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The staggering statistics associated with pandemics sometime makes it difficult to remember that each number represents a single, human life. In this section, several survivors share their intimate recollections of either their own illness or that of a loved one. All these storytellers are 90-plus years of age and they have carried with them for a lifetime their memories of the 1918 flu pandemic.

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I Survived, The staggering statistics associated with pandemics sometimes makes it difficult to remember that each number represents a single, human life. In this section, survivors share their intimate recollections of either their own illness or that of a loved one.

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Pandemic Poems: May Day! - THE POETRY SOCIETY OF NEW YORK

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Large events are cancelled, restaurants and non-essential businesses are closed, and in many states, residents have been asked to shelter in place, all to limit the spread and impact of the COVID-19 virus. But are strict and early isolation and other preventative mandates really effective in minimizing the spread and impact of a disease outbreak?

Stefan E. Pambuccian, MD, a Loyola Medicine cytologist, surgical pathologist and professor and vice chair of the Department of Pathology and Laboratory Medicine at Loyola University Chicago Stritch School of Medicine, has reviewed published data and research from three papers dating back to the 1918-19 Spanish flu pandemic, which infected one-fifth to one-third of the world's population and killed 50 million people.

According to the data and analysis, cities that adopted early, broad isolation and prevention measures -- closing of schools and churches, banning of mass gatherings, mandated mask wearing, case isolation and disinfection/hygiene measures -- had lower disease and mortality rates. These cities included San Francisco, St. Louis, Milwaukee and Kansas City, which collectively had 30% to 50% lower disease and mortality rates than cities that enacted fewer and later restrictions. One analysis showed that these cities also had greater delays in reaching peak mortality, and the duration of these measures correlated with a reduced total mortality burden.

"The stricter the isolation policies, the lower the mortality rate," says Dr. Pambuccian. He studied the Spanish flu, including prevention measures and outcomes, to help develop standards for staffing and safety in the cytology lab, where infectious diseases like the COVID-19 virus are diagnosed and studied at the cellular level. His broader article appeared online this week in the Journal of the American Society of Cytopathology.

Like today, not everyone in 1918 and 1919 thought the strict measures were appropriate or effective at the time.

An estimated 675,000 people died in the U.S. from the Spanish flu, "and there was skepticism that these policies were actually working," says Dr. Pambuccian. "But they obviously did make a difference."

In 1918, the world was still at war "with overcrowded barracks," and much of the U.S. lived with "poverty, poor nutrition, poor hygiene, household/community-level crowding, and a lack of preparation of the population and decision makers due to cognitive inertia and poor medical and insufficient nursing care," says Dr. Pambuccian.

"Although the world is a much different place than it was 100 years ago, the efficacy of the measures instituted during the 1918-19 pandemic gives us hope that the current measures will also limit the impact of the COVID-19 pandemic."

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influenza; bird flu; cold and flu; bird flu research; virology; veterinary medicine; public health; poverty and learning; world development

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Lessons from the Spanish flu: Early restrictions lowered disease, mortality rates

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Large events are cancelled, restaurants and non-essential businesses are closed, and in many states, residents have been asked to shelter in place, all to limit the spread and impact of the COVID-19 virus. But are strict and early isolation and other preventative mandates really effective in minimizing the spread and impact of a disease outbreak?

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The world is currently battling a global pandemic of SARS-CoV-2, the novel coronavirus that causes COVID-19. As of April 1, 2020, there are 921,924 confirmed cases of COVID-19 worldwide with 46,252 total deaths. In the United States, there are 186,101 cases with a total of 3,603 deaths.

At this time, vast swaths of the U.S. population are under a semi-quarantine dubbed "social distancing," with most businesses closed except for essential businesses, such as hospitals and doctors' offices, grocery stores, banks and utilities. Many people are working from home, if able. The goal is to "flatten the curve," which refers to various graphs of the outbreak which show a very steep curve that would concentrate the number of cases diagnosed and treated in a very short period of time, which would overwhelm hospitals. By flattening the curve, the outbreak's spread would be slowed, and cases would be spread out over a longer period of time in hopes of giving healthcare institutions the ability to better manage the cases.

Computer models projecting the COVID-19 range dramatically, with one out of Imperial College of London predicting about 2.2 million deaths in the U.S. if no action was taken to slow the spread of the disease. A more hopeful but still catastrophic model projects somewhere between 100,000 to 240,000 deaths, some of which come out of the Trump administration and some which came from the University of Washington's Institute for Health Metrics and Evaluation (IHME) and other sources.

The IHME model, for example, doesn't take into consideration federal social-distancing recommendations, but instead looks at a state-by-state basis, because some states have taken very aggressive and early actions, such as Ohio, Michigan, Illinois and California, while others, such as Florida, have been very late to do anything. The IHME model, however, assumes that by April 7 all states will have imposed a full variety of social-distancing rules.

Although the IHME projection suggests that in many states the pandemic will have peaked in mid to late-April, Chris Murray, IHME's director, told NPR, "Our rough guess is that come June, at least 95% of the U.S. will still be susceptible. That means, of course, it can come right back. And so, then we really need to have a robust strategy in place to not have a second wave."

Spanish Flu of 1918 Compared to COVID-19

Although the world has faced several major pandemics over the last 100 years, one of the worst was the 1918 influenza pandemic, the so-called Spanish flu. It was caused by an H1N1 virus that originated in birds. It was first identified in the U.S. in military personnel in the spring of 1918. It was dubbed the Spanish flu because it was thought at the time to have originated in Spain. Research published in 2005 suggest it actually originated in New York. It was named Spanish flu because Spain was neutral in World War I (1914-1918), meaning it could report on the severity of the pandemic, but countries fighting the war were suppressing reports on how the disease affected their populations.

At its worse, the Spanish flu infected 500 million people worldwide, which at the time was about a third of the Earth's population. More than 50 million people died of the disease, with 675,000 in the U.S. There is some disagreement on that figure, with recent researchers suggesting it was about 17.4 million deaths, while others go as high as 100 million. Generally speaking, the fatality rate for the Spanish flu is calculated at about 2%.

Although it is something of a moving target as more deaths occur and broader diagnostic testing is performed, finding higher levels of infection, sometimes with no symptoms, the global fatality rate for COVID-19 as of April 1 is about 5%, although in the U.S. it is about 2.16%. Some experts believe the 5% figure is significantly lower because of doubts about the accuracy of China's reporting of the cases, where COVID-19 originated.

Some experts, such as Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, who is something of the public point-man for the U.S. response to COVID-19, project the fatality rate will be about 1%, which is still about 10 times the fatality rate of a typical seasonal influenza of 0.1%.

Another commonality between the Spanish flu's H1N1 and the COVID-19 coronavirus is that both are considered "novel," which is to say, they are so new nobody in either era had any immunity to them. One marked difference between the two is the most affected groups in the 1918 pandemic were otherwise healthy adults between the ages of 20 to 40. Mortality was also higher in people younger than five years of age and 65 and older.

"The 1918 pandemic strain influenza was new and novel for most people under the age of 40 or 50, but that's where the death rate really was high-that's different than the usual flu," Mark Schleiss, a pediatric infectious disease specialist at the University of Minnesota told Healthline.

Demographics of the Pandemics

The most affected groups for COVID-19 are adults over the age of 65 with underlying health conditions. For the most part, children seem to have much milder symptoms.

There were no vaccines for the Spanish flu and there are currently no vaccines for COVID-19. One reason the Spanish flu was so lethal was there were no antibiotics to treat secondary bacterial infections, so control efforts around the globe were limited to non-pharmaceutical responses like isolation, quarantine, disinfectants and limiting public gatherings, although then as now, they were applied erratically. The first flu vaccine to be licensed in the U.S. came about in the 1940s.

The 1918 pandemic ended in the summer of 1919, mostly, Healthline reports, due to deaths and higher immunity levels. Christine Kreuder Johnson, a University of California - Davis professor of epidemiology and ecosystem health and a researcher on USAID's Emerging Pandemic Threats PREDICT project, said that another thing to take into consideration for the 1918 pandemic was the world was in the middle of a war and soldiers were spreading the virus globally. People also lived in crowded conditions and had extremely poor hygiene.

To date, about 1.25 million people have been confirmed to have COVID-19 worldwide, with about more than 66,000 deaths. Of course, the world population in 1918 was about 1.8 billion. The higher estimate of 50 million deaths would suggest the Spanish flu killed 2.7% of the world population, while the 17.4 million figure suggest about 1%.

The current world's population is about 8 billion people with significantly lower death rates from COVID-19 overall. Although the pandemic is far from over, the lower figure is likely related to greater awareness of how viruses and pandemics work, better healthcare, both in terms of access to hospitals, but antibiotics, antiviral drugs and other approaches to treating diseases. In fact, although healthcare facilities are being stretched thin by COVID-19 in many countries, it was quite a bit worse in 1918, as hospitals were dealing with mass casualties and injuries from the war, and many physicians were with the troops, leaving medical students to take care of the influenza patients.

On the other hand, we have a far more connected world with air travel and denser populations, which make the spread of COVID-19 easier and faster.

Cautions on Comparison

With all the similarities, it should be emphasized that there are several significant differences between the two pandemics. First off, simply, is that COVID-19 is not influenza, it is more like a chronic acute pneumonia. They are both caused by novel viruses, but different types of viruses with different methods of action and infectiousness.

Secondly, and perhaps most importantly, the ability of researchers to marshal technology and science to quickly develop and/or test drugs for the disease, has never been as strong as it is now. There are more than 100 ongoing clinical trials worldwide of experimental and already approved drugs that might be repurposed to fight COVID-19, with literally dozens of companies globally working on developing vaccines against the SARS-CoV-2 virus that are already in clinical trials might be available to battle a second wave of the disease, although that will depend on when or if there is a second wave and when or if a vaccine is developed. Many experts believe a second wave is possible in the fall of 2020, and most optimistic projections don't have a vaccine available until early 2021, although that will depend a great deal on the types of technologies available, clinical trial results, and the world's willingness to rush regulations in the face of an emergency.

