Health & Place 18 (2012) 701709

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Health & Place

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Influenza preparedness and the bureaucratic reflex: Anticipating and

generating the 2009 H1N1 event
Kezia Barker n
Department of Geography, Environment and Development Studies, Birkbeck, University of London, UK

a r t i c l e i n f o abstract

This paper draws together work on the event to problematise the generative implications of
Keywords: anticipatory governance in the management of emerging infectious disease. Through concerns for
H1N1 preparedness, the need to anticipate outbreaks of disease has taken on a new urgency. With the
Anticipatory governance identification of the H1N1 virus circulating amongst human populations in 2009, public health
Preparedness measures and security practices at regional, national and international levels were rapidly put into
Bureaucratic reflex play. However, as the ensuing event demonstrated, the social, political and economic disruptions of
Event emerging infectious diseases can be matched by those of anticipatory actions. I argue that the event-
making potential of surveillance practices and the pre-determined arrangements of influenza pre-
paredness planning, when triggered by the H1N1 virus, caused an event acceleration through the
hyper-sensitised global health security architecture. In the UK, this led to a bureaucratic reflex, a
security response event that overtook the present actualities of the disease. This raises questions about
the production of forms of insecurity by the security apparatus itself.
& 2012 Published by Elsevier Ltd.

Against all expectation, even if it has been partially expected or
anticipated, such is in fact the essence of the event (Dastur,
2000, 183).
The extent of the UK governments preparedness for high impact
pandemic may mean that the Government seemed to react rather
slowly to the more mild profile of H1N1, of which its cleaving
overlong to reasonable worst case planning assumptions rather
than evolving projections (with uncertainty) of the H1N1 epi-
demic seemed symptomatic (Royal Statistical Society, 2010, 4).
The scope of the event is part of its effects, of the problem posed in
the future it creates. Its measure is the object of multiple
interpretations, but it can also be measured by the multiplicity
of these interpretationsy (Stengers, 2000, 67).
1. Introduction: against all Expectationy
1.1. The 2009 H1N1 Event
increased and sustained transmission in the general populations of
most countries, but remained mild and only an estimated 15,000
people died worldwide, far fewer than the average seasonal
influenza.1 After an initial peak in August, a much smaller second
wave occurred in December. In England, the number of consulta-
tions stayed below the threshold for epidemic influenza activity.
25,785 people were hospitalised, with 2326 critical care admissions.
At approximately 10% of all hospitalised cases, this was against all
expectation significantly lower than the pre-pandemic modelling
suggestions of 25% (Hine, 2010). The disease was mild in most cases
and the case fatality rate at 457 deaths was low. The virus did not
mutate into a more virulent form, and the pandemic fizzled out by
February 2010. In the UK, an independent review broadly endorsed
the approach taken in England and the devolved administrations,
but warned us to stay vigilant for the next possible influenza attack
(Hine, 2010). The Spanish flu of 1918 with 2040 million deaths
worldwide has remained influenzas historic discursive fear event,
and a highly pathogenic H5N1 avian influenza virus as the next big
thing (Davis, 2005).

In the spring of 2009, an influenza virus (an acute infectious 1.2. The 2009 H1N1 Event (II)
viral illness, characterised by the sudden onset of fever, chills,
headache, muscle pain, severe prostration and a cough) began The first human cases of the swine-origin influenza A H1N1
circulating amongst public around the globe. The virus achieved virus were confirmed in Mexico and the USA on 23rd April 2009.

n 1
Tel.: 44 207 631 6619. An estimated 12,000 people die each year from seasonal influenza in
E-mail address: k.barker@bbk.ac.uk England and Wales alone (DoH, 2007).

1353-8292/$ - see front matter & 2012 Published by Elsevier Ltd.

doi:10.1016/j.healthplace.2011.11.004
702 K. Barker / Health & Place 18 (2012) 701709
Within three weeks Roche, the manufacturer of the antiviral drug
oseltamivir (Tamiflu), fulfilled orders of 220 million treatment
courses to over 85 countries (Cooker, 2009) two weeks prior
to the World Health Organisations (WHO) declaration of a world-
wide pandemic on the 11th June. In England during the course
of the pandemic health authorities worked with a reasonable
worst-case planning assumption of 65,000 fatalities. Over 1.1 million
courses of antiviral treatment from a stockpile sufficient for 34
million people were distributed from 2000 antiviral collection points
established across the country, while a further 1.7 million people
sought advice about possible symptoms through the National
Pandemic Flu Service (NPFS) (Hine, 2010). Advanced purchase
agreements with two pharmaceutical companies were activated to
produce 132 million doses of vaccine. A UK wide media campaign
ran on television, radio and in print. The Governments advice to
catch it, bin it, kill it was offered online, on bus shelters, billboards,
even shopping trolleys, and every home across the county received
an H1N1 information leaflet through their letterbox. Considerable
strain was placed on primary care by the worried well contacting
their general practitioners (GPs) for advice, and GPs in attempting to
deliver a complex containment and treatment model were pushed
towards burnout. The total cost of the pandemic in the UK alone has
been estimated at 1.243 billion (Hine, 2010), diverting significant
resources from an already stretched public health system, with 16%
of PCTs admitting they were forced to cut other health care services
to fund the response (Community Practitioner, 2010).
1.3. Events
These two conflicting yet irreducibly linked stories outline
what happened in the UK during the 2009 H1N1 pandemic.
