1.

2 How to Get the Most From This Unit

How to Get the Most from This Unit

Here are suggestions for getting the most from this learning experience.

Build on Your Own Experience

You'll get the most out of the unit when you are able to connect your own experience to the concepts
covered. This will help you activate knowledge and build deeper understanding. At various points in the
unit, you may be prompted to make connections to your own work. These are designed as opportunities to
reflect and extend the relevance of the unit examples to your own setting.

Physical and Technical Suggestions

This unit is best used on a laptop or desktop computer, which will give you the best view of the visual
content.

Headphones are recommended.

Internet connectivity is required, preferably with a strong connection. Some wifi networks may not be
suitable.

Tips

Navigate with the arrows at the bottom of each page. - You can click Modules on the left of the page any
time to return to the course outline.

Use the video controls to see full-screen videos and captions. -The controls let you show side captions or
screen captions and let you select video speed.
2.1 The Threat of a Pandemic

The Threat of a Pandemic

Hypothetical Pandemic Threat

In this unit, we will use the example of a pandemic threat to work through each of these systematic decision-
making approaches. While the scenario here is hypothetical, it is inspired by real-world events that illustrate
how public officials make important and sometimes urgent decisions. 

For the purposes of this unit, please consider yourself the decision-maker responsible for your country, state,
or district, and imagine that you are faced with the threat of a health pandemic.

Over the past few months, your medical and public health advisors have been tracking reported cases of an
unknown respiratory illness at hospitals, mostly in heavily populated areas. They have reached out to the
Centers for Disease Control in the U.S. and the World Health Organization to help diagnose the cases. As of
today, they report with confidence that there have been at least 50 confirmed cases, with up to a 120 more
candidates. Twenty people have died so far.

This hypothetical is taken from the health sector, but the decision-making approaches we will use to analyze
it can be applied to a wide range of decisions across all sectors. 

The H1N1 Pandemic

While this example is hypothetical, it is not unrealistic.  Health pandemics are a serious concern in today's
globalized world, for government agencies at every level.

This situation provides an opportunity to examine and learn about systematic approaches to policy decisions,
including learning from past pandemic situations. For example, national and regional governments
developed responses to the 2009 H1N1 pandemic. A map produced by the World Health Organization on
this pandemic is shown below. (Original image is here. (Links to an external site.))  
See the Further Resources in Module at the end of the unit for more examples of pandemic policy
responses. 

To learn more about the 2009 global pandemic, explore the optional information below.

Swine Flu Outbreak: Day by Day

Science Insider: Swine Flu Outbreak, Day by Day. Jon Cohen, Science, published online 9 June 2009.

This Science Insider column has an early day-by-day sequence of the swine flu events in 2009, tracing the
record of infection in March 2009 in Mexico City through the next 3 months of key events around the globe.
As the disease appeared in Mexico and North America in the first two months, the Mexican regional and
national public health authorities responded with a series of emergency policies to contain the epidemic. The
chronological sequence also notes the use of the WHO pandemic alert system and cites some reports that
criticize WHO and some of the national policy responses to the pandemic threat.

China and US: Responses Compared

The Council on Foreign Relations: Comparing the H1N1 Crisis and Responses in the United States
and China. Yan Zhong Huang, NTS Working Paper No. 1, November 2010.

This Council on Foreign Relations article compares the differing Chinese and U.S. responses to the H1N1
crisis. The U.S. pursued a mitigation approach; rather than focusing efforts on containing the spread of the
virus, energy was directed to strengthening surge capacity to best treat existing cases and diminish virus
spread, as was recommended by the WHO. On the other hand, China focused on a containment approach,
treating the H1N1 pandemic with the same protocol that would be used for much more severe diseases such
as the plague or cholera. These differing approaches can be partially attributed to Chinese political
incentives, which after the previous SARS outbreak led policymakers to act in such a way as to maximize the
appearance of legitimacy and visible concern for public health.

Lessons Learned in Mexico

BioMed Central: The influenza A (H1N1) epidemic in Mexico. Lessons learned. Cordova-Villalobos et
al. Health Research Policy and Systems, 28 September 2009.

