The Expert and the Lay Public: Reflections on Influenza A (H1N1) and the Risk Society

摘要

Trust between the lay public and scientific experts is a key element to ensuring the efficient implementation of emergency public health measures. In modern risk societies, the management and elimination of risk have become preeminent drivers of public policy. In this context, the protection of public trust is a complex task. Those actors involved in public health decision-making and implementation (e.g., mass vaccination for influenza A virus) are confronted with growing pressures and responsibility to act. However, they also need to accept the limits of their own expertise and recognize the ability of lay publics to understand and be responsible for public health. Such a shared responsibility for risk management, if grounded in participative public debates, can arguably strengthen public trust in public health authorities and interventions. The influenza A (H1N1) virus pandemic was not as devastating as expected, so the preventive health measures that were deployed to cope with the outbreak are now being challenged. 1,2 Questions remain about the appropriateness of large-scale population vaccination programs, such as those promoted as the best response to the expected influenza epidemic in spring 2009. Large-scale vaccination involves considerable financial (and other resource) costs for governments, and the political decision to make such an investment in public health is not without repercussions. In particular, if such decision-making processes are not fully transparent and well justified—for example, if accusations of conflict of interest arise, as was the case with World Health Organization (WHO) recommendations 2,3 —public trust in the resulting public health program or intervention can be threatened. Clearly, an erosion of public trust in the judgments of public health authorities (whether they be local, national, or international) can have serious negative consequences on the future implementation of other emergency response programs. 4 To respond to this problem of a loss of (or weakened) public trust, we must understand its sociocultural and historical origins. The examination of past implementations of emergency programs can hopefully help us understand our strengths and faults and eventually serve as tools for continuously improving our management of public health in such emergency situations. Neustadt and Fineberg’s book on the 1976 swine flu “affair” is a good example of how critical of ourselves we should be to react better to such crises in the future. 5 For this same purpose, and by placing a sociological macroscopic lens over a particular recent crisis, we are presenting a case analysis of the 2009 H1N1 flu pandemic. Drawing on the literature in the social sciences, we have affirmed that the management of health crises is necessarily also the management of human crises. We integrate reflections from contemporary bioethics and political philosophy, in line with views about the responsibility of decision makers in democratic states. First, we argue that the concept of trust (e.g., by the public in health experts) should be situated in the context of modernity—namely, in a risk society in which the public and policymakers are increasingly concerned with safety and the maximal reduction of certain risks. Second, we highlight a close relation between risk perception (known to be subjective) and risk assessment (expected to be objective), which deserves special attention, given the important role played by experts in the management of public health. Third, we suggest that public health actors (professionals, science advisers, policymakers) need to accept the limits of their own expertise (and of its objectivity) and responsibility and recognize the ability of lay publics to understand and to take responsibility for their public health. As a consequence, we argue that public health actors should engage more actively in ongoing participative and deliberative public debates both to preserve and to strengthen public trust toward public health authorities and interventions. We do not aim to judge or to hold accountable the individuals for the decisions that were made during the crisis, which is beyond the scope of this article and, to our minds, less interesting than examining the structural elements that make such behavior “the norm” for experts and decision makers and thus lead repeatedly to situations like H1N1. If we simply focus on pointing fingers at a few individuals to be held personally responsible, we miss the larger social dynamics that arguably generated the problematic inconsistencies between the messages put forward by public health experts and what was understood or accepted by the general public.