In fact, one of the primary pharmaceutical treatments for the Spanish flu was aspirin, which had been trademarked by Bayer in 1899, but whose patent expired in 1917, allowing companies to manufacturing it during the pandemic. At the time, medical professionals were recommending up to 30 grams of aspirin daily, which we now know is toxic-doses above four grams are unsafe. Aspirin poisoning symptoms include hyperventilation and pulmonary edema (fluid in the lungs), so many medical historians believe many of the deaths from the Spanish flu were either caused or accelerated by aspirin poisoning.

Global communication and sharing of information are also significantly better than in 1918, which has seen researchers sharing data on the pandemic, the virus and numerous drugs, and governments doing the same.

Hope

The COVID-19 epidemic is without a doubt an enormous and unique challenge worldwide, and the battle is nowhere near being over. But there are signs that government policies in several countries, including Germany and South Korea, have been able to contain the virus, and news about several antiviral drug trials, such as Gilead Sciences' remdesivir, are expected in the next few weeks, should give people hope. Even in China, where the pandemic appears to have originated, seems three months later, to have things largely under control.

As Ross Douthat wrote in The New York Times on March 28, there are signs of what he calls "rational hope," which "is not the same as reckless optimism. It doesn't require, for instance, quickly lifting quarantines based on outlying projections of low fatality rates, as some return-to-normalcy conservatives have been doing in the last week. Rational hope accepts that the situation is genuinely dark, but then it still looks around for signposts leading up and out. It recognizes that things are likely to get worse but keeps itself alert to the contexts in which they seem to be getting better-or at the very least, getting worse more slowly."

And as has been pointed out, pandemics, from the 1918 Spanish flu to the H1N1 pandemic of 2009, do end. Sometimes with seemingly unbearable numbers of deaths, but eventually they do end.

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compare: 1918 spanish influenza pandemic versus covid-19

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Compare: 1918 Spanish Influenza Pandemic Versus COVID-19 | BioSpace

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The world is currently battling a global pandemic of SARS-CoV-2, the novel coronavirus that causes COVID-19. As of April 1, 2020, there are 921,924 confirmed cases of COVID-19 worldwide with 46,252 total deaths. In the United States, there are 186,101 cases with a total of 3,603 deaths.

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By the middle of the second millennium, Indian botanicals were essential items of European life as medicines, food flavorings and food preservatives. The facemask of the plague doctor shown in this image was filled with various strongly aromatic spices including Indian spices, believed to be effective against bubonic plague that devastated Europe in the 15th century.

The vital role all Asian spices and medicines in medieval Europe households is illustrated by an apothecary's bill from Filipo di Lapo & Co, Florence to the household of Francesco Marco Dantini, a rich Venetian merchant, at the beginning of the 15th century. The bill is for "Pounded pepper, Pounded cloves, Pounded ginger and other strong fine spices." (Origo, Iris,"The Merchant of Prato," Nonpariel Books, 1986).

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Der Doctor Schnabel von Rom, a plague doctor wearing protective mask with beak filled with aromatic spices - P. Furst - Google Arts & Culture

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By the middle of the second millennium, Indian botanicals were essential items of European life as medicines, food flavorings and food preservatives. The facemask of the plague doctor shown in this image was filled with various strongly aromatic spices including Indian spices, believed to be effective against bubonic plague that devastated Europe in the 15th century.

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Correspondence to: Professor Belinda Bennett, Faculty of Law, University of Sydney, New South Wales 2006. Fax: (02) 9351 0200; e‐mail belinda.bennett@sydney.edu.au

Abstract

Objective: To explore social equity, health planning, regulatory and ethical dilemmas in responding to a pandemic influenza (H5N1) outbreak, and the adequacy of protocols and standards such as the International Health Regulations (2005).

Approach: This paper analyses the role of legal and ethical considerations for pandemic preparedness, including an exploration of the relevance of cross‐jurisdictional and cross‐cultural perspectives in assessing the validity of goals for harmonisation of laws and policies both within and between nations. Australian and international experience is reviewed in various areas, including distribution of vaccines during a pandemic, the distribution of authority between national and local levels of government, and global and regional equity issues for poorer countries.

Conclusion: This paper finds that questions such as those of distributional justice (resource allocation) and regulatory frameworks raise important issues about the cultural and ethical acceptability of planning measures. Serious doubt is cast on a 'one size fits all' approach to international planning for managing a pandemic. It is concluded that a more nuanced approach than that contained in international guidelines may be required if an effective response is to be constructed internationally.

Implications: The paper commends the wisdom of reliance on 'soft law', international guidance that leaves plenty of room for each nation to construct its response in conformity with its own cultural and value requirements.

A revised version of a paper presented at the 2nd Annual Biosecurity Symposium 'Integrating Knowledge, Implementing Change' 9-10 February 2009 Footbridge Theatre, University of Sydney. Research for this paper is supported by a Discovery Grant from the Australian Research Council.

There were three influenza pandemics during the 20th century (in 1918, 1957 and 1968), the first of which killed at least 40 million people worldwide, far exceeding the 8.3 million military deaths during World War I. 1 In recent years, outbreaks of highly pathogenic avian influenza (H5N1) and an increasing number of human cases of H5N1 infection, have led to growing concern about another potentially deadly world pandemic of human influenza. In 2009, the World Health Organization (WHO) declared the first influenza pandemic of the 21st century - not from H5N1 as feared, but from the international spread A/H1N1 swine influenza. 2 Although the H1N1 pandemic has been relatively mild to date, WHO has warned countries in the northern hemisphere to prepare for a second wave of the pandemic 3 and the potential for H5N1 and H1N1 viruses to combine into a new deadly influenza strain remains a sobering possibility. 4 The WHO has recognised the importance of legal and ethical issues to pandemic planning in its proposed 'unified' approach, but responding to pandemic influenza raises a great number of social equity, health planning, regulatory and ethical dilemmas that may prove problematic. Pandemic influenza, either in the form of the current A/H1N1 pandemic or in the form of human‐to‐human transmission of the avian (H5N1) influenza virus, should it emerge, may well affect Australia's regional partners, greatly compounding dilemmas posed by diversity of cultural, legal and value systems within the region.

Asian countries are already experiencing a heavy proportion of human global cases of H5N1: of 440 cases, including 262 deaths, from avian influenza to August 2009, Indonesia experienced 141 cases (115 deaths), Vietnam 111 (56 deaths), and Thailand 25 (17 deaths). 5 H1N1 has been far more widespread. By late August 2009 the WHO Regional Office for the Americas had recorded 110,113 cases with 1,876 deaths, WHO's European office reported more than 42,557 cases with at least 85 deaths, WHO's South‐East Asian office had reported 15,771 cases with 139 deaths and WHO's Regional Office for the Western Pacific had reported 34,026 cases with 64 deaths. 6 These figures are, however, almost certainly an underestimate of the number of actual cases as countries are no longer required to test and report individual cases of H1N1. 6 While the number of human deaths so far appears relatively small by comparison with the pandemics of the 20th century, the potential for another deadly pandemic is very real. The pool of human infection with H5N1 is such that the WHO noted in 2005 that "[a]ll prerequisites for the start of a pandemic had been met save one, namely the onset of efficient human‐to‐human transmission". 1 On 23 May 2005 the World Health Assembly therefore called on Member States to develop and implement national preparedness plans. 7 Australia and the South East Asian region have developed national influenza preparedness plans based on WHO guidelines. 1, 8 The 9 the same year the Australian Management Plan for Pandemic Influenza was released for comment in June 2005 before being finalised in 2006, 10 Interim National Pandemic Influenza Clinical Guidelines were published.

Estimates of the impacts of a flu pandemic are highly speculative. Between its 2006 modelling of a 'worst case' scenario of 71 million deaths worldwide and its most recent predictions in mid 2008, the World Bank revised its assessment of loss of world gross domestic production. Earlier it has estimated a 3.1% drop (or about US$ 2 trillion) but now puts this as high as 4.8% (or US$ 3 trillion). 11, 12 A recent New Zealand Treasury Report estimated that the economic impact of the A/H1N1 pandemic would be less than the 0.7% drop in GDP modelled under a mild pandemic scenario. 13 While the milder‐than‐expected impact of H1N1 to date is encouraging, particularly in light of the global financial crisis, the pandemic is not yet over and it will be some time before we are in a position to make final assessments of the full impact of this pandemic on the global economy. 12 Furthermore, it has been noted that developing countries would be hardest hit, because of their higher population densities and poverty that accentuate the economic impacts.

Whatever the range of impacts, the features of the flu pandemics encountered to date predispose them to affect both the undeveloped and the developed world, and to do so at times not tied to the usual 'winter flu' season or to target the usual sub‐populations of the old and the young, Tong 14 points out. Although influenza typically strikes hardest at the very young and the very old, the WHO has noted that during the 1918 pandemic "99% of deaths occurred in people younger than 65 years". 1 This disproportionate impact on the young is also evident in the current H1N1 pandemic with WHO noting: "To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in stark contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older." 3

These features challenge orthodox ethical and legal frameworks, such as potentially altering the calculus of theories of distributional justice (favouring treatment of the most gravely ill), or liberal principles regarding construction of legislation to balance achievement of social goals against incursions on individual rights. However, responses to 'emergencies' and the resolution of difficult ethical conundrums may not necessarily attract a single consensus of the type presumed by WHO and other guidelines for national action.

Legal preparedness in Australia and its region

In common with other countries influenced by Chadwick's championing in 19th century Britain of the clean water, sanitation and quarantine models of public health, Australia has an extensive array of emergency management tools with which to respond to a pandemic. 15 However, these tools work best for regional issues arising within the borders of the States and Territories that are the successors in title to all except the quarantine powers of their colonial predecessors.

