Rethinking the influenza a h1n1 2009 pandemic singaporean youth perspectives

ii ACKNOWLEDGEMENTS My thanks go to  my advisor Associate Professor Paulin T. Straughan for her precious time, effort, and patience in guiding the course of work on this study;  the NUS Sociology Department for a stimulating postgraduate education that also provided the opportunity to present this study;  my fun-loving youth(ful) respondents for their participation in this study, and also some of their helpful teachers for connecting me to them;  Professor Chua Beng Huat and Dr. Daniel Goh for invaluable lessons and discussions;  my brother Kean Fan for his time and effort in proofreading and providing helpful insights on earlier drafts;  Lorraine and Hongyi from the NUS English Department for their helpful notes on earlier drafts and assistance in enhancing the clarity of my prose;  Dr. Stefan Wagner for listening to my concerns and steering me towards the right direction;  my students in SC2211 Medical Sociology (January - May 2010) for their helpful comments on my preliminary findings;  my friends, particularly Shawn, Pamela, Mastura, Thomas, Hui Hsien, Nurul, Seuty, Audrey, Julien and the „homegang‟ from U.C. Berkeley for ceaselessly cheering me on not only during the course of completing this study, but also in my struggle with several personal difficulties;  my sister-in-law Stephanie, my mother and also my late father for ceaselessly caring for my health and unconditionally supporting whatever I do. iii TABLE OF CONTENTS Acknowledgements Table of Contents Summary List of Figures, Plates and Tables List of Abbreviations ii iii v vii viii Chapters 1 Background and Thesis Objective . . . . . . . . . . . . . . . . . . . 1 1.1 Background 1.2 Scope for Inquiry on Youth Perspectives 1.3 Research Question and Central Argument 1.4 Organization of Thesis 2 Insights from the Literature . . . . . . . . . . . . . . . . . . . . . . 13 2.1 Agency of Individuals in Engaging with Infectious Disease Outbreaks 2.2 Where Individuals Experience Official Responses to Outbreaks Matters 2.3 Conclusion 3 Analytical and Methodological Approaches . . . . . . . . . . . . . . 22 3.1 Analytical Approach 3.2 Methodological Approach: Data Generation 3.3 Methodological Approach: Data Analysis 3.4 Conclusion 4 Policing Pandemic Response Measures in Schools and its Implications for Pandemic Control . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Background 4.2 Daily Temperature-screening 4.3 Home Quarantine 4.4 Educational Campaign 4.5 Policing the Practise of Preventive Measures in Schools: Implications, Reflections, Suggestions 4.6 Conclusion 41 iv 5 Policing Pandemic Response Measures in Schools in Relation to Youths’ Memories of SARS . . . . . . . . . . . . . . . . . . . . . . . 75 5.1 Background: Formal Policing of Preventive Measures in Schools during the SARS Epidemic 5.2 Formal Policing of Pandemic Response Measures in Schools: The Limitations of Remembering SARS 5.3 Implications and Suggestions 5.4 Conclusion 6 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 6.1 Formal Policing of Pandemic Response Measures in Schools: Limitations, Implications and Suggestions 6.2 Suggestions for Future Research Appendices 103 Works Cited 110 v SUMMARY This thesis explores two groups of Singaporean youths‟ perspectives of the official control and preventive response protocol implemented during the H1N1-2009 pandemic period. Its research design and approaches are informed by symbolic interactionist assumptions that posit individuals such as the young respondents in my sample as social agents who define the pandemic situation individually vis -àvis their internalization of and engagement with rules and norms in their microand macro-social contexts. The first group of youths comprises 15 students of ages from 13 to 17 who were attending schools under the Ministry of Education (MOE) system. They were formally policed, monitored and educated by school teachers in their practice and understanding of response measures during the pandemic period. The second group comprises 15 youths of ages from 18 to 25 who were undergraduates or employees in various work organisations. Unlike the first group, they did not experience the pandemic response measures and education in the same formal school setting. Qualitative data were generated from interviews with these 30 youths from October 2009 to December 2009. Two key findings arose from these interviews. One, younger respondents from the first group were significantly less appreciative of and responsive to formal control and prevention than respondents in the second group. Two, the younger group of youths engaged negatively with their past experiences of SARS response measures in schools and consequently developed less concern and tolerance for reexperiencing a similar strategy for H1N1-2009 in the same formal school setting. In view of these findings, this thesis posits that formal policing of pandemic response measures in schools has its limitations in its approach to fully involve youths‟ participation in pandemic response efforts. vi Both findings have implications for effective pandemic control and prevention, as they affect the overall quality of students‟ participation in the protocol and their preventive and knowledge-seeking behaviour adopted. Instead of rigidly mandating and maintaining students‟ literal compliance to response measures, there is a need to redirect focus on gaining their understanding to improve the quality of their compliance to prevention and control in a formal school setting. Rethinking the implementation of response measures in schools that take their perspectives into account is necessary to attain this goal. vii LIST OF FIGURES, PLATES AND TABLES Figure 3.1 Page Writer‟s analytical framework Plates 4.1 4.2 Tables 1.1 3.1 3.2 26 Page Screenshot of HPB‟s updates on H1N1-2009 on Facebook Screenshot of HPB‟s FluSingapore Twitter page 63 63 Page Chronology of key events and control measures in the H1N12009 pandemic in Singapore 4 Research sample 28 Timeline of Research Process 32 viii LIST OF ABBREVIATIONS CMGs - Crisis Management Groups DERC - Department‟s Ethics Review Committee DORS - Disease Outbreak Response System HCMS – Homefront Crisis Management System HPB – Health Promotion Board ILI - Influenza-like illness LOA - Leave of Absence MC - Medical Certificate MOE - Ministry of Education MOH - Ministry of Health PRRP - National Influenza Readiness and Response Plan PPCs - Pandemic Preparedness Clinics PIS - Participant Information Sheet PAP - People‟s Action Party QO - Quarantine orders RHs - Restructured hospitals SARS - Severe Acute Respiratory Syndrome WHO - World Health Organization 1 1 Background and Thesis Objective 1.1 Background Following the outbreak and global spread of Influenza A H1N1-2009 in April 2009, the World Health Organisation (WHO) declared the highest level of pandemic influenza alert in June 2009. 1 As of 1 August 2010, “more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18449 deaths” (WHO, 2010, August). Also known as “swine flu”, the H1N1-2009 pandemic was the next major public health issue in Singapore between April 2009 and January 2010 after the severe acute respiratory syndrome (SARS) outbreak in 2003. This pandemic allowed Singapore‟s National Influenza Readiness and Response Plan (PRRP) – developed by its government after the SARS epidemic to confront a real infectious disease threat for the first time, following only regular exercises by government agencies and healthcare institutions (Tay et al. 2010). The government thus reacted promptly to the news of H1N1-2009 by swiftly implementing strict containment measures with enhanced surveillance and hospital isolation (refer to Table 1.1 for a chronology of official actions reproduced from 1 To be precise, a strain of the type of flu virus known as H1N1 (H1 and N1 being the abbreviations for two of the virus‟s characteristic proteins) crossed the species barrier from pigs to people in Mexico before spreading globally. To be clearer about the currency of this strain, it was officially declared as Influenza A H1N1-2009. First declared a „Public Health Emergency of International Concern‟ by the WHO on 26 April 2009, its six-phase Influenza Pandemic Alert was quickly notched to Phase 4 on 27 April 2009, and then to Phase 5 on 29 April 2009. After five weeks, the alert peaked at Phase 6; this strain was officially declared a pandemic by the WHO on 11 June 2009. 2 Tay et al. 2010). An official response protocol comprising community-wide implementation of control measures and public education of the pandemic threat was aggressively rolled out in two phases – namely, containment (late April 2009 to early July 2009) and mitigation (early July 2009 to February 2010). The containment phase saw H1N1-2009 put under the Infectious Disease Act (Government of Singapore, Statutes, Infectious Disease Act). control measures were implemented in all healthcare settings, 3 2 Infection including a dedicated „933‟ ambulance service to ferry suspect H1N1-2009 patients to restructured hospitals (RHs) and van-size taxis to handle increased patient load to minimize the spread of infection within the community through the public transport system. 4 Thermal scanners at the airports were to screen all arriving passengers for fever. A massive public health education campaign was launched to educate the lay public about the importance of personal hygiene and social responsibility in slowing the spread of the disease. People with influenza-like illnesses (ILI) were asked to stay away from school or work, avoid crowded public 2 The 33-year-old Act is “the principal piece of legislation that deals with the prevention and control of infectious diseases in Singapore”, administered jointly by the Ministry of Health (MOH) and National Environmental Agency (NEA) (ibid.) This act penalizes people who resist or escape from quarantine or treatment and accords power to senior clinicians within public sector restructured hospitals (RHs) who were designated as health officers to issue mandatory isolation orders to resistant patients. 3 The mandatory use of personal protective equipment (PPE), masks, disposable gloves and gowns was emphasized. Pandemic Preparedness Clinics (PPCs) were also set up. PPCs are primary healthcare providers and a vital part of the pandemic preparedness framework. When activated, they are supported with PPE and Tamiflu from the national stockpile to help manage the flu outbreak in the community. All polyclinics are also listed as PPCs. Movement of doctors and healthcare workers was strictly limited, patients were separated, and temperature monitoring of healthcare workers was carried out. All patients confirmed to be positive for H1N1-2009 were admitted to RHs for isolation. Contact tracing was initiated for these cases. 4 From 28 April 2009 to 29 June 2009, all suspect and confirmed cases of H1N1 -2009 had to be reported to the MOH. From 30 June 2009, only laboratory-confirmed H1N1-2009 cases as well as clinically suspected cases of those seriously ill had to be reported . MOH had to also be informed of all H1N1-2009-related deaths within 24 hours of death, for both confirmed cases and deaths in which H1N1-2009 was strongly suspected (Tay et al. 2011). 3 areas, and to seek immediate medical attention. Non-healthcare establishments were advised to do temperature- and symptom-screening of visitors. All schools within the Ministry of Education (MOE) system implemented the following: twice-daily temperature checks; granting seven-day Leave of Absence (LOA) to students with recent travel history to affected countries; home-based learning programmes for affected students; suspension of school assembly; and scaling down of co-curricular activities to minimize congregation. The subsequent mitigation phase focused on treatment. Hospitals admitted H1N1-2009 cases based purely on clinical indications - rather than for isolation purposes. 5 Contact tracing and the issuance of quarantine orders (QOs) for contacts of confirmed cases were discontinued unless there was a specific public health need. Close contacts were advised to monitor the ill. Organizations and tertiary education institutions screened staff members‟ and visitors‟ temperature based on their own risk assessment. They were also advised, whenever possible, to relieve staff that were at higher risk. Schools under the MOE system, however, remained active in daily temperature-screening and issuance of LOAs to students, scaling down on them and resuming public assemblies and co-curricular activities only one month into the mitigation phase. 5 Temperature screening and the declarations of health were also discontinued at the border entry points. Mild cases were discharged from hospitals with oseltamivir treatment and a quarantine order if clinically stable, without significant co-morbid conditions, if they had physically suitable local accommodations and a designated caregiver, and did not have vulnerable individuals at home. Oseltamivir treatment was recommended for high-risk patients with ILI when the surveillance prevalence of H1N1-2009 was about 30% in ILI cases. Patients with mild symptoms were advised to visit specially-identified PPCs – publicized in the media and provided in hotels - that were supported with oseltamivir and the necessary equipment from the national stockpile. Clinically mildly-ill patients with suspected H1N1-2009 were given medical leave to cover a self-quarantine period at home (seven days for adults and ten days for children below 13 years of age). 4 Table 1.1 Chronology of H1N1-2009 Key Events and Control Measures in Singapore Source: Reproduced from Tay et al., 2010 5 During both phases, the Singapore government worked closely with the media to provide regular updates so that the public was continually apprised of the latest H1N1-2009 situation globally and in Singapore. Citizens were also consistently reminded of steps they could take to reduce their risk of acquiring and spreading the disease. A dedicated government website on influenza also facilitated the public‟s easy access to information (http://www.h1n1.gov.sg; accessed 10 October 2009). News reports in the press tapered off after February 2010. On 12 February 2010, MOH concluded the handling of the event and thanked Singaporeans for having “put up a good fight” against H1N1-2009, and asked for their “continued support and cooperation” (Press Release, 12 February 2010, MOH). This signified that the pandemic was „over‟ in Singapore, with no reference to WHO‟s six-phase alert, which still marked H1N1-2009 a pandemic until mid-2010. Against this background, scope for inquiry about young people‟s views of the event and the official response emerged, to which I now turn. 1.2 Scope for Inquiry on Youth Perspectives This pandemic event provided a good opportunity to develop a study to explore how “pandemic preparedness” operated on the informal microsocial level. Despite the government‟s ability to implement strategic plans to promptly and fully control the situation, the H1N1-2009 pandemic is still unique to Singapore because several aspects of the preparedness plan could not be fully applied to the H1N1-2009 virus: …prior preparation and exercises failed to fully anticipate a virus that was highly transmissible but caused low morbidity 6 and mortality and had a different demand on health services, and a pandemic first wave lasting more than six weeks (Tay et al. 2010, p. 319). For example, despite initially raising its own colour-coded Disease Outbreak Response System (DORS) alert level in tandem with WHO‟s elevated pandemic alert levels (Tay et al. 2010), 6 Singapore decided to de-link its alert levels from WHO‟s pandemic phases in early May 2009, feeling that local concerns should be on the virulence of the virus instead of the indicators used by WHO - that is, the transmissibility and geographic spread of the virus. As strong governmental control was still encumbered with these limitations, variations in responses within the local context were therefore possible, providing scope for research to explore how the public viewed the situation and the measures implemented and policed to prevent, control and mitigate the pandemic virus. As Holmes (2008) has pointed out, attention to qualitative data generated from “the great diversity of groups referred to collectively as the public” will reveal context-specific complexities involved in perspectives of emerging infectious diseases and the official response protocol (p. 350). Here, youths appear as one of those groups whose views have strong implications on effective pandemic control and relevance for evolving better pandemic control and prevention strategies for the following reasons. First, observations of H1N1-2009 cases in Singapore in the medical literature (Cutter et 6 DORS is a colour-coded alert system that serves to guide “the ramping up or scaling down of response measures” (Tay et al. 2010: 315). Premised on a virulent virus, its different levels corresponded with WHO‟s six-level alert system, each indicating a list of prescribed nation-wide responses when Singapore is threatened by a pandemic flu or infectious agent. Thus, on 28 April 2009, the alert was on Yellow and then Orange on 30 April 2009. As Singapore de-linked it from WHO, DORS returned to Yellow on 11 May 2009 and remained so until it turned Green in February 2010 to signal its end. A DORS table is appended as Appendix I. 7 al. 2010) posit that the disease affected mainly youths and children. Indeed, novel flu strains, as Dr. Gregory Poland explains in BBC‟s documentary Pandemic (2006), typically have a predilection for the young: “[Younger people] have…overly responsive immune systems compared to older adults”, a fact that could work against them in cases of emerging flu strains that trigger overwhelming immune responses to release more chemicals (different cytokines) that aggravate infections. Thus, in emerging infectious flu diseases, youths are relatively more at risk than middle-aged and older adults. Their perspectives of pandemic response measures and reception to public health educational campaigns should therefore be given additional analytical attention for uncovering implications on disease prevention strategies. Second, as youth sociologist Ken Roberts (2003) argues, young people do not passively absorb a given culture and school curricula. Rather, their agency in actively reconstructing meaningful definitions of events should always be recognized. This includes their perspectives on preventive measures implemented and policed in schools and other less-policed contexts. Indeed, as Holmes (2008) also highlighted, it would be a mistake to assume [public communication of an emerging infectious disease outbreak] is simply a matter of informing the public about what steps to take to protect themselves…[as such assumptions] often stop short of accounting for context (p. 354). Inquiring about youths‟ perspectives could therefore fulfil one of the research agendas that deal with disease outbreaks as suggested by Phua and Lee (2005): how a particular group in a society reacts to disease outbreaks and why. 8 Third, the literature has suggested that young people in general can perceive and practise preventive measures differently from older adults during an epidemic. Quah and Lee (2004), for example, found that age and attitude were associated with the good practice of preventive measures during the SARS outbreak - respondents who were 35 years old and above were more inclined to take preventive measures than their younger counterparts. Barr et al. (2008) also argued that younger people in Australia are less likely to comply with infectious disease protocols. In their study, highest levels of threat perceptions also tended to come from older people, suggesting that the younger ones felt less threatened by an impending pandemic. In Hong Kong, the likelihood of adopting infection control behaviors in the face of a possible avian influenza outbreak is also associated with older age, perceptions of risk and susceptibility to infection, perceived likelihood of a local outbreak, perceived severity as compared to SARS, perceived efficacy of the behaviors and concern for family members (Lau et al. 2007). No studies on the perspectives of young adults and youths below 20 have yet been conducted, making this exploratory study on younger people‟s perspectives of and compliance with pandemic response measures both justified and timely. 1.3 Research Question and Central Argument The principal question underlying this study is: how did Singaporean students and young working adults understand and respond to the H1N1-2009 pandemic in Singapore? Guided by this question, the research is designed to capture themes and possible differences in the perspectives of youths towards the H1N1-2009 9 pandemic event as they experience the formal pandemic response in Singapore in schools under the Singapore Ministry of Education (MOE) system and other settings such as tertiary institutions and workplaces. I sought to generate and analyze qualitative interview data from semi-structured interviews with 30 young Singaporean respondents from the ages of 13 to 25. Respondents are divided into two age-group-specific categories bearing in mind the contexts to which they belong - the formal school system and the less regulated university and work environments of the older youths. One reason for dividing my sample this way is that the school, a key environment in which youths operate, is an important health-promoting setting (Gardin and Hammarstrom 2002; Wells 2000); in addition, youth cultural scholars maintain that “schools are strategic sites where youths struggle to make sense of the worlds they create and re-create with peers and adults” (Morill et al. 2000: 528). As people‟s accounts of phenomenon provide insights into the milieu within which they live, work and make sense of the world (Mitchell et al. 2001), youths‟ accounts of their experiences “can offer exceptional insights into the character and operations of the institutions [where they belong], how these are changing, and the links and mismatches between them” (Roberts 2003: 15). Since this is the case, the division of my sample allows for contrast in both groups‟ perspectives that offer scope to explore effectiveness of the role of the school as a surveillance site and a messenger of public health education during the management of H1N1-2009. In this light, my thesis seeks to explore the extent to which youths that experienced the policing of pandemic control measures in schools view the event differently 10 from older youths who encountered the measures outside the school context. 7 It also seeks to provide informed reasons to the findings and to discuss their implications for effective pandemic control strategies. Two key findings arose from my analysis of the interview data. First, the first group of youths in schools were significantly less appreciative than the second group in the relevance and importance of formal infection control and prevention strategies during a pandemic. I attribute this to their experience of the formal policing and surveillance methods exercised in schools. Second, their memories of practising the same response measures in schools during the SARS epidemic in 2003 contributed further to their lack of concern and tolerance for the formal control of and prevention against the pandemic. I attribute this to schools, in dealing with youths who were experiencing a repeat of the same policing and surveillance of mandatory anti-flu measures six years back that did not sufficiently address the significance of disease-specific control and mitigation. The central argument of this thesis is that formal policing of pandemic response measures in schools has its limitations in its approach to fully involve youths in pandemic response efforts. This, I argue, is because (1) the implementation of the infection control measures was fraught with scope for younger youths to flout the rules, and (2) their memories of SARS had its hand in creating fatigue and intolerance for the measures over confidence and preparedness. Two empirical chapters in this thesis will therefore demonstrate respectively that (1) younger youths‟ direct experiences of the formal policing of 7 I am also cognizant that it could be differential responses to the pandemic, caveat was maintained throughout my differential responses to the contexts differences critically. the difference in age of the groups of youths that explains and not necessarily the contexts in which they operate. This entire research process; due care was taken not to attribute they were located in before and without considering age 11 practising pandemic control measures in schools and (2) how they viewed this experience in relation their previous similar experiences during the SARS epidemic both contributed to poor attitudes towards formal control and prevention of H1N1-2009. In both chapters, contrasts with older youths‟ experiences outside the school context would be made to illustrate and substantiate my claim that current formal policing in the school context during a pandemic/epidemic warrants a rethinking of its scope and methods. 