impact has very rarely been observed in past pandemics. Often the plans refer to social or economic functions that are threatened, rather than systems, and differ in how they describe society in terms of complexity, interdependence, stability and resilience. The vital functions or systems considered to be under threat also vary. All plans naturally mention protection of the health care system, and some also emphasise the 'common' functions that are used by the general population and where disruptions would make people suffer directly (e.g. energy supply, postal service, and public transport). Others emphasise functions or systems vital to public order and national security, such as police and the military, or to the national economy, such as trade, tourism, and production. This makes the question 'security for whom' relevant.
The multiple framings we have described show differences in how radically the securitisation has progressed in the different countries and with what underlying strategic logic. The two largest countries in this study, France and the UK, are the most advanced in this respect. However, according to Lentzos and Rose (2009) they differ in their logic of health security preparedness with France taking a more 'contingency planning' route and the UK a more 'resilience building'. Some of the other plans come close to what Lentzos and Rose (2009) name 'protection', which is a more public health-oriented and traditional approach. Still other plans seem to be a mixture of these logics.
How the pandemic preparedness plans are framed tells us something about how the different countries want pandemics and preparedness to be understood by the public. The plans do not necessarily reflect the totality of their policies, and some agendas might not be communicated. Furthermore, the framing might not always reflect deliberate communicative goals; some frames can emanate from unreflected assumptions in the 'epistemic communities' that are responsible for giving advice on the plans, or, in the words of Forster (2012), 'reductive technical framings emerging from tight, unreflexive actor networks' (p. 1).
Exactly which of these epistemic communities are present or influential in the different countries is not possible to determine from the plans. To fully understand the framing, it is necessary to gain knowledge of the processes of pandemic preparedness planning in the different countries, who influences them, and who the stakeholders are. As Leach and Dry (2010) put it: 'Depending on which actors (working within which institutions and political contexts) are doing the framing, different forms of knowledge, different entities and indeed, different problems will be considered relevant' (p. 13). Cultural traditions, world views and social structures in the respective countries, as well as different bio-political strategies and different pandemic narratives must also be considered in studying preparedness planning. These are subjects for future work.
This paper has focused on differences in framings more than on similarities. Of course, the different European countries in many ways deal with pandemic preparedness in similar ways. There were only a few major controversies during the 2009 pandemic, and much of the management was well coordinated. However, a close reading of the new post-2009 pandemic preparedness plans shows considerable variation in framing and the overall logic of the preparedness policies. The EU parliament and council decision No 1082/2013/EU on serious cross-border threats states in paragraph 12:
Consultation with a view to coordinating among the Member States is necessary in order to promote interoperability between national preparedness planning in view of the international standards, while respecting Member States' competence to organise their health systems. Member States should regularly provide the Commission with an update on the status of their preparedness and response planning at national level.
The pandemic preparedness plans in the member states diverge in ways that will challenge their 'interoperability' and the ambition of the European Commission to coordinate actions in future pandemics.
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