Slipping through the Net: Social Vulnerability in Pandemic Planning

In the spring of 2009, a number of U.S. schools closed in response to government health directives designed to prevent the transmission of the contagious respiratory influenza virus known as H1N1. Thousands of children were asked to stay home and avoid congregating in groups. Public health authorities asked ill workers to stay home. As spring stretched into summer, camps sent symptomatic children home. The traditional public health containment strategy known as "social distancing" has rippled throughout affected communities. Parents have been forced to risk their jobs, take unpaid leave, or use limited sick leave to care for housebound children. Children who typically rely on school or camp meal programs have gone without. Local businesses have suffered when workers and shoppers stayed home. These experiences are now being repeated in the southern hemisphere as H1N1 moves south, but with the added burdens and complications that come with the more limited infrastructures and fewer resources of the developing world. The public health efforts to stem a flu outbreak have potentially serious social ramifications.

More importantly—and seemingly overlooked in pandemic planning for a virus such as H1N1—social context has major implications for the potential effectiveness of public health strategies to minimize morbidity and mortality and prevent the further spread of disease. For example, an undocumented restaurant worker receiving low wages and lacking job security and health benefits may have no real choice but to continue working through an illness, and may avoid seeking medical attention that he cannot afford and fears might lead to deportation. The worker's life situation makes it both impractical and inadvisable to respond to well-intentioned but unrealistic public health directives, putting both restaurant workers and diners at risk of infection. Policies that fail to take into account the realities of individuals' lives and the social contexts in which they live cannot hope to succeed. The accomplishment of the public health goal of minimizing the effects of outbreaks may depend in significant part on social vulnerabilities that affect an individual's or community's capacity to respond to public health directives.

Vulnerabilities and Social Contexts

Little attention has been given to the impact of social vulnerabilities on the effectiveness of public health preparedness strategies, a shortcoming in both policy-making and in how we think about the ethics of public health. How should we incorporate thinking about social vulnerability into pandemic planning? How should we account for social capacity to respond to directives designed to prevent the spread of disease? Whose responsibility is it to address those social barriers? Failure to account for social vulnerability may doom a prevention effort and may lead to long-lasting distrust of the public health system and of government generally in the affected population.

As in other areas of health policy, pandemic flu planning may acknowledge vulnerability, but by using a categorical approach based on membership in an identifiable population subgroup. For instance, policy guidelines and scholarly work have referenced readily identifiable subgroups as more vulnerable in determining priorities for distribution of scarce vaccines and antivirals. In shortages of seasonal flu vaccine, those over sixty-five years of age typically receive priority in vaccine distribution because of their vulnerability to severe medical consequences. More recently, antivirals were recommended for treatment of H1N1-infected pregnant women as a priority group. While this categorical approach may be well meaning, the broad grouping of populations may mask social vulnerabilities that require special attention, such as improved access to health care and appropriately targeted directives.

Broadly defined categories of vulnerability tend both to exclude people who belong in them and include people who do not. Groupings are necessary, though, as public health policy-making must focus on the population level; it cannot operate efficiently or effectively if it focuses on every individual at risk. The difficulty is that policies risk failure if they cannot identify and address those at risk of contracting or spreading disease. In any community, there are individuals who cannot afford to practice social distancing—undocumented workers, for instance, and those who rely on community settings for their livelihood or for their day-to-day existence (as...