Problems arise in crafting a coordinated approach to a national challenge, due to the latitude for different approaches to implementation of pandemic planning between the States/Territories, as illustrated when Queensland followed the national pandemic plan and briefly encouraged food stockpiling during the 2009 swine flu episode, before falling into line with the national view that this would unsettle the public. Federal divisions of power and responsibility are a particular issue, 16, 18 consequent on the political legacy of sovereign power of the States. The various techniques and avenues for harmonisation of laws are one way of dealing with this, 19 including consideration of options such as a checklist for each jurisdiction to use for benchmarking, consultation around elimination of more egregious forms of disharmony, a 'model act', referral of powers or national legislation based on federal powers. 18 17 as is the potential for division of approach between the two levels of government,

To date, the milder checklist or guideline measures have been favoured in Australia, 9, 10 but this was tested by the recent A/H1N1 outbreak of swine flu. In the US, the 20 Concerns included the lack of specificity of the evidence‐base in national frameworks for assessing compliance by emergency preparedness plans and entitlement to federal funding (potentially compounding lack of preparedness in non‐complaint jurisdictions). 20 Such reservations about cooperative federalist models of governance resonate with Australian experience of 'blame game' federalism, indicating that similar issues may arise in this country. Clarity of purpose of the plan is another potential problem. Even renovated laws in a well‐prepared State jurisdiction such as North Carolina (where pathbreaking legal and ethical planning was conducted), make fine distinctions between 'isolation' and 'quarantine' orders that the public (and professions) may find hard to follow. 21 Other problematic aspects include: defining the 'emergencies' able to trigger the special powers; deciding how 'much' preparedness is adequate; and measuring actual (as compared to apparent) readiness. 22 While some of these differences can be accounted for by the different historical, constitutional and cultural legacies of Australia and the US, it casts some doubt on the prevailing models of governance of the issue. More broadly, differences may arise between competing approaches, such as between liberalism and communitarianism, both in crafting overall regulatory responses of national governments to such emergencies, and in shaping confidence in such measures depending on the values and beliefs held by members of the public. 23 For instance the US leans much further towards so‐called classical liberalism (privileging autonomy or the 'right to be left alone') while Australia broadly favours a utilitarian liberal rationale permitting overriding of autonomy on the basis of harm to others, or undue risk. Pandemic and All‐Hazards Preparedness Act of 2006 adopted a similar low‐key cooperative strategy of developing and deferring to 'action plans' across the different levels of government, but it was criticised for its lack of national guidance and planning failure during the notorious Hurricane Katrina episode.

The importance of clarifying relationships between different levels of government was highlighted in a Canadian report on the experience of dealing with severe acute respiratory syndrome (SARS). Drawing on a metaphor of firefighting to articulate the need for emergency preparedness, the Canadian report noted:

"We expect that firefighters and fire engines from different jurisdictions will come together seamlessly to contain an emergency. In the public health field, this seamlessness can only come about from effective preparedness and coordination by public health authorities at the local, provincial, federal and territorial levels. As with firefighting, there must be knowledge of common operating procedures, compatible training and equipment, and most importantly, prior agreements for mutual assistance in emergencies requiring a sudden surge capacity." 24

Clarity in the legal frameworks for public health is a critical part of providing an enabling infrastructure to support the work of public health officials when responding to public health emergencies. The confusion and duplication potentially created by lack of legal clarity can complicate and obstruct effective emergency responses.

There is also a critically important 'supra‐national' element to any effective national response, due to the mobility of populations and ease of international travel in a globalised world. The capacity for infectious disease to spread along international travel routes dramatically shortens the time needed for the spread of a pandemic, compromising our capacity to respond if large parts of the world are affected simultaneously. To date these pressures have resulted in support for 'soft‐law' initiatives or cooperative models of governance. In recent times this global governance dimension has found expression in initiatives such as the International Health Regulations, 25, 27 In 2007, the WHO's revised 26 and, closer to home, guidelines developed by regional organisations such as APEC. 28 The purpose and scope of the IHR (2005) are, in the words of Article 2, to "prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade". The IHR (2005) require States to develop the capacity "to detect, assess, notify and report" public health events (Article 5.1) and assess and notify events that may constitute a "public emergency of international concern". The IHR contain a decision instrument to assist states in this process. While the IHR are an important tool in international public health law t here are also other more radical and as yet largely unexplored sources of international law, including the Security Council of the UN, which might potentially play a role in managing a major pandemic disaster in light of changed assessments of risks to security within a globalised world 29 and the growing understanding of the potential for infectious diseases to present risks to domestic and global security. 30 International Health Regulations (2005) (IHR (2005)) took effect.

The Asia‐Pacific Economic Cooperation (APEC) has developed guidelines to assist Member States in planning for pandemic influenza. The APEC Guidelines also recognise the role for law in pandemic planning, calling on APEC Members to inter alia :

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"Work towards 'preventive action' as a priority initiative, including improved regional capacity on surveillance and detection, infection control, containment and communication strategies as well as reviewing and reinforcing relevant laws." 27

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"Take steps to ensure that border control, quarantining, surveillance and screening measures are designed to comprehensively address containment and infection issues while limiting the impact on trade in most goods and services." 27

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"In line with the International Health Regulations (2005), and WTO Agreements, to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." 27

As argued above, legal frameworks play a vital role in supporting effective public health responses to infectious diseases. Yet legal frameworks do not emerge in a vacuum. They are informed by ethical, cultural and historical assumptions and principles that guide the direction of legal development. Law and public health ethics (in its various forms or schools 31) are both critical parts of pandemic planning and emergency preparedness.

A role for ethics

The WHO has recognised the importance of according separate attention to the ethical issues raised in pandemic planning. In its Checklist for Influenza Pandemic Preparedness Planning , the WHO highlights the importance of legal frameworks to support the required response measures during a pandemic. These measures commonly include ethical minefields such as: limitations on freedom of movement with the enforcement of quarantine, use of private premises for hospitals, off‐licence use of medicines, compulsory vaccination and maintenance of essential services. 32 Other legally contentious issues identified by WHO include: "the advantages or disadvantages of a declaration of a state of emergency during a pandemic"; the legal and policy basis for vaccination of healthcare workers, essential services workers and individuals at high risk; liability for unforseen adverse events from vaccines or anti‐viral medication; and the inclusion of influenza within occupational health and safety laws. 32

While an effective vaccine is a key part of pandemic planning, 34 no country has sufficient vaccine supplies and the lead time of three to six months to develop an effective vaccine for a new strain means that non‐pharmaceutical measures will be important, particularly in the early stages of a pandemic. 35 Non‐pharmaceutical measures include community hygiene such as cough etiquette, social distancing measures such as closure of schools and cancellation of major sporting events, infection control within hospitals (during the SARS crisis healthcare workers were disproportionately among those infected 36), isolation and quarantine, and restrictions on cross‐border and international movement of people. 37- 39

Responding to pandemic influenza raises a great number of social equity, health planning, regulatory and ethical dilemmas, few of which have yet been addressed. For example, one vital issue stemming from limited vaccine supply is the 'distributional justice' issue of resource allocation, including identification of priority and high‐risk groups for receipt of vaccines and the ethical foundations for decisions. In common with other 'triage' issues in allocation of health resources, 40 there are various ways of domestic rationing of vaccines, 41 including possible priorities for essential workers, children, intergenerational equity questions, and social justice issues regarding the poor or the powerless. At the economic or regulatory level, questions arise about optimal incentives for manufacture of vaccines, streamlining and harmonising overlapping regulatory requirements for new medicines, and liability for unforseen adverse events associated with emergency use of new vaccines. 41

There are also global and regional equity issues for poorer countries, similar to issues in world poverty and international development. Inequality, poor health and disease are ready partners. Despite the impact of infectious disease on large numbers of people across the globe, western bioethics has traditionally paid little attention to infectious diseases. 42 These issues are not simply issues for the developing world. Global health inequalities are both unethical and contrary to the interests of individual countries. 43 In the increasingly globalised world that we all live in, risks to health are shared by us all. SARS provided a dramatic reminder of this a few years ago 26, 45 It is commonly pointed out that germs do not recognise borders and outbreaks of infectious disease can escalate rapidly across the globe. The development of effective public health infrastructures in all countries, both rich and poor, is an essential aspect of managing health risks in a globalised environment. 44 and avian influenza may yet provide a far more dramatic reminder. Poorer countries may lack the health resources and infrastructure necessary to meet the challenges of a severe pandemic.

Difference and public health ethics

One manifestation of the difference is in the way triage questions present. In clinical medicine hard choices about rationing of medical care are avoided as inappropriate, or are implicitly sought to be defended (in areas such as care of the frail aged) on the basis of measures such as favouring the foreseeable 'adjusted quality years of life'. In public health the temptation is to rely on objective cost‐benefit assessments, and longer time horizons. In disaster management triage this has been summed up some commentators as 'doing the most for the most', irrespective of age or perceived 'worth'. 40 This does not mean that public emotions like fear of disaster will not play a part. As Quigley and Harris 49 point out, the cost of stockpiling tamiflu (oseltamivir) in anticipation of an avian flu outbreak is high and of dubious utility. It may be good public relations, but its efficacy (if any) and distributional impact (will it 'save' the old rather than the likely very high numbers of young and fit victims) is unknown, though a scientific case can be mounted for taking better advantage of any future inter‐pandemic years. 34 As Gostin and Gostin have recently argued, this may call for a new ethical paradigm, a 'population‐based' perspective, where "utility is not measured by enhancing short‐term individual preferences, but by maximising overall societal welfare; savings in pain, disability and life within the populace". 50 Other ethical differences, however, present in determining the form of the legislative (quarantine and emergency powers) and public policy dimensions of public health responses to pandemics. Important issues arise in determining the balance between coercive state powers and human rights, 15, 52, 54 The same was true of the highly regarded ethically‐grounded framework for pandemic response planning developed in North Carolina, where that state endorsed most of the values and priorities developed by the Joint Centre for Bioethics in Ontario, Canada, save for a sharp rejection of the Canadian inclusion of 'communitarian' principles of solidarity and stewardship. 14 53 Differing weightings of factors, or indeed differences in the overall ethical paradigms, have been found to account for variation in the laws and policies in Europe. 47, 51 and the role for law in assisting and supporting preparedness across diverse cultural and legal contexts.

