Discourses of disease, discourses of disadvantage: A critical analysis of National Pandemic Influenza Preparedness Plans

Social Science & Medicine 67 (2008) 1133–1142

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Discourses of disease, discourses of disadvantage: A critical analysis of National Pandemic Influenza Preparedness Plans Joshua P. Garoon a, *, Patrick S. Duggan b a b

Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior & Society, 624 N Broadway, Baltimore 21205, MD, United States Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 24 July 2008

Growing recognition of the threat of pandemic influenza to global health has led to increased emphasis on pandemic influenza preparedness planning. Previous analysis of national pandemic preparedness plans has revealed that those plans paid scant attention to the needs and interests of the disadvantaged. This paper investigates those findings via critical discourse analysis of the same plans as well as World Health Organization guidance documents. The analysis reveals that the texts operate within and as parts of an ordered universe of discourse. Among the six discourses which emerge from the analysis the scientific, political, and legal dominate the social, cultural, and ethical. This order of discourse delineates a specific regime of truths within which the lives, needs, and interests of the disadvantaged are masked or neglected. Unless the plans recognize their discursive construction, implementation of the policies and practices they prescribe runs the risk of further disadvantaging those very populations most likely to require protection. Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Pandemic influenza Preparedness Disadvantaged populations Critical discourse analysis Ethics Health policy

Introduction The threat of pandemic influenza to global health is garnering increased international attention. Forecasts of the death toll from an influenza pandemic range from 2 million (World Health Organization [WHO], 2004) to a worst-case estimate of 150 million (BBC, 2005). Hundreds of millions more would fall ill; the economic and social impacts would likely be severe. The increased concern regarding pandemic influenza has also intensified deliberations on pandemic influenza preparedness – leading the WHO to issue recommendations (WHO, 2005a) and a checklist (WHO, 2005b) for national planning and driving the publication of national pandemic influenza preparedness plans around the world. Researchers, in turn, have taken these documents as objects of study, subjecting the plans and their policy

* Corresponding author. Tel.: þ1 443 844 7570. E-mail address: [email protected] (J.P. Garoon). 0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.06.020

prescriptions to technical, economic, and political analysis (Barnett et al., 2005; Coker & Mounier-Jack, 2006; Mounier-Jack & Coker, 2006). These analyses have paid relatively scant attention to ethical considerations, however (Kotalik, 2005; Thompson, Faith, Gibson, & Upshur, 2006), and while researchers have applied ethical frameworks to different elements of pandemic influenza preparedness (e.g., Emanuel & Wertheimer, 2006; Gostin, 2006; Kotalik, 2005; Thompson, Faith, Gibson, & Upshur, 2006), few have specifically analyzed national plans. Yet the policies proposed in the plans, like preparedness policies in general, are rife with ethical challenges (Gostin, 2007; Lakoff, 2006). In the absence of expressly ethical analysis, preparedness policies are unlikely to deal adequately with such challenges (Eckenwