# Abstract According to the latest [[World Bank (WB)]] estimates, over the past decade some US $4.3 billion has been pledged by governments to combat the threat of pandemic influenza. Presidents, prime ministers, and even dictators the world over have been keen to demonstrate their commitment to tackling this disease, but this has not always been the case. Indeed, government-led intervention in responding to the threat of pandemic influenza is a relatively recent phenomenon. I explore how human understandings of influenza have altered over the past 500 years and how public policy responses have shifted accordingly. I trace the progress in human understanding of causation from meteorological conditions to the microscopic, and how this has prompted changes in public policy to mitigate the disease’s impact. I also examine the latest trend of viewing pandemic influenza as a security threat and how this has changed contemporary governance structures and power dynamics. # History According to the Oxford English Dictionary, “influenza” is from the Italian influenza, which literally means “influence,” although its origins can also be traced to the medieval Latin influere meaning “to flow in.” The official adoption in 1782 of the term “influenza” by the British College of Physicians firmly established its place in medical parlance and displaced several of the alternative names the disease was known by, such as the French “la grippe,” the English “catarrh,” and the Scottish “rant.”3 Yet, although the name may have changed over time, historical accounts of the symptoms experienced by victims display a striking commonality that leaves little doubt that the disease has been a persistent element of the human condition for millennia. Generally speaking, however, influenza did not rate particularly high on medical and political agendas even at the beginning of the 20th century. As late as 1837, there was a strong view that governments had little to no role in ensuring public health9; although this sentiment progressively began to change, government intervention in the form of large-scale public health campaigns was rare, particularly any relating to influenza. Until the 1918 “Spanish Flu” pandemic forever changed societal notions about the disease. [[Fun fact]] Although the pandemic is suspected to have originated in the United States, it was inappropriately termed the Spanish Flu in 1918 only because the Spanish authorities were the first to declare that they were experiencing a nationwide epidemic; as W. I. B. Beveridge aptly noted, “this misleading name stuck.” The next pandemic commenced in 1957 named the Asian Flu after cases were first recorded in China and the surrounding region. [[Surveillance should be focused on places with crowded conditions and inadequate hygiene]] The emerging practice of disease surveillance revealed what many had long suspected: that locations such as schools and military camps proved fertile grounds for spreading the disease because of crowded conditions and inadequate hygiene. The written record of 1957 pandemic can be attributed to one organization in particular: [[World Health Organization (WHO)]]. In 1947, following a request by a respected group of scientists, the Interim Commission of the WHO agreed to establish the World Influenza Centre (WIC) to collect and distribute information, conduct and coordinate laboratory work on the virus, and train new laboratory workers. WHO Influenza Program to (1) plan against the reoccurrence of future pandemics, (2) develop control methods to limit the impact when a pandemic did appear, and (3) limit as much as possible the economic impacts of influenza epidemics and pandemics. [[Insights]] So, right from the start of WHO program, they must limit the economic impacts of pandemic. At the heart of the WHO Influenza Program, though, was an international network of laboratories and scientists that shared information on the latest influenza-related scientific discoveries—a network that continues to function to the present day and that forms the basis of international efforts to control and mitigate the health impacts of influenza. From the network’s inception, every member state of the organization was encouraged to establish a national influenza center to collaborate with the WIC; by 1968, when the next influenza pandemic commenced, the network had grown to include 79 national influenza centers in some 54 countries and 2 reference centers (later known as “collaborating centres”) in London and the United States. 1968 “Hong Kong Flu” pandemic In the context of pandemic influenza, the cornerstone of pandemic planning and preparedness was widely promoted as ensuring ready access to influenza vaccines.45 The advent of influenza antiviral medications in the 1990s added to the pharmacological arsenal; however, despite limited clinical trials demonstrating their efficacy,46 on the advice of medical practitioners antivirals were soon identified alongside vaccines as “the two most important medical interventions for reducing illness and deaths during a pandemic.”47 The heightened political attention accorded to the threat of infectious diseases has, for instance, prompted the passage of new legislation that grants governments extended powers,57 given greater impetus for intervention (and ownership) by central governments in health care services,58 and resulted in millions (and in some instances billions) of dollars worth of investment in civil and military biodefense initiatives. [[Patterns of securitizing diseases to distort governance and shift political power and influence]] In the specific context of pandemic influenza, the fixation on vaccines, combined with the recent policy shift toward securitizing the disease, has served to distort the existing governance arrangements, granting pharmaceutical manufacturers a disproportionate amount of political power and influence. Some public health experts have been complicit in this, arguing that School closure, quarantine, travel restrictions and so on are unlikely to be more effective than a garden hose in a forest fire. Indonesia refused to share influenza virus samples in 2007 with WHO’s Global Influenza Surveillance Network (GISN) without improved access to vaccine. After some 4 years of diplomatic negotiations, a new agreement--[[Pandemic Influenza Preparedness Framework]] was endorsed by the 64th [[World Health Assembly (WHA)]] in 2011. Through new obligations placed on pharmaceutical companies that are part of the GISN to contribute 50% of the network’s operating costs, the agreement transforms what was previously a largely publicly funded network (supported principally by funds from Japan, Australia, the United Kingdom, and the United States) into a new [[public private partnership]]. At the same time, those companies that are not members of the network (and thereby exempt from contributing to the network’s operating costs) are required to agree to a package of measures intended to improve access to medicines and diagnostics for low-income countries. In this regard, the agreement may begin to address the power imbalance between pharmaceutical companies and governments that has arisen in the wake of the global dissemination of avian influenza, although it remains to be seen whether equity in access between governments will be achieved under the terms of the agreement. > Perhaps the most intriguing aspect of the recent shift to securitizing diseases such as pandemic influenza has been the fact that Indonesia—a relatively small geopolitical power— successfully used the perceived threat of a disease to force some of the world’s most powerful countries to the negotiating table. What this reveals is that the concept of health security has gained a measure of traction within contemporary international politics. One could overplay the significance of the case; however, that a country like Indonesia can command global attention and require changes to existing influenza governance arrangements by withholding virus samples represents a notable shift in contemporary global governance.