Together, they challenge and destabilise our understandings of
what constitutes a crisis disease event, and question the role of
anticipatory security practices in creating such events. As
Anderson and Harrison (2010) highlight, there are many ways
in which the event is conceptualised: as a disruption, a surprise
(Dastur, 2000), a creator of difference (Stengers, 2000), the
condition of truth, as continual differing against a changing
complex of other potential events (Whitehead, 1920; 1985;
Fraser, 2006), as housing potential, as a becoming (Deleuze,
2004). If we approach the event as a surprise, as something that
brings contingency, unpredictability, and chance into the world,
then one key way in which H1N1 surprised was through its mild
nature (Dastur, 2000, 179). The event that was prepared for and
that drove the response to the pandemic was highly pathogenic
avian influenza (see Hine, 2010; Chambers et al., in this issue). For
H1N1 to have precipitated an event of this magnitude required its
mutation into a more virulent form leading to further sickness
and deaths, more disruptions to the normal. A biological occur-
rence with social, political, financial and emotional implications.
However, if following Badiou (2005) we also approach the event
as a rupture, a disruption, then social, political and financial
disruptions occurred in spite of the mild nature of the virus, as
the most severe economic impact [was] due to the policies to contain
pandemic rather than the pandemic itself (quoted in Warren et al.
(2010, 733)), and this pattern is reflected in a host of other
biosecurity and health security events.2 The response to H1N1
repeated an a priori understanding of what the event was, which
2
The 2001 Foot and Mouth diseases (FMD) far-reaching political and
economic consequences (Donaldson and Murakami Wood, 2007, 1), occurred
due to the slaughter of 10 million cattle and sheep, and the shutdown of the
countryside, not due to sick, less productive cattle (see Donaldson et al., 2006), and
during the SARS outbreak, biosecurity actions were taken specially to enhance
business confidence rather than simply for the business of disease management
(Sanford and Ali, 2005).
served to produce and extend the event as disruption. This is
contrary to the very logic of preparedness, which purportedly
involves planning to contain the wider disruptive effects of events
after an initial precipitating event (Anderson, 2010a). For the
2009 H1N1 outbreak, the eruptive force of the event was caused
by the security apparatus. It therefore provides the opportunity to
explore the ways in which the range of security practices involved
in infectious disease management can lead to the creation of
disruptive events, resulting in the production of insecurity by
security practices themselves.
A rich vein of work in the domain of anticipatory geographies
interrogates the relationship between future events and security
practices (Anderson, 2010a, 2010b; Cooper, 2006; Lakoff and
Collier, 2008). Imagined future crisis events and understandings
of the contingency of life have become the cause and justification
for anticipatory actions in the present, as they come to require
governance response and institutional building (Anderson,
2010a). Different technologies of anticipatory governance of
pre-emption, precaution and preparedness are understood as
attempts to stop the future event or control the emergent effects
of the event. However, as Anderson argues, these anticipatory
security logics are also generative as they bring the future into the
present as an object of knowledge, justify present forms of
intervention, the building of infrastructure, and the ongoing
problematisation of emergent life. In the context of pre-emptive
warfare, Cooper (2006, 125) has extensively detailed the logics of
anticipatory governance that actualise the future as a way of
managing it:
The doctrine of pre-emptive warfare assumes that the only
way to survive the future is to become immersed in its
conditions of emergence to the point of actualizing it
ourselvesy
In particular, pre-emptive action has been shown to unleash
transformative events to protect certain forms of life through
interventions into the lives of others over there to protect valued
life at home (Braun, 2008). However, the generative effects of
preparedness activity and surveillance infrastructures have been
less explored. In this paper I hope to add to the ongoing debates
over the making of geographies through anticipatory action
(Anderson, 2010a), by considering the ways in which anticipatory
practices of preparedness and surveillance could be said to create
not just action in the present, but also become generative of
events themselves.
Following this, the questions this paper seeks to address are
the following: as H1N1 was a mild virus, why did it become an
event in ways that seasonal flu does not? And what do we need to
learn about preparedness and anticipatory governance to prevent
this form of bureaucratic reflex? The term bureaucratic reflex
refers to automatic governing response without policy reflection.
Here it is used specifically to highlight the ways in which
preparedness architectures can, counter intuitively, restrict flex-
ible responses, prevent the rescaling of management responses
and constrain the ability of agencies to adapt and tailor security
policies and practices to rapidly evolving situations. Rather than
working with multiple futures or scenarios, in the event influenza
preparedness in its manifestation in England reduced possible
policy directions and prevented flexible responses by locking
officials into a mode of response that did not fit the mild nature
of the virus.
The H1N1 event was differentiated nationally, regionally and
locally, and obtains a singular status only in registers such as media
reporting, national and international reviews and reports. The focus
for this paper is the response by the English administration, as it
forms an excellent example of this bureaucratic reflex, in which
 K. Barker / Health & Place 18 (2012) 701709
security responses themselves generate the wider effects of a much
more reduced disease occurrence. As Greenhough (2010, 41) argues,
how and why events occur are always entangled with when and where
they take place. The UK has been particularly commended for being
very well prepared for pathogenic influenza. This international
reputation for influenza preparedness produced a strong desire on
the part of the government to be seen to be acting like a state
(paraphrased from Scott, 1998), constraining the possibility for a
more tailored, flexible response to the emerging situation, and
particularly for responding in a more reduced capacity.
In what follows, I consider the rise of the catastrophic event
within health security, defined by its emergent, globalised and
disruptive qualities, and consider how it has been responded to
through anticipatory governance and practices of preparedness. I
then draw on wider understandings of the event in social, cultural
and political theory, marking the creation of an event as a process of
making-political, making-visible and the making-of-associations.