WHO has recognised the need to adapt global guidelines for local contexts, noting: "Since specific decisions will depend on local circumstances and cultural values, it will be necessary to adapt this global guidance to the regional and country‐level context, with full respect to the principles and laws of international human rights." 33

The importance of recognising difference and cultural specificity in the development of appropriate legal and ethical measures for pandemic preparedness presents complex issues about whether it is ever truly possible to develop a 'global bioethics'. 57 Additional complexities arise when bioethics meets human rights, 58- 60 for human rights are typically expressed in terms of universal values and entitlements, and tend to best guarantee so‐called 'negative' or liberal rights (such as to autonomy) rather than 'positive' rights such as a right to health or other social rights of citizenship. Indeed, as bioethics is reshaped by human rights discourses there are new possibilities to develop deeper, more nuanced understandings of ethics premised on the inherent dignity of all persons and an express recognition of the need for bioethics to address global inequities and disadvantage.

As Rosemarie Tong 14 has observed in respect of western legal systems, "the kind of ethics most likely to persuade people to do their duty and more is not a rights‐based, duties‐based, or utility‐based ethics, but a care‐based ethics". Ethical approaches based on care and relational ethics 14, 64 This is slightly unsettling given the prominence of utilitarian liberalism as the foundational paradigm for public health legislation, but as Gostin and Gostin observe, the assumptions such as that actions are either self‐ and other‐regarding actions, or that actors either have or lack capacity, are much more nuanced than many analyses may suggest. 50 61- 63 provide another indication of the need to look beyond the dominant individual‐focused ethics shaping clinical care, where Kantian autonomy (consent to healthcare) or Millean principles of 'harm to others' are uppermost (e.g. in the use of coercion in mental health treatment). Wendy Parmet for example has recently questioned the appropriateness of a Millean harm to self/others rationale for US quarantine laws on the bases that too much room is left for executive power (and arbitrariness) and that it fails Mill's test of showing a sound ethical foundation for the public health services themselves.

Of course there is still purchase in public health policy, especially for ethical frameworks that address the bases and limits around the use of coercion to isolate, or treat victims of a pandemic. But the calculus of risk/harm is not the usual one contemplated by philosophy and private law (such as the tort of negligence). Instead of determining the proportionality of the coercive intervention based on the individual risk to the public by reason of being infected, the debate in public health management is about levels of global statistical risk within populations, the pathways of spread of infection to the disease‐free portion of the population, and the 'critical mass' effects of given levels of infectivity within the population. While the first of these is familiar as the philosophical grounding for measures such as mass immunisation of children or compulsory seat belt laws, the latter two are more challenging. Pathways of spread of infection, and the critical mass of infected individuals within a population do not follow a straight line. They often involve either geometric curves or even sudden jump changes in risk levels, as small increases in numbers of infected individuals lead to escalating risk levels or cliff effects. As a consequence, individuals find themselves almost instantly converted from being trusted to autonomously self‐govern their disease to someone who is to be compelled to enter perhaps very spartan quarantine facilities. As demonstrated by the reaction of the members of the Australian lacrosse team placed in isolation in South Korea during the recent A/H1N1 episode, 65 the philosophical foundation or 'fairness' of such public health actions is not understood at all by the public and the popular media.

The ethical challenges are not confined to the interests of citizens who become infected. The question of the expression and limits of the ethical duty to treat on the part of health workers faced with risks of serious illness or death, 66- 68 including, at the extremes, the case for the medical equivalent of military conscription should the pool of workers fall too low, or place unreasonable burdens on particular groups (such as young singles) needs to be considered. Furthermore, we need to recognise that health professionals in developing countries may be at greater risk of infection than their developed country counterparts due to the impact of global disparities in health resources, running the risk that as Reiheld noted in the 69 Even in less fraught circumstances there are distributional justice issues with regard to whether danger money incentives should be paid. Similar questions are posed for other essential services workers, along with tricky economic and social decisions about what the core activities may be. 14 American Journal of Bioethics in 2008 "[a]n absolute duty to treat thus demands more of those who have less".

Together with the challenges of deciding priorities for rationing access to treatment and other necessary supports, there is a rich set of complex ethical questions to be answered in pandemic planning.

Conclusion

This paper has analysed the role of legal and ethical considerations for pandemic preparedness, including cross‐jurisdictional and cross‐cultural perspectives bearing on the feasibility of harmonisation of laws and policies both within and between nations.

The soft‐law guidance by the WHO towards development of national pandemic plans is superficially attractive to the extent that it leaves scope for variations in national approaches that reflect cultural, institutional or other differences. However, it carries some considerable baggage. The US experience with Hurricane Katrina and in tailoring plans to local state conditions suggests that soft‐touch governance and cooperative federalism, have their limitations and highlight the need for these limitations to be expressly considered as part of pandemic planning. For developed economies, the implicit endorsement of western philosophical concepts of individual autonomy, and utilitarian liberal bases for public health interventions, is shown to be problematic for certain sections of the public who come from different cultural traditions or who do not share those assumptions. For Asia and the Pacific, it is argued that the challenges are heightened by factors such as markedly lower levels of resources, sharply limited roles of the state in the domain of health and government services, and cultural traditions that emphasise collective extended family or community responsibility. Checklists that assume a rural division of labour, or a service capacity to support an individual outside their subsistence economy and isolated community, will require considerable adaptation to accord with local conditions. As the swine flu experience in Australia has so graphically demonstrated in exposing the limitations of pre‐ordained plans with presumptive actions linked to pandemic 'stages', what is critical is the capacity to make flexible and responsive decisions in light of public health assessments of the actions required.

Our argument is that the cultural and ethical acceptability of pandemic planning measures require to be more flexible and more nuanced than is currently envisaged in international guidelines if an effective response is to be constructed internationally. As shown by the APEC Guidelines, there is potential for regional measures to supplement (and refine) international instruments and guidelines. These may take the form of institutional coordination of planning, training and responses to regional disease outbreaks, or even culminate in bi‐lateral or regional treaties. Time will tell, but such options are consistent with the argument in this paper regarding the fallacy of the notion that 'one size fits all', and the wisdom of reliance on soft law international guidance that leaves plenty of movement for each nation to construct its response in conformity with its own cultural and value requirements, and for the scope of this movement to be expressly included in pandemic planning.

Number of times cited according to CrossRef: 9

Monica Schoch-Spana, Emily K Brunson, Howard Gwon, Alan Regenberg, Eric S Toner, Elizabeth L Daugherty-Biddison, Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study, Journal of Participatory Medicine, 10.2196/18272, 1, (e18272), 12,

Aun Lor, James C. Thomas, Drue H. Barrett, Leonard W. Ortmann, Dionisio J. Herrera Guibert, Key Ethical Issues Discussed at CDC-Sponsored International, Regional Meetings to Explore Cultural Perspectives and Contexts on Pandemic Influenza Preparedness and Response, International Journal of Health Policy and Management, 10.15171/ijhpm.2016.55, 11, (653-662), 5,

Alana Devereaux, Pandemic influenza: an evolutionary concept analysis, Journal of Advanced Nursing, 10.1111/jan.12654, 8, (1787-1796), 71,

Yara Oyram Ramos Lima, Ediná Alves Costa, Implementação do Regulamento Sanitário Internacional (2005) no ordenamento jurídico-administrativo brasileiro, Ciência & Saúde Coletiva, 10.1590/1413-81232015206.06552014, 6, (1773-1783), 20,

Terry Carney, Belinda Bennett, Framing pandemic management: New governance, science or culture?, Health Sociology Review, 10.1080/14461242.2014.11081968, 2, (136-147), 23,

Ben Dewar, Ian Barr, Priscilla Robinson, Hospital capacity and management preparedness for pandemic influenza in Victoria, Australian and New Zealand Journal of Public Health, 10.1111/1753-6405.12170, 2, (184-190), 38,

Lee Daugherty Biddison, Kenneth A. Berkowitz, Brooke Courtney, Col Marla J. De Jong, Asha V. Devereaux, Niranjan Kissoon, Beth E. Roxland, Charles L. Sprung, Jeffrey R. Dichter, Michael D. Christian, Tia Powell, Ethical Considerations, Chest, 10.1378/chest.14-0742, 4, (e145S-e155S), 146,

Allen Y. Lai, Organizational Collaborative Capacity in Fighting Pandemic Crises, Asia Pacific Journal of Public Health, 10.1177/1010539511429592, 1, (7-20), 24,

Belinda Bennett, Terry Carney, Review Paper: Pandemic Preparedness in Asia: A Role for Law and Ethics?, Asia Pacific Journal of Public Health, 10.1177/1010539511408411, 3, (419-430), 23,

Abstract

Objective: To explore social equity, health planning, regulatory and ethical dilemmas in responding to a pandemic influenza (H5N1) outbreak, and the adequacy of protocols and standards such as the International Health Regulations (2005).

Approach: This paper analyses the role of legal and ethical considerations for pandemic preparedness, including an exploration of the relevance of cross‐jurisdictional and cross‐cultural perspectives in assessing the validity of goals for harmonisation of laws and policies both within and between nations. Australian and international experience is reviewed in various areas, including distribution of vaccines during a pandemic, the distribution of authority between national and local levels of government, and global and regional equity issues for poorer countries.

Conclusion: This paper finds that questions such as those of distributional justice (resource allocation) and regulatory frameworks raise important issues about the cultural and ethical acceptability of planning measures. Serious doubt is cast on a 'one size fits all' approach to international planning for managing a pandemic. It is concluded that a more nuanced approach than that contained in international guidelines may be required if an effective response is to be constructed internationally.

Implications: The paper commends the wisdom of reliance on 'soft law', international guidance that leaves plenty of room for each nation to construct its response in conformity with its own cultural and value requirements.