8 This argument has implications on effective pandemic disease control as their unappreciative engagement with the response measures was seen to affect their responsiveness in adopting the measures, their initiatives in knowledge acquisition, and the overall quality of their adherence to prevention and control during the pandemic period. Put differently, a critical rethinking of current pandemic policing and surveillance strategies in schools is necessary to gain youths‟ appreciation of and adherence to future pandemic response protocols. 1.4 Organization of Thesis In the next chapter, I draw relevant insights from the literature on perspectives of emerging infectious diseases that inform this study‟s analytical and methodological approaches. I will elaborate on these two approaches in Chapter Three. In Chapter Four, I select and present excerpts of respondents‟ perspectives 8 Extending from the previous footnote, I reiterate here that while these older youths could be experiencing the pandemic differently because they were older (and therefore, possess higher levels of maturity), I maintain that their experiences of the pandemic outside the formal school system and my analytical attention to how their references to the lack of formal policing affected their views and experiences could still offer interesting contrasts with younger youths who had undergone the formal implementation of the control measures in schools. 12 generated in my interviews on the pandemic response measures and explore how formal policing of these measures in schools led to lapses in their interest and appreciation for the entire pandemic event and the quality of their compliance with preventive and control strategies. Chapter Five will argue that formal policing of H1N1-2009 measures contributed further to their poor attitudes towards pandemic prevention as younger youth respondents also associated their experiences of practising anti-flu preventive measures in schools with their memories of adopting the same measures under the same mode of surveillance during the SARS epidemic. Both chapters would include discussion of older youths‟ perspectives of the pandemic to support the arguments I put forward. I also discuss implications of these arguments for effective pandemic control and future preventive and control strategies. I conclude the study in Chapter Six and suggest directions for future research. 13 2 Insights from the Literature This chapter draws relevant insights from the literature on people‟s perspectives of infectious disease outbreaks and their response protocols. I show that the literature points towards the need for more studies that explore young people‟s perspectives and experiences of the health crises in their specific contexts. This dearth in youth perspectives notwithstanding, I have managed to glean that (1) an awareness and acknowledgment of people‟s agency in redefining emerging infectious disease situations is learned from the literature, and (2) people‟s perspectives would differ according to where they experienced the pandemic – be it micro-level settings like schools and macro-level contexts like a society with previous experiences of epidemic control. These insights, I argue, suggest that an analytical framework for exploring young respondents‟ perspectives of the H1N1-2009 pandemic event will need to draw from theoretical perspectives that (1) take into account how youths individually negotiate and comply with information and education of pandemic measures and also (2) locate their viewpoints within the formal school context and other less policed contexts in order to examine the former‟s effects on their perspectives. 14 2.1 Agency of Individuals in Engaging with Infectious Disease Outbreaks Many quantitative studies have examined positive associations between risk perception and anticipated behaviors in a potential avian influenza pandemic (Fielding et al. 2005; De Zwart et al. 2007; Sadique et al. 2007; Di Giuseppe 2008; Jones and Iverson, 2008; Eastwood et al. 2009; Taylor et al. 2009). Others reflect positive associations between implementation of infection control behavior and knowledge, efficacy beliefs, and risk perceptions during the SARS epidemic (Leung et al. 2004; Leung et al. 2005; Lau et al. 2007; Lau et al. 2005; Tang and Wong 2004). During the SARS outbreak, for example, willingness to comply with risk-reducing behavior was linked with perceived immediacy and seriousness of the threat (Leung et al. 2003; Tang and Wong 2003, 2004). These factors are observed to be less influential in preventive behavior if the virus is not no vel and seen by many as a familiar and everyday risk, thus underscoring the importance of the emerging character of the disease (Vingilis et al. 1998; Hong and Collins 2006). While studies focusing exclusively on young adults and youths below 18 are absent, what we learn from this body of literature here is a cognizance of the agency of lay people as social actors to engage differently with top-down implemented response protocols on the ground; they do so with reference to what they know, how vulnerable they feel and to what extent they deem the disease as novel. Qualitative studies have also drawn attention to the agency of social actors at play during health crises. Jiang et al.‟s (2009; see also Jiang 2009) focus group discussions with Chinese residents in the U.K. and the Netherlands reveals that despite existence of formal channels of information and instituting of SARS 15 control measures in 2003, Chinese individuals and communities in Europe developed strategies shaped by a multitude of other factors in order to manage the perceived risk. Eichelberger‟s (2007) qualitative inquiry in the production of dominant American risk discourses during the SARS epidemic also reveals that even within a Chinese community which is generally considered homogenous in New York‟s Chinatown, the epidemiology of SARS was interpreted by social actors that form divergent discourses that run counter to official public health instructions. Such competing discourses arising from active social agents at work have been linked with exclusionary immigration attitudes in Switzerland (Green et al. 2010), SARS-related jokes (Zhang 2007), artistic responses to an epidemic (Newman 2007). They can also be located in everyday talk, biomedical encounters, and government institutions after the epidemic to challenge public health development, as in the case of Hong Kong (Siu 2008). By informing how responses and reactions could vary over contexts and individual attitudes at play, these works lend important insights for the development of this study‟s analytical and methodological approach in uncovering youth perspectives of the H1N1-2009 pandemic event. To strengthen the case of agency at play in people‟s responses towards a pandemic event, we can also look at early quantitative studies of perspectives of H1N1-2009. These works indicate the agency of social actors in seeking information to re-assess the pandemic situation in their own rights despite the formal policing involved in their respective contexts. Rubin et al. (2009), 9 for 9 Specifically, the authors conducted 997 telephone interviews in May 2009 to assess whether perceptions of the outbreak predicted changes in behavior among the public in England, Scotland and Wales. 16 example, reported low levels of anxiety amongst interviewees in the United Kingdom who were not convinced of the possibility of growing severity in H1N1 2009 in May 2009. Their observations complement Seale et al.‟s (2009) 10 study that shows how rapid increase in the number of H1N1-2009 cases worldwide and a large amount of information made available about the disease and its spread did not lead their research participants into believing that they were at high to very high risk of contracting pandemic influenza. The authors attributed this finding to many reports describing the H1N1 virus as causing milder influenza than other pandemic-related viruses. Finally, Van et al. (2010) 11 argued that although nearly all respondents were aware of the Australian pandemic situation, more than half of them reported “no anxiety” or “disinterest”. This observation is linked to them not adopting any specific behavioral changes beyond hand hygiene. Viewed collectively, these three studies support the rationale for this thesis to explore young people‟s perspectives of the disease outbreak as they appear, as active social agents, to re-define the pandemic situation in light of multiple sources of information and personal experiences of the event. People‟s agency in making sense of health situations has also been conceptualised by various researchers over the past two decades. For instance, Davison, Smith and Frankel (1991) conceptualise informal viewpoints driven by individual motives as lay epidemiology, a scheme in which individuals interpret health risks through the routine observation and discussion of cases of illness and death 10 Like Rubin et al., Seale et al. also conducted the study in May 2009 on the Australian community‟s feelings and risk perceptions of the H1N1-2009 pandemic. 11 Van et al. drew data from an online survey (n=2882) completed by a university‟s staff and students in June 2009. 17 in personal networks and in the public arena, as well as from formal and informal evidence arising from other sources, such as television or magazines (p.428).12 Instead of attributing resistance to or neglect of health education messages to irrationality, the authors urge social researchers to understand prevention and adherence to health education from the viewpoints of those whose behavior they seek to change. Since then, various terms have emerged in the literature to describe the views of people on health and illness. They include lay theorizing (Milburn 1996), lay constructions (Pawluch et al. 2000), practical logic (Craig 2000) and ordinary theorizing (MacDougall 2003), all of which were based on the existence and acknowledgment of human agency in assessing health crises. People can be fully aware of potential negative outcomes of certain „unhealthy activities‟. Nevertheless, the space for counter-discourses and selective appropriation of prescribed behavior will always remain as long as the individual is actively assessing his/her actions with regard to the magnitude of the negative outcome, the immediacy of the threat, and/or the personal, social and economic cost of not participating in preventive behavior. These works have not included youth perspectives in particular, but they serve as support for my argument that agency of respondents can be the starting point of my analytical and methodological approaches in this study. 12 The empirical material from their study also provided bases for understanding the rationality of responses to health education (Frankel, Davison and Smith, 1991) and exploring variations in illness prevention (Davison, Frankel and Smith, 1992). 18 2.2 Where Individuals Experience Official Responses to Outbreaks Matters Different micro- and macro-social contexts where people experience official infectious disease outbreak response protocols would have significant influence on how they engage with pandemic and epidemic response measures. For example, Morrison and Yardley‟s (2009) focus group on people‟s perceptions of infection transmission and likely adherence to infection control measures reveal that most participants would adhere to infection control protocols with the provision of adequate education about control measures in where they live or work. Likewise, Janssen et al.‟s (2006) found that knowledge and awareness of pandemic influenza amongst the general public in the U.S. was on the whole very poor. There was little concern for a potential pandemic and few individuals were willing to learn and implement behaviors to control a pandemic, leading the authors to argue that initiatives to improve understanding in smaller-scale settings like schools and through doctors to patients are valuable methods to facilitate implementation of the recommended behaviors. What we learn here is the assumption that youths who experience the pandemic in schools where educational messages and formal policing of the pandemic control measures are strongest would be more likely to comply and appreciate the measures. There is therefore reasonable scope for my study to explore their perspectives to reveal the extent of their appreciation and compliance in schools against youths who were not policed and monitored by formal settings. Morrison and Yardley‟s (2009) work also suggests the importance of relating qualitative perspectives of epidemics and response protocols to the 19 particular societal context in which they are articulated, as perspectives could differ in contexts where recent experiences with an epidemic vary. In Hong Kong, Lau et al. 2007 actually found that responses to and concerns with infection control protocols and public health management to the risk of a potential humanto-human H5N1 outbreak were largely heterogeneous in Hong Kong, despite it being an epicentre of SARS. Hong Kongers‟ likelihood of adopting infection control behaviors was associated with older age. More notably, people actively approached the threat by comparing its severity with SARS (cf. agency in Section 2.1) and remained largely driven to protect themselves and their family members rather than the society in general (Ibid.). This is observed, interestingly, even when the impacts of SARS have led to Hong Kong residents practising more favourable health-seeking behaviors in general (Lau et al. 2005). Thus, it is useful here to include Doshi‟s (2009) posit that past experiences with novel infectious disease outbreaks may not be necessarily beneficial to dealing with forthcoming ones. Ever since SARS, Doshi notes, pandemic preparations have focused on responding to worst case scenarios, incurring more sums of public money to be spent on pandemic preparedness and also the tendency for lay people to overreact. Singapore, given its experience with SARS, therefore serves as an interesting site for inquiring how people view the pandemic of H1N1-2009. Given these insights, the exploratory stance in this thesis can serve to tease out whether the SARS experience in schools has led to youths‟ better appreciation and improved compliance with H1N1-2009 response measures. Moreover, the body of literature on SARS in Singapore has focused largely on the triumphant (hi)story of top-down implementations in conquering the 20 disease (Chng et al 2004; James et al 2006; Tan 2006) and the praiseworthy effectiveness of communications during the outbreak (Auyash 2005; Menon 2006). In the case of H1N1-2009, it is noted that the application of these past lessons was considerably limited by the low severity of the virus as well as the WHO‟s changing definitions of what constitute a pandemic (Li 2010; Tay et al. 2010). Fischoff‟s (2005) contention, therefore, is relevant here. Lessons learned from historical event regarding pandemic flu are limited, he argues, if society relies only on the opinions and concerns of experts in the fields of public health and health care and neglects the perspectives of the general public, surfacing the significance of lay perspectives in understanding an event like H1N1-2009 (Ibid.). These insights show the need for the contribution of this study on whether micro social contexts like schools managed to benefit from youths‟ past experiences with the daily practice of anti-SARS measures. 2.3 Conclusion In this chapter, I have drawn relevant insights from the literature on people‟s perspectives of infectious disease outbreaks and response protocols and underscored the fact that there are still no studies exploring young people‟s perspectives of pandemic management. Nevertheless, what I have gleaned from this review include (1) an awareness and acknowledgment of people‟s agency in redefining emerging infectious disease situations despite the presence of top -down implementation and policing of response measures in their lives; and (2) people‟s perspectives would differ according to the micro- and macro-social contexts in which they experience the pandemic. These contexts include micro-level settings 21 like schools and/or larger social settings like societies with previous experiences of epidemic control. In light of these insights, I argue that an analytical framework for exploring young respondents‟ perspectives of the H1N1-2009 pandemic event needs to draw from theoretical perspectives that (1) take into account how youths individually negotiate and comply with the information and education of the pandemic measures which affect their understanding of the pandemic event and also (2) locate their viewpoints within the formal school context and other less policed contexts in order to examine their effects on youth perspectives. The next chapter will discuss my analytical and methodological approaches accordingly. 22 3 Analytical and Methodological Approaches This chapter has two objectives. Sequentially, they pan out as follows: First, I argue that a symbolic interactionist perspective serves well in developing this study‟s analytical framework. I support this argument by discussing its merits for studying youth perspectives and subsequently establishing an analytical approach based on them. Second, I outline my analytic processes of data generation and data analysis. This step is essential as many recent works (e.g. Finlay 2002; Mauthner and Doucet 2003; Pyett 2003; Stige, Malterud and Midtgarden 2009) have conceded that in order for readers‟ to give credence to the quality of findings and interpretations in a qualitative study, it is best for researchers to be transparent in detailing the procedures and interpretations and openly reflexive about their positions in the research process. 3.1 Analytical Approach Symbolic interactionism: defining the situation Taking insights from relevant literature discussed in the previous chapter, I follow the symbolic interactionist paradigm in recognising agency of the young individual to (re)define the pandemic event he/she is situated in. Based largely on the work of George Herbert Mead (1934) and Herbert Blumer (1969), this paradigm is a distinctly American theoretical tradition which maintains that 23 “social reality is constructed on a micro-level by individuals interacting with one another on the basis of shared symbolic meanings” (Cockerham and Scambler 2010: 7). I argue that this perspective is fitting for this study‟s analytical approach as it argues for differential responses towards pandemic measures in its standpoint that “[h]uman beings were seen to possess the capacity to think, define situations, and construct their behavior on the basis of shared symbolic meanings” (Ibid: 7). Moreover, this perspective maintains that large-scale social processes and structures have their effects on people‟s behavior, but they do not necessarily confine them in rigid monolithic ways: “It is the position of symbolic interaction that the social action of the actor is constructed by him; it is not a mere release of activity brought about by the play of initiating factors on his organization” (Blumer 1969: 55). Following these assumptions, youth behavior can then be seen as “self-directed on the basis of common understandings symbolized by language that are shared, communicated, and manipulated by interacting human beings in social situations” (Cockerham 2010: 91). As Blumer (1969) explains, “the actor selects, checks, suspends, regroups, and transforms the meanings in the light of the situation in which he is placed and the direction of his action” (p.5). Youths as interacting agents therefore choose their own behavior as they internalize and negotiate the symbolic meanings and norms governing their actions in their respective contexts, such as the pandemic response measures implemented and policed in their schools and workplaces. Here, the work of William I. Thomas (1928) – a variant strand of symbolic interactionism - is particularly instructive. Thomas‟s perspective sees crisis as residing in the individual‟s „definition of the situation‟ and his/her behavior 24 depends on the consistency and stability of this definition. 13 In the presence of rival definitions (from society and from his/her own spontaneity) that disrupt habitual behavior, the individual experiences disorganization and anticipates uncertainty. How the individual copes with this crisis would be strongly related to his/her socialization experiences that have taught him/her how to cope with new situations. In the context of this study, the principal observation informed by Thomas is that the same crisis does not necessarily produce the same effect uniformly in all youths, and that adaptability to and control of a crisis situation is an outcome of the young individual‟s definition of the situation. It is also a result of his/her ability to negotiate the present event with reference to similar ones in the past and perceive and act upon the basis of these past experiences. In addition, recent works on situation-defining have taken into account the fact that although individuals do define situations differently, their power to control the situations for consistency with their individual definitions also differ according to where they experience the situation (Hollander and Howard 2000; Cast 2003). This position is consistent with the argument presented earlier that many divergent discourses are at play on different analytical (macro and micro) levels during the H1N1-2009 situation, as Elliott (2010) explains: “individuals craft their own interpersonal scripts to fit the context of their particular situation and interactions…[involving] internal motivations, desires, and anxieties in the construction of the event” (p. 193). Thus, this perspective validates a critical consideration of youth perspectives of the H1N1-2009 pandemic crisis in both micro- and macro-social contexts because while they may not have the power to 13 William I. Thomas developed this concept in The Child in America (1928) with Dorothy Swaine Thomas and came up with the theory that rests fundamentally on this assumption: "If men define situations as real, they are real in their consequences" (Thomas and Thomas 1928: 572). 25 control the workings of the general pandemic response, they do possess the agency to construct definitions that will influence their personal responsiveness and the overall quality of their actions. Analytical Framework Following the arguments and assumptions of the symbolic interactionist perspective as discussed above, I treat what these two groups of youths described of the pandemic event as qualitative data (1) reflecting their personal construction of the event (cf. Sannino 2008) and also (2) reflective of the workings of institutions and ideologies of the wider society they belong to (cf. Lupton 2003). In this analytical way of seeing, themes underpinning their viewpoints can be, interpretively, reflective of both personal autonomy in defining the events and the workings of the institutions within the society. This analytical approach is diagrammatized as the study‟s analytical framework in Fig 3.1. 26 Fig. 3.1 Writer’s analytical framework Here, respondents‟ perspectives can complement and/or challenge the reigning official disease management discourse involving the „whole-ofgovernment‟ response protocol to H1N1-2009.14 Their perspectives are not taken as a scattering of constructions of multiple realities that float in time and space, but as interpretive and critical reflections of how official disease management 14 During the pandemic, this „whole-of-government‟ response protocol was the umbrella term for the organizational framework of the response strategies. This framework is also termed Homefront Crisis Management System (HCMS) and is responsible for coordinating all national response efforts to control the pandemic. Within this framework, ministries and agencies were functionally clustered into Crisis Management Groups (CMGs). Each CMG was an inter-agency group led by a ministry. Schools belong to the Education CMG, led by the Ministry of Education (MOE). Thus, MOE is responsible for implementing and policing the practice of control measures such as temperature-taking and home quarantine of at-risk students found in schools. It is also responsible for the implementation of educational information to enhance students‟ awareness of the relevance of these measures (Tay et al. 2010). 