Why Should We Care about Social Justice?

Deep and enduring socioeconomic inequalities form the backdrop to any public health policy, and influenza policy is no different. And although social justice is a core value of public health, it is important to be reminded that public health officials can neglect the disadvantaged and even exacerbate underlying inequalities.

Uscher-Pines and colleagues give us such a reminder. They show how three measures of social justice are missing from influenza plans across the globe: identification of traditionally disadvantaged groups, civic engagement with these communities, and policies to address their special needs. These are important measures of whether a nation is attuned to social justice in its disaster planning. I want to discuss why social justice requires that we care about these measures. This will also help us understand what social justice requires—not only in influenza planning, but throughout public health practice.

A core insight of social justice is that the many dimensions of disadvantage have many causes. Poverty, inferior education, unhygienic and polluted environments, social disintegration, and other causes lead to systematic hardships in health and in nearly every other aspect of social, economic, and political life.¹ Prevailing inequalities beget other inequalities, which is one major reason those already disadvantaged will suffer disproportionately from major health hazards.

Among the most basic and commonly understood meanings of justice is fairness or reasonableness, especially in the way people are treated or decisions are made. Justice stresses fair disbursement of common advantages and the sharing of common burdens. But it does more than that by demanding equal respect for all members of the community.

There is good reason to believe that the poor and less powerful will be treated unfairly in an influenza pandemic. Medical countermeasures such as vaccines and antiviral medications will almost certainly be extremely scarce, forcing nations to set treatment priorities. In the United States and most other countries, influenza plans give preference to those necessary for scientific/medical functioning (scientists, health workers, vaccine producers), those necessary for social functioning (public officials, first responders, security personnel, critical infrastructure personnel), and those with special medical needs (infants, the elderly, pregnant women). The first two categories strongly favor those in high socioeconomic groups. The latter purports to give preference to the vulnerable, although not all infants, older people, and pregnant women are seriously disadvantaged. Left out in most plans are the entrenched poor, institutionalized populations, and people with mental and physical disabilities.

The most disadvantaged will also be likeliest to suffer from policies that might be implemented during an epidemic. The World Health Organization and national pandemic influenza plans favor containment measures such as closing public places and isolation or quarantine. Everyone will suffer from these measures, but the disadvantaged will suffer the most. They are the least able to endure the loneliness and emotional detachments, the disruption of social and economic life, the absence of medical and nursing care, and the loss of work and income. And ostensibly neutral pleas for people to stay home, or to stock up on basic necessities, are meaningless for the poor or homeless—as we saw during the Gulf Coast hurricanes, when the poor and vulnerable lacked the means to follow public health advice to “evacuate” or “shelter in place.” Thus state plans and programs should pay special attention to the needs of the disadvantaged.

Social justice demands more than fair distribution of benefits and burdens in extreme health emergencies. A failure to plan, and act, in support of the disadvantaged and with equal concern for all citizens harms the whole community by eroding public trust and undermining social cohesion. It signals to everyone that the basic human needs of the disadvantaged matter less, and it thereby fails to show respect for all members of the community. Social justice therefore requires action to preserve human dignity for all, particularly those who suffer from systematic disadvantage.² That is the normative message from Uscher-Pines and her colleagues. It is worth emphasizing not only for pandemic influenza but also for all policies, thereby restoring the ideal of social justice as a core value of public health.