A revised version of a paper presented at the 2nd Annual Biosecurity Symposium 'Integrating Knowledge, Implementing Change' 9-10 February 2009 Footbridge Theatre, University of Sydney. Research for this paper is supported by a Discovery Grant from the Australian Research Council.

There were three influenza pandemics during the 20th century (in 1918, 1957 and 1968), the first of which killed at least 40 million people worldwide, far exceeding the 8.3 million military deaths during World War I. In recent years, outbreaks of highly pathogenic avian influenza (H5N1) and an increasing number of human cases of H5N1 infection, have led to growing concern about another potentially deadly world pandemic of human influenza. In 2009, the World Health Organization (WHO) declared the first influenza pandemic of the 21st century - not from H5N1 as feared, but from the international spread A/H1N1 swine influenza. Although the H1N1 pandemic has been relatively mild to date, WHO has warned countries in the northern hemisphere to prepare for a second wave of the pandemic and the potential for H5N1 and H1N1 viruses to combine into a new deadly influenza strain remains a sobering possibility. The WHO has recognised the importance of legal and ethical issues to pandemic planning in its proposed 'unified' approach, but responding to pandemic influenza raises a great number of social equity, health planning, regulatory and ethical dilemmas that may prove problematic. Pandemic influenza, either in the form of the current A/H1N1 pandemic or in the form of human‐to‐human transmission of the avian (H5N1) influenza virus, should it emerge, may well affect Australia's regional partners, greatly compounding dilemmas posed by diversity of cultural, legal and value systems within the region.

Asian countries are already experiencing a heavy proportion of human global cases of H5N1: of 440 cases, including 262 deaths, from avian influenza to August 2009, Indonesia experienced 141 cases (115 deaths), Vietnam 111 (56 deaths), and Thailand 25 (17 deaths). H1N1 has been far more widespread. By late August 2009 the WHO Regional Office for the Americas had recorded 110,113 cases with 1,876 deaths, WHO's European office reported more than 42,557 cases with at least 85 deaths, WHO's South‐East Asian office had reported 15,771 cases with 139 deaths and WHO's Regional Office for the Western Pacific had reported 34,026 cases with 64 deaths. These figures are, however, almost certainly an underestimate of the number of actual cases as countries are no longer required to test and report individual cases of H1N1. While the number of human deaths so far appears relatively small by comparison with the pandemics of the 20th century, the potential for another deadly pandemic is very real. The pool of human infection with H5N1 is such that the WHO noted in 2005 that "[a]ll prerequisites for the start of a pandemic had been met save one, namely the onset of efficient human‐to‐human transmission". On 23 May 2005 the World Health Assembly therefore called on Member States to develop and implement national preparedness plans. Australia and the South East Asian region have developed national influenza preparedness plans based on WHO guidelines. The Australian Management Plan for Pandemic Influenza was released for comment in June 2005 before being finalised in 2006, the same year the Interim National Pandemic Influenza Clinical Guidelines were published.

Estimates of the impacts of a flu pandemic are highly speculative. Between its 2006 modelling of a 'worst case' scenario of 71 million deaths worldwide and its most recent predictions in mid 2008, the World Bank revised its assessment of loss of world gross domestic production. Earlier it has estimated a 3.1% drop (or about US$ 2 trillion) but now puts this as high as 4.8% (or US$ 3 trillion). Furthermore, it has been noted that developing countries would be hardest hit, because of their higher population densities and poverty that accentuate the economic impacts. A recent New Zealand Treasury Report estimated that the economic impact of the A/H1N1 pandemic would be less than the 0.7% drop in GDP modelled under a mild pandemic scenario. While the milder‐than‐expected impact of H1N1 to date is encouraging, particularly in light of the global financial crisis, the pandemic is not yet over and it will be some time before we are in a position to make final assessments of the full impact of this pandemic on the global economy.

Whatever the range of impacts, the features of the flu pandemics encountered to date predispose them to affect both the undeveloped and the developed world, and to do so at times not tied to the usual 'winter flu' season or to target the usual sub‐populations of the old and the young, Tong points out. Although influenza typically strikes hardest at the very young and the very old, the WHO has noted that during the 1918 pandemic "99% of deaths occurred in people younger than 65 years". This disproportionate impact on the young is also evident in the current H1N1 pandemic with WHO noting: "To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in stark contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older."

These features challenge orthodox ethical and legal frameworks, such as potentially altering the calculus of theories of distributional justice (favouring treatment of the most gravely ill), or liberal principles regarding construction of legislation to balance achievement of social goals against incursions on individual rights. However, responses to 'emergencies' and the resolution of difficult ethical conundrums may not necessarily attract a single consensus of the type presumed by WHO and other guidelines for national action.

Legal preparedness in Australia and its region

In common with other countries influenced by Chadwick's championing in 19th century Britain of the clean water, sanitation and quarantine models of public health, Australia has an extensive array of emergency management tools with which to respond to a pandemic. However, these tools work best for regional issues arising within the borders of the States and Territories that are the successors in title to all except the quarantine powers of their colonial predecessors.

Problems arise in crafting a coordinated approach to a national challenge, due to the latitude for different approaches to implementation of pandemic planning between the States/Territories, as illustrated when Queensland followed the national pandemic plan and briefly encouraged food stockpiling during the 2009 swine flu episode, before falling into line with the national view that this would unsettle the public. Federal divisions of power and responsibility are a particular issue, as is the potential for division of approach between the two levels of government, consequent on the political legacy of sovereign power of the States. The various techniques and avenues for harmonisation of laws are one way of dealing with this, including consideration of options such as a checklist for each jurisdiction to use for benchmarking, consultation around elimination of more egregious forms of disharmony, a 'model act', referral of powers or national legislation based on federal powers.

To date, the milder checklist or guideline measures have been favoured in Australia, but this was tested by the recent A/H1N1 outbreak of swine flu. In the US, the Pandemic and All‐Hazards Preparedness Act of 2006 adopted a similar low‐key cooperative strategy of developing and deferring to 'action plans' across the different levels of government, but it was criticised for its lack of national guidance and planning failure during the notorious Hurricane Katrina episode. Concerns included the lack of specificity of the evidence‐base in national frameworks for assessing compliance by emergency preparedness plans and entitlement to federal funding (potentially compounding lack of preparedness in non‐complaint jurisdictions). Such reservations about cooperative federalist models of governance resonate with Australian experience of 'blame game' federalism, indicating that similar issues may arise in this country. Clarity of purpose of the plan is another potential problem. Even renovated laws in a well‐prepared State jurisdiction such as North Carolina (where pathbreaking legal and ethical planning was conducted), make fine distinctions between 'isolation' and 'quarantine' orders that the public (and professions) may find hard to follow. Other problematic aspects include: defining the 'emergencies' able to trigger the special powers; deciding how 'much' preparedness is adequate; and measuring actual (as compared to apparent) readiness. While some of these differences can be accounted for by the different historical, constitutional and cultural legacies of Australia and the US, it casts some doubt on the prevailing models of governance of the issue. More broadly, differences may arise between competing approaches, such as between liberalism and communitarianism, both in crafting overall regulatory responses of national governments to such emergencies, and in shaping confidence in such measures depending on the values and beliefs held by members of the public. For instance the US leans much further towards so‐called classical liberalism (privileging autonomy or the 'right to be left alone') while Australia broadly favours a utilitarian liberal rationale permitting overriding of autonomy on the basis of harm to others, or undue risk.

The importance of clarifying relationships between different levels of government was highlighted in a Canadian report on the experience of dealing with severe acute respiratory syndrome (SARS). Drawing on a metaphor of firefighting to articulate the need for emergency preparedness, the Canadian report noted:

"We expect that firefighters and fire engines from different jurisdictions will come together seamlessly to contain an emergency. In the public health field, this seamlessness can only come about from effective preparedness and coordination by public health authorities at the local, provincial, federal and territorial levels. As with firefighting, there must be knowledge of common operating procedures, compatible training and equipment, and most importantly, prior agreements for mutual assistance in emergencies requiring a sudden surge capacity."

Clarity in the legal frameworks for public health is a critical part of providing an enabling infrastructure to support the work of public health officials when responding to public health emergencies. The confusion and duplication potentially created by lack of legal clarity can complicate and obstruct effective emergency responses.

There is also a critically important 'supra‐national' element to any effective national response, due to the mobility of populations and ease of international travel in a globalised world. The capacity for infectious disease to spread along international travel routes dramatically shortens the time needed for the spread of a pandemic, compromising our capacity to respond if large parts of the world are affected simultaneously. To date these pressures have resulted in support for 'soft‐law' initiatives or cooperative models of governance. In recent times this global governance dimension has found expression in initiatives such as the International Health Regulations, and, closer to home, guidelines developed by regional organisations such as APEC. In 2007, the WHO's revised International Health Regulations (2005) (IHR (2005)) took effect. The purpose and scope of the IHR (2005) are, in the words of Article 2, to "prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade". The IHR (2005) require States to develop the capacity "to detect, assess, notify and report" public health events (Article 5.1) and assess and notify events that may constitute a "public emergency of international concern". The IHR contain a decision instrument to assist states in this process. While the IHR are an important tool in international public health law t here are also other more radical and as yet largely unexplored sources of international law, including the Security Council of the UN, which might potentially play a role in managing a major pandemic disaster in light of changed assessments of risks to security within a globalised world and the growing understanding of the potential for infectious diseases to present risks to domestic and global security.

The Asia‐Pacific Economic Cooperation (APEC) has developed guidelines to assist Member States in planning for pandemic influenza. The APEC Guidelines also recognise the role for law in pandemic planning, calling on APEC Members to inter alia :

*
"Work towards 'preventive action' as a priority initiative, including improved regional capacity on surveillance and detection, infection control, containment and communication strategies as well as reviewing and reinforcing relevant laws."

*
"Take steps to ensure that border control, quarantining, surveillance and screening measures are designed to comprehensively address containment and infection issues while limiting the impact on trade in most goods and services."

