This paper builds from historical evidence from the 1918-1919 influenza pandemic that lower social classes and oppressed groups had higher mortality rates than the dominant or ruling population and suffered more from severe social and economic disruption. It examines the application of social justice to the situation of a pandemic and asks for attention to groups characterised by severe economic poverty or subordinate social status and power in the context of planning for and responding to a pandemic. Its specific analysis is of national pandemic planning using criteria set forth in a checklist created from the bio-ethics principles set forth by the Bellagio Group.


According to the authors, there is already social disruption creating serious hardships for disadvantaged groups, such as economically poor women and children, where avian influenza has required culling of backyard poultry flocks. "The potential for a pandemic to exacerbate existing social and economic inequalities underscores the importance of considering a pandemic not only as a pressing public health issue, but also as an urgent matter of social justice."


Because the World Health Organization (WHO) Checklist for Influenza Pandemic Preparedness Planning and most subsequent pandemic preparedness documents do not specifically address the needs of socially and economically disadvantaged groups, an international panel of experts met in Bellagio, Italy, in July 2006, "to identify current and potential responses to pandemic influenza that are likely to have profound effects on the world’s disadvantaged, and to recommend concrete steps to prevent - or at least mitigate - those outcomes that are the most unjust." The group developed a statement of principles and checklists intended to provide specific guidance to planners and those working in the field. The checklist criteria for the development of pandemic preparedness and response plans used for this analysis are:

1. explicitly identify disadvantaged groups within society;
2. engage these groups in the planning process, either directly or through their representatives; and
3. identify and address the special needs of disadvantaged groups in the context of a pandemic.

The authors did a web-based review of 37 national pandemic plans available in English using the checklist criteria. Dates of the plans ranged from 2001 - 2006; income distribution of the countries represented was: 15 high-income, 18 middle-income, and 4 low-income, with wide geographic distribution.


The authors found that no plans explicitly indicated that they had systematically identified groups who were socially or politically at risk. Instances of reference to "vulnerable" individuals or groups referred to medical vulnerability. Some plans made general reference to special needs of those who are “poor,” “uninsured,” or “low income,” or who live in “extreme poverty.” Some plans from high-income countries identified groups who might be socially disadvantaged or have special needs in the context of a pandemic, including racial and ethnic minorities, indigenous or native populations, religious groups, and immigrants.


According to the document, "while the systematic identification of disadvantaged groups is an important step, protecting their rights and interests is difficult unless these groups also participate in the planning process." The research found that three plans discussed policies to engage these groups (two engaged indigenous groups and one engaged farmers) in the planning process, though seven countries convened stakeholder meetings allowing for public participation.


Several plans included policies to address special needs of disadvantaged groups with respect to public health communications and, in some instances, social services. "The plans of six high-income countries and one low-income country called for culturally appropriate communications in a variety of formats, including the translation of messages into multiple languages; three plans also discussed the need to use communication interventions to counteract the possible stigmatization of groups such as farmers and health care workers." Social services suggested in three plans included counseling, temporary housing, and delivery of food and medications. Of these plans, one called for voluntary organisations to serve the disadvantaged, and the other encouraged "community solidarity" to assist with support services. Only two plans addressed special attention to the barriers encountered by the disadvantaged in securing vaccines or antivirals or accessing medical care. A number of plans addressed the newly disadvantaged - those who would be affected early by the economic effects of a pandemic - including property confiscation, wage loss, and orphaned children. Eleven plans discussed culled-poultry compensation.


The document states that only a few plans recognise the national disadvantage of countries without vaccine production capacity and with a significant population living in economic poverty, where medical countermeasures are unlikely to be available. This indicates the potential for inequalities in burden both nationally and internationally. The authors recognise that the Bellagio checklist is deceptively simple in that it calls countries to identify groups, include them in planning, and take steps to create and implement pandemic protection policies on their behalf. If these disadvantaged populations are not equally served, the document suggests that, like the pandemic of 1918, mortality rates could be ten-fold more in the developing world than in the developed world.