Vulnerability: A Contentious and Fluid Term

To the Editor: As governments and public health officials respond to H1N1, important ethical considerations remain unaddressed regarding the inclusion and recognition of persons and populations designated as “vulnerable” in pandemic planning and response. Therefore, we were pleased to see Anna C. Mastroianni highlight the importance of understanding how social context adds to the potential effectiveness of pandemic response (“Slipping Through the Net: Social Vulnerability in Pandemic Planning,” Sept–Oct 2009). Rather than relying on static, predetermined categories of vulnerability, Mastroianni proposes a robust evaluation of social vulnerabilities that may impact an individual’s or community’s capacity to respond to public health directives, thus drawing attention to the shifting and contextual nature of vulnerability.

The need for a more nuanced understanding of the interplay between social context and vulnerable populations in pandemic influenza response has emerged as a key preliminary finding from recent research undertaken by the Canadian Program of Research on Ethics in a Pandemic (CanPREP). These findings are taken from two data sources: a national telephone survey and focus groups held across Canada in 2008 and 2009. This research shows the label “vulnerable” to be contentious and fluid. Communities often described as vulnerable have the resources and capacities to take care of themselves in an emergency situation, if given the space and support to do so.

First, as Mastroianni articulates, “broadly defined categories of vulnerability tend both to exclude people who belong in them and include people who do not.” This sentiment was reflected in many of our focus groups, as participants explained that a variety of different conditions might make a person more vulnerable at a certain point during an influenza pandemic, and that the condition of vulnerability may change as circumstances evolve. One participant articulated the conditional or situational context of vulnerability by stating: “You may look at me and think I’m vulnerable. I am the head of a family, I am the wage earner. I’m only vulnerable when you take away my personal support worker.”

Further, our findings to date suggest that the wholesale categorization of older persons and persons with disabilities as “vulnerable” is unhelpful. One participant explained: “I somewhat resent using the term ‘vulnerable’ for [older] people . . . Am I vulnerable? Well, some of my colleagues are much younger than I am, and are very vulnerable.” Another participant with a physical disability described his difficulty with the label “vulnerable,” given his significant personal responsibilities: “I have a dependent child, a nine-year-old, an aging mother. You know, we have some responsibilities and responsible jobs, too. I’m managing a program that funds seven hundred people across the province.” The contextual nature of vulnerability also sometimes makes those vulnerable who are normally deemed otherwise. For instance, health care workers were identified in our focus groups as potentially vulnerable in a pandemic due to the very nature of their profession.

Second, understanding the unique resources and capacities of communities helps us address the needs and gaps of community responses to an influenza pandemic. Mastroianni argues that community participation leads to greater effectiveness in responding to pandemics, as communities are more aware of their vulnerabilities and existing resources. Contrast this with simply allowing local health departments to set their own priorities independent of community participation. Focus group participants suggest that communities want to be involved. One noted: “I guess my key point at this point is to say, let us participate—we must participate—because we can contribute.” Furthermore, engaging communities will empower their members and thereby perhaps decrease their situational vulnerability, while also engendering a sense of trust with decision-makers. The need for community engagement was highlighted by another participant, who stated: “Let them be part of the planning, and they can be part of the delivery.”

As the H1N1 pandemic progresses, we must provide opportunities for moral deliberation and problem-solving among “vulnerable” persons to address the issues facing their communities. CanPREP is currently conducting further focus groups with vulnerable populations, whose oft-neglected views are necessary for thorough and ethical pandemic planning and response. Through these groups, we aim to form networks with our community partners to continue conducting publically relevant research and to best inform decision-makers on the views of the entire public, particularly those who are marginalized by social and political circumstance.