*
"In line with the International Health Regulations (2005), and WTO Agreements, to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are restricted to public health risks, and which avoid unnecessary interference with international traffic and trade."

As argued above, legal frameworks play a vital role in supporting effective public health responses to infectious diseases. Yet legal frameworks do not emerge in a vacuum. They are informed by ethical, cultural and historical assumptions and principles that guide the direction of legal development. Law and public health ethics (in its various forms or schools) are both critical parts of pandemic planning and emergency preparedness.

A role for ethics

The WHO has recognised the importance of according separate attention to the ethical issues raised in pandemic planning. In its Checklist for Influenza Pandemic Preparedness Planning , the WHO highlights the importance of legal frameworks to support the required response measures during a pandemic. These measures commonly include ethical minefields such as: limitations on freedom of movement with the enforcement of quarantine, use of private premises for hospitals, off‐licence use of medicines, compulsory vaccination and maintenance of essential services. Other legally contentious issues identified by WHO include: "the advantages or disadvantages of a declaration of a state of emergency during a pandemic"; the legal and policy basis for vaccination of healthcare workers, essential services workers and individuals at high risk; liability for unforseen adverse events from vaccines or anti‐viral medication; and the inclusion of influenza within occupational health and safety laws.

While an effective vaccine is a key part of pandemic planning, no country has sufficient vaccine supplies and the lead time of three to six months to develop an effective vaccine for a new strain means that non‐pharmaceutical measures will be important, particularly in the early stages of a pandemic. Non‐pharmaceutical measures include community hygiene such as cough etiquette, social distancing measures such as closure of schools and cancellation of major sporting events, infection control within hospitals (during the SARS crisis healthcare workers were disproportionately among those infected), isolation and quarantine, and restrictions on cross‐border and international movement of people.

Responding to pandemic influenza raises a great number of social equity, health planning, regulatory and ethical dilemmas, few of which have yet been addressed. For example, one vital issue stemming from limited vaccine supply is the 'distributional justice' issue of resource allocation, including identification of priority and high‐risk groups for receipt of vaccines and the ethical foundations for decisions. In common with other 'triage' issues in allocation of health resources, there are various ways of domestic rationing of vaccines, including possible priorities for essential workers, children, intergenerational equity questions, and social justice issues regarding the poor or the powerless. At the economic or regulatory level, questions arise about optimal incentives for manufacture of vaccines, streamlining and harmonising overlapping regulatory requirements for new medicines, and liability for unforseen adverse events associated with emergency use of new vaccines.

There are also global and regional equity issues for poorer countries, similar to issues in world poverty and international development. Inequality, poor health and disease are ready partners. Despite the impact of infectious disease on large numbers of people across the globe, western bioethics has traditionally paid little attention to infectious diseases. These issues are not simply issues for the developing world. Global health inequalities are both unethical and contrary to the interests of individual countries. In the increasingly globalised world that we all live in, risks to health are shared by us all. SARS provided a dramatic reminder of this a few years ago and avian influenza may yet provide a far more dramatic reminder. Poorer countries may lack the health resources and infrastructure necessary to meet the challenges of a severe pandemic. It is commonly pointed out that germs do not recognise borders and outbreaks of infectious disease can escalate rapidly across the globe. The development of effective public health infrastructures in all countries, both rich and poor, is an essential aspect of managing health risks in a globalised environment.

Difference and public health ethics

One manifestation of the difference is in the way triage questions present. In clinical medicine hard choices about rationing of medical care are avoided as inappropriate, or are implicitly sought to be defended (in areas such as care of the frail aged) on the basis of measures such as favouring the foreseeable 'adjusted quality years of life'. In public health the temptation is to rely on objective cost‐benefit assessments, and longer time horizons. In disaster management triage this has been summed up some commentators as 'doing the most for the most', irrespective of age or perceived 'worth'. This does not mean that public emotions like fear of disaster will not play a part. As Quigley and Harris point out, the cost of stockpiling tamiflu (oseltamivir) in anticipation of an avian flu outbreak is high and of dubious utility. It may be good public relations, but its efficacy (if any) and distributional impact (will it 'save' the old rather than the likely very high numbers of young and fit victims) is unknown, though a scientific case can be mounted for taking better advantage of any future inter‐pandemic years. As Gostin and Gostin have recently argued, this may call for a new ethical paradigm, a 'population‐based' perspective, where "utility is not measured by enhancing short‐term individual preferences, but by maximising overall societal welfare; savings in pain, disability and life within the populace". Other ethical differences, however, present in determining the form of the legislative (quarantine and emergency powers) and public policy dimensions of public health responses to pandemics. Important issues arise in determining the balance between coercive state powers and human rights, and the role for law in assisting and supporting preparedness across diverse cultural and legal contexts. Differing weightings of factors, or indeed differences in the overall ethical paradigms, have been found to account for variation in the laws and policies in Europe. The same was true of the highly regarded ethically‐grounded framework for pandemic response planning developed in North Carolina, where that state endorsed most of the values and priorities developed by the Joint Centre for Bioethics in Ontario, Canada, save for a sharp rejection of the Canadian inclusion of 'communitarian' principles of solidarity and stewardship.

WHO has recognised the need to adapt global guidelines for local contexts, noting: "Since specific decisions will depend on local circumstances and cultural values, it will be necessary to adapt this global guidance to the regional and country‐level context, with full respect to the principles and laws of international human rights."

The importance of recognising difference and cultural specificity in the development of appropriate legal and ethical measures for pandemic preparedness presents complex issues about whether it is ever truly possible to develop a 'global bioethics'. Additional complexities arise when bioethics meets human rights, for human rights are typically expressed in terms of universal values and entitlements, and tend to best guarantee so‐called 'negative' or liberal rights (such as to autonomy) rather than 'positive' rights such as a right to health or other social rights of citizenship. Indeed, as bioethics is reshaped by human rights discourses there are new possibilities to develop deeper, more nuanced understandings of ethics premised on the inherent dignity of all persons and an express recognition of the need for bioethics to address global inequities and disadvantage.

As Rosemarie Tong has observed in respect of western legal systems, "the kind of ethics most likely to persuade people to do their duty and more is not a rights‐based, duties‐based, or utility‐based ethics, but a care‐based ethics". Ethical approaches based on care and relational ethics provide another indication of the need to look beyond the dominant individual‐focused ethics shaping clinical care, where Kantian autonomy (consent to healthcare) or Millean principles of 'harm to others' are uppermost (e.g. in the use of coercion in mental health treatment). Wendy Parmet for example has recently questioned the appropriateness of a Millean harm to self/others rationale for US quarantine laws on the bases that too much room is left for executive power (and arbitrariness) and that it fails Mill's test of showing a sound ethical foundation for the public health services themselves. This is slightly unsettling given the prominence of utilitarian liberalism as the foundational paradigm for public health legislation, but as Gostin and Gostin observe, the assumptions such as that actions are either self‐ and other‐regarding actions, or that actors either have or lack capacity, are much more nuanced than many analyses may suggest.

Of course there is still purchase in public health policy, especially for ethical frameworks that address the bases and limits around the use of coercion to isolate, or treat victims of a pandemic. But the calculus of risk/harm is not the usual one contemplated by philosophy and private law (such as the tort of negligence). Instead of determining the proportionality of the coercive intervention based on the individual risk to the public by reason of being infected, the debate in public health management is about levels of global statistical risk within populations, the pathways of spread of infection to the disease‐free portion of the population, and the 'critical mass' effects of given levels of infectivity within the population. While the first of these is familiar as the philosophical grounding for measures such as mass immunisation of children or compulsory seat belt laws, the latter two are more challenging. Pathways of spread of infection, and the critical mass of infected individuals within a population do not follow a straight line. They often involve either geometric curves or even sudden jump changes in risk levels, as small increases in numbers of infected individuals lead to escalating risk levels or cliff effects. As a consequence, individuals find themselves almost instantly converted from being trusted to autonomously self‐govern their disease to someone who is to be compelled to enter perhaps very spartan quarantine facilities. As demonstrated by the reaction of the members of the Australian lacrosse team placed in isolation in South Korea during the recent A/H1N1 episode, the philosophical foundation or 'fairness' of such public health actions is not understood at all by the public and the popular media.

The ethical challenges are not confined to the interests of citizens who become infected. The question of the expression and limits of the ethical duty to treat on the part of health workers faced with risks of serious illness or death, including, at the extremes, the case for the medical equivalent of military conscription should the pool of workers fall too low, or place unreasonable burdens on particular groups (such as young singles) needs to be considered. Furthermore, we need to recognise that health professionals in developing countries may be at greater risk of infection than their developed country counterparts due to the impact of global disparities in health resources, running the risk that as Reiheld noted in the American Journal of Bioethics in 2008 "[a]n absolute duty to treat thus demands more of those who have less". Even in less fraught circumstances there are distributional justice issues with regard to whether danger money incentives should be paid. Similar questions are posed for other essential services workers, along with tricky economic and social decisions about what the core activities may be.

Together with the challenges of deciding priorities for rationing access to treatment and other necessary supports, there is a rich set of complex ethical questions to be answered in pandemic planning.

Conclusion

This paper has analysed the role of legal and ethical considerations for pandemic preparedness, including cross‐jurisdictional and cross‐cultural perspectives bearing on the feasibility of harmonisation of laws and policies both within and between nations.

The soft‐law guidance by the WHO towards development of national pandemic plans is superficially attractive to the extent that it leaves scope for variations in national approaches that reflect cultural, institutional or other differences. However, it carries some considerable baggage. The US experience with Hurricane Katrina and in tailoring plans to local state conditions suggests that soft‐touch governance and cooperative federalism, have their limitations and highlight the need for these limitations to be expressly considered as part of pandemic planning. For developed economies, the implicit endorsement of western philosophical concepts of individual autonomy, and utilitarian liberal bases for public health interventions, is shown to be problematic for certain sections of the public who come from different cultural traditions or who do not share those assumptions. For Asia and the Pacific, it is argued that the challenges are heightened by factors such as markedly lower levels of resources, sharply limited roles of the state in the domain of health and government services, and cultural traditions that emphasise collective extended family or community responsibility. Checklists that assume a rural division of labour, or a service capacity to support an individual outside their subsistence economy and isolated community, will require considerable adaptation to accord with local conditions. As the swine flu experience in Australia has so graphically demonstrated in exposing the limitations of pre‐ordained plans with presumptive actions linked to pandemic 'stages', what is critical is the capacity to make flexible and responsive decisions in light of public health assessments of the actions required.