Finally, I return to the 2009 H1N1 event, detailing some actions
and implications of this bureaucratic reflex. I argue that despite the
rehearsal of preparedness purportedly to allow flexible responses to
different situations, the most unrehearsed and difficult decision to
make remains the decision not to (over) act.
2. The crisis event and security responses within health
governance
The articulation of infectious disease as an issue requiring a
security response changed in the last decade of the twentieth
century. While the relationship between humans and microbes
had long been conceptualised as a war, this was warfare of a
different kind, one that unsettled the dogmas of the quarantine
state (Cooper, 2006, 115). Critical to this new way of governing
infectious disease as a security threat, is the underlying concept of
the catastrophic or crisis event.
The crisis event and the governance responses it demands can
be distinguished from routine disease management in three ways.
Firstly, it refers to the condition of biological emergence, dyna-
mism and indeterminacy (Clark, 2002; Cooper, 2006; Dillon and
Lobo-Guerrero, 2009; Hinchliffe, 2001). Rather than a knowable
list of historic diseases, biological life understood as emergent
phenomena presents the continual possibility of producing new,
unknown and unpredicted infectious diseases. An emergent
threat, according to Cooper (2006, 124), is a threat whose actual
occurrence remains irreducibly speculative, impossible to locate
or predict, yet always imminent: the not if, but when. This
emergency of emergence (Dillon and Reid, 2009) necessitates
public health governance focused on biological emergence itself,
producing a state of permanent warfare against microbes (Lakoff,
2008a). As Anderson (2010a) highlights, this unpredictable future
both exceeds our present knowledge, and disallows perfect
knowledge it will surprise and shock.
Secondly, this dangerous emergent life is amplified and accel-
erated through the increasingly complex globalised circulations of
people and things, operating as the dark side of globalisation
(Braun, 2008; Ali and Keil, 2008). This further enhances the
conditions for new mutations and emergent threats to occur,
but crucially also the spatio-temporal impacts of this emergence:
Even if as seems likely a pandemic originates abroad, it will
probably affect the UK within two to four weeks of becoming
an epidemic in its country of origin, and could then take only
one or two more weeks to spread to all major population
centres here (DoH, 2007, 6).
Thirdly, the crisis or catastrophic event is marked by its wide-
spread disruptive influence, with the potential to dramatically alter
703
the conditions of liberal life (Beck, 1992). For infectious disease
management, this potential for disruption concerns not just the
virulence of a virus, measured by the case fatality rate, but also the
age groups most affected, the mode of transmission and the speed
and severity at which the disease peaks.
The forms of uncertainty that stem from the emergent,
imminent, networked and disruptive catastrophic event present
differing challenges to that of risk, the subject of extensive
research in the decades since the publication of Becks (1992)
thesis. While predictable risks can be made knowable through
historic data on the frequency and severity of past events
(statistical archival forms of reasoning), uncertain events are
incalculable, as the probability of their occurrence is unknown
(Anderson, 2010b; Lakoff, 2008b). For these uncertain threats, the
traditional tools at the disposal of the risk planner such as
probability analysis, monitoring and insurance are unworkable.
It is instead the emergency planner who must develop counter-
measures against the unpredictable, uninsurable and irreparable
crisis event. These counter-measures are increasingly framed in
the domain of security, and as action must happen before the full
occurrence of a crisis event to prevent or mitigate its worst
effects, practices of actively securing the future in the present
are mobilised (Anderson, 2010a). This contains at its heart a
conflict for governance, which is normally expected to respond to
accidents by transforming them into risks that can then become
routine matters, through a host of practices and discourses (Barry,
2002). While anticipatory governance heightens the affectual
charge of future crisis events as a way of bringing them into the
present, it also attempts to normalise and habitualise both
security practices and the crisis event.
2.1. Preparing for the pandemic
Attempts to secure the future catastrophic event operate within
different registers of anticipatory governance, such as precaution,
pre-emption and preparedness (Adey, 2009; Amoore, 2009;
Amoore and de Goede, 2008; Anderson, 2010a; Cooper, 2006;
Lakoff, 2008a, 2008b). While precaution and pre-emption aim to
stop a future event directly, the logic of preparedness aims to halt
the event in a different way, by preventing the possible wider
effects of an event spiralling out of control. Our understandings of
preparedness have been particularly informed by the work of Lakoff
(2008a, 2008b), who charts the rise of a norm of preparedness that
has come to structure public health particularly in the US. In his
research into the 1976 Swine flu fiasco, Lakoff writes that due to a
rationality of prevention then existing in public health, officials did
not have a mechanism with which to engage in responsible, but
provisional action under conditions of urgency and uncertainty
(Lakoff, 2008b: 408). He argues that preparedness is an attempt to
provide this mechanism, by allowing governance responses to
adapt to the contingencies of crisis events through a permanent
infrastructural readiness.
Firstly, preparedness involves pre-making decisions through
preparedness planning by outlining the range of possible futures
under the crisis event and developing blueprints of how to
respond under each different scenario. As Hine (2010, 4)
remarked in her review of the UK administrations response to
H1N1: many decisions had been made in principle prior to the
pandemic. This is seen as necessary to increase the speed of
governance responses and to reduce political and wider public
panic. The World Health Organisation (WHO), through the Global
Influenza Programme, drives international and national epidemic
and pandemic influenza preparedness planning. In 2003 the WHO
raised the likelihood of an influenza pandemic in the face of
concerns over avian influenza, leading to preparedness activity in
signature countries. Since 2005, all European Union member
704 K. Barker / Health & Place 18 (2012) 701709
states have produced pandemic influenza plans. The UKs plan-
ning framework: Pandemic Flu: A national framework for
responding to an influenza pandemic (the National Framework)
(DoH, 2007) was jointly published in 2007 by the Home Office
and the Department of Health, superseding the UK Health
Departments UK Influenza Pandemic Contingency Plan (2005).