27 discourse was reproduced, differently received, or conflicted by their agency in redefining the pandemic situation in schools or other settings. They are also concomitantly understood as perspectives operating on an informal level and reflective of specific contexts such as the schools they were in, the post-SARS context of Singapore, and possibly even the wider ideological frameworks that predominately structure social behaviour in Singapore. While I acknowledge that there could be age-specific definitions of the situation that may not necessarily reflect the settings of the youths, analysing themes in their perspectives could also lead to discussions of how they redefined the event and how these perspectives reflect the workings and flaws of the contexts in which they experienced the pandemic event. Overall, this framework allows for an exploratory approach to understanding the differential responses and interpreting the reasons behind them, and it also allows for inquiry into whether the perspectives differ significantly between schools, tertiary institutions, and workplaces, and how this difference (or non-difference) complements or challenges the overall pandemic response. I now put forward my methodological approach in two separate sections: data generation and data analysis. 3.2 Methodological Approach: Data Generation Research participants and other sources of data Using the snowball sampling technique, I recruited 30 respondents – 15 schoolgoing students and 15 young adults - following recommendations from my family members, acquaintances, and friends who teach in secondary schools and junior 28 colleges. Group A respondents comprise 12 secondary school students and three junior college students from nine secondary schools and three junior colleges respectively. Group B respondents were working in different places or attending tertiary institutions such as the National University of Singapore, Singapore Institute of Management, and Nanyang Technological University. I controlled the age among my informants and divided them into two groups as illustrated in Table 3.1. 15 This division would serve mainly to distinguish the formal school setting (directly under the surveillance of MOE) of the respondents in Group A from the less-controlled-by-government environments of the older respondents in Group B, keeping Starks and Trinidad‟s (2007) comments in mind: “sampling different groups that participate within a given [public health] discourse can illuminate the ways in which participants appeal to external discourses and identify their influence on the discourse [youth perspectives] under study” (p.1375). Group Ages A 13 to 17 Contexts in which the pandemic was experienced Number of Respondents Secondary schools, 15 junior colleges Tertiary institutions 16, B 18 to 25 15 work organisations Table 3.1. Research sample 15 16 A copy detailing the age and occupation of each respondent is appended as Appendix II. To be clear, tertiary institutions refer to settings of further education and higher learning beyond secondary schools and junior colleges (high school in the U.S.). They include universities and private degree-awarding business institutes. 29 In order to have varied responses from my respondents, I ensured that I had a sufficient variety of respondents from as many different ethnic and/or sociocultural backgrounds. For this purpose, I divided respondents first alon g the Singapore-specific racial classification – Chinese, Indian, Malay and others. However, given the small sample size and the focus on talking about the acuteness and fast-paced nature of the H1N1-2009 event in relation to their schools and workplaces, I did not expect any ethnic-specific trend to emerge. Neither was it observed in the data. The sample was also initially identified with gender, but with a small sample size and an even smaller number of males and females in each group, I ruled out the feasibility of claiming gender-specific perspectives. Following which, I left the distinction of the sample only to age with a focus on the different microsocial-level contexts in which they experienced the pandemic event. While recruiting respondents and planning the interviews, I also consolidated and studied all the available local news reports to date related to the outbreak as a reflection of the public health discourse against which their views were set. Instrument: semi-structured interview An interview schedule comprising three broad sections informed by themes in the literature and my analytical framework was designed to explore respondents‟ perspectives of the H1N1-2009 event. 17 The first section entails open-ended questions to ascertain where, when, and how respondents first learnt about H1N12009 (or swine flu, as it was first termed). I also wanted respondents to describe 17 A copy of the interview schedule is appended to this thesis as Appendix II. 30 their initial reactions to the threat of the pandemic, knowledge of the symptoms, and also what they felt and or were still feeling about measures like temperaturetaking, quarantine, isolation, sick leave and vaccines. This section also aimed to include their views on what their schools or workplaces had done in response to the pandemic threat. In the second section, more broad open-ended questions were aimed at ascertaining how and where they obtained their sources of information about the disease and the news of its development in Singapore. Here, questions were also framed to capture respondents‟ notions of the disease, who they discussed the threat and news with, and whether they knew anyone who was infected with it. The third section of the questions was concerned with their preventive health action (or the lack of it) in relation to their perceived threat of H1N1. Questions about whether they worried about contracting the disease and how they reacted to death cases are also included. I also included a question on whether this pandemic threat reminded them of any other similar outbreaks, considering the plausibility that past experiences could influence perspectives of the present situation. Each semi-structured interview was flexibly guided by this interview schedule with me – the interviewer – constantly bearing in mind the significance of being flexible and explorative so that respondents could direct discussions as they wished. Probes were used where necessary to deepen discussions. The interviews took place in quiet cafes of the respondents‟ choosing or in a quiet condominium lounge to ensure clarity in both the spoken conversations and the audio recording. Each respondent then took part in one interview that lasted between 35 minutes to an hour. 31 The choice of conducting one-to-one interviews over focus group discussions was decided after carefully weighing the costs and benefits of each approach. One-to-one interview was eventually preferred for the following two reasons. First, focus group participation entails respondents being interviewed alongside others, such that their comments and reactions could influence each other (Mason 2002) while one-to-one interviews allow more scope for respondent to elaborate freely without the interactional constraints characteristic of a group discussion. Second, given respondents‟ widely-varying work and school schedules, more time (and sometimes, more suitable venues) would be required to organize successful group sessions and ensure respondents‟ attendance. This provides considerably less flexibility for both respondents and researcher in deciding on the date, time and venue as allowed for one-to-one interviews. Timeline of Research Process From October 2009 to December 2009, I interviewed a total of 30 youths. This was a period when H1N1 was still in its mitigation stage (cf. “Background” in Chapter One p.3). Following six months from the first appearance of H1N1 and when the mitigation phase was still in process, the fieldwork period of this study could still minimize the threat of recall bias. The period of my interviews is contextualized within the time frame of the pandemic event in Table 3.2. The key events and control measures are drawn from the timeline provided in Tay et al. 2010 (cf. Table 1.1 in Chapter One p.5). There were 30 successful interview sessions in all. Revisits for clarification were only deemed necessary in the event 32 that specific points were undecipherable or too ambiguous during the data analysis process. Date 27 April 2009 – 30 April 2009 26 May 2009 30 May 2009 – 28 June 2009 29 June 2009 9 July 2009 18 July 2009 August 2009 5 – 13 September 2009 18 September 2009 1 October 2009 – 31 December 2009 February 2010 Key events/Control Measures  Singapore‟s alert system moved to second level (Yellow)  Containment Phase began  H1N1-2009 made a legally notifiable infectious disease in Singapore  Singapore‟s alert system moved from Yellow to third level (Orange)  Temperature screening in schools  Education campaigns began  First imported case H1N1-2009 detected in Singapore  Four-week mid-year school holiday  WHO declared pandemic status (11 June 2009)  First community case of H1N12009 detected in Singapore (18 June 2009)  School reopened for Group A respondents  Seven-day leave-of-absence granted for suspect cases  Twice-daily temperature-screening exercise instituted in schools  Mitigation Phase began  First H1N1-2009-related death in Singapore  Control measures scaled down gradually across the country  One-week school holiday for Group A respondents  18 H1N1-2009-related deaths in total  Mitigation phase continued  Pandemic preparedness framework relaxed – alert reverted to normal (Green) Research  Keeping up with news reports  Learning WHO‟s guidelines  Keeping up with news reports  Reviewing Singapore‟s pandemic preparedness framework  Contemplating potential scope of inquiry  Discussion with supervisor  Review of the relevant literature  Refining research question  Constructing interview guide  Application for ethics review  Recruiting interview participants for the study  Minor amendments made to application for ethics review  30 interviews with respondents (between October 2009 – December 2009)  Transcribing interview data  Analysis of data Table 3.2 Timeline of Research Process 33 Ethical Considerations Each interview session comprised a pre-interview stage involving a briefing of the project, respondents (or their parents‟) reading and signing of the Participant Information Sheet (PIS) and consent form if they were below 18 years. 18 This stage was ethically essential to ensure their informed consent as well as the strictly voluntary nature of their participation in my research. I extended no financial incentives to respondents. However, beverages and snacks were provided during the interviews. These steps were proposed to the National University of Singapore Sociology Department‟s Ethics Review Committee (DERC) in September 2009 and the study was approved in October 2009. All interviews were audio-recorded with respondents‟ consent and transcribed verbatim in English. The digital audio files were used for as long as the writing process of the study was going on, and subsequently locked up and discarded after the study‟s completion. The transcripts and tapes were labelled with pseudonyms. In the discussion, I tag extracts from the interview data based on respondents‟ groups (A1, B1 and so on). Respondents‟ information is kept separately from their responses and will not be disclosed. Limitations There are some limitations to consider when interpreting the findings of this study. First, it is evident that the study‟s sample is not representative of the entire Singaporean population. The findings may converge to illustrate, for example, 18 Samples of PIS and consent form are appended (Appendix IV ) . 34 certain characteristics of the institutions in which the respondents belong, but any generalisations are inherently qualitative. Second, it is possible that the findings could be affected by my method of recruitment. By that I mean there is a chance that I only recruited people who shared similar views or experiences of the phenomenon. 19 I argue that this was unlikely as I believe the pre-interview briefings and PIS were clear enough to the respondents in explaining that I intended to explore as much as I could about their views while not limiting or leading them to any positive or negative specifics. Finally, this study is reliant on the respondents‟ recollections of the event which were subject to distortions of memory and a possibly lackadaisical attitude following the gradual scaling down of the control measures and successful mitigation. However, I argue that respondents were voluntarily forthcoming with their opinions and spoke earnestly and clearly about the control measures, allowing for me to probe in ways that could tease out the time-specific sentiments (e.g. what they felt about the response protocol in July 2009 rather than in October 2009) as much as I could to minimize the possible shortcomings above.20 In sum, although I have acknowledged these limitations, I maintain that they are 19 I acknowledge another possibility in relation to this point: in aiming for a spread of views I could also be getting more variations than what could actually be several exceptions to what a majority of people think. However, I maintain that the qualitative approach in this thesis is aimed to generate a broad sense of what young people thought of the pandemic and its control protocol as an exploratory argument to further research on their perspectives. 20 In fact, I would further argue that since I was aiming for their perspectives of the pandemic event in relation to their experiences, that has to be memory. (Studying their reactions-on-the-spot for data would be impossible unless I was secretly filming them!) Thus, it is necessary to assume that their experiences of the health crisis event would impact their memories. Nostalgia and recollection is not a problem unless factual accuracy (of exact time when measures were implemented or bad attitude was observed, for example) was a goal. Their reactions to the infection control measures and other related protocol would inevitably be a matter of memory as the narrativization of any experience or event is always belated. 35 compensated by the insights garnered which could lend support to further studies on lay accounts of disease outbreaks and complement the literature on associations between attitudes and knowledge of pandemics observed from quantitative methods. 3.3 Methodological Approach: Data Analysis Coding and thematizing According to Potter (2004), “the principal task of coding is to make the task of analysis more straightforward by sifting relevant materials from a large body of recording and transcript.” (p. 615). I take coding as “more of a preliminary task that facilitates analysis” (Ibid.). First, I read the transcripts literally. I then began by open coding them by hand on paper to identify instances of the phenomenon that were of interest to the research question. I regularly revised the codes and eventually developed a preliminary list of codes to apply to the data. This list was elaborated with continued coding. After working through the data with these codes, recurring themes emerged. Focused coding then ensued, in which I returned to the digital copies of the transcripts and started to categorize the data under thematic headings with reference to the printed copies, creating another set of data organized in themes. Some examples of thematic headings include “indifference to the event”, “intolerance for control measures in schools”, “information-seeking behaviour”, “reference to formal policing in schools”, “routinization of the response protocols”, “assuming personal responsibility” and “comparison with SARS”. 36 In view of Ryan and Bernard‟s (2003) contention that “themes come from both the data (an inductive approach) and from the investigator‟s prior theoretical understanding of the phenomenon under study (an a priori approach)” (p.88), my coding process was carried out concurrently with a conscious maintenance of balance between (1) letting the data come through clearly on its own and (2) applying my „way of seeing‟ informed by themes in the literature and analytical framework. In other words, although I approached the data with prior insights gleaned from the literature and my analytical framework, I also made a conscious effort to avoid finding only what I was looking for. I then extracted parts of the data that best illustrate these recurring themes and started writing them up in potential sections that eventually got reorganized into section- and chapter-specific arguments. In sharing his qualitative data analysis approach, Addison (1999) reminds researchers that “it is impossible to interpret sufficiently the significance of a singular event without reference to the larger context within or on which the event took place” (p. 158). Given the sociological premise of this study, my aim is to describe and uncover significant background conditions, understandings, and practices of these themes that contribute to youths‟ understanding of the H1N1 2009 phenomenon. Although I follow the symbolic interactionist perspective in acknowledging individuals as social agents capable of responding to social settings on the basis of personal beliefs and feelings, their interpretations of the event, thoughts, and recollections of their actions during and after the event expressed in our interviews were not treated as pure mental and cognitive entities (cf. discursive psychology) divorced from the larger social context in which they 37 are located. In distilling the textual data to a set of themes, my objective was to examine the descriptions in their talk of the event, to reveal what knowledge they brought to the encounter of the pandemic threat and its response protocol, as well as to find out what other factors-in-contexts encourage or sustain the use of one engagement with the pandemic over another. In Holdaway‟s (2000) words, my data analysis process went on with the overarching aim of “document[ing] the ways in which meanings are constructed, negotiated within particular social contexts and become regarded as taken for granted” (p. 166). Reflexivity and Rigour Because researchers use subjective lenses to read and code the qualitative data, interpretive and reflexive stages of reading are vital steps that follow the focused coding of recurring themes. These stages require reading through and beyond the data and subsequently making inferences about the norms and rules with which the individual respondent is operating, or discourses by which they are influenced. My interpretive and reflexive stages of reading the data therefore included a constant methodological consideration of my positionality, as the principal investigator, in the process of generating the dataset, and how my interviewees may or may not be significantly affected by our interviewer-interviewee relationship. The implication of selecting qualitative interviewing as a research instrument is that respondents‟ accounts and articulations of the event can only be constructed or reconstructed in our interviews, and “the interview method is heavily dependent on people‟s capacities to verbalize, interact, conceptualize and 38 remember” (Mason, 2002: 64; also cf. memory in “Limitations”, p.35). Thus, I bear in mind that their understandings of the H1N1-2009 event generated in our interviews are not to be treated “as though they are a direct reflection of understandings „already existing‟ outside the interview interaction, as though [I] am simply excavating facts” (Ibid.). This reflexive process of reading (and at times, re-listening to the audio recordings of) the data allowed me to be selfcritical in judging how well the interviews had provided the necessary data, and whether the data generated could be meaningfully engaged with the construction of my analysis and argument. Any part of the data that seemed ambiguous was then questioned or regarded at best as ambiguous to avoid overstating claims in the discussion. Following these stages of reading, the analysis was continually repeated even after I had drafted the empirical chapters. These steps are necessary chiefly because it is customary among social and cultural researchers to assume that as soon as they enter the field, they influence or change the setting and the behavior of the people being interviewed or observed. However, as Michael (1992) also notes, “such a proximal context [the immediate social situation between interviewer and respondent] is itself an analytic construct, and there are numerous other contexts that the analyst can bring to bear in the process of interpreting discourse” (p.316). For example, in his study on lay discourses of science, Michael argues that “one can locate talk in the broad context of the relation between public (including self) and science, in which the participant is assumed to be addressing – over the interviewer‟s head, so to speak – another audience, namely, science or „scientists‟” (Ibid.). Indeed, for this study, it is this broader context of the relation between respondents and their talk 39 about the H1N1-2009 situation that informs my analysis, “as such the immediate context of interview is bracketed” (p.316). 21 Following Michael (1992), then, “the consequence is that the present analysis is partial – but then…it must necessarily select some context of “horizon”, as Gadamer (1975) puts it, over others” (p.316).22 3.4 Conclusion In the first section of this chapter, I have discussed the merits of a symbolic interactionist perspective and demonstrated how its ideas and assumptions can be integrated and developed into an analytical framework for this study. This framework is then diagrammatized to illustrate my analytical approach towards the study of youth perspectives. I continued the chapter by clarifying and critically reflecting upon my research process in two subsequent sections. The first section detailed the time, setting, sampling, and the research instrument involved in my data-generating process, including a discussion of the possible limitations. In the second section, I discussed the data analysis process by highlighting the ways I coded, thematized and analyzed the data as well as my consideration of the requisite reflexivity and rigour involved in the overall research process. Following Green and Thorogood (2004), I concur that “a good qualitative analysis should also say something about social life, as well as what participants 21 The act of „bracketing‟ also echoes a necessary and inevitable methodological consideration in the phenomenological approach where the individual‟s attempts at making sense/meaning of his/her lived experiences of the event-in-question is the goal of inquiry (cf. Stark and Trinidad 2007). 22 Apart from Michael (1992), other similar studies that adopted the same methodological stance in studying people‟s perspectives in relation to contexts include Schoenberg et al.‟s (2005) work on lay discourses on diabetes, Lupton and Chapman‟s (1995) piece on lay discourses of diet, cholesterol control and heart diseases as well as Lupton‟s (2005) thesis on lay discourses related to food risks. 40 say about it. It should provide a „thick‟, rich description of the setting studied, link into theory, and provide a satisfying and credible account of „what is going on‟ ” (p.180; my emphases). Bearing this in mind, the two upcoming chapters will explore respondents‟ perspectives of the H1N1-2009 pandemic situation that enhance our understanding of their experiences-in-context and how formal policing in schools entailed limitations and implications for future pandemic control strategies respectively. Also, in these two chapters I follow Morrison and Yardley‟s (2009) assertion that “the frequency with which each code occurred was noted, but is only reported qualitatively...(e.g. stating that a view was expressed by „most‟, „some‟ or „a few‟ participants)” (p. 261). This is because exact frequencies will only reflect a measure of how prevalent a view is within my sample of 30 (or 15, if they reflect the prevailing views of either Group A or Group B youths), and reporting numbers to account for the prevalence may prove more distracting than helpful in telling the story of their perspectives. 