This article assesses lessons learned from the Mexican response to the crisis. At the recommendation of the
WHO, Mexico developed a National Pandemic Influenza Preparedness and Response Plan in 2003 in
anticipation of such a crisis. Within five days of the first H1N1 death, all levels of the Mexican State, with the
active support of the President, fully engaged with the response. The success of the Mexican response
stemmed from the Preparedness and Response plan, a high level of coordination among Councils,
transparent communication with the public, and the solidarity of international organizations and foreign
governments. Operational difficulties encountered in implementing the Response plan, such as lack of
uniform data collection, will be solved and incorporated into future plans.

Australia's H1N1 Response

Australia's Winter with the 2009 Pandemic Influenza A (H1N1) Virus. James F. Bishop, Mary Murnane
and Rhonda Owen. New England Journal of Medicine, 31 December 2009.

Australia acted rapidly after April 25, 2009, when the World Health Organization declared H1N1 a "public
health emergency of international concern." The national coordination of efforts and use of a national
pandemic plan were again key aspects of the response, with the response particularly focused in this case
on vulnerable groups such as children under 5 and indigenous populations. The public messaging regarding
the pandemic used the phases "Delay," "Contain," and "Protect," to educate the public on appropriate
personal actions to reduce the impact of the virus.

H1N1 After Action Review

H1N1 after action review: learning from the unexpected, the success and the fear. David P. Fidler.
Future Microbiology, September 2009.

Finally, this high-level, ex-post perspective reflects on global lessons learned from the H1N1 pandemic. The
unexpected swine origins of the virus, combined with memories of the extremely deadly 1918-1919 influenza
pandemic, caused a global expectation that the virus would result in more severe mortality than it ultimately
did. In addition, the WHO pandemic-alert system at that time did not take into account the severity of the
virus, but only its geographical spread, leading the organization to classify the virus as a pandemic despite
the opinion of many governments and public health officials that its severity did not constitute a true
pandemic. Though the crisis was not as severe as imagined, it did unveil serious weaknesses in many
countries' response capabilities and highlighted the impossibility of geographically containing a highly
transmissible influenza virus, both of which have implications for future pandemics.

2.2 Pandemic Details and Valuing Impacts

Pandemic Details and Valuing Impacts

Pandemic Details

Before you think through how you'd handle this pandemic threat, take a moment to familiarize yourself with
some of the dimensions of the threat by reading the description here.  

HYPOTHETICAL PANDEMIC THREAT

The illness, respiratory in nature and transmitted by close contact, appears to be caused by an unknown
coronavirus strain.  Over the past month, medical and public health officials have been tracking cases of
these respiratory illnesses.  50 cases have been confirmed to date, with up to 120 other suspected cases.
20 deaths have resulted so far.
 HUMAN IMPACT:
The estimated mortality rate of 40% suggests an exceptionally deadly virus, but health authorities caution
that it is simply too early to conclude anything about mortality.  Even if the number of deaths is accurate,
the overall infection rate might be much higher than currently known.  All of the confirmed cases come from
the most populated, most urban areas, and data is scarce for rural areas that might also be affected.  Even
confirmed cases in the urban areas may only be the most serious cases (that present to hospital). 

At the present time, health authorities know little about the virus or the extent of the outbreak.  There is not
enough data to determine whether the worst is already over, or if the cases so far are just the beginning of
a serious outbreak.

ECONOMIC IMPACT:
Economically, your jurisdiction is struggling.  Unemployment rates are high, and a recent recession has
taken a toll on the financial resources you and your administration have to deal with this crisis.  You are
certainly in no position to deal with a major health catastrophe should this crisis worsen.

OPERATIONAL IMPACT:
Your department is understaffed and overworked.  If this threat requires immediate action, it will be a
challenge for your department to marshal the resources necessary to implement an immediate response.

DECISION:
What should your jurisdiction do to respond to this pandemic threat? 

Take a Perspective on Impacts

Based on the description you just read, think about the relative importance you might place on each of the
impacts this threat and your response to the threat is likely to have.

 There is the human impact, in terms of potential morbidity and mortality.

 There is the economic impact on the region.
 And then there is the operational impact on the staff and other resources of your department.

In approaching this problem, please indicate the relative importance that you would give to each of these
impacts in the survey below. This is a general survey of all participants taking the unit. You'll see the results
after you submit your response.  