The UK had been preparing for pandemic influenza for some
years, evident in the 2002 publication Getting Ahead of the
Curve: A Strategy for Combating Infectious Disease (DoH, 2002).
The curve here refers to an epidemiological curve, but also signals
the UKs desire to be seen on the global stage as well prepared.
The British Medical Association have referred to the very wide
range of guidance on responding to an influenza pandemic,
developed through joint workings between the Department of
Health and devolved administrations, the Health Protection
Agency, BMA and the Royal College of GPs (BMA, 2010). At a
local level, Primary Care Trusts (PCT), NHS Trusts and Local
Authorities developed and tested pandemic flu plans, which in
turn were quality assured for their robustness by regional
Strategic Health Authorities (Chambers et al., in this issue). The
National Framework sets out a range of pandemic influenza
containment measures to be considered and assessed by govern-
ment in light of the emerging picture. These measures include
school and border closures, travel restrictions, postponement of
mass gatherings and the limited prophylactic use of antiviral
medication in households to reduce transmission from index
cases to close contacts. The total cost of this preparation phase
in the UK was 654 million (Hine, 2010).
Secondly, preparedness involves developing the operational
capabilities necessary to respond to an event. This involves building
resilient systems that can respond and recover, as well as
mitigating certain effects on structural processes to support the
continuity of essential services and protect critical national
infrastructure (DoH, 2007, 9; Lakoff, 2008a). The pandemic flu
preparedness infrastructure in England in 2009 included a
national clinical director for pandemic preparedness, professional
advisory committees and managerial flu leads at the Strategic
Health Authority level (Baker, 2010). These built on existing
structures such as SAGE (the Scientific Advisory Group in Emer-
gencies) and newly established groups including the SPI (Scien-
tific Pandemic Influenza Group) and PICO (Pandemic Influenza
Clinical and Organisational Group). Pandemic resilience fora at
local and regional levels act as a stakeholder co-ordination tool,
bringing together resilience planners, police leads, what are
termed category 1 responders (blue light services, the NHS,
local authorities, the HPA and Health and Safety Executives), and
category 2 responders (representatives from public organisa-
tions, large businesses, etc.). In terms of the operational capabil-
ities themselves, the National Framework focused on developing
surge capacity in health and social care, on developing business
continuity arrangements, and putting in place measures to main-
tain essential services and supplies during a pandemic (DoH,
2007). This included the advance purchase of antivirals and
advance contracts for pandemic vaccines, and facilitating arrange-
ments for the rapid development and supply of relevant vaccines.
These preparedness plans and capability response infrastructure
are continually tested through event scenarios, simulations and
enactments, to map system vulnerabilities and response capabil-
ities (Anderson, 2010b; Collier and Lakoff, 2008; Lakoff, 2008b).
Thirdly, surveillance and monitoring provide two key functions:
outbreak detection, an early warning system giving as much time
as possible to put into position these pre-planned response
measures, and the monitoring of disease progression and virus
characteristics during the outbreak itself. The Global Influenza
Surveillance Network (GISN), coordinated by the WHO, has an
expanding network of 134 designated National Influenza Centres
(NICs) in 104 countries, integrated by 5 WHO Collaborating
Centres (WHO CC) on Influenza in Atlanta, Tokyo, London,
Melbourne and Memphis (McCauley, 2010). This network is in
place to allow the rapid sharing of results on the emergence,
mutation and variation of viruses, and the identification of
suitable strains for vaccine production. Outbreak detection is
undertaken through systems such as syndromic surveillance,
which analyses pre-diagnostic data for indications of care-seeking
behaviour (Robertson et al., 2010; Fearnley, 2008). These systems
scan numerous information sources including print and online
media, even pharmaceutical sales, to detect irregular clusters of
symptoms that may indicate the emergence of new viruses
(Fearnley, 2008). The UKs national biosurveillance system, Qsur-
veillance, analyses patients records from 35,000 enroled GP
surgeries and the NHS syndromic surveillance project draws on
information produced by NHS call centres (Parry, in this issue).3
The Royal College of General Practitioners Research and Surveil-
lance Centre undertakes twice weekly reporting and surveillance
of influenza-like illness and other respiratory diseases presented
to GPs. Hospital admissions data, information derived through the
national Laboratory Reporting Scheme and data from the Medical
Officers of Schools Association are also used to provide informa-
tion on influenza-like illness. In addition, the HPA (2010) under-
takes horizon scanning of emerging threats, through the
monitoring of literature and media reports on the Internet, as
well as direct research. This surveillance apparatus transforms
occurrences of ill-health into forms that can be responded to
politically, as statistical tests for spatial aberrations, tests for
spacetime interaction, visualisation tools and GIS are used to
highlight possible disease clusters.
The preparedness logic of envisioning and pre-making deci-
sions for multiple scenarios, developing operational capabilities
and ensuring robust surveillance networks, is that when an
entirely separate disease occurrence with the potential to become
a crisis event materialises, the apparatus is in place to prevent it
spiralling out of control. In seeking to understand the wider
disruptive impacts of H1N1, however, it may be useful to probe
whether the preparedness apparatus and crisis disease events are
in fact more tightly bound than this thinking implies, by con-
sidering the event-generative potential of these forms of antici-
patory governance.