41 4 Policing Pandemic Control Measures in Schools and its Implications for Effective Control and Prevention From my analysis of the interview data, younger youths saw response measures implemented in schools as inconveniences rather than health preservation and disease control strategies. This reduced the quality of their responsiveness in adherence and attitudes towards information that educates them on the emerging infectious disease. Older youths, on the other hand, were less likely to feel the same way about these response measures and expressed relatively more appreciation for them with reference to them outside the context of the schools. In this light, this chapter argues that formal policing of pandemic measures in schools was fraught with scope for youths to flout the rules and ignore their relevance for control and mitigation of the H1N1-2009 pandemic. This explains the unintended consequence of respondents not treating the accompanying education of the pandemic and its preventive strategies as the authorities would like. The chapter is structured as follows. After presenting details of what and how exactly the pandemic preventive measures were undertaken and policed in schools, I explore Group A respondents‟ perspectives on temperature-taking and home quarantine in contrast with those of Group B. I follow this by highlighting how the qualitative differences in their perspectives also consequently affected their level of engagement with the educational campaigns in school by detailing 42 how school-based youths were significantly more uninterested than older ones in acquiring more knowledge on the situation. The latter group, as I will also show, managed to benefit from governmental efforts in educating the public on the significance of the health crisis. Finally, I outline the implications of this finding on effective pandemic prevention strategies in schools, and offer suggestions for future strategies. 4.1 Background Apart from the larger background of pandemic management in Singapore presented in Chapter One, this chapter explores the data – especially Group A respondents‟ perspectives – more specifically against measures undertaken in schools. On 2 May 2009, schools in Singapore instituted daily temperature-taking for all students, staff and visitors. Information as detailed as the date and time of temperature check, personal particulars and contact numbers were recorded and re checked to facilitate contact tracing if necessary. Although the national pandemic alert level remained unchanged at Yellow after 11 May 2009, schools were still considered by the management framework as critical points vulnerable to transmission and the same precautionary measures resumed when schools reopened in late June 2009 after a four-week break. Stations at school gates were set up to screen temperature of students and staff entering the school premises. Those who had returned from affected countries on and after 22 June 2009 were granted a seven-day LOA and sent home. Those who were unwell were also advised to go home. 43 Temperature-taking exercises intensified to twice a day in July 2009. In the first hour each day, class teachers were to conduct and monitor the exercise. Students were then asked to submit a declaration form with their temperature recorded for their teachers‟ perusal. Those who registered a fever or had travelled to affected countries were immediately moved to another room. Those who were unwell and had travelled recently to affected countries were isolated and taken by the pandemic 933 ambulance service for medical treatment. The school would inform parents of unwell students so that they would ensure that their children were well before returning to school. The same exercise was repeated in the middle of the school day. My findings show that younger respondents in schools demonstrated a clear lack of appreciation for both the implementation and practise of these measures. As we shall observe in the next two sections, Group A respondents‟ perspectives on temperature-taking and home quarantine differ substantially from those of Group B because they were not looking at the significance and relevance of having response measures inserted in their school routine, but focussing on the inconvenience to their timetables caused by them. This has implications on effective pandemic control and prevention as they found scope to get by complying with the measures but not as seriously and responsibly as the authorities would have wanted. In the third section, I discuss how both groups‟ consequent engagement with pandemic knowledge and updates therefore also differ in a similar way: Group A respondents did not feel the need to be informed or engaged as the inconvenience of the mandatory measures was what they were concerned with, while Group B respondents exhibited grounded initiatives to 44 acquire knowledge of the situation for their personal awareness. This too, has implications on effective pandemic control and prevention as the students‟ lack of initiatives and motivation for gaining updates could exert more pressure on teachers to ensure the overall implementation of response measure was done accordingly to plan. 4.2 Daily Temperature-screening Most Group A respondents expressed that the daily temperature-screening exercise was more of an assurance of preventive safety for their parents than it was for them. In one example among these responses, a respondent revealed that the twice daily temperature-screening exercise was routine lah – they want to take our temperature, fine we‟ll take our temperature. I just think it is all in the mind. If we do this it just makes our parents happier. I personally do not think it is too useful. I will not even come to school if I have a fever since I know I will be called out to wear a mask in the sick bay, so how can my temperature suddenly increase in a few seconds every morning? (A15, 14, secondary school student) In a similar vein, another respondent remarked that her parents would be [feel] safer if they know schools have strict rules and check on us. But I think also we would make sure we are well before we go to school, so that the temperature thing is just like…a safety measure. (A5, 15, secondary school student) This respondent also noted that the existence of the temperature-screening exercise alone would deter people with fever to stay home. From the frequent use of the word “just” in their responses, the temperature-taking exercise was conceived as 45 „no more than‟ and „merely‟ a normal routine rather than a relevant implementation in the formal response protocol. The act of temperature-taking became normalized by these respondents in which it was routinely accommodated in daily practice in schools. The urgency of detection and prevention in a pandemic situation was therefore undermined, suggesting that formal policing of this measure in school was focussed more on ensuring students perform the act, but not necessarily the need for them to comprehend why. This consequently created the scope for them to think divergently from the relevance and significance of emplacing these measures. Many Group A respondents did not even screen their body temperature seriously, rendering their compliance with this exercise futile as they turned out to be falsifying the records: …sometimes we just faked it – took already, took already, but we were just too lazy to take it again…Towards the end we didn‟t really take it seriously…and I think the teachers also gave up since I noticed that they didn‟t even look at all of us closely…I don‟t think they would know if we didn‟t even do it properly…They also needed to count all our forms and make sure we all wrote the correct temperature if not they would ask questions. (A7, 17, junior college student) From this extract, it is evident that school teachers themselves did not exert full control over the temperature-screening measure. Like A7, many Group A respondents informed that their teachers were not exceptionally stringent on the exercise, but busied themselves more with record-keeping and ensuring they did not miss anything significant in the students‟ declaration forms. One of them noted: 46 Sometimes my teacher would close one eye [pretend to be oblivious] and let it pass. I think we are all bored cos we do it everyday…I don‟t think we put in the effort to be serious about this…Some more they need to make sure we are all fine on paper [cf. the temperature records on students‟ declaration forms] cos I think if anyone get H1N1 they wouldn‟t be in trouble for not keeping checks on us (A3, 14, secondary school student) Here, the policing of temperature-taking exercise in schools was happening without close supervision. School teachers‟ preoccupation with bureaucratic paperwork duties involved in the temperature-taking exercise was observed to be one barrier to effective surveillance and education. 23 The necessary message of prevention that underpins this preventive measure has not been thoroughly conveyed and internalized through regulatory actions. Respondents found scope to falsify their temperature records and got away with it. This implicates effective pandemic disease prevention because whenever students found opportunities to falsify records of their body temperature, they make it impossible for the correct temperature to be monitored for fever detection. Also, most Group A respondents viewed the temperature-screening exercise as a potential avenue for social exclusion; its relevance as a response measure to contain the virus and stop its spread through identifying potentially ill and/or H1N1-infected individuals did not mean anything to them. For instance, one respondent shared the following: 23 In fact, the problem could also be that the temperature-taking exercise is regarded by teachers to be yet another „bureaucratic paperwork duty‟, so there is multifaceted irony present here that could also be further explored if teachers‟ views of the measures and its implementation are captured in another exploratory project. This point is included in the concluding chapter‟s “Suggestions for Future Research” on p.99. 47 OK, I didn‟t really understand why we had to take temperature all the time. That time we didn‟t even have a single case here yet, isn‟t it dumb to think that they could find out anything? We were quite scared some more, ‟cos once anyone got like slightly higher temperature everyone stepped away from him…worse is they say he kiss a pig!” (A2, 15, secondary school student) To most of them, to record and submit a temperature above 38 degree Celsius would mean the following: being singled out from their classes to another room as an at-risk individual or suspect, leaving the rest of the „healthy‟ class speculat ing on the outcome or joking about it. Formal policing of students‟ temperature-taking act appears here to preclude instilling in them the relevance of post-detection isolation. Thus, the necessary separation of feverish cases provided a space for speculation and further exclusion in the classroom. The implication on effective pandemic response here is worrying: students‟ detachment from the relevance of their actions could affect the quality of their compliance as they could turn to falsifying temperature to stay included (as opposed to being excluded and isolated). The responsibility to disclose their physical well-being could in turn be undermined. On the other hand, although older respondents from Group B also came under pressure to conform to heightened security requirements (especially when visiting public buildings), they felt that because these control measures were more flexibly enforced in their contexts of tertiary institutions and workplaces, they did not view them as inconveniences like their younger respondents from Group A. One representative vignette reads: I think they [the control measures] are essential since we didn‟t really know how serious the flu was, but we were also not so 48 strictly under supervision like school students with their thermometers… there was no compulsory temperature-taking and things like that so the control measures didn‟t bother me as much in my daily life. It‟s more…easy and flexible in the workplace than say, in school or in the army…Outside we have more time to learn about it on our own and monitor our own body temperature and know why health authority do the things they do (B3, 24, bank employee; my emphases) Evidently, formal policing of temperature-taking in schools has inadvertently diluted younger youths‟ appreciation for and the quality of their mandatory compliance. To further support this argument, another excerpt is worth highlighting: Actually, I don‟t think because we get older so we actually like the measures more or, like what you said, appreciate it… [Interviewer probes: You mentioned „getting older‟ and „like the measures‟, could you say more about that?]…I mean, if you tell me because we grow older we learn more and act more maturely about H1N1 prevention, I would disagree to some extent „cos I think I personally feel more urgency for acting out ‘cos I don’t have a need to do it every day like my [14-year-old] brother…where everyone checks the thermometer reading together in class and then record it down for our teachers every morning in school and hope nobody around us has a spike in fever….Yes I actually think that not having to take my temperature like this [in schools] makes me know how useful it can be since it really does give, like, tell us our immediate body condition and we can act fast to see a doctor and stay away from everyone as soon as possible…Like, normally if we have a fever it can‟t be H1N1 and now we never know, so yes the temperature-taking is good cos we get [medical] help fast. (B4, 19, student in a tertiary institution; my emphases) 49 In light of what B4 said, I argue that while it could be differences in age being accountable for my observations of respondents‟ feelings towards the temperature screening measure, it is more evident here that formal policing of this measure in schools was the more considerable barrier to younger respondents‟ responsiveness, appreciation and overall quality of their adherence to the response protocol. Despite having the measures firmly policed in schools, we have seen that youths, being active social agents, navigated around them based on how they defined it in the context of their schools and respective environments. Following this observation, effective strategies in monitoring students‟ temperatures in schools should therefore entail (1) less bureaucratic duties for teachers to perform vis-à-vis their roles as important educators and enforcers of students‟ responsible compliance to the protocol, (2) the increased need to carefully explain the rationale of temperature-screening to students, and (3) a stronger emphasis on avoiding „social exclusion‟ as an outcome of the exercise in favour of socially responsible spread control and containment. 4.3 Home quarantine During the pandemic, apart from identifying specific individuals for home quarantine, a set of triggers for class closures was also developed to break any potential chain of transmission within schools in Singapore (Tay et al., 2010). These triggers applied even in the mitigation phase just two months before my interviews began. Classes would be closed for seven days if the class had three or more known confirmed H1N1-2009 cases or five or more cases that had been 50 given a seven-day Medical Certificate (MC) within the previous five days. Between 28 June and 31 August 2009, unpublished data from the MOE shows that even when H1N1-2009 did not necessitate alarmist levels of worry on the pandemic scale, there were still 66 class closures at the primary and secondary schools, junior colleges and centralized institutes (Tay et al., 2010), indicating the importance of social distancing in order to contain the spread in schools. From a containment perspective, therefore, quarantine is a useful nonpharmaceutical measure to halt a pandemic in its early stages. Though a seemingly draconian measure, it has been contended by many in both scientific and social scientific literature to be an effective measure to contain a threat (Day et al. 2006; Lipsitch 2005; Jefferson et al. 2008; Tan 2006; James et al. 2006; Ferguson et al. 2006; Ferguson et al. 2005; Krumkamp et al. 2009; Teo, Yeoh, and Ong 2005; Anderson et al. 2004). Group A respondents, however, did not seem to view or intend to practise the quarantine measure in this light. Their understandings of quarantine can be broadly classified into two types: (1) being “locked up” at home for no apparent reason and at the cost of being ridiculed, and (2) in the words of some respondents, “a waste of time”. Both have implications on effective pandemic control and prevention, which I now explore. The first type of understanding is exemplified in a respondent‟s use of metaphors of “cage” and “cabin” to describe his understanding of the measure: It‟s like in a cage right…Can‟t even go anyway…Someone will stand guard…I think will get cabin fever. It‟s damn embarrassing…No freedom…I don‟t actually know how LOA works except we are separated so we won‟t spread to the public and create trouble. But that also means we will feel imprisoned 51 and get poked fun of by our friends for something that is not even our fault (A11, 14, secondary school student). Also, in the variants of this type of response from many Group A respondents, risk and spread were not their primary concerns; being seen by peers as an at-risk individual confined to the home for a week was notably more troubling. In one interview, for example, a respondent shared that if he were identified for LOA, everyone would know I never show up or get locked up somewhere like suspect…and then they will remember me as the quarantined guy…Nobody cares if it protects them from the disease…and I don‟t ever want that [being identified for LOA] to happen if possible. (A2, 15, secondary school student; emphasis added) Here, I note that although respondents would not resist LOA if they had been identified for it, their concern for the measure was apparently not invested in its significance as a key control strategy. Rather, it revolved around the worry of potential embarrassment and stigma upon being identified. The formal policing of LOA in schools, as I argue, did not seem to have this concern covered. The implication of this finding on effective pandemic prevention is that respondents may not be strong adherents to the measures, because they negotiate the worth of the measure with reference to worries about stigma and social exclusion rather than their participation in a response measure for the collective good. This actually corresponds to findings in other studies, where some researchers have raised concerns for the socio-emotional and psychological well-being of those who were quarantined (either institutionally or home) during recent communicable disease outbreaks around the world and consequently called for increased consideration of 52 these factors during the implementation of this measure (Hull 2005; Barrett and Brown 2008; Cava et al. 2003; Lee et al. 2005). The second type of understanding can be illustrated by one respondent‟s description of how sickness could merely be “all in the mind” of the individual. Moreover, to this respondent, temperature checks were already excessive, let alone receiving a mandatory order from school to stay home involuntarily: Respondent: If I keep thinking I may get a fever then maybe I really will get a fever. I think what we do every day [like the twice-daily temperature-screening exercise] is more than enough. Nobody wants to get LOA, waste time at home and then miss the important classes… Interviewer: When you said more than enough, what do you mean? Respondent: The temperature checks, and we already stopped assemblies and cancelled CCAs, that‟s quite enough. (A9, 16, secondary school student) Here, considering the practice of home-quarantine a “waste of time” devalues it as a significant and relevant part of disease outbreak response. In addition, the practise of daily temperature screening only served to exacerbate this respondent‟s trivializing attitude towards the concept and practise of home quarantine. Again, I argue that formal policing of this measure here appears to fall short of highlighting its usefulness in an infectious disease outbreak, even if it means an involuntary sacrifice of time in school. I understand that for pandemic control and prevention in schools, Group A respondents need not necessarily like the response measures as long as they adhered to it, but I also argue that the attitudes they adopt towards them create a risky scope for individual resistance, as I reiterate this reaction from 53 the earlier extract: “then they will remember me as the quarantined guy…Nobody cares if it protects them from the disease” (A11, 14, secondary school student; emphasis by author). The implication of this attitude on effective pandemic control and prevention would be that LOA/home quarantine oscillates between a timewaster and a mandatory-but-perhaps-over-the-top responsibility to the public, providing respondents scope to re-evaluate the extent of their adherence and creating room for possible resistance. On LOA/home quarantine, Group B respondents‟ perspectives are, again, qualitatively different mainly because they did not perceive these measures in a context of formal policing.24 A mandatory LOA was, according to one Group B respondent, “…necessary to protect ourselves and everyone else from getting infected in school or at work, since there….[is] no other way to ensure the virus doesn‟t spread” (B9, 24, marketing employee). Another older youth shared that: …of course we know there are downsides to quarantine but we understand…if someone needs to go for LOA because of exposure to the virus or they came back from a more seriously affected place, we rather they get checked and isolated from others whether at work or [in] school so we won‟t have risks walking around everywhere and all of us can feel safer that some people have sacrificed their time to prevent a disaster (B15, 22, student in tertiary institution; my emphases). Many similar comments like the one above from Group B respondents further point to a contrast in the perspectives between those who experienced the control measures in the policed context of schools and those in less formal contexts of 24 I kept in mind the fact that simply by being older could be the cause for better appreciation of LOA, but when my data includes references that point towards differences in where the measures were perceived, I would argue for a critical look at formal policing and its limitations rather than resting upon the fact that students become „wiser‟ and more receptive and responsible when they grow older. 54 universities and workplaces. Here, it is evident that the idea and policing of LOA in schools have implications on effective pandemic control and prevention. Undoubtedly, the measure was implemented and enforced by schools. But beneath this formal layer of surveillance, youths‟ perspectives of it were not complementary but had appeared rather adversarial. This finding supports my argument that the implementation of and emphasis on policing these preventive measures in schools have been limited in engaging youths fully as participants in the pandemic response protocol. Consequently, the speed, integrity and quality of their compliance with the response measures were compromised. The best way of explaining and policing LOA, as such, requires more effort on the part of teachers and schools. Given Group A respondents‟ attitudes, I would argue that the presentation and exercise of home quarantine must avoid framing it as an exclusionary measure detached from normal conditions. Rather, it should be presented and policed - with enough fortitude - as a form of useful practice to strengthen individual and public health conditions. Disciplinary action could extend towards students who outwardly seek to make light of the measure and/or trying to stigmatise quarantined individuals. Taking insights from the data, additional emphasis on risk, individual co-operation and important time sacrifices must be strategically made so as not be outweighed or foreclosed by thoughts of stigma, social exclusion, and trivialization stemming from a lack of appreciation in the measure‟s effectiveness and relevance for disease control. By merely policing and monitoring students‟ compliance in a formal context, there were therefore considerable limits to effective pandemic prevention and control. As we shall observe in the next section, formal policing of both temperature-taking and home 55 quarantine measures in schools also had adverse effects on the effectiveness of the pandemic educational campaign. 