Check Your Understanding, Reflections, and Try it Yourself Questions  

Every time you see this icon  , there will be a question for you to reflect upon and answer on your own.
You may be asked to write a short text response, answer  a multiple choice or true/false question, or
complete another question type. These are opportunities for you to apply what you are learning in the unit
and for you to view and understand your progress.  Please keep track of your responses along with any
notes you may be taking in order to support your learning.   

 
  Try it Yourself: Take a Perspective on Impacts 
How Important Do you Consider these Impacts? 

1 Not 2 3 4 Very

Human Impact 1 Not - Human Impact 2 - Human Impact 3 - Human Impact 4 Very - Human Impact

4 Very - Economic
Economic Impact 1 Not - Economic Impact 2 - Economic Impact 3 - Economic Impact
Impact

4 Very - Operation
Operation Impact 1 Not - Operation Impact 2 - Operation Impact 3 - Operation Impact
Impact

Feedback

There is no best answer here. Taking a perspective on the value of these impacts can support the decision-
making process. One value of taking a systematic approach is that, by making your priorities explicit, you
bring to the surface fundamental differences that -- if not addressed -- could lead to endless debate.

2.3 Emergency Response

Emergency Response

Recall your role in this scenario: you are the decision-maker responsible for the government response to
major health threats in your jurisdiction. You have economic, medical, and public health advisors.

Self-Check - Given What You Know Now, How Would You Proceed?

Given the pandemic information you have so far, and the competing opinions offered your advisors, which of
these would be your next action?

Take aggressive action immediately.

Wait to see whether the outbreak is severe or mild.

Feedback

On the next page, you’ll have the opportunity gather evidence and learn from similar cases. With this
additional information, think about whether your confidence in your choice of what to do next would increase
or whether you might change your mind. Note that this question is designed to get you thinking.

2.4 Making an Informed Decision

Making an Informed Decision 

Gathering More Evidence About the Current Situation

One step towards making a more informed decision is to gather more evidence about the current situation.
Here are questions you might pose to learn more about the relevant data currently available about the
pandemic scenario. As you will see, each question yields more information.

 
 Your economic advisor expects that an emergency response will reduce
What is the projected economic cost of economic activity in the region. He estimates the cost of the response to the
the emergency response? economy to be $600 million this year and $400 million next year (for residual
impacts).

After much debate, your advisors agree that there is a roughly 30% probability
What is the likelihood the outbreak is
that this will turn out to be a serious outbreak and a 70% probability that it will
very severe?
turn out to be mild.

How many lives will be saved by an Your health advisors project that a severe outbreak, unchecked by an immediate
emergency response in the case of emergency response, could claim around 600 lives. Under emergency response,
severe outbreak? they project mortality would be reduced to 120 lives, a difference of 480 lives.

Over 90% of the cases that have been reported so far have been reported by
Where are the reported cases coming
city hospitals. It is unknown how many additional cases have presented at rural
from?
hospitals, which are not as prepared to identify and report cases.

In 2 weeks, you will be able to get better, though not perfect, information on the
When will the severity of the outbreak severity of the outbreak. If the outbreak looks severe in two weeks (50% likely),
be known? there is a 50% chance it actually is severe. If it looks mild (50% likely), there is a
90% chance it actually is mild. 

Learning from Similar Past Cases

Another step towards making a more informed decision is to learn from similar cases in the past. Like many
countries, Canada, Mexico, the UK, and China have all had experience using aggressive emergency
procedures in response to pandemic threats, with varying degrees of success. You can read more about
each case below.

SARS in Canada

In late March 2003, Canada responded to an outbreak of the SARS coronavirus in Toronto by quarantining
roughly 100 people for every one confirmed case of SARS. In May 2003, the number quarantined had been
greatly reduced and the WHO declared Toronto free of SARS. One week later, SARS outbreaks reappeared
and quarantine procedures were put back in place.

H1N1 in Mexico

In 2009, Mexico's President Calderon declared an emergency in response to his country's H1N1 flu virus
outbreak, virtually shutting down the local economy in Mexico City. His actions were widely credited with
bringing the epidemic under control.