3. Generating the security event
The process of anticipating and preparing for a crisis EID event
speaks to a wide vein of work on action, governmentality and
temporality, through which event thinking has contributed to our
understandings of science, ethics, history and politics. In what
follows I draw out three understandings of the event from this
work, to explore the ways in which this preparedness apparatus
developed in anticipation of a crisis event, could be understood to
be productive of events themselves.
3.1. The event as new problematisation: a making-political
The concept of the biosecurity event as a new problematisa-
tion is notable in the work of anthropologists Lakoff, Collier and
Rabinow, who develop this understanding through a reworking of
Foucaults attention to events as shifts in epistemes, for example
from a pastoral society to a society of discipline (Foucault, 1975).
Collier and Lakoff (2008) urge attention to the kind of problem
3
See Fearnley, 2008 for a discussion of syndromic surveillance and prepared-
ness logics in the US, and Amoore, 2009, for a discussion of surveillance
technologies in the context of the War on Terror.
 K. Barker / Health & Place 18 (2012) 701709
biosecurity events are seen to pose, the discourses and practices
invoked to respond to this problem, and the ways in which these
responses are justified and mobilised. They highlight the intro-
duction of uncertainty as a key element in this process of
problematisation: something prior must have happened to intro-
duce uncertainty, a loss of familiarity; that loss, that uncertainty
is the result of difficulties in our previous way of understanding,
acting and relating (Collier and Lakoff, 2008:12). Barry (2002:9)
also considers how an occurrence is translated into being some-
thing that is regarded as problematic and contestable. For Barry,
not all accidents or errors are reckoned to be political events.
A political event, he argues, demonstrates the existence of a
problem that is not fully contained by existing political or
economic arrangements.
This uncertainty was introduced into health governance in the
1990s through the resurgence of existing and the emergence of
new infectious diseases (Cooper, 2006; King, 2002). These newly
perceived threats were seen to problematise the existing spatio-
temporal framework of health governance, leading to the con-
struction of potential future disease events as biosecurity threats
of global significance (Collier and Lakoff, 2008). The ensemble of
discursive and non-discursive practices that support this inter-
section between security and health governance include the
mobilisation of discourses of war, terror and security in everyday
domains of governance (Barker, 2009); the operation of global
health institutions working within an emergency modality
(Lakoff and Collier, 2008); and the development of rationalities
and technologies of preparedness and other anticipatory govern-
ance techniques. Through these key practices and processes,
infectious disease is problematised and made political, and
transformed into a biological threat requiring a security response.
Barry (2002, 8) focuses on how particular practices of demon-
stration and inspection can render occurrences into political
events within particular problem fields: Inspection provides the
occasion for events which precipitate political conflict and
debate.4 Following from this, surveillance can be understood as
a practice which, when operating in the problem-field of global
health security concerns, works to transform occurrences of ill-
health into a political event. The WHO 2007 International Health
Regulations require states to notify about any event occurring in
their territory that may constitute a public health emergency of
international concern (DoH, 2007, 11). While, as Sparke (in this
issue) notes, Mexico and Mexicans paid a heavy economic price
for globally responsible reporting as H1N1 initially became
labelled Mexican flu, with flights and vacations to Mexico being
cancelled, Mexican restaurants globally experiencing a painful
drop in business and Mexico struggling to demonstrate public
health responsibility through the suspension of public events;
China is still the ongoing subject of viral suspicion through its
perceived failure to rapidly report SARS. The WHO regulations
together with the global reach of surveillance therefore make
both reporting and failing to report ill health a political event.
3.2. The event as a rupture in the visible: a making-visible
A second key articulation of the event, of particular signifi-
cance for the governance of crisis EID events, is strongly related to
the first. This demonstrates that the process of making political
crucially involves a process of making visible.5 There are two
different senses in which this applies. Firstly, it refers to a
4
Barry (2002) highlights that some forms of inspection, demonstration, or in
this case surveillance, are undertaken to contain the political implications of
events.
5
See Louise Amoores (2007) paper on Vigilant Visualities for a discussion in
the context of the War on Terror.
705
visualising action productive of events. Surveillance techniques
exemplify this, as they strive to make visible occurrences in a way
that generates events. On the 2nd April 2009 reports of a surge in
respiratory disease and the deaths of three young children in La
Gloria, Mexico were made visible to global surveillance networks
by the Veratect Corporation in Kirkland, Washington; a private
company which monitors world press and government reports to
provide early warnings for clients, including the US Centre for
Disease Control and Prevention (Mackenzie, 2009). It was then on
the 12th April that an influenza-like illness was reported by the
Mexican General Directorate of Epidemiology to the Pan Amer-
ican Health Organisation. The first human cases of the new swine-
origin influenza A/H1N1 virus were then confirmed in Mexico and
the USA on the 23rd April following laboratory tests at the WHO
CC in Atlanta, and the outbreak announced a day later by the
WHO (McCauley, 2010). There are suggestions that the virus had,
however, been circulating for some time in the US states of Ohio,
Wisconsin and Texas, unidentified, unnamed, unreported, invisi-
ble. This demonstrates that an epidemic is not an epidemic of
occurrences, but an epidemic of visibility:
When understood as an event any [object or occurrence]
which is monitored or made visible is different from one which
is undisturbed or unrecognized even if its physical and
chemical composition remains the same (Barry, 2002, 9).