Our argument is that the cultural and ethical acceptability of pandemic planning measures require to be more flexible and more nuanced than is currently envisaged in international guidelines if an effective response is to be constructed internationally. As shown by the APEC Guidelines, there is potential for regional measures to supplement (and refine) international instruments and guidelines. These may take the form of institutional coordination of planning, training and responses to regional disease outbreaks, or even culminate in bi‐lateral or regional treaties. Time will tell, but such options are consistent with the argument in this paper regarding the fallacy of the notion that 'one size fits all', and the wisdom of reliance on soft law international guidance that leaves plenty of movement for each nation to construct its response in conformity with its own cultural and value requirements, and for the scope of this movement to be expressly included in pandemic planning.

Number of times cited according to CrossRef: 9

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Aun Lor, James C. Thomas, Drue H. Barrett, Leonard W. Ortmann, Dionisio J. Herrera Guibert, Key Ethical Issues Discussed at CDC-Sponsored International, Regional Meetings to Explore Cultural Perspectives and Contexts on Pandemic Influenza Preparedness and Response, International Journal of Health Policy and Management, 10.15171/ijhpm.2016.55, 11, (653-662), 5,

Alana Devereaux, Pandemic influenza: an evolutionary concept analysis, Journal of Advanced Nursing, 10.1111/jan.12654, 8, (1787-1796), 71,

Yara Oyram Ramos Lima, Ediná Alves Costa, Implementação do Regulamento Sanitário Internacional (2005) no ordenamento jurídico-administrativo brasileiro, Ciência & Saúde Coletiva, 10.1590/1413-81232015206.06552014, 6, (1773-1783), 20,

Terry Carney, Belinda Bennett, Framing pandemic management: New governance, science or culture?, Health Sociology Review, 10.1080/14461242.2014.11081968, 2, (136-147), 23,

Ben Dewar, Ian Barr, Priscilla Robinson, Hospital capacity and management preparedness for pandemic influenza in Victoria, Australian and New Zealand Journal of Public Health, 10.1111/1753-6405.12170, 2, (184-190), 38,

Lee Daugherty Biddison, Kenneth A. Berkowitz, Brooke Courtney, Col Marla J. De Jong, Asha V. Devereaux, Niranjan Kissoon, Beth E. Roxland, Charles L. Sprung, Jeffrey R. Dichter, Michael D. Christian, Tia Powell, Ethical Considerations, Chest, 10.1378/chest.14-0742, 4, (e145S-e155S), 146,

Organizational Collaborative Capacity in Fighting Pandemic Crises, Asia Pacific Journal of Public Health, 10.1177/1010539511429592, 1, (7-20), 24,

Belinda Bennett, Terry Carney, Review Paper: Pandemic Preparedness in Asia: A Role for Law and Ethics?, Asia Pacific Journal of Public Health, 10.1177/1010539511408411, 3, (419-430), 23,

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Law, ethics and pandemic preparedness: the importance of cross‐jurisdictional and cross‐cultural perspectives

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Correspondence to: Professor Belinda Bennett, Faculty of Law, University of Sydney, New South Wales 2006. Fax: (02) 9351 0200; e‐mail belinda.bennett@sydney.edu.au Objective: To explore social equity, health planning, regulatory and ethical dilemmas in responding to a pandemic influenza (H5N1) outbreak, and the adequacy of protocols and standards such as the International Health Regulations (2005).

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Thomas Rowlandson; Dance of Death, Todentanz, Ars Moriendi; hand colored aquatinta - The Night Out - 1815

In remarkably good condition. As such rare.

(The English Dance of Death)

Original Aquatint & Etching plate with Original Hand Colour

UNUSUALLY FINE EXAMPLE with full margins and only very minor marginal wear

Rudolph Ackermann, London, 1815.

Thomas Rowlandson: Along with Hogarth, Gillray and Cruikshank, Thomas Rowlandson is at the uppermost peak of English satirical art. Amongst these masters, however, Rowlandson was the most gifted artist and his compositions always seemed the closest to the truth for he often lived the dissipated style of life he so memorably satirized. Along with Hogarth, Gillray and Cruikshank, Thomas Rowlandson is at the uppermost peak of English satirical art. Amongst these masters, however, Rowlandson was the most gifted artist and his compositions always seemed the closest to the truth for he often lived the dissipated style of life he so memorably satirized. After studying in both Paris and London, Thomas Rowlandson began his career as a portrait painter. By 1782, however, he devoted himself almost exclusively to his first love; caricature and satirical art. After receiving a large inheritance, Thomas Rowlandson quickly gambled it away. After losing his fortune at a thirty-six hour card game he is known to have exclaimed, "I've played the fool, but (holding up his pencils) here is my resource."

Working with such British publishers as Flores and Thomas Tegg, Thomas Rowlandson designed many memorable satires. His greatest work, however, lay ahead in the early nineteenth century when he collaborated with the famous London publisher, Rudolph Ackermann, to produce some of the finest satirical series in the history of art. These included The Microcosm of London (1808), the Tour of Dr. Syntax in Search of the Picturesque (1812) and The English Dance of Death, published in two volumes in 1815 and 1816. Loosely based upon Holdbein's Renaissance "Dance of Death", this latter series superbly uncovers the foibles of early nineteenth century life. For each of these original prints, Rowlandson created the drawings and etched the plates. Ackermann and his studio then provided the aquatinting and hand-colouring. The etchings from The English Dance of Death have long taken their place as among Rowlandson's greatest works of original art. This particular engraving deals with the hazards and consequences of boxing (pugilism). The words beneath the engraving read; "How vain are all your Triumphs past: For this Set-To will be your last".

23 x 14.2 cm

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Thomas Rowlandson; Dance of Death, Todentanz, Ars Moriendi; hand colored aquatinta - The Night Out - 1815

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(The English Dance of Death) Original Aquatint & Etching plate with Original Hand Colour UNUSUALLY FINE EXAMPLE with full margins and only very minor marginal wear Rudolph Ackermann, London, 1815. Thomas Rowlandson: Along with Hogarth, Gillray and Cruikshank, Thomas Rowlandson is at the uppermost peak of English satirical art.

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The Plague by Albert Camus

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Hear "The Masque of the Red Death" read aloud.
The Masque of the Red Death

The "Red Death" had long devastated the country. No pestilence had been ever so fatal, or so hideous. Blood was its Avator and its seal - the redness and the horror of blood. There were sharp pains, and sudden dizziness, and then profuse bleedings at the pores, with dissolution. The scarlet stains upon the body and especially upon the face of the victim, were the pest-ban which shut him out from the aid and from the sympathy of his fellow-men. And the whole seizure, progress and termination of the disease were the incidents of half an hour.

But the Prince Prospero was happy and dauntless, and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends from among the knights and dames of his court, and with these retired to the deep seclusion of one of his castellated abbeys. This was an extensive and magnificent structure, the creation of the prince's own eccentric yet august taste. A strong and lofty wall girdled it in. This wall had gates of iron. The courtiers, having entered, brought furnaces and massy hammers and welded the bolts. They resolved to leave means neither of ingress or egress to the sudden impulses of despair from without or of frenzy from within. The abbey was amply provisioned. With such precautions the courtiers might bid defiance to contagion. The external world could take care of itself. In the meantime it was folly to grieve, or to think. The prince had provided all the appliances of pleasure. There were buffoons, there were improvisatori, there were ballêt-dancers, there were musicians, there were cards, there was Beauty, there was wine. All these and security were within. Without was the "Red Death."

It was towards the close of the fifth or sixth month of his seclusion, and while the pestilence raged most furiously abroad, that the Prince Prospero entertained his thousand friends at a masked ball of the most unusual magnificence. It was a voluptuous scene that masquerade.

But first let me tell of the rooms in which it was held. There were seven - an imperial suite. In many palaces, however, such suites form a long and straight vista, while the folding doors slide back nearly to the walls on either hand, so that the view of the whole extent is scarcely impeded. Here the case was very different; as might have been expected from the duke's love of the bizarre. The apartments were so irregularly disposed that the vision embraced but little more than one at a time. There was a sharp turn at every twenty or thirty yards, and at each turn a novel effect. To the right and left, in the middle of each wall, a tall and narrow Gothic window looked out upon a closed corridor which pursued the windings of the suite. These windows were of stained glass whose color varied in accordance with the prevailing hue of the decorations of the chamber into which it opened. That at the eastern extremity was hung, for example, in blue - and vividly blue were its windows. The second chamber was purple in its ornaments and tapestries, and here the panes were purple. The third was green throughout, and so were the casements. The fourth was furnished and litten with orange - the fifth with white - the sixth with violet. The seventh apartment was closely shrouded in black velvet tapestries that hung all over the ceiling and down the walls, falling in heavy folds upon a carpet of the same material and hue. But, in this chamber only, the color of the windows failed to correspond with the decorations. The panes here were scarlet - a deep blood color. Now in no one of the seven apartments was there any lamp or candelabrum, amid the profusion of golden ornaments that lay scattered to and fro or depended from the roof. There was no light of any kind emanating from lamp or candle within the suite of chambers. But in the corridors that followed the suite, there stood, opposite to each window, a heavy tripod, bearing a brazier of fire that projected its rays through the tinted glass and so glaringly illumined the room. And thus were produced a multitude of gaudy and fantastic appearances. But in the western or black chamber the effect of the fire-light that streamed upon the dark hangings through the blood-tinted panes, was ghastly in the extreme, and produced so wild a look upon the countenances of those who entered, that there were few of the company bold enough to set foot within its precincts at all.