4.4 Educational Campaign To complement the implementation and policing of the response measures, all schools in Singapore each received an Education Package during the June 2009 holidays comprising the following: a set of slides for teachers to use in educating and advising their students; posters to be displayed at strategic locations within the school to raise student awareness; as well as pamphlets for students for reading and sharing with their families (MOE Press Release, 23 June 2009). The pamphlets included messages on good hygiene practices and social responsibility such as stating the need for students on LOA to stay at home to monitor their health condition and not congregate at public places. Schools also dedicated time on the first day of school after the June 2009 holidays for teachers to help students gain a better understanding of H1N1-2009 and the situation in Singapore. Teachers used these materials to educate their students and communicate to them the importance of their role in helping to slow down the spread of H1N1-2009 (Ibid.). However, I argue that Group A respondents did not feel the need to engage with the above-stated educational efforts because the inconvenience of the mandatory measures in their daily lives was what they were chiefly concerned with. For many of them, the pandemic was something to joke about, rather than understood in its significance as a health threat, because the measures disrupted 56 their daily timetables or loomed uneasily as potential threats of exclusion. This attitude links us back to the problems identified with the implementation of temperature-taking and the uninformed introduction and policing of LOA in schools earlier. In an interview, one respondent informed how he and his peers focussed primarily on making fun of the disease because it caused them to be policed and inconvenienced by teachers in taking up the response measures: …first called the Mexican Flu, then pig's flu, so they finally settled down on "H1N1" because it probably felt more medical right…Can't make funny cartoon picture with H1N1, although it was easy to make fun of Mexicans or of pigs visually…I don‟t really know much about the details of this disease…We tried to make jokes about the name of H1N1 but it is harder than swine flu to actually produce something really funny…Why was this our focus?...OK we needed to take temperature two times every day and [to] stay away [from school] if we had fever, this already is boring and we don‟t actually feel that it is too, how to say, necessary, so it is good to have something funny to link H1N1 to make us laugh until, I guess it‟s no longer that funny (A8, 16, secondary school student) This excerpt also helps shed light on why so many Group A respondents‟ accounts of H1N1-2009‟s etiology were often characterized by jokes precluding the vital knowledge that this flu strain had crossed species and made possible a human-tohuman transmission and that it could always happen again at any period in time. The real threat of the pandemic disease appeared to be fuzzed out by the perceived threat borne of students‟ concerns on the disruptions to their timetables and of trivializing attitudes towards pandemic awareness. This has implications on effective pandemic control and prevention as students‟ lack of reception to accompanying educational messages offered no opportunities for them to adhere to 57 them with the requisite integrity, exerting more pressure on the teachers‟ role to ensure they physically complied with what they deemed as inconveniences. Also, I argue that their concerns on the inconveniences emplaced by formal policing of the response measures created considerable room for them to question among themselves the significance of having the measures heavily policed in school every day. For example, one respondent expressed scepticism about the worth of the preventive measures: …I admit don‟t really know about when exactly we need to take the temperature every day and when we should stop…I don‟t remember the teachers telling us much about it also…I believe the system has it so we have to follow it…like it is such a bother to have to record our body temperature one or two times a day and I don‟t know if it is really so useful anyway. (A12, 15, secondary school student) Another respondent relied on scant pieces of information in relating how she felt about the pandemic after the preventive measures were scaled down after August: “Apart from the fact that H1N1 is not really so scary anymore [after August] and we step down on some measures, I did not know what happened or how effective our measures were” (A13, 15, secondary school student). Every other respondent in Group A provided a similar variant of the above response, revealing varying degrees of scepticism over the measures and a lack of engagement with their relevance in the pandemic disease control and prevention program. The implication of this finding on effective pandemic response is that youths contin ued to find the measures “a bother” and questioned their effectiveness as they experienced the formal policing in schools, maintaining considerable room to sustain the lack of their meaningful participation and requisite responsiveness. At 58 this point, it is also useful to note Razum et al.‟s (2003) warning on lay redefinitions of SARS in Hong Kong when expert knowledge was not effectively passed down to the populace. The significance of the above implication on effective pandemic control is further extended by the finding that given preventive measures being enforced and policed formally in schools, Group A respondents exhibited a considerable lack of interest in reflecting on and better understanding what actually „happened‟ even with the benefit of hindsight. For instance, one of them expressed the following: I didn‟t do much to prevent [from getting the disease]…[because] the school checks our temperature, told us what was the issue…we update[d] our travel plans, [there was] not much to worry about and I don‟t think I would be too keen on knowing more….They notified us what to do if we were sick, so now that it [most of the pandemic period] is over I think we have moved on…it‟s not an issue to think anymore [of] once it is over. (A6, 17, secondary school student) Another respondent commented that as long as she was not in an at-risk group (of which she referred to as being identified for home quarantine), her understanding of the virus could remain being drawn from the laity of informal everyday talk: I don‟t actually understand the virus. First it is scary, then it is not that scary. In that case I suppose we are fine, no more taking temperature every day…and nobody has to go for quarantine or stay away from school or other people. I was glad the measures were stopped finally, because initially we thought it‟s going to go on until end of the year. (A13, 15, secondary school student) Many of them viewed the pandemic event as something that could be sufficiently understood mainly by virtue of these measures being implemented and policed 59 instead of what actually happened to warrant the need for preventive strategies. This observation further suggests that their compliance to the response measures in schools were, at best, acts policed by teachers rather than their informed adherence and responsible participation in the pandemic response protocol. This has implications on effective pandemic control and prevention as students‟ lack of understanding of the relevance of these mandatory measures in place even in retrospect could mount pressure on teachers – who already appeared encumbered with existing duties - to ensure that future strategies would be adhered by policing more so than by both policing and educating. I contend that policing student youths‟ adoption of preventive measures is certainly necessary, but it should not create an absolute sense of security that overshadows their knowledge and appreciation for why these measures are even in place. As such, it is crucial for educators to ensure that the pandemic educational campaign launched in school aligns actively with their policing of the students in complying with the response measures. Furthermore, Group A respondents‟ concerns over the inconveniences caused by formal policing of response measures in schools also reduced their initiatives to seek knowledge and understanding from other sources outside the framework of school-based prevention and education. In fact, all respondents in Group A were neither aware nor interested in the existence of additional channels of information on the global pandemic found in the internet media because they felt that they already had “enough” of the pandemic going on in their lives. For example, although most of them had personal profiles and accounts on Facebook25 25 Facebook is a social networking website launched in February 2004 and operated and privately owned by Facebook, Inc. Apart from typically creating a profile of themselves and adding people as 60 and/or Twitter 26 during the time of our interviews, Singapore Health Promotion Board‟s (HPB) stake in these social networking sites did not reach them. HPB had harnessed social networking channels to update the latest news on the H1N1-2009 event, particularly Facebook and Twitter. One respondent who has her own Facebook profile chose to define the pandemic situation by relying on what is already taking place in school and hoping it would end as soon as possible: The information I get is…maybe…what is in the news and perhaps…what the school reports to us…I think the school does a lot to make us record our temperature, check if we have a fever and then pushing us to get MCs and so on….These activities already was done every day, frankly, I didn‟t know when that was going to end but of course the sooner the better… Erm, in terms of going the extra mile, I didn‟t personally go on the internet to find out the updates about H1N1…In fact we didn‟t even ask the teachers for more information except when this would end. We do what we are supposed to do in school and that should be enough to keep H1N1 under control unless someone doesn‟t co-operate…” (A14, 17, junior college student). Another respondent shared a similar view: “I personally didn‟t go on [the] Internet to look for more [information]…cos we are already flooded with all the H1N1 friends and sending them messages, individuals or companies can create "Like Pages" which allows users to "like" the individual, product, service, or concept. Owners of these pages can send updates to their “fans”, which shows up on their home page. They also have access to insights and analytics of their fan base. As of 2011, fan pages have been converted to “Like” pages. 26 Twitter is another social networking service that enables its users to send and read other user messages called tweets. Publicly visible by default, „tweets‟ are text-based posts of up to 140 characters displayed on the author's profile page. In his paper in The New Scientist, Palmer (2008) has found that blogs, maps, photo sites and instant messaging systems like Twitter did a better job of getting information out during emergencies than either the traditional news media or government emergency services. „Facebook‟ or „Tweet‟ have become recent buzzwords. HPB has also jumped on this social media bandwagon. Its FluSingapore profile page (Plate 3.2.) „tweets‟ updates on H1N1-2009 to more than a thousand followers. 61 stuff [daily practise of preventive measures] in school…I think what we are doing is giving us enough awareness” (A4, 15, secondary school student). In becoming overly absorbed within the boundaries of formal policing in their schools, they grew detached and also lost interest in the significance of wider pandemic prevention efforts. The implication on effective pandemic control and prevention here is that given students‟ detachment from the broader pandemic event beyond their school environments, there was additional need to police them to adhere to the measures responsibly as they could not appreciate the urgency of infection control. In addition, they would likely fail to serve as effective messengers of the official response protocol to their family when they get home. To illustrate this implication, we can consider this extract: Well I go to school, we check our temperature, fill in the forms and then have our lessons…Then we took the temperature again in the afternoon and hopefully nobody gets LOA…I guess that‟s all…I did not look for other information…I also did not actually tell my parents anything about what we learn for H1N1…What I mean is I don‟t think I learnt anything to tell them except that we need to bring our thermometers to school every day. (A10, 13, secondary school student) It is thus essential for disease control measures in future to be policed in school with significantly more scope for gaining students‟ motivation in seeking updates and additional sources of information for themselves and their families to prevent losing touch with what goes on outside of it. 62 Unlike Group A respondents who stayed within the confines of formal policing and did not manage to gain an appreciation for responsible adherence and additional information, older youths in Group B sought information on the pandemic from several sources beyond their universities, workplaces, and the websites of MOH and HPB. They were actively making use of Facebook and Twitter to keep up with the pandemic situation and they made it a point to be aware and active in the overall pandemic response efforts. I understand that Brownstein, Freifeld, and Madoff (2009) have cautioned against an uncritical use of emergent web-based information like search-team surveillance and social media tools in detection of and disseminating information of the H1N1-2009 outbreak. 27 However, I would argue that in the context of Singapore, the government‟s presence in these social networking sites (as illustrated clearly in Plates 4.1 and 4.2) stood firm as the official source of information vis-à-vis other „noises‟ emitted by the plethora of online news sources. This advantage had afforded MOH and MOE a prime opportunity to tap on the educational benefits of the internet and communicate with this group of youths in a rapid and refreshing way. 27 Specifically, in The New England Journal of Medicine, the authors have observed the American CDC‟s engagement with emergent tools of new media and wrote that “Though traditional official and media communication channels remain in place, Web-based mapping, search-term surveillance, “microblogging,” and online social networks have emerged as alternative forms of rapid dissemination of information. Understandably, some observers worry about their ability to inspire public concern beyond the necessary levels. Clearly, these tools must be used with restraint and appropriate evaluation.” (p. 2156) 63 Plate 4.1. Screenshot of HPB’s Updates on H1N1 on Facebook, January 2010 Plate 4.2. Screenshot of HPB’s FluSingapore Twitter page, January 2010 64 In fact, Group B respondents appear to exhibit the kind of understanding Abraham (2010) was hoping experts and policy makers in the H1N1-2009 pandemic would attain, “not for the audience to accept the views or arguments of the communicator, but to raise the level of understanding so that all those who are involved are adequately informed within the limits of available knowledge” (p.1307). Most of them discovered the updates available in Singapore mainly after coming across reports of the U.S. government harnessing tools of social media for campaigns, all sorts of political promotions, and for raising awareness of social and economic issues. 28 Here, I note that respondents‟ quick access to disease outbreak information on Facebook and Twitter is an unprecedented observation in the Singapore literature. It reflects how its government has engaged technology creatively during a crisis. One of them shared his view on these channels and how it motivated his agency in knowledge acquisition outside the school context: I think it is quite creative and not so boring [as compared to how they were educated of the epidemic during SARS]…Like Facebook, who would think the government would ever update their statuses like we do, hah!...It‟s good that they are keeping up. Makes it more in touch too…Who will keep going to read their press releases on their own?...But if they provide the link there, sure I can have a quick look easily...I think as long as we get many choices of receiving information it is better than back in school...where teachers would teach in the usual way[s]... (B5, 18, student in tertiary institution). 28 The American CDC engaged actively in social media tools during the outbreak of H1N1-2009. According to their website (http://www.cdc.gov/socialmedia/campaigns/h1n1/, accessed 1 July 2009), since 2009 they had been “provid[ing] consumers and partners with social media tools that provide information about the ongoing 2009 novel influenza A (H1N1) outbreak. Widgets, mobile information, online videos and other tools reinforce and personalize messages, reach new audiences, and build a communication infrastructure based on open information exchange.” 65 Similarly, another respondent also kept herself posted with news on the pandemic regularly via these channels: I follow some Twitter pages for news, like Straits Times and all that. Once there‟s something new or interesting usually they will tweet the link quite fast and so it is very easy to know a lot of things quite fast. During H1N1 I also followed the American CDC lah, though only a bit later then I follow FluSingapore‟s updates. (B2, 23, marketing employee) These extracts represent the enthusiasm and engagement of Group B respondents with the communication tools harnessed by HPB for educating and informing the public, suggesting the potential of these tools for future public educational strategies also in schools during health crises. As noted earlier, these social media tools were considerably limited in their effectiveness on the student respondents in Group A as they experienced the pandemic situation within their schools in more traditional ways through the practise of preventive measures in schools with accompanying pamphlets in their education packages. Their lack of engagement with other outlets did not help in improving their attitudes towards their unenthusiastic practise of control measures in schools. This puts forward support for the argument that formal policing of response measures in schools was the facilitator to younger youths‟ attitudes and disengaged compliance with the response protocol. What should be seriously considered, therefore, is the ability for authorities to leverage the internet literacy of school students 29 and getting them to engage productively with this aspect of 29 It has been argued that the majority of Singapore youths (from 12 to 18 years old) have access to the internet at home, fostering a heavy use of the internet for communication and obtaining information (Cheong 2008; Mythily, Qiu, and Winslow 2008). Also, the internet has an important role in adolescents‟ repertory of health information sources (Gray et al. 2005). 66 technology for involvement in both school-based and wider levels of pandemic prevention. 4.5 Policing the Practise of Preventive Measures in Schools: Implications, Reflections and Suggestions To reiterate the earlier findings, I have demonstrated that what took place in these respondents‟ schools appears to be a mundane and routinized set of actions in pandemic prevention. These actions were firstly misperceived as disruptive inconveniences to a typical school day, and secondly, contributed to the ineffectiveness of the educational campaign. Older youth respondents in Group B did not experience the same policed school environment as the younger ones had, and they had shown significantly more appreciation for the preventive measures and displayed a greater degree of agency in expanding their awareness of the pandemic situation. How pandemic control and prevention strategies were implemented in schools is arguably why younger youths in school tend to miss the forest for the trees and consequently lose the meanings of the pandemic prevention and the motivation or desire to seek for any. Their reservations towards the control measures emplaced in schools and their consequent lack of agency in knowledge acquisition has implications on effective pandemic disease prevention. The integrity of their compliance and the quality of their responses were reduced, even if everyone had responded accordingly given the mandatory enforcement of it. Room for resistance and scepticism about the worth and relevance of these measures in the official response protocol existed. 67 With this knowledge in mind, I argue that an official rethinking of how policing in school could be done more effectively by firstly reducing the paperwork duties involved in implementing the measures, and secondly, by getting school teachers to renew their focus on both educating and policing the measures to students. As the literature has stated, for the health authorities, the urgency of expert knowledge to be absorbed by the community during an emerging infectious disease outbreak is significantly heightened: although community participation provides access to the collective knowledge and expertise within a community, the infrequent and complex nature of a pandemic means that much information will have to be acquired from expert sources (Paton et al. 2008: 47). Indeed, as evidenced from my respondents‟ perspectives, “[a]lthough public education assumes that people will absorb and use any information from expert sources…people take a more deliberate approach to this task” (Ibid. p. 47-48). To avoid the risks of students‟ not participating responsibly or trivializing the relevance of these measures in place, teachers would need to redirect their efforts towards the quality of students‟ compliance and responsiveness, and not by focussing predominantly on the written records of students‟ temperatures in/and literal implementation of the measures itself. Since Group B respondents possessed an agency in knowledge acquisition that was notably absent in Group A respondents, this finding provides not only a contrast to Group A respondents‟ perspectives of the pandemic for us to rethink the formal policing strategies in schools, but also raises a consideration for the formal pandemic response taskforce to reconsider the agency of youths – both 68 younger and older – in knowledge acquisition. Learning from Group B respondents‟ experiences and perspectives, I argue that it is essential for us to leverage on school students‟ internet literacy and involvement in social media tools to enhance their experience of the pandemic response efforts they participate in schools. I reiterate here that relying on several sources of pandemic information as opposed to merely one conventional approach i.e. the Education Package in schools could more effectively diffuse the educative discourses during the pandemic event. The aim for MOE, therefore, should be to develop a more creative educational package to complementarily integrate knowledge acquisition skills from multiple channels with the daily monitoring and surveillance of their practise in and adherence to the response measures. Moreover, in the case of H1N1-2009, the Singapore government made some changes to its initial alignment with WHO‟s classification in order to react more effectively within the local context. This has implications on effective pandemic response as changes to local official reactions to the global pandemic would certainly affect people‟s responses to it. As Tay et al. (2010: 320) note, leaving behind the DORS framework midway through a pandemic was a tremendous challenge…[and] communicating a new set of public health measures under the new system was particularly difficult, producing some variability in the implementation of appropriate measures by different stakeholders. (Tay et al. 2010: 320). Given such sudden fluctuations in public discourse during a period of uncertainty and risk, it is all the more useful to leverage on several sources of official information and education for all youths to keep themselves updated on the changes and translate their knowledge among themselves, their peers and their 69 families. In this respect, I have learnt that many Group B respondents were in touch with the developments, as they had referred to WHO‟s website and other news sources to gain, in one of their expressions, “a better picture of the situation”. One respondent noted the following: I saw the news and tried to check the WHO site quickly, because I had to work and couldn‟t spend too much time on the internet on this issue. Then I read the WHO raised the alert to five…I didn‟t know exactly what that meant at that point, but Singapore also changed its alert status to orange, from what I saw on [the] ministry [of health‟s] website. Finally I picked up from the news and twitter that said that Singapore is not the same because WHO only counts the cases or something like that while we are more focused on our local situation...At least it became clear that we were dealing with it within the country and the measures they take would be to deal with how serious we fare in the pandemic (B12, 24, government employee) Indeed, the vital difference between WHO‟s and Singapore‟s response was something that the Straits Times clarified to the public when MOH decided to lower the flu alert (from Orange to Yellow) eleven days after it initially ramped it up (from Yellow to Orange) in tandem with the WHO‟s move from Phase Four to Phase Five.30 Singapore‟s pandemic alert colour-coded system was based on knowledge of the virus – how infectious and deadly it is…this differs from the WHO pandemic alert levels, which progress from one to six and are based only on how far the 30 As presented in Chapter One, the WHO employed an alert system based on the geographic spread of the disease and not on its severity and susceptibility. Although Singapore started off aligning itself with the WHO‟s alert levels as a prudent move in a tense and uncertain period of the outbreak, its treatment of the global pandemic crisis switched rather abruptly to a local-specific view of H1N1-2009 as being “contagious, but not deadly”, rendering WHO‟s pandemic alert phases were no longer meaningful for its public. The health minister also justified the downward adjustment by saying that Singapore‟s public health measure “cannot over-react forever” (Straits Times 7 May 2009). 