Following from this initial visualisation,6 occurrences of flu-
like symptoms in a host of countries could then be identified,
named and made visible as H1N1, through the identification of
the molecular characteristics of the virus genome using the
quantitative Polymerase Chain Reaction (qPCR) technique. This
information was shared through GISAID, the dedicated public
database of influenza viruses. From this unique identifier, national
laboratories of other WHO Collaborating Centres were able to
both identify the H1N1 virus directly from its nucleotide
sequence, and generate molecular diagnostic reagents for validat-
ing tests (McCauley, 2010).
Secondly, the event can also be conceived of as a rupture or
disturbance in the field of visibility. Emerging infectious diseases
such as H1N1 act like tracer dye in the veins of global interconnec-
tivity, revealing the proximity of both human and animal bodies, and
of bodies in Mexico, Texas and Birmingham. In turn, this highlights
vulnerabilities for future event planning and is used to justify
institutional redevelopment. Following the H1N1 outbreak for exam-
ple, the UK Government proposed to strengthen the national response
on emergency preparedness and health protection (DoH, 2010, 8) by
abolishing the Health Protection Agency and establishing instead a
centrally controlled, national public health service called Public
Health England. It is instructive that this moment of visibility can
so quickly be rendered opaque and the event foreclosed, as H1N1 did
not lead to challenges to industrial farming or the cross-border
outsourcing of a polluting industry from the US to Mexico (Sparke, in
this issue), but to calls for further preparedness activity.
Taken together, understanding the event as a process of
making-visible highlights that this visibility is not just the
outcome of an event (so an event is such if it changes the field
of the politically visible), but that making-visible is part of the
constitution of the event itself. This bears particular significance
for understandings of the generative potential of surveillance
activities.
6
The geography of this moment of initial visualisation is crucial in the
ensuing attribution of blame, as Sparke (this issue) discusses in the context of
the global stigmatisation of Mexico and Mexicans.
706 K. Barker / Health & Place 18 (2012) 701709
3.3. The event as associations which transform reality: a making of-
associations
Understanding the generation of the event through the making of
associations contains no prior assumptions about the political effects
or political interpretation of events. Barry (2002, 8), developing the
work of the philosopher AN Whitehead, argues that the event is not
only defined by sudden conjunctions or accidents, but with new,
transformative associations. Following Barry, this highlights that
surveillance and preparedness activity can constitute events, when
they transform the reality of these events, placing them in conjunc-
tion with other events, in a new environment (Barry, 2002, 9). It is
not that these associations pre-exist the event, but that through the
process of making associations, events are generated. This operates at
different scales. In the context of public health security overall, Lakoff
and Collier (2008, 7) argue that the WHOs policy framework has
brought together previously distinct technical problems and political
domains, associations which work to constitute ill-health as a
security event. Then, in the production of H1N1 itself as an interna-
tional health security event, practices of surveillance and epidemiol-
ogy made associations between different sick individuals, connecting
them locally, nationally and internationally, both with each other
and with the virus, to constitute a pandemic. The first samples from
potential H1N1 victims taken in different countries were shared with
WHO Collaborating Centres to confirm these initial sets of results
(McCauley, 2010). Londons WHO Collaborating Centre alone
received over 200 samples from 50 different countries. These results
were integrated with those produced by other WHO CCs from
around the world. This allowed occurrences of flu-like symptoms
in a host of countries to be identified, named and grouped as H1N1.
Before these establishing tests, paradoxically, all temporally relevant
occurrences of flu-like symptoms became part of the H1N1 event,
with the effect of both inflating the infection numbers and in some
instances the case fatality ratio, as well as incorrectly diagnosing
individuals who may have required different medical interventions.
The UKs National Patient Safety Agency was notified of many
delayed or missed diagnosis of other conditions mistakenly labelled
as swine flu (BMA, 2010).
Further examples are apparent within the response to H1N1.
As part of early attempts to contain its spread in the UK, the
associates of symptomatic patients were identified through con-
tact-tracing and prescribed Tamiflu as a prophylactic, a key and
controversial element of the event (see Chambers et al., in this
issue). This was undertaken to attempt to contain the spread of
the disease, as well as to provide information to the HPA on the
spread. The conflicting messages GPs received about the provision
of antiviral medicine to contacts in this prophylactic fashion
added to their experience of the event as being one of confusion
and near burn-out (BMA, 2010). Influenza surveillance also
involves making associations between behaviour in different
domains, and the potential onset of a pandemic. Care-seeking
behaviour including the use of particular Internet search terms
and over-the-counter pharmaceutical sales are used as an early
warning system, and the HPA is exploring whether flu-related
absenteeism from a major employer in London could be used as a
future surveillance indicator (Hine, 2010).
In what follows, I return to the story of 2009H1N1 pandemic in
the UK. I argue that the English administrations response can be
characterised as a bureaucratic reflex, activated by the event-
making potential of the surveillance and preparedness nexus of
influenza anticipatory governance. We see how preparedness
plans were invoked before information was known about the
virulence, severity or infectivity of the virus, demonstrating an
inability to move away from normal, where normal is the crisis
event. This suggests that the crisis event has become inherent
within the surveillance and preparedness apparatus itself.
4. The bureaucratic reflex: practicing preparedness
It y felt as if the response was being tailored to fit what was in
the plan, rather than the nature of the virus itself (evidence
submitted to the Hine Report (2010), 47).
The UK government was by many accounts well prepared for
influenza, and had received international acclaim for its prepa-
redness. It had been ensured, for example, that it would not be
short of antivirals, antibiotics or vaccines. But the UK was
prepared for a very different pandemic:
Many people journalists, officials and emergency planners
alike had been waiting for a pandemic for a long time, based
upon the expectations built up around H5N1y [T]here was a
widespread expectation that pandemic H1N1 would be the
big one. In the event, in terms of its severity, this was not the
case, although these expectations coloured a great deal of
thinking about the pandemic (Hine, 2010, 137).