It was in this apartment, also, that there stood against the western wall, a gigantic clock of ebony. Its pendulum swung to and fro with a dull, heavy, monotonous clang; and when its minute-hand made the circuit of the face, and the hour was to be stricken, there came forth from the brazen lungs of the clock a sound which was clear and loud and deep and exceedingly musical, but of so peculiar a note and emphasis that, at each lapse of an hour, the musicians in the orchestra were constrained to pause, momently, in their performance, to harken to the sound; and thus the waltzers perforce ceased their evolutions; and there was a brief disconcert of the whole gay company; and, while the chimes of the clock yet rang, it was observed that the giddiest grew pale, and that the more aged and sedate passed their hands over their brows as if in confused reverie or meditation. But when the echoes had fully ceased, a light laughter at once pervaded the assembly; the musicians looked at each other and smiled as if at their own nervousness and folly, and made whispering vows, each to the other, that the next chiming of the clock should produce in them no similar emotion; and then, after the lapse of sixty minutes, (which embrace three thousand and six hundred seconds of the Time that flies,) there came yet another chiming of the clock, and then were the same disconcert and tremulousness and meditation as before.

But, in spite of these things, it was a gay and magnificent revel. The tastes of the duke were peculiar. He had a fine eye for colors and effects. He disregarded the decora of mere fashion. His plans were bold and fiery, and his conceptions glowed with barbaric lustre. There are some who would have thought him mad. His followers felt that he was not. It was necessary to hear and see and touch him to be sure that he was not.

He had directed, in great part, the moveable embellishments of the seven chambers, upon occasion of this great fête, and it was his own guiding taste which had given character to the costumes of the masqueraders. Be sure they were grotesque. There were much glare and glitter and piquancy and phantasm - much of what has been since seen in "Hernani." There were arabesque figures with unsuited limbs and appointments. There were delirious fancies such as the madman fashions. There was much of the beautiful, much of the wanton, much of the bizarre, something of the terrible, and not a little of that which might have excited disgust. To and fro in the seven chambers there stalked, in fact, a multitude of dreams. And these, the dreams - writhed in and about, taking hue from the rooms, and causing the wild music of the orchestra to seem as the echo of their steps. And, anon, there strikes the ebony clock which stands in the hall of the velvet. And then, momently, all is still, and all is silent save the voice of the clock. The dreams are stiff-frozen as they stand. But the echoes of the chime die away - they have endured but an instant - and a light, half-subdued laughter floats after them as they depart. And now again the music swells, and the dreams live, and writhe to and fro more merrily than ever, taking hue from the many-tinted windows through which stream the rays from the tripods. But to the chamber which lies most westwardly of the seven there are now none of the maskers who venture; for the night is waning away; and there flows a ruddier light through the blood-colored panes; and the blackness of the sable drapery appals; and to him whose foot falls upon the sable carpet, there comes from the near clock of ebony a muffled peal more solemnly emphatic than any which reaches their ears who indulge in the more remote gaieties of the other apartments.

But these other apartments were densely crowded, and in them beat feverishly the heart of life. And the revel went whirlingly on, until at length was sounded the twelfth hour upon the clock. And then the music ceased, as I have told; and the evolutions of the waltzers were quieted; and there was an uneasy cessation of all things as before. But now there were twelve strokes to be sounded by the bell of the clock; and thus it happened, perhaps, that more of thought crept, with more of time, into the meditations of the thoughtful among those who revelled. And thus, again, it happened, perhaps, that before the last echoes of the last chime had utterly sunk into silence, there were many individuals in the crowd who had found leisure to become aware of the presence of a masked figure which had arrested the attention of no single individual before. And the rumor of this new presence having spread itself whisperingly around, there arose at length from the whole company a buzz, or murmur, expressive at first of disapprobation and surprise - then, finally, of terror, of horror, and of disgust.

In an assembly of phantasms such as I have painted, it may well be supposed that no ordinary appearance could have excited such sensation. In truth the masquerade license of the night was nearly unlimited; but the figure in question had out-Heroded Herod, and gone beyond the bounds of even the prince's indefinite decorum. There are chords in the hearts of the most reckless which cannot be touched without emotion. Even with the utterly lost, to whom life and death are equally jests, there are matters of which no jest can be properly made. The whole company, indeed, seemed now deeply to feel that in the costume and bearing of the stranger neither wit nor propriety existed. The figure was tall and gaunt, and shrouded from head to foot in the habiliments of the grave. The mask which concealed the visage was made so nearly to resemble the countenance of a stiffened corpse that the closest scrutiny must have had difficulty in detecting the cheat. And yet all this might have been endured, if not approved, by the mad revellers around. But the mummer had gone so far as to assume the type of the Red Death. His vesture was dabbled in blood - and his broad brow, with all the features of the face, was besprinkled with the scarlet horror.

When the eyes of the Prince Prospero fell upon this spectral image (which with a slow and solemn movement, as if more fully to sustain its rôle, stalked to and fro among the waltzers) he was seen to be convulsed, in the first moment, with a strong shudder either of terror or distaste; but, in the next, his brow reddened with rage.

"Who dares?" he demanded hoarsely of the group that stood around him, "who dares thus to make mockery of our woes? Uncase the varlet that we may know whom we have to hang to-morrow at sunrise from the battlements. Will no one stir at my bidding? - stop him and strip him, I say, of those reddened vestures of sacrilege!"

It was in the eastern or blue chamber in which stood the Prince Prospero as he uttered these words. They rang throughout the seven rooms loudly and clearly - for the prince was a bold and robust man, and the music had become hushed at the waving of his hand.

It was in the blue room where stood the prince, with a group of pale courtiers by his side. At first, as he spoke, there was a slight rushing movement of this group in the direction of the intruder, who at the moment was also near at hand, and now, with deliberate and stately step, made closer approach to the speaker. But from a certain nameless awe with which the mad assumptions of the mummer had inspired the whole party, there were found none who put forth hand to seize him; so that, unimpeded, he passed within a yard of the prince's person; and, while the vast assembly, as if with one impulse, shrank from the centres of the rooms to the walls, he made his way uninterruptedly, but with the same solemn and measured step which had distinguished him from the first, through the blue chamber to the purple - through the purple to the green - through the green to the orange, - through this again to the white - and even thence to the violet, ere a decided movement had been made to arrest him. It was then, however, that the Prince Prospero, maddening with rage and the shame of his own momentary cowardice, rushed hurriedly through the six chambers - while none followed him on account of a deadly terror that had seized upon all. He bore aloft a drawn dagger, and had approached, in rapid impetuosity, to within three or four feet of the retreating figure, when the latter, having attained the extremity of the velvet apartment, turned suddenly round and confronted his pursuer. There was a sharp cry - and the dagger dropped gleaming upon the sable carpet, upon which instantly afterwards, fell prostrate in death the Prince Prospero. Then, summoning the wild courage of despair, a throng of the revellers at once threw themselves into the black apartment, and, seizing the mummer, whose tall figure stood erect and motionless within the shadow of the ebony clock, gasped in unutterable horror at finding the grave-cerements and corpse-like mask which they handled with so violent a rudeness, untenanted by any tangible form.

And now was acknowledged the presence of the Red Death. He had come like a thief in the night. And one by one dropped the revellers in the blood-bedewed halls of their revel, and died each in the despairing posture of his fall. And the life of the ebony clock went out with that of the last of the gay. And the flames of the tripods expired. And Darkness and Decay and the Red Death held illimitable dominion over all.
Edgar Allan Poe Published 1842 Image by Byam Shaw

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Hear "The Masque of the Red Death" read aloud. The "Red Death" had long devastated the country. No pestilence had been ever so fatal, or so hideous. Blood was its Avator and its seal - the redness and the horror of blood. There were sharp pains, and sudden dizziness, and then profuse bleedings at the pores, with dissolution.

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Reading articles on the Great Plague, 1918 Spanish Flu and the present day Novel Coronavirus
ATLs addressed:
Research, thinking skills, communication, self-management
ATTs addressed:
Inquiry-based, Conceptual, Collaboration, Local and Global contexts
Concepts:
Culture, Identity, Perspective

Students Activities:
I. Research

1. In groups students assigned to research on the Plague, 1918 Spanish Flu and the present pandemic- history, medical advancement, response to the epidemic and pandemics, the reaction of societies (thinking skills, self-management, communication).

2. Students in groups can create padlets or google slides as a timeline of events and medical discoveries and share (Learner Portfolio).

II. Readings:

1. Students read literary and non-literary texts (thinking skills. self-management).

2. Close reading and annotations (thinking skills, communication)

3. Students select concepts for discussion and connect them to quotes from their readings (thinking skills, intertextuality, time and space)

Explore Concepts of:
culture (values, beliefs, time and place), perspective (point of view, bias, interpretation), and identity (the individual- growth/development/human condition)Reinforcement instruction must be followed up by the teacher.
III. Viewings:
Note-taking on the viewing od the art and videos- making connections to texts reads of culture, identity, and perspective; ATTs local and global contexts (Learner Portfolio).
Discussion on the viewings (perspective, thinking skills, communication)
IV. Application: Practice and Assessment

1. Students will define the concept they select and find at least 2-3 quotes from their readings to make connections (Learner Portfolio)

2. Students write a paragraph or a one-page journal on the connections they have found.

3. Students create journals, blogs, or video essays addressing local and global contexts

4. In-class analysis essay writing on given topics (Paper 1 and 2 practice)

5. Drafted essays (HL essay (practice)

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ATLS:

Thinking Skills

Communication

Research (required)

Self Management (for research and assessments)

AOEs addressed:

Time and Space

Intertextuality

Added AOE:

Readers, Writers and Texts

ATTs

Inquiry

Conceptual understanding

Collaboration

Local and Global contexts

Conceptual questions based on:

Culture

Identity

Perspective