70 virus has spread throughout the world, not its severity. (Straits Times 7 May 2009). Here we observe how the benefits of Group B respondents‟ agency in knowledge acquisition matters in that knowing the development of the H1N1-2009 had served them well in their appreciation for the relevance of the government‟s response measures (as opposed to perceiving them as inconveniences). This agency should certainly be instilled in younger respondents in Group A as during the interviews, most of them seemed only dimly aware of the existence of a localised system of outbreak response. One respondent even appeared to have given up her right to information in assuming that someone with authority would take the lead and guide with the requisite expertise and knowledge of the pandemic threat: I think this one [the severity of the pandemic based on DORS and/or WHO‟s classification] is for teachers and [the] principal to know because they have to know how to react [to the pandemic threat]…I don‟t exactly know the situation because we are already being told to do so much in school…The teachers are supposed to have some guidelines on what to do each time, don‟t they? (A10, 13, secondary school student) The implication of such a disengagement on pandemic control and prevention for effective outbreak control strategies is that eventually, school students acted only in accordance to what their teachers dictated rather than what they felt was urgently relevant for prevention and mitigation. The daily mechanical performances of temperature-screening and misperceptions of home quarantine may then contribute to further perceptions of inconveniences as respondents did not practise them with the right attitudes. 71 Finally, I also reflect that my respondents did exhibit some signs of selfinitiative and self-responsibility in defining the pandemic, as evidenced by extracts like: We all do know about handwashing and to cover your mouth when you cough even without H1N1…If I get the disease, I would really just shut off from everyone including my family…like, common sense right, you won‟t think normally be going out and infect[ing] people and of course other people won‟t be so evil [and as he later added, “irresponsible”] as to, like, purposely come out and infect us…OK, maybe the threat of the virus is not the same [as SARS] because it can be cured…but I still won‟t just go out and be a social hazard…If I know someone who does it then I will be very angry lah…There is no need for learning about it or having to make sure we do this and that every day since we already know what it‟s about. (A4, 15, secondary school student; emphases added by author) Excerpts like the above were occasionally present in data generated from both groups of respondents. Thus, while I am studying their perspectives of the pandemic event per se, I also found that their compliance to the response protocol was described with reference to general preventive health behavior that they viewed as “common sense”. Nevertheless, MOE posited that “the temperaturetaking exercises also serve to educate pupils on the need to take personal responsibility for their own health and to exercise social responsibility for the health of others” (MOE Press Release, 29 April 2009, http://www.moe.gov.sg/media/press/2009/04/media-statement-by-moe-on-the.php accessed: June 2009). This finding‟s implication on effective pandemic control and prevention lies in respondents‟ current detachment of the response measures 72 they experienced in schools from what they viewed as “commonsensical” actions of responsibility. Group A respondents‟ views on temperature-taking and appreciation of home quarantine as inconveniences have challenged MOE‟s agenda of using them for emphasising the need to adopt personal and social responsibility during the pandemic period. In this light, I suggest that educators could expand this foundational “common sense” from adopting an educational strategy that integrates the significance of temperature-taking and home quarantine within the scope of youths‟ existing volitional self-responsibility. For example, students could first be made to list what they deem as “common sense” actions during an infectious disease outbreak. Educators would then insert daily temperature-taking and appreciation of LOA as key aspects of this “common sense” that merits policing and surveillance by formal authorities on a larger scale. This could enhance the integrity and quality of their compliance as they begin seeing the forest through the trees by redefining the pandemic situation in view of why they needed to participate responsibly in the overall response protocol. Whichever model is used, it should be one that encompasses a strong and balanced co-presence of formal policing and interactive education. 4.6 Conclusion In summary, I have explored data that reflect how perspectives of the H1N1-2009 pandemic differ significantly between both groups of respondents. I have argued that the extent of policing in the contexts where both groups of youths experienced 73 the pandemic matters, because formal policing of the pandemic control measures in schools of younger youths had inadvertently disengaged them from actively participating in the response protocol. Younger youths from Group A viewed the preventive measures of temperature-taking and home quarantine as timetabledisrupting inconveniences that were policed by school teachers who appeared over-encumbered with paperwork duties to enforce the measures appropriately and effectively. Consequently, their preoccupations with and reservations for the inconvenience-ness of these measures contributed to ineffectiveness of the formal educational campaign. I support this argument by contrasting data generated from older respondents in Group B. These respondents reflected relatively more appreciation for the response measures implemented in various settings and exhibited promising initiatives in seeking additional sources of information and updates on the pandemic situation. Difference in age and levels of maturity was considered as reasons behind the contrast, but Group B respondents‟ references reflect more than just a higher level of maturity and reveal feelings about how being formally policed would affect their initiatives and responsiveness. The implications of these findings on effective pandemic control and prevention are also discussed. Given the mandatory nature of practising response measures religiously in schools during the pandemic period, their perspectives did not threaten their compliance per se. However, the overall integrity and quality of their compliance were compromised. Their responsiveness was thrown into question when they did not actually treat the measures in a manner commensurate with their importance and relevance in a pandemic situation. Room for resistance 74 and scepticism were clearly present and posed as risks for slippage in the formal control strategies. In light of this knowledge, I have raised suggestions for people who are planning pandemic response strategies to consider in the future. First, I discussed the importance of unburdening teachers of excessive administrative duties to facilitate their vital roles in policing and educating students of the measures concomitantly. I also suggested the necessity for health authorities to tap on the existing internet literacy of Singaporean youths and develop educational strategies that can reach out to them beyond the conventional way as evidenced by the Education Package in this pandemic event. In addition, I raised an observation on how youths described preventive health behaviour against flu with reference to “common sense”, noting its significance for future pandemic response strategies to include and build upon to achieve even better preventive efforts. In the next chapter, I explore data that show how formal policing of these response measures in schools also inadvertently created a sense of fatigue and established a context of dependency for Group A respondents. I argue that this is due to how they redefined their present experience with reference to the SARS epidemic in 2003. Data from both Group A and Group B respondents would be explored and contrasted for the chapter‟s discussion, and further implications on pandemic prevention would be raised. 75 5 Policing Pandemic Control Measures in Schools In Relation to Youths’ Memories of SARS “…people who are at least more than 10 years old know instinctively what needs to be done to keep the new flu [H1N1-2009] at bay” (Straits Times 2 May 2009) In this chapter, I explore data that reveal how respondents‟ memories of the SARS epidemic in 2003 have an effect on their experience and reception of the H1N1 2009 response protocol. In my analysis of the data, I found that as Group A respondents had once experienced formal policing of the same response measures in schools in 2003, formal policing of the H1N1 pandemic response measures in schools for a second time had inadvertently contributed to their reduced concern, increased fatigue, and passive dependency on school-level pandemic response. In sharp contrast, Group B respondents neither expressed feelings of fatigue nor dependency on the official pandemic response protocol. Like respondents in Group A, all of them also experienced the SARS epidemic in formal school settings. However, their experiences of H1N1 pandemic response measures outside of formal policing in schools had motivated them to engage more introspectively with their memories of SARS to enhance preparedness and appreciation for pandemic control and prevention. In view of these findings, I argue that formal policing of response measures in schools did not benefit sufficiently from the previous experience of SARS. Whenever Group A respondents compared the pandemic to SARS, they appeared 76 tired of and disengaged from the formal policing of the pandemic response measures. This finding has implications for effective pandemic response because, as I will elaborate in the chapter, feeling fatigued by and passively reliant on the existence of response measures in schools also affected the overall speed and quality of respondents‟ compliance with these measures. In relation to findings discussed in the previous chapter, this fatigue also contributed to their views of the response measures as inconveniences over relevance. I suggest that future formal policing of response measures in schools would do well in rethinking its approach in light of this implication. The chapter will be structured as follows. After briefly presenting the background information upon which this chapter‟s discussion is based, I contrast Group A and Group B respondents‟ comparisons of H1N1-2009 to SARS to argue that formal policing of pandemic response measures in schools was limited in its effectiveness insofar as benefiting from the past is concerned. To this end, I show that in thinking about SARS, Group A respondents‟ views on the H1N1-2009 response protocol were concomitantly centred on reduced concern, increased fatigue, and passive dependency; Group B respondents‟ views, in contrast, comprised an active engagement with the development of H1N1-2009 vis-à-vis the severity of SARS. Subsequently, I highlight the implications of this difference on effective pandemic control and prevention, and conclude with suggestions on how future formal policing in schools could rethink its approach in relation to past experiences. 77 5.1 Background: Formal Policing of Preventive Measures in Schools during the SARS Epidemic When the SARS epidemic hit Singapore seven years ago, all respondents from both Group A and B were students in the formal education system. For the first time, they were given digital thermometers by the government for daily temperature checks to prevent transmission. Twice-daily temperature monitoring of all school children from 6 to 16 years of age was made mandatory between April 2003 and July 2003, stopping only two months after WHO‟s removal of Singapore from its list of SARS-infected places in May 2003 (Tan 2006). Students were not allowed to attend school if their temperature reading was more than 37.8 degrees Celsius for students less than 12 years old, or 37.5 degrees Celsius for students more than 12 years old (Chng et al. 2004), even if they were asymptomatic. Given the similarity of the response protocol with H1N1-2009, SARS served as a good public reference for discussing preparedness for the newlyemerged pandemic flu. Upon the discovery of H1N1-2009, Singapore‟s public discourse reminded citizens that SARS “killed 33 people here; daily temperature checks on students and hospital staff were imposed, as well as 10-day home quarantines on SRS [severe respiratory syndrome, omitting the acute] suspects” (Straits Times 29 April 2009). SARS was then publicly invoked as a “lesson learned” to assure readers that thanks to a previous experience, “Singapore has been able to respond swiftly now” (Straits Times 30 April 2009). Minister Mentor Lee Kuan Yew also opined that “We are taking no chances. We learnt from SARS. We have got all the precautions in place, thermal imaging; slightest sign of 78 something wrong, you go straight into quarantine. We check you, check for (the) virus, but so far (it is) all right” (Straits Times 29 April 2009) while Deputy Prime Minister Teo Chee Hean echoed his sentiments by claiming that “Singapore has built up many strengths from its experience with SARS” and “is probably the best place in the world to be ill, when H1N1 virus sooner or later lands on these shores” (Straits Times 9 May 2009). Embedded in this discourse is the assumption that formal response to H1N1-2009 should benefit from this previous experience. However, as I will show in the next two sections, although formal policing of pandemic response measures in schools was re-experienced by Group A respondents in the same setting, their memories of the previous epidemic lowered the degrees of their concern for the pandemic response measures. These memories also generated fatigue and a more passive dependency on the sheer existence of these measures in schools. Contrastingly, Group B respondents, who were no longer part of the formal school setting during H1N1-2009 as they were during the SARS epidemic, engaged differently with their memories of SARS. They actively compared the severity of H1N1-2009, exhibiting more concern for the development of the pandemic and appreciation for effective pandemic prevention while revealing how being out of the school context motivated these actions . I will subsequently discuss the implications of these findings for effective pandemic control and prevention, and provide suggestions for future outbreak response strategies. 79 5.2 Formal Policing of Pandemic Response Measures in Schools: The Limitations of Remembering SARS Remembering the SARS episode in schools influenced many Group A respondents‟ thoughts about preparedness for H1N1-2009 in terms of their familiarity with the control measures. However, it was also this familiarity that had its hand in how respondents turned out being less concerned for the overall prevention against H1N1-2009 carried out in schools. For example, one of them remarked that …it is like SARS during that time [sic]. I still remember we had to take our temperature and everyone had to be alert….This time [for H1N1] it‟s still the same, we also have to bring our thermometers to schools and take our temperature every day…and hope that nobody gets a flu if not there would be quarantine for us…The same old thing stuff again. [Interviewer probes: So, when you engaged with H1N1 response measures again, did you feel you were more equipped with experiences to think about the H1N1 pandemic now?] Respondent continued:…Overall I‟d say I don‟t have actually have much concern for H1N1 [disease] cos after I know we need to do the same [preventive and control] precautions…Well I thought, OK then, we are prepared and so far it‟s fine so we need not worry about it like we did for SAR. [Interviewer probes: So was there an improvement in your thoughts about the measures the schools need you to perform everyday?] 80 Erm, not really actually. We just do [what] we‟re supposed to do [in schools] and get it done with so our teachers can move on quickly…Was only just hoping it ends soon and wont become too dangerous. (A12, 15, secondary school student). Here, this extract underscores the significance of how SARS had characterised most Group A respondents‟ perspectives on H1N1-2009. Evidently, and perhaps even expectedly, it served to remind students that they had already “done it” once in schools, and confronting H1N1-2009 in the same setting of formal policing and control was deemed as no different. However, this mode of thought also contributed to their reduced concern for pandemic prevention. Remembering SARS when experiencing H1N1-2009 control measures in schools for the second time, I argue, did not enhance the responsiveness or the overall quality of their compliance with the H1N1-2009 response protocol. This negates effective pandemic control as it generates scope for students to become somewhat complacent with existing efforts and subsequently less concerned about practising the response measures responsibly. In addition to the reduced concern observed in their responses, most Group A respondents also expressed fatigue in re-experiencing formal policing of the response measures. With fatigue, their views included an increased intolerance for performing the same measures again. In one interview, for instance, a respondent described how it was “really troublesome to be faced with the same thing again” in school and expressed his growing intolerance for the measures: Although we know what to do…you know, the usual temperature checks on our thermometers everyday to record for the teacher, and then seeing a doctor and staying at home if we get the flu…It is just tiring and troublesome to find out what is exactly the virus 81 this time again…Like I know it spreads the same way [as SARS], and we need to reduce contact with other people and so on…During SARS we did it…but I think we also felt tired of doing it over again [in schools] for H1N1 and we were wondering how long it H1N1 would last before we gave up on caring about it totally (A9, 16, secondary school student). Evidently, like what I learned from many Group A respondents, A9‟s feeling of fatigue for the response measures here is associated with a growing lack of tolerance for them. For them, I argue, remembering what they did during SARS in light of the current formal policing experiences served no benefits for improved or effective pandemic control in schools. Here, I highlight that the implication for pandemic control and prevention is a potential scope for incompliance had the fatigue and intolerance escalated over time. To explore this implication further, we can consider, for another example, the following extract: Respondent: It‟s [H1N1-2009] like, SARS but not really SARS…We do the same things for it…we take our temperature everyday, they put up the body [thermal] scanning machines in buildings, and people get quarantined if they are suspected. At that time [when the pandemic was beginning] I just hoped this [H1N1-2009] wasn‟t a repeat of SARS. Interviewer: But you did know H1N1 is quite different right? I mean, OK, for example, there are antiviral drugs likely to be effective for H1N1, but not SARS. They are still different and can be seen differently, do you agree? Respondent: I know…It‟s just like, we‟re thinking that they [SARS and H1N1] are different, but the things done [control measures] are the same, so it actually gets quite tiring for us to go through it every day in school…So we take out our 82 thermometers and take our temperature every day [in schools] to show our teachers and they had to do it every day to make sure we‟re fine…I was glad it didn‟t continue until the end of the year…honestly I got quite tired of it after two weeks and totally lost interest in H1N1 already (A15, 14 years old, secondary school student) Given that respondents like A15 had slipped into familiar roles they performed not too long ago during the SARS epidemic, adhering to the same formal policing strategy in school appears to have diminished the novelty of the newly emerging virus. Fatigue and increased intolerance for the response measures being policed in schools were bred from their recollections of SARS and could potentially expand, if felt over a longer period before the measures scaled down. Given the problematic effects of formal policing of response measures on Group A respondents who did not forget SARS, did experiencing the H1N1-2009 pandemic event outside the formal policing and surveillance in schools make a difference for Group B respondents who also remembered SARS in their accounts? My data reflect that an older age and high level of maturity are not likely keys to this difference. Unlike Group A respondents, they did not express relatively lesser concern, fatigue, or intolerance from and for H1N1-2009 response measures when SARS featured in their answers to my interview questions. Rather, they were predominantly talking about the uncertain severity of H1N1-2009 and its difference from SARS, revealing a concern for the development and prevention of the ongoing pandemic event in Singapore. For example, one respondent brought up SARS when he shared his initial thoughts on the discovery of H1N1-2009 outside the context of formal policing in schools: 83 At the beginning, I kind of knew it‟s not like SARS but I was also very curious whether it will change and become very serious later. I mean, you can‟t tell about these things right…in April I thought [that] since I wouldn‟t get it because it was mainly in Mexico and America…but I was still worried whether it can become very bad like SARS as they spread quite fast and we no longer people watching us in our workplaces to look out for potential victims [as opposed to schools]...I guess I do remember what to do since SARS had us prepared...fever would be important, and face masks are essential for general flu…Anyway, the H1N1 checks [preventive measures] are quite flexible at my office and so we have to act up more in understanding it…whether it becomes another SARS or not, we still need to be very careful! (B7, 24, government employee; my emphases) The above extract illustrates that H1N1-2009, to the respondent, “is not like SARS” but may become “very bad like SARS”. It indicates the lethality of SARS being acknowledged in B7‟s memories and used actively as a point of comparison with the emerging condition of the H1N1-2009 pandemic. In a similar vein, another respondent also commented that chances of getting it [H1N1] were still low at first, but I was also more worried about whether the thing [H1N1] was as deadly as SARS…Last time it was a deadly virus that really scared us, now we‟re not really sure H1N1 could become harmless or harmful..I mean, now we are at work so there are no teachers forcing us to check this and that…so I think we are free to actually understand H1N1 better rather than rely on what we did as students back then during SARS…I was hoping it won‟t turn out like SARS of course (B1, 24, bank employee; my emphases). 