MERS in the UK

In 2013, the United Kingdom responded to an outbreak of the MERS coronavirus by initiating an aggressive
emergency response strategy despite having only 11 reported cases. France, Germany, and Spain had a
similar number of reported cases, but chose not to respond aggressively. The outbreak was contained in all
four countries.

H1N1 in China

In 2009, China responded to the H1N1 pandemic with an aggressive containment approach. Chinese
officials conducted on-board temperature checks for every incoming international flight and quarantined
entire groups of passengers if even one was found to have a high temperature. When the virus was
determined to be less lethal than originally thought, China scaled back its response measures which in
retrospect were determined by some experts to be an overreaction. 
Reflection Question: Are Similar Cases Relevant?

Do you find these similar cases relevant enough that they would inform your decision in this scenario?

No, they do not seem relevant.

Yes, they seem relevant.

Feedback: This question is designed to get you thinking.

3.1 Identifying Pros and Cons

Identifying Pros and Cons

Now that you have gathered more evidence about the current situation and have looked for lessons from
similar cases in the past, it helps to have a framework for processing this information. The first approach
we’ll consider is the simple approach of listing the pros and cons of implementing the emergency response.

The Pros of an Aggressive Emergency Response

The advisors in favor of this strategy argue that the emergency response will save lives. Taking immediate
action now, they say, will project strength which carries reputational benefits for the governing administration.
An emergency response now is also likely to prevent the virus from spreading further into other regions,
where if unchecked, it has the potential to take even more lives and cause additional economic damage.

Summary of the pros from the advisors in favor:

Minimizes potential loss of life

Immediate action projects strength to constituents

Prevents virus from spreading and affecting other parts of country

Another group of your advisors disagrees strongly with the emergency response strategy. They suggest that
the number of infected individuals simply does not justify any aggressive action -- yet. The outbreak itself has
already damaged the economy. The emergency procedures will further reduce economic activity in the area
by increasing panic and general disruption. These advisors also point out that the severe lack of information
on the virus at this point argues against doing anything drastic immediately. Too little is known about the
virus to suffer the expected economic costs of shutting down your jurisdiction. And the direct costs of the
emergency response itself are significant.

Summary of the cons from the advisors against:

Reduces economic activity in the region

Little currently known about virus -- emergency response may be overreaction

Expensive to implement

Reflection Question: Identify Another Pro or Con

Having considered your advisors' different positions, take a minute to brainstorm another pro or another con
you would add to either list based on your knowledge of the situation.

Write down whether you are identifying a pro or a con.

3.2 The Units of a Pro and Con List

The Units of a Pros and Cons List

Faced with this list of pros and cons, how do you compare the lists and arrive at a decision?

What are the units for items on the list of Pros and Cons for an Aggressive Response?

Match the correct unit to the corresponding Pro

Pros:

1. Minimizes potential loss of life

2. Immediate action projects strength to constituents

3. Prevents virus from spreading and affecting other parts of country

Units:

A. Unit = Regions Protected

B. Unit = Reputation Improved

C. Unit = Lives Saved

Match the correct unit to the corresponding Con

Cons:

1. Reduces economic activity in the region

2. Little currently known about virus--emergency response may be overreaction

3. Expensive to implement

Units:

A. Unit = Money Lost

B. Unit = Money Spent

C. Unit = Future Information Foregone

Click here to see the answer key:

bill.png Try It Yourself: Comparing Units

Examine the units for the pros and cons. Can you make any direct comparisons?

Yes, the units allow for comparison.

No, the units don't allow for comparison.

Feedback
The factors that make up the list of pros and cons are measured in very different units that make direct
comparisons problematic. Therefore, the correct answer is "No, the units don't allow for comparison."

Comparison Difficulties

On the previous page, you were prompted to add a new pro or con for this list. Does your additional item
share a common unit with the units for pros and cons already on the list? If your additional item does not
share a unit listed here, the direct comparison may have become even more complex by adding a factor that
is measured in a completely different unit.

Generating a list of pros and cons can be a good way to start on a problem, but for all but the most obvious
decisions it can become very difficult to weigh the pros against the cons and make a choice. Tackling this
problem involves one type of systematic approach to decision-making: the Cost-Benefit Analysis.