Preparing for a pandemic
LAST OCTOBER, a group of experts met in Geneva and acknowledged that, despite tremendous progress, the goal of eradicating polio by 2005 would not be realized. They also noted that the ''single greatest risk to a polio-free world" was Nigeria.
Why Nigeria? And, why does it matter to avian flu?
Today, the remaining polio is circulating in some of the world's poorest, most marginalized populations. Some of them are angry, frustrated, and distrustful of their own governments as well as foreign, particularly American, donors. They question why they should let their children be constantly vaccinated against polio when they are not getting vaccines and medicines to address diseases such as measles and malaria that they feel are their priority.
Distrust around the polio eradication campaign became so acute in a few states in northern Nigeria that they boycotted polio vaccination, some convinced that it was a sterilizing agent targeting Muslims. As one local leader said, ''We see the news. We see what America is doing in Iraq. And, you want us to take these vaccines?" Kano State sustained the boycott for 11 months, leading to polio outbreaks that spread beyond Nigeria as far as Indonesia, presumably via Mecca.
Nigeria was not the first country where vaccine refusals emerged. In 2002, a polio outbreak in Northern India was partly fueled by similar rumors and vaccine refusals. In one year, the number of polio cases in India increased from 268 to 1,600.
What does this all have to do with avian flu?
One of the biggest lessons from the polio eradication effort is the importance of building trust with communities, particularly marginalized, underserved communities that are distrustful of the ''powers that be." Many have not received the services they rightly need, and they are not going to easily collaborate with a state-driven agenda, unless there is clear understanding of why it matters to them. Not, why it matters to somebody else, but why it matters to them.
Isolation or ''social distancing" measures to minimize the spread of a lethal flu are not going to be easily adhered to in the current environment where many feel that their civil liberties are being over-impinged upon. Trust between health authorities, communities, and local businesses needs to be built through transparent, early, and candid information sharing. Trust is not built in a time of crisis or emergency.
In the polio eradication initiative, the importance of trust building was learned late in the game. The technical strategy was in order. The vaccines were available. There was financial and political commitment at the highest levels. What was missing at the end of the day, in some of the most difficult-to-reach areas, was social will. All of the ''political" will in the world is not enough to achieve public health goals without the will of the public.
An investment in building public trust, before the vaccine delivery ''push," might have saved the polio eradication effort millions of dollars. Some of the areas where the global effort hit stumbling blocks should have been no surprise. The problems arose among populations marginalized for political, religious, and socioeconomic reasons, where health service delivery is weak or nonexistent. An earlier effort was needed to understand the local sociocultural and political risks, and to look for opportunities for positive engagement with communities. Similar advance analysis could save resources and lives should a human avian flu pandemic occur.
We may or may not have a vaccine ready for H5N1 or any other lethal strain of the flu that may emerge. Even if there is a vaccine, it is unlikely that there will be enough for everyone. What we can have ready is an informed public that understands what they need to do in order to protect themselves and their community to whatever extent possible and to build community-resilience networks.
Now is the time to start considering the implications of reorganizing ourselves in the face of a pandemic. Who will we rely on if we cannot go to work, the schools are temporarily suspended, and the markets are running out of food and water? Who can we trust in a time of distress? We have time to assess where the weak points in the system will be and start to address them, to start community dialogues, and understand the fears as well as strengths of local communities to respond. Vaccine and drug strategies are essential, but are not enough.
This is not just about avian flu. This is about overall preparedness.
Heidi J. Larson is a research associate at the Harvard University Center for Population and Development where she is working on a book, ''Risk and Rumor in Public Health." 