84 Both extracts reveal that experiencing the pandemic out of a less-policed environment did not remove respondents from what they learnt from the previous epidemic. In fact, being out of the formal surveillance context in schools during a second emerging infectious disease outbreak motivated them to engage more positively with their past experience of the epidemic. This differs markedly from Group A respondents‟ lack of concern generated in a more controlled environment where, ironically, measures were still firmly in place and formal education of the pandemic was supposed to accompany them complementarily. The implication on effective pandemic control here is that while there is no doubt formal policing in schools could ensure students act according to the implementations, it could not eliminate students‟ fatigue for the measures in light of their previous experience. This brings us back to how reduced concern, fatigue, and growing intolerance affect effective disease control, as argued earlier. To further explore this argument, we could also consider the following extract that relates how formal policing of SARS in 2003 had benefitted Group B respondents who did not experience a repeat of the same response measures in the same setting: H1N1 was like the newest thing that we heard about. Other than SARS, it is the next big thing that hit Singapore in terms of, like, medical illness. We knew how to react since it is a flu because we did it back in schools during SARS. I mean, teachers checked our temperature and some of my friends had to stay at home for isolation and so on…but now we are no longer in school and have more freedom to look at it, I don‟t think we should just under-estimate H1N1 because we did the same for SARS and it worked…Well I 85 thought it‟s good to be more careful personally (B8, 23, student in a tertiary institution). Here, it appears that the memory of SARS actually strengthened the respondent‟s sense of urgency in thinking about the preventive measures. This finding also corresponds with what the Straits Times reported in May 2009 on Singaporean youths‟ behaviour in New York City where the older university-attending youths “[were] making a point to avoid crowds, unlike their American friends. They attributed this to their brush with SARS – and to their parents‟ warnings. All had received phone calls from home since the outbreak of the [H1N1-2009] disease, the reminder of SARS explicit in those conversations” (Straits Times 3 May 2009). There is, however, one important caveat to highlight in arguing that older youths‟ active engagement with their memories of SARS in redefining H1N1-2009 (as opposed to a passive dependency on formal policing methods in schools) has merits for pandemic prevention and control. In taking the liberty to assess the severity of the pandemic vis-à-vis a previous lethal epidemic, it is also possible for them to make decisions that may not be socially responsible. For instance, one respondent did note that In the end maybe it‟s still alright to be out [in public] even when you have H1N1. It is not like SARS anyway…If you know that it won‟t kill lah, of course…Like, maybe I won‟t go to crowded places and I will still be socially responsible…but even if I do, it might not be a big deal…as long as it is stated that the disease is just like a normal flu. (B11, 25, public relations employee) Such varying degrees of responsibility that operated in older youths‟ definitions of the situation could perhaps shed light on an event where a community outbreak of 86 H1N1-2009 originated from a dance club in Singapore from June 2009 to Jul y 2009. The median age of the cases was 22 (Chan et al. 2010).31 Fortunately, the cases – or what the local media term as „H1N1 cluster‟ - were quickly isolated and treated, while contact tracing was also carried out and close contacts of cases were placed under a strict 7-day home quarantine order (Ibid.). Here, the implication on effective pandemic control and prevention is that while formal policing of response measures in schools could reduce the level of concern and generate fatigue for student youths, the total absence of policing or over-relaxed rules could also lead to older (and also younger, if that takes place in schools) youths acting in their right and causing community outbreaks unwittingly. This observation notwithstanding, I maintain that the reduced concern and fatigue experienced by Group A respondents in schools are nevertheless important observations for future policing to note in its implementation and practice. It is, of course, unlikely or even impossible to devise totally different measures to control the spread of a novel flu disease that emerged fairly quickly after a previous outbreak was controlled successfully by an existing set of measures. Thus, this makes Group A respondents‟ experiences of being formally policed again in adhering to the control measures during the H1N1-2009 pandemic inevitable. However, given the negative ways in which they engaged their memories of SARS in responding to H1N1-2009, it is vital for formal policing methods in schools to rethink its implementation process and develop one that takes into account the fatigue and reduced concern that students would feel following the previous encounter. Here, leveraging on novel communications technologies and perhaps 31 A total of 48 (laboratory-confirmed) cases were identified, of which 36 were patrons and dance club staff and 12 others were household members and social contacts (Chan et al. 2010). 87 even presenting instructive visuals while they take their temperatures could change the previous less interesting ways in which the same measures were conducted. Youths‟ attitudes towards these measures could therefore be more conducive for responsible adherence. In the next section, I highlight the overall implications of policing the preventive measures in schools in relation to youths‟ memory of SARS and offer suggestions to leverage Singapore‟s post-epidemic context for better preventive control strategies in future. 5.3 Implications and Suggestions The overall implication of this chapter‟s argument on effective pandemic control and prevention is that Group A respondents‟ decreased concern, increased fatigue and intolerance, and passive dependence on the existence of response measures in schools can jeopardise future efforts in response strategies entailing the necessity of similar measures. For instance, students may feel no impetus to undertake additional preventive measures outside the school setting and thereby fail to transfer the practise of prevention to their daily routine beyond the policed environment, undermining the overall preventive effort to spread control and disseminate information. For instance, one of them informed me that …SARS was the first time I encountered this kind of virus spreading around and killing or infecting people quite badly…and I was really scared because it was like anyone could get it…not that H1N1 is harder to get but…it is just not so scary or threatening since we know that this is another round of temperature and quarantine affair, like it‟s 88 a new flu virus again but we have the measures in schools put up to protect against it…tired of it, yes I think I don‟t exactly put in effort in the exercise lah…Actually I still think that there really isn‟t a need for me to go the extra mile to do anything or give more thinking [sic] about the disease or to protect myself (A14, 17, junior college student) Given these sentiments, I argue that it is essential for schools to rethink post SARS and now, post-H1N1 contexts of emerging infectious disease prevention to avoid the kind of passive dependency on formal policing and the dwindling concern for a similar health crisis as displayed by Group A respondents. Following what MacDougall‟s (2006) Toronto-based study on emerging infectious disease control has discussed, past responses and strategies could be limited and it may even generate apathy if the success of the past managements were over-emphasised or over-relied upon. 32 I argue that pandemic control and prevention in school has more to include in its response framework in future when it comes to implementing and policing the same set of preventive measures practised by the students before. As students like my Group A respondents get fatigued by the “sameness” or similarity of response protocols towards novel flu diseases, additional lessons and interactive visual media and materials emphasising the uniqueness of each case could (1) heighten their sense of awareness towards prevention and control for individual epidemic viruses and (2) maintain their requisite tolerance for committing to the daily checks and 32 MacDougall‟s (2006) examination of top-down responses to a range of infectious diseases in Toronto for over two hundred years revealed that the very success of prior public health efforts in disease prevention can even lead to societal apathy and a subsequent lack of prophylaxis. 89 monitoring in schools. What we can avoid, therefore, is youths feeling what Elledge et al. (2008) thematised as „disaster fatigue‟ in their study: Many [of their research participants] believed that public health concerns about avian influenza resembled “the boy who cried wolf”. They reported that they had heard this before with severe acute respiratory syndrome [SARS], mad cow disease, and the Y2K scare…Focus group members reported they were not more concerned and had not purposefully prepared for a pandemic like avian influenza because “I don‟t believe it will actually happen: we live in the United States – we‟re immune to catastrophe; the government will help us – they must have a plan” and “by the time it‟s a problem, we‟ll have a vaccine” (p. 58). 33 To further argue for the importance of distinguishing disease outbreaks in future implementations of prevention and control measures, I highlight Siu‟s (2010) recent qualitative project on the knowledge perceptions of and the preventive health behaviors towards the H1N1 pandemic among previously stigmatized chronic renal disease patients in Hong Kong: to the participants, both SARS and H1N1 are very similar in nature. Because of their previous unpleasant experiences, participants therefore believed that they would encounter in the H1N1 pandemic would be very similar to what they had encountered in the SARS outbreak. This motivated the participants to adopt the same belief system during the new pandemic. (p. 903). Although Siu‟s (2010) study focused on the stigmatized dimension of the memory of SARS in the patients‟ anticipation and response to H1N1-2009, the implications for effective pandemic control in this chapter could benefit from her observation 33 Elledge et al.‟s (2008) Tulsa-based qualitative project investigates how individuals related to public health authorities with regards to a potential avian influenza pandemic. 90 that because “very little information about H1N1 was transmitted to chronic renal disease patients” (p. 903), past experiences had scope to colour their understandings of the emerging H1N1-2009 disease, leading to similar thoughts of being stigmatised. While it is perhaps not reasonable to claim that information about H1N1-2009 has not been sufficiently disseminated in schools here, the insight from Siu is nevertheless useful for future preventive strategies in schools. Formal policing of pandemic control would do well to note the agency of youths in re-defining the pandemic situation and view the mandatory measures in their own comparisons with the past. More formal effort to deal with this agency in future, therefore, is needed for ensuring successful control and prevention in these settings. Finally, I argue that it is helpful to think about these implications in relation to Fine‟s (2007) symbolic interactionist model of historical equivalence that refers to the perception that two events, separate in space and time, belong to the same cognitive category, or speak to the same issues. Put another way, they are “good to think together” (p.28).34 34 Specifically, Fine (2007) notes that events that are similar in magnitude, metaphoric continuity, analogous causation, and comparable effects would mean that they are of historical equivalence. These four areas, as Fine and Beim (2007) contend, “not only provide for a comparison of events that have been collectivized but sustain the ability of those events to be collectivized in the first place” (p.3). In this view, SARS and H1N1-2009 appear to be historically equivalent. However, public discourse in Singapore comprised only in harnessing the public‟s collectivizing of SARS to enhance their overall preparedness for H1N1-2009. This approach was limited by the existence of differential memories on the ground that achieved different ends. Practices worked in tandem with memories here. Youths reexperiencing the measures in the same formal policing setting in this study, for example, would not necessarily benefit thinking about both SARS and H1N1-2009 together, despite their „historical equivalence‟. 91 As I have shown earlier, younger youths in schools grew fatigued by being policed for practising preventive measures once again in schools. This finding resonates with Fine‟s model in that students think of both health crises “together”, as they are typologically so and were often associated with each other in respondents‟ discourse. However, this very similarity also allowed them to develop negative attitudes and fatigued feelings about the pandemic based on how similar the response efforts towards it were when compared to that of the previous epidemic. In this light, I argue that it is in the interest of MOH and MOE to inform school students in ways that cultivate an informed appreciation of both SARS and H1N1 2009 as distinct health threats despite the similar measures undertaken to control and mitigate them in both events of historical equivalence. As one respondent paused to reflect when we discussed the differences between SARS and H1N12009: I think it‟d be nice if they actually show us a documentary on SARS to remind us about it and the main difference with H1N1…erm for example like why was there no vaccine for SARS but they go on talking about vaccines for H1N1…Cos we tend to think of SARS and H1N1 together because, starting [initially] the media talks about it, people get hospitalised, some actually die, and then our school suddenly gave us thermometers and forms to fill in again…Like, both are the same, we will put on face masks and we cannot sneeze openly and we need to be in quarantine if sick. (A8, 16, secondary school student; my emphases) Thus, instead of stopping short at feeling relatively more prepared for H1N1-2009 than it was for SARS, creative steps could be developed to re-emphasise the differences between past epidemics and the present one to interest students and let 92 them understand the significance of acting collectively to combat any health threat. This could include, for example, getting them to begin the education process by drawing upon what they already know before making the necessary corrections or additions to emphasize the importance of distinction in the various health crises. Initiatives like the above could allow a “similar setting” to enliven youths‟ sentiments towards something practising the same response measures but approached in a different angle, as one of them had actually commented in an interview: I would prefer them [schools] to actually do it quite differently. I mean, yeah we have to do the same measures but I was also wondering like, why can‟t they at least think of a better way to get it done [implemented]? They have the past experience and although it worked I think it‟s kind of sad to see we‟re still going to the same boring routine for H1N1 because maybe to them there really isn‟t a better way to do it when the same powerful flu virus attack us (A7, 17, junior college student) In addition, it is suggested that a more efficient way of implementing and monitoring students performing the preventive measures in school could entail better record-keeping technologies (as opposed to a tedious recording and collection of declaration forms) to enhance teachers‟ crucial roles as messengers of public health education and implementers of preventive measures. This would not only reduce students‟ perceptions of pandemic control in school as inconveniences (cf. Chapter Four) but also represent to the public an informed and enhanced departure from past experiences in epidemic management and control. 93 5.4 Conclusion I have argued in this chapter that formal policing of pandemic control measures in schools have contributed to younger youths‟ lack of concern and tolerance for formal pandemic response and generated their fatigue towards experiencing a similar event in the same formal school setting. Practices, as we have seen, worked in tandem with memories. Practices during the SARS period were transplanted to the H1N1-2009 pandemic, but were neither fully applicable nor effective. This has implications on effective pandemic control and prevention, as their lack of concern and reduced tolerance level for these mandatory measures could affect their strict adherence to such measures both inside and outside the classroom that may escape the surveillance of their teachers and put more people at risk. Older youths expressed different concerns and engaged more interpretively with their memories of SARS. They did so not evidently because they were older and thus more matured in thinking about the health crisis (although this could be the reason in cases beyond the scope of my sample), but referred ostensibly to how formal policing in school could limit their initiatives and actions in relating both SARS and H1N1-2009 more critically. I have also highlighted that it will serve well for educational strategies and general official pandemic management discourse to more carefully explain H1N1 (and any subsequent emerging infectious disease) as a distinct disease dissociated from SARS and, in future, both SARS and H1N1-2009. Given what we have learnt from the data – that youths experiencing a repeat of the same response measures in the same formal policing system would not necessarily be beneficial – I also suggested how youths‟ memories of SARS (and in future, both SARS and H1N1- 94 2009) can be effectively harnessed to improve the overall preventive effort against future emerging infectious diseases. As Li (2010) warns, “reliance on strategies based on past outbreaks, and a fear of recurrence of the outbreaks‟ adverse effects, may be counterproductive” (p.265). It is always a good time to begin developing improvements in how the measures were implemented in the past. The following chapter concludes this study by drawing together the main themes of its arguments and considering avenues for future research. 95 6 Conclusions To recapitulate, the development of this study was driven by the potential scope for inquiry on youth perspectives during the H1N1-2009 pandemic period in Singapore. Its research design and approaches are informed by symbolic interactionist assumptions that posit individuals such as the young respondents in my sample as social agents who define the pandemic situation individually vis-àvis their internalization of and engagement with rules and norms in their microand macro-social contexts. Guided by this way of seeing, their views could therefore reflect both (1) the speed and quality of their reception to the control measures and educational materials and (2) the context(s) in which they experience the pandemic and illuminate its/their effectiveness as setting(s) for pandemic control measures to be implemented. In this concluding chapter, I summarise the findings and arguments made in the two preceding chapters and delineate their overall implications for effective pandemic control and prevention. I will also suggest ways – further informed by my data – to circumvent the problems identified. I conclude by offering suggestions for future research. 96 6.1 Formal Policing of Pandemic Response Measures in Schools: Limitations, Implications and Suggestions In Chapters Four and Five, I have argued that formal policing and monitoring of pandemic response measures in schools was limited in its approach to fully involve youths in Singapore‟s pandemic response efforts. According to my respondents, the ways these measures were implemented and policed in schools appear to turn them away from adhering to these regulations diligently and also from truly appreciating their significance for containment and prevention purposes during a national health crisis. Furthermore, the respondents‟ memories of SARS, in this case, did not serve its purpose in enhancing their preparedness and practise of flu control measures. Rather, they became less concerned with the H1N1-2009 pandemic and relatively more intolerant of the mandatory pandemic control measures implemented because they remembered the tedium of practising daily control measures during SARS. They also grew passively dependent on and yet fatigued by re-experiencing the same protocol. To further illustrate that formal policing and surveillance in schools were limited in gaining students‟ responsiveness, I showed that older youth respondents who did not experience the pandemic in the school context were exhibiting significantly more appreciation and awareness of the pandemic conditions. Unlike younger respondents who considerably lacked motivation in acquiring any additional information on the situation, the older group of respondents displayed initiatives to seek additional sources of information and updates on the crisis both in and beyond Singapore, and were observed to be engaging with HPB‟s efforts on Facebook and Twitter meaningfully. In addition, their memories of SARS served well in preparing them for evaluating the severity of the H1N1-2009 in their 97 respective contexts. They did not experience the kind of passive dependence and fatigue that were common in the responses from the school students. Was the difference in age groups of respondents the reason behind this contrast? It could be, but in the context of this study, I observed in my interviews how they linked the pandemic to the contexts in which they operate rather than simply express more appreciation without any reference to potential differences in contexts that were more formally policed in terms of control measures and educational campaigning. I have also discussed in both chapters the implications of these findings for effective pandemic control and prevention. Although every younger respondent in Group A complied with the mandatory act of screening temperature and would not resist LOA, the quality of their compliance was at stake because of how these measures were implemented, practised, policed and educated in the school context. As they did not appear to be complying with control measures with the necessary educated appreciation intended for them, they found reasons to challenge these measures through ways like falsifying their temperatures, joking about and trivializing the pandemic, focussing on the stigma and social exclusionary aspects of its control measures, and growing unconcerned with the situation as a national health crisis. While these observations may not be obvious to teachers who are busy with implementing these measures in the classrooms, they were evident in my data and were observed to be affecting the quality and accuracy of their adherence to the measures that generated risky scope for incompliance. Consequently, it also affected their motivation to stay involved as informed individuals both in and beyond the school setting. This was further evidenced by the absence of motivation to keep themselves updated via additional channels and 98 relying instead on traditional media and the existence of preventive measures being policed in their schools. In an infectious disease outbreak, schools are one of the most conducive points of spread, as seen by the emphasis on class closures and authorities‟ h eavy focus on prevention and control in schools during both SARS and H1N1-2009 crises. What they could note now and in the future, as Reynolds and Quinn (2008) point out, is that “public trust in disaster policies is far from certain”, and “individuals and entire communities must believe the NPIs [non-pharmaceutical interventions like temperature-taking and quarantine] will be effective and that they can implement them” (p14S.). This is especially so in schools, as Lee et al, (2003) elucidate: strengthening the public health measures at schools would protect children as well as providing the students an opportunity to learn about infectious disease control through life event approach. The public health measures at schools include two important components: basic understanding of the disease so schools would put on high alert on caution cases, and the measures to improve environmental hygiene at schools and preventive measures to stop infectious disease transmission. This will help to empower the whole community the readiness to deal with other outbreaks in the future. Moreover, “[t]he one truth about influenza virus”, reminds Dr. Gregory Poland in BBC‟s documentary Pandemic (2006), “is that they [sic] are inherently unpredictable. No one knows whether this virus will change or mutate to infect humans…All there that has to happen is a critical mutation or two before that 99 happens.” 