From the moment that the first reports of a new respiratory
illness emerged from Mexico on the 12th April, the UK health
security nexus was on alert, ready to invoke the extensive
preparedness plans. The first human cases of the new influenza
A/H1N1 virus were confirmed in Mexico and the USA on the 23rd
April. It took only four days for the first UK cases to be confirmed,
at the same time as the WHO raised its pandemic alert level to
Phase 4. From these early stages and throughout the unfolding of
the event, substantial uncertainty and ambiguity underpinned
key parameters of the career of the virus.
The UK response was led by planning parameters laid down in
the National Framework, with alarming worst-case planning
assumptions that had been produced in anticipation of an avian
H5N1 flu virus. The National Framework designates that key
aspects of the UK preparedness plans are to be triggered by the
WHO pandemic scale. In the UKs National Framework, the WHO
alert level Phase 6 is intended to trigger the UK alert levels 24,
instigating particular public health actions which may include:
Requesting voluntary isolation at home of those who believe
they are ill.
Advice against non-essential travel.
Recommendations that schools and early years/childcare set-
tings close.
Pre-distribution to primary care trusts of national stockpiles of
antivirals.
Securing sufficient pre-pandemic and pandemic-specific vac-
cines to protect the population as soon as available, through
advance supply contracts trigged by a declaration of a WHO
pandemic Phase 6.
Procedures to minimise delays in burials and cremations.
Activation of the Civil Contingencies Committee (CCC).
Activation of the National Pandemic Flu Line Service (Hine,
2010, 20).
In particular, this pandemic scale was intended to trigger three
crucial policies that later emerged as particularly controversial
aspects of the English administrations response: advanced supply
agreements of vaccines, negotiated and signed in 2007 with two
pharmaceutical companies, GlaxoSmithKline and Baxter Health-
care; the prophylactic provision of antivirals (Tamiflu) as a mode
of containing the spread of the virus; and the use of the National
Pandemic Flu Service (NPFS) to facilitate the response.
The WHO scale, however, crucially refers to the geographic spread
of infection, not its severity. In an article published in the British
Medical Journal during the pandemic in September 2009, Doshi
(2009) proposes an additional framework to augment the WHO
 K. Barker / Health & Place 18 (2012) 701709
phases and introduce a measure of severity, distinguishing between
widespread and severe, and widespread and mild disease patterns.
This missing measure is recognised in the Government commissioned
Independent Review undertaken by the former Health Secretary for
Wales Dame Deirdre Hine, which recommends that planners con-
sider the practicalities of developing methods to measure the severity
of a pandemic in its early stage (Hine, 2010, 69).
In the event, however, the UK acted in advance of the WHO
declaration of a Phase 6 pandemic on the 11th of June. On 29th
April 2009, the then Prime Minister Gordon Brown announced
that the antiviral stockpile was to be increased to provide cover-
age for 80% of the population. No record of when or how this
decision was made is available: It is unfortunate that there is no
clear audit trail behind the decision to purchase enough antivirals
to cover 80% of the population (Hine, 2010, 103). During the
containment phase of the response in England, these antivirals
were distributed not just to those with symptoms of H1N1, or to
their close contacts, but in some instances, to entire school year
groups. This mass prophylaxis of healthy people was undertaken
as a containment method to slow the spread of the virus. In a
survey of family doctors in August 2009 by the GP periodical
Pulse, 61% believed that the government should review this
policy (Anekwe, 2009). Concerns over utilising antiviral provision
in this way include the economic cost, the side-effects of the drug
on individuals, and the potential for anti-viral resistance to build
in the population as a whole. Even more troubling, perhaps, is the
ethical issue of asking individuals to take a drug not for the
benefit of their own health, but for the purpose of pre-emptively
securing the health of the population.
When efforts to contain the pandemic were abandoned in
favour of a treatment approach, the strategy adopted in England
(in contrast to the devolved administrations), was again contro-
versial. The National Pandemic Flu Service (NPFS) was launched
on the 23rd July, a telephone-based system utilising call opera-
tors, following a computer algorithm to diagnose H1N1, a practice
without precedent on this scale. The computer algorithm, worked
only to a treat-all measure (the at-risk measure had not been
developed and agreed by the time of the pandemic). All indivi-
duals with self-reported symptoms of pandemic influenza were
treated with antivirals, irrespective of their status in groups most
at risk of severe illness or complications, and beyond the point at
which Tamiflu was imagined to provide any containment benefit
for the population. This was against the finely balanced advice of
the SAGE group. As the Hine Report (2010, 99) acknowledges: the
final treatment strategies adopted in each country were not solely
guided by scientific advice. The Hine Report implies that a range
of drivers other than scientific factors or health considerations
were behind these decisions: Presentational and operational
considerations also need balancing against scientific ones, since
maintaining public, professional and media confidence in the
Governments response was crucial (Hine, 2010, 103).
This eagerness to be seen to act continued into the procure-
ment of vaccines. On the 14th of May, the then Secretary of State
for Health, Alan Johnson, announced to the House of Commons it
is our intention to acquire sufficient stocks to vaccinate the entire
UK population (Hine, 2010, 115). This decision was made in
advance of the meeting of SAGE7 :
[M]inistersy made a decisiony to procure vaccine for 100% of
the population without the full advice being available to
themy It would have been better if ministers had made these
7
This differed from the approach agreed just three days earlier on the 11th
May, to procure enough pre-pandemic vaccine to cover 45% of the population,
with H1N1 vaccine for the remaining 55% of the population purchased under the
advanced purchase arrangements if and when a pandemic was declared.