35 Even as I am writing this, infectious disease outbreaks continue to emerge and re-emerge, infecting and killing people. California‟s health authorities are declaring an epidemic of pertussis (whooping cough) in the state and urging residents to get vaccinated against this highly contagious disease (New York Times 24 June 2010) and a new „superbug‟ NDM-1 was found in UK hospitals, requiring tight surveillance and new drugs as it could cause country- and worldwide infections that are resistant to all antibodies (BBC News 11 August 2010). Thus it might be interesting to heed what a German footballer Sepp Herberger once said: “After the game is before the game”! Indeed, for pandemic or epidemic influenza, the “game” will change, but the general rules will probably not. It is therefore not sufficient to merely ensure students act mechanically to mandatory orders in a health crisis, but also that they stay motivated and informed to bring their knowledge and their ability to handle such crises beyond the classroom to their peers and families. Formal policing methods in schools would do well to take their perspectives into account in order to attain this goal. Finally, apart from developing more creative ways to engage youths in schools and gain their commitment to quality adherence to pandemic control measures in future, I also suggest that schools would do well to leverage the Singaporean context of post-SARS and -H1N1 experiences and its existing ideological principle of social responsibility that governs its people‟s social behavior. As Teo et al. (2005) point out in their study of SARS epidemic, the high proportion of „responsibilised‟ citizens willing to co-operate with the government could be explained by a societal context in which Singaporeans, whether there is a 35 In fact, the risk of a pandemic in Southeast Asia is probably the highest in the world insofar as the WHO has stationed teams of expert fieldworkers across the region, ready to investigate any reports of bird (or other animal-originated) flu infections (Pandemic, 2006). 100 pandemic or not, have always been urged by the People‟s Action Party (PAP) to dutifully submit to all state policies as they are supposed to be formulated for the common good of the people (cf. also Abdel-Nour 2003). Indeed, the Singapore context has been variously argued as different – the public can be both generally uninformed and responsible, as evident in the case of SARS (Durenberg-Yap et al. 2005; Chua 2006; Weber, Tan and Law, 2008). Given that social expectations in health behavior play up prominently to police individuals to a large extent during an epidemic in Singapore, schools here could tap on this social reality and renew their focus on developing educational strategies that reiterate the significance of such responsibility and, subsequently, the power of being both informed and responsible. This can potentially shape a generation of individuals who not only act dutifully as responsible citizens within a steadfastly existing ideological framework of social responsibility for the collective good, but also as an informed (or at least, more informed) citizenry who are kept updated with the necessary knowledge and tools to empower themselves during a health crisis. I now end this thesis by suggesting directions for future research. 6.2 Suggestions for Future Research First, I argue that exploring the perspectives of the teachers regarding their roles in implementing the control measures and educating students on the pandemic in schools could complement students‟ perspectives of the formal policing of control measures. Questions to ask should include: Were teachers too encumbered with paperwork duties and consequently less focussed on the quality of students‟ compliance? Were they too concerned with students‟ mechanical actions and paper 101 records of their temperatures to an extent that compromised the accompanying educational measures that were intended to complement the practise of them? How did they feel about the response protocol in schools? Sociological and social psychological inquiries for answers to these questions would certainly be useful for enhancing future strategies vis-à-vis the youth perspectives uncovered in this study. In addition, as it seems that schools had not been effective implementers and messengers of the formal policing strategies and the pandemic educational campaign, approaches that incorporate a critical examination of the school as a site of infectious disease education based on findings from a representative sample can be instructive for pandemic management in particular and public health education in general. Also, it has been noted that “many youth researchers have a special affection for and a desire to practise qualitatively…however qualitative evidence from necessarily small-scale studies is most valuable when it can be set within the larger picture which can only be constructed from quantitative evidence from larger, and more representative, samples” (Roberts 2003: 22). Indeed, the stance adopted in this study is undoubtedly qualitative and exploratory; its data could be still further engaged as preliminary material for quantitative approaches to youth perspectives/perceptions of pandemic events. In particular, the consistency in responses of the two groups of respondents may create the impression that each group is homogenous. Indeed, apart from the exceptions highlighted in the thesis i.e. a Group A respondent‟s view that playing by the rules of a widely-accepted „social responsibility‟ was still the case for him (see p. 71) and a Group B youth‟s undermining of the threat and public exposure (see p. 85), the extent of within- 102 sample variation in attitudes in both groups of respondents is limited. Given that the 15 respondents in Group A were drawn from a total of nine secondary schools and three junior colleges, it is arguable that their responses relate to their attendance at these kinds of institutions. It is, nevertheless, also possible that specific approaches and procedures of the few particular institutions they were enrolled in could be partly responsible for the attitudes recorded (cf. suggestion in the preceding paragraph on school as a site of future study). This, I observe, is where the value of quantitative evidence can build upon the present understanding by extending or challenging this thesis‟s central argument. Finally, respondents‟ engagement with the memory of SARS observed in this study also opens the door for approaches – both qualitative and quantitative – that seek to compare public responses to H1N1-2009 and to SARS, generating and discussing further evidence to illustrate the extent to which the latter event feature in lay attitudes and beliefs about H1N1-2009. Given the tendency for authorities and public rhetoric to harness history for public confidence, this comparison can provide important clues for public health messages and public communications in future to avoid unnecessary or even uninformed comparisons of events which may take place in the lay context during emerging infectious disease outbreaks. Notably, both suggestions are generally aimed towards the goal of enhancing lay people‟s willingness to comply responsibly with containment measures through investment in context-specific education with the aim of increasing the level of informed and empowered participation in future disease control programmes. As mentioned, “after the game is before the game”, and the post-H1N1-2009 context is inevitably a period before the next emerging infectious disease situation. 103 APPENDIX I SINGAPORE’S DISEASE OUTBREAK RESPONSE SYSTEM (DORS) DORS Green (Pre-pandemic) Yellow (Pre-pandemic) Orange (Pre-pandemic) Red (Pandemic) Black (Pandemic) Public Health Situation Control Measures / Strategies  Isolated external or local cases of animal-to-human transmission.  Threat of human-to-human infection remains low. The disease, if any, is basically limited to animals.  Inefficient human-to-human transmissions of flu caused by a novel virus, requiring close and sustained contact to an index case.  Risk of import into Singapore elevated. Isolated imported cases may occur but there is no sustained transmission.  Step up vigilance and make preparations to meet the potential threat.  Virus becoming increasingly better adapted to humans but may not yet be fully transmissible, requiring close contact with an index case.  Larger clusters appear in one or two places outside Singapore but a pandemic has not yet been declared. A cluster of cases may also occur in Singapore but human-to-human spread remains localized.  WHO declares that an influenza pandemic has begun. Singapore eventually also affected.  Higher risk of acquiring the disease from the community once pandemic spreads to Singapore.  Isolation and quarantine will be effective to break the chain of transmission to contain a spread arising from any local cases and break the chain of transmission, while preserving essential services and resources.  High rates of severe disease and deaths. Emergency measures implemented to bring the situation under control.  Healthcare and social support systems are overwhelmed by the pandemic. Economic activities are severely disrupted.  Strategy is to ensure that medical & public health measures take precedence over social & economic considerations.  Focus is to contain the “damage” and regain control of the situation. Drastic measures like stopping all social events may be implemented.  The majority of measures are the same as Alert Red plus the following action:  Suspend all public gatherings, schools and Institutes of Higher Learning (IHL).  Issue advisory to public to stay home or even consider imposing curfew.  Further spread can be prevented through public health measures to isolate cases and quarantine contacts.  To prevent further import of cases, and to ring fence and isolate cases to prevent spread. The focus will be to provide treatment of all cases, and antiviral prophylaxis to contacts including exposed healthcare workers.  All measures taken in Alert Orange will continue to be applied.  Closing of schools and suspension of selected events to prevent congregation of large groups of people. (Compiled in table by author, source of information: Singapore Government Crisis News Website http://app.crisis.gov.sg/influenzaa/Page.aspx?id=198) 104 APPENDIX II INTERVIEW SCHEDULE Study title: Perspectives Rethinking the Influenza A H1N1-2009 Pandemic: Singaporean Youth Principal Investigator: Lim Kean Bon Interview Period: September – December 2009 1. Biography, general knowledge    Where do you work? Where do you go to school? How much do you know about influenza in general? 2. Moving on       When did you first learn of H1N1 (or swine flu)? How did you feel when you first learnt about it? Describe what you know about H1N1 now. What are the symptoms of H1N1? What do you feel about quarantine and isolation? What about vaccines? (Are you aware of the developments?) What is your school/workplace doing in response to the outbreak? (temperaturetaking or other cues to action) 3. Sources of Information and Influences       Do you look out for H1N1 news? Where do you go to for information regarding the pandemic? What kinds of messages are available to you? Do you talk about it with your school mates / friends / colleagues / family? Do you know anybody infected with it? Do you talk about it at your school / work place? 4. Preventive Health Behaviour, Severity, Contexts         Do you think you may get H1N1? How often do you think about the disease? Are you worried? What would you do if you suspect yourself of having H1N1? What do you think of the recent deaths? (Do they appear threatening?) What do you do to lower your risk of getting H1N1? Which part of your life is most affected by the outbreak? Does H1N1 as a novel infection in Singapore remind you of any particular past incident? (wrt SARS, avian flu) 105 APPENDIX III LIST OF RESPONDENTS GROUP A (13 to 17 years old) No. A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 Age 14 15 14 15 15 17 17 16 16 13 14 15 15 17 14 Ethnicity* C C C C C I C C M I M C C C I Secondary School/ Secondary Junior College Secondary Secondary Secondary Secondary Junior College Junior College Secondary Secondary Secondary Secondary Secondary Secondary Junior College Secondary Ethnicity* C C C M M I M C C C C C C C C Tertiary Institution/ Occupation Bank employee Marketing employee Bank employee Tertiary student Tertiary student Government employee Government employee Tertiary student Marketing employee School Teacher Public relations employee Government employee Tertiary student Government employee Tertiary student GROUP B (18 to 25 years old) No. B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 Age 24 23 24 19 18 25 24 23 24 24 25 24 20 25 22 *C – Chinese, M- Malay, I-Indian, O-Others (Singapore’s Racial/Ethnic Classificatory System) 106 APPENDIX IV PARTICIPANT INFORMATION SHEET (PIS) 1. Study title: Rethinking the Influenza A H1N1-2009 Pandemic: Singaporean Youth Perspectives Principal Investigator: Mr. Lim Kean Bon (Contact No.: +65 [omitted by author], email: [omitted by author]), Graduate Student, Department of Sociology, National University of Singapore 2. What is the purpose of this research? The effectiveness of health messages and responsiveness in public and students’ adoption of control measures in schools is most crucial when there is an emerging infectious disease outbreak. This study sees Singapore as a critical context in which to discuss perspectives of public health messages and pandemic response in the time of the H1N1 pandemic. Broadly, it asks the following question: how do youths in Singapore communicate and understand the outbreak of H1N1? You are invited to participate in this research. This information sheet provides you with information about the research. The principal investigator (the person in charge of this research) is Mr Lim Kean Bon. He will also describe this research to you and answer all of your questions. Read the information below and ask questions about anything you don’t understand before deciding whether or not to take part in the study. 3. Who can participate in the research? School-going students between the ages 13-17 and young adults between the ages 18-25. 4. What is the expected duration of my participation? The dialogue between the principal investigator and you will last between 35 minutes to one hour. 5. What is the duration of this research? The study first began in July 2009 and will be completed by December 2010. Interviews will begin in October 2009 and expected to end latest in January 2010. 6. What is the approximate number of participants involved? There are approximately 30 participants involved. 7. What will be done if I take part in this research? You will first be given this Participant Information Sheet to read, and a consent form to sign if you agree to participate in this study. The principal investigator will subsequently describe the research, answer all your questions, and begin to tape-record the 107 conversation. The recorded information will only be used as part of a data set for the study. 8. How will my privacy and the confidentiality of my research records be protected? Your confidentiality and anonymity will be respected at all times. Only the principal investigator has your identifiable information (e.g., names, contact numbers) and this will not be released to any other person. Identifiable information will NOT be used in a publication or presentation. All your identifiable personal information and research data will be coded (i.e. only identified with a code number) and separated (de-linked) at the earliest possible stage of the research. 9. What are the possible discomforts and risks for participants? There could be instances during the conversation that may trigger personal aspects of your experiences that you may be uncomfortable in sharing. 10. What is the compensation for any injury? As the interview is done only after obtaining informed consent and lasts no more than an hour in a single session, there is no injury and/or compensation expected by the principal investigator. 11. Will there be reimbursement for participation? There will be no reimbursement for participation. Transport cost, however, could be arranged on a case-by-case basis. 12. What are the possible benefits to me and others? There is no direct benefit to you by participating in this research. The study is aimed at complementing other approaches in better understanding people’s perspectives of response protocols in times of crisis. The knowledge gained will benefit the public in the future. 13. Can I refuse to participate in this research? Yes, you can. Your decision to participate in this research is voluntary and completely up to you. You can also withdraw from the research at any time without giving any reasons, by informing the principal investigator and all your data (and samples collected if any) will be discarded. 14. Whom should I call if I have any questions or problems? Please contact the Principal Investigator (Attn: Lim Kean Bon at +65 91839139 or keanbon@nus.edu.sg) for all research-related matters and in the event of research-related injuries. 108 APPENDIX V CONSENT FORM (for participants 18 and above) I hereby acknowledge that: 1. I have agreed to take part in the above research. 2. I have received the Participant Information Sheet that explains the objectives and nature of this research. I understand its contents and agree to participate in this research. 3. I can withdraw from the research at any point of time by informing the Mr Lim Kean Bon and all my data (and samples if any) will be discarded. 4. I also agree that I will not derive any monetary or other benefits from this research. ___________________________ _______ Name and Signature (Participant) Date ___________________________ _______ Name and Signature (Consent Taker) Date 109 APPENDIX VI PARENT/GUARDIAN CONSENT FORM FOR OF RESEARCH PARTICIPATION BY MINORS (UNDER 18) I hereby acknowledge that: 1. My signature below is my acknowledgement that I have agreed to allow my child/ward Name: ________________________________ NRIC: ______ Date of Birth: _______ to take part in this research project carried out by Mr Lim Kean Bon of the Department of Sociology, NUS. 2. My child/ward and I have read the Participant Information Sheet that explains the collection and use of my child’s/ward’s data in this research project. I understand its contents and agree that the data can be used for this research. 3. 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Horizon Series. [...]... individual attitudes at play, these works lend important insights for the development of this study‟s analytical and methodological approach in uncovering youth perspectives of the H1N1- 2009 pandemic event To strengthen the case of agency at play in people‟s responses towards a pandemic event, we can also look at early quantitative studies of perspectives of H1N1- 2009 These works indicate the agency... into believing that they were at high to very high risk of contracting pandemic influenza The authors attributed this finding to many reports describing the H1N1 virus as causing milder influenza than other pandemic- related viruses Finally, Van et al (2010) 11 argued that although nearly all respondents were aware of the Australian pandemic situation, more than half of them reported “no anxiety” or “disinterest”... I argue that an analytical framework for exploring young respondents‟ perspectives of the H1N1- 2009 pandemic event needs to draw from theoretical perspectives that (1) take into account how youths individually negotiate and comply with the information and education of the pandemic measures which affect their understanding of the pandemic event and also (2) locate their viewpoints within the formal... will always remain as long as the individual is actively assessing his/her actions with regard to the magnitude of the negative outcome, the immediacy of the threat, and/or the personal, social and economic cost of not participating in preventive behavior These works have not included youth perspectives in particular, but they serve as support for my argument that agency of respondents can be the starting... strategic plans to promptly and fully control the situation, the H1N1- 2009 pandemic is still unique to Singapore because several aspects of the preparedness plan could not be fully applied to the H1N1- 2009 virus: …prior preparation and exercises failed to fully anticipate a virus that was highly transmissible but caused low morbidity 6 and mortality and had a different demand on health services, and a. .. with the provision of adequate education about control measures in where they live or work Likewise, Janssen et al.‟s (2006) found that knowledge and awareness of pandemic influenza amongst the general public in the U.S was on the whole very poor There was little concern for a potential pandemic and few individuals were willing to learn and implement behaviors to control a pandemic, leading the authors... Seale et al also conducted the study in May 2009 on the Australian community‟s feelings and risk perceptions of the H1N1- 2009 pandemic 11 Van et al drew data from an online survey (n=2882) completed by a university‟s staff and students in June 2009 17 in personal networks and in the public arena, as well as from formal and informal evidence arising from other sources, such as television or magazines... with the media to provide regular updates so that the public was continually apprised of the latest H1N1- 2009 situation globally and in Singapore Citizens were also consistently reminded of steps they could take to reduce their risk of acquiring and spreading the disease A dedicated government website on influenza also facilitated the public‟s easy access to information (http://www .h1n1. gov.sg; accessed... levels of anxiety amongst interviewees in the United Kingdom who were not convinced of the possibility of growing severity in H1N1 2009 in May 2009 Their observations complement Seale et al.‟s (2009) 10 study that shows how rapid increase in the number of H1N1- 2009 cases worldwide and a large amount of information made available about the disease and its spread did not lead their research participants into... is a cognizance of the agency of lay people as social actors to engage differently with top-down implemented response protocols on the ground; they do so with reference to what they know, how vulnerable they feel and to what extent they deem the disease as novel Qualitative studies have also drawn attention to the agency of social actors at play during health crises Jiang et al.‟s (2009; see also Jiang ... describing the H1N1 virus as causing milder influenza than other pandemic- related viruses Finally, Van et al (2010) 11 argued that although nearly all respondents were aware of the Australian pandemic. .. the overall pandemic response I now put forward my methodological approach in two separate sections: data generation and data analysis 3.2 Methodological Approach: Data Generation Research participants... youth perspectives of the H1N1- 2009 pandemic event To strengthen the case of agency at play in people‟s responses towards a pandemic event, we can also look at early quantitative studies of perspectives