707
decisions in full possession of all the relevant facts (Hine, 2010,
124)
Securing the vaccine as soon as it became available (in
competition with other countries) reduced the UKs flexibility in
responding to both the type and the severity of the virus. Initially
there was no break clause within these advance-purchase
arrangements, preventing orders from being cancelled when the
pandemic turned out to be mild, although this was later nego-
tiated with Baxter Healthcare. The lack of such a clause led to a
situation in which the government was taking delivery of and
paying for vaccines well past the point at which the virus was still
circulating (Hine, 2010, 121).
The Hine Reports subsequent recommendations imply that these
responses were disproportionate to the level of perceived risk:
Ministers should determine early in the pandemic how they
will ensure that the response is proportionate to the perceived
level of risk and how this will guide decision-making (2010, 4).
The process of determining this level of risk was itself a source
of conflict between the different forms of knowledge and exper-
tise relied on by the CCC. The English administration was heavily
reliant on modelling data to predict the future development of the
pandemic. This led to disagreement between the UKs modellers
(world leaders in this work, DoH, 2007, 15), and those involved
in operational epidemiology, over the assumed severity of the
virus. While those on the ground were reporting the relative
mildness of the virus, this was at odds with the range of possible
futures produced through these modelling assumptions (see also
Chambers et al., in this issue). Reliance on modelling had also
been criticised during an earlier biosecurity event in the UK. The
report into the 2001 Foot and Mouth outbreak states that:
The fact that a stochastic model predicts a range of possible
futures, reflecting the unpredictability of real life, means
that it must be used with care as a decision support tool.
Decision-makers must not rely on the model to make a
decision for themy (Taylor, 2003, 6)
This over-reliance on modellers as court astrologers (Hine,
2010, 67) continued during the 2009 H1N1 pandemic, demonstrat-
ing the discursive strength of these future-predictive practices.
5. Conclusions: prepared for nothing?
But the danger of another, more severe, pandemic has not gone
away and the governments of the UK must avoid complacency
and use this opportunity to learn lessons and make improve-
ments y (Hine, 2010, 2).
The Great H1N1 Pandemic of 2009 is now prone to re-
interpretation; to be projected into the future as a dress rehear-
sal for the real event; to leave its mark as an opportunity for
institutional capacity building. Far from questioning the role of
security in healthcare, H1N1 has reinforced the status quo of
planning and preparedness. The virus demonstrated the contin-
gency of life in which the future is conceived as a surprise: The
virus writes the rules. And it can change them at any timey
(Margaret Chan, Director of the WHO, June 11th 2009). This
biological contingency, this potential for surprise, has lead to
healthcare being governed by emergency:
yit is increasingly also a matter of being governed by
emergency, in ways that describe the logos of war into the
logos of peace via the discourses of security that now prolif-
erate throughout the politics of life itself.y Newly challenged
to govern through contingency, liberal government finds
708 K. Barker / Health & Place 18 (2012) 701709
itself governed by contingency (Dillon and Lobo-Guerrero,
2009, 17).
Yet in this case the surprise was the relative mildness of the
virus: the most unexpected factor was that the H1N1 pandemic
was a less severe pandemic than had been planned for (BMA,
2010, 6). Despite our preparedness, purportedly to allow flexibility
to respond to unknown events, we were unable to cope appro-
priately with this particular contingency, made up of mild cases
and hoards of worried-well. What if the virus had surprised us in a
different, more dangerous way? As this discussion has attempted
to argue, however, it is not simply that biological contingency, in
this case a mild contingency, drove or governed liberal govern-
ment. Instead, the emergence of a novel virus sprang the sensitised
surveillance trap of global influenza preparedness. In response to
contingency, to uncertainty, to the potential for the virus to
surprise, the bureaucratic reflex produced an event that acceler-
ated beyond the present actuality of the socio-biological occur-
rence of the virus. If SARS was significant for demonstrating the
emergent, networked and globalised ability of viruses to rapidly
materialize, mutate and disperse, H1N1 demonstrated the emer-
gent, self-justificatory nature of the health security apparatus itself.
Emerging infectious diseases are significant in formalizing and
revitalizing the legitimacy of anticipatory action and modalities of
security (Anderson, 2010a). Cooper (2006) highlights the double
bind of governing for future catastrophic events the necessity of
acting under conditions of uncertainty, together with the possibi-
lity that these governance actions will harm. I have tried to push
this further, by arguing that the governing nexus of health security
preparedness has the potential not just to harm but to produce
events themselves. The resources for generating information about
biological emergence have been shown to be immense; small
clusters or even individual instances of ill health are visible to
global scrutiny. This excess of information is masking the issue of
information utility, and the actual mechanisms of determining
proportional responses to that information are undeveloped.8 In
other areas of biosecurity there are institutionalized mechanisms
through which decisions not to act form part of the formalized
response to unwanted biological entities (see Barker, 2008). For
potentially catastrophic disease events whose magnitude is
unknown prior to their inception, how can we make possible such
decisions not to act? For Chambers et al. (in this issue), one step
towards this goal is through the continuous monitoring of the local
situation and sensitive, responsive information exchange between
different scales of government. Perhaps health security institutions
need to rehearse the enacting of non-action to counter the bureau-
cratic reflex, to figure non-action as an actionable event. One thing
is certain: we need to be prepared for nothing, if we are to prevent
the wider disruptive effects of the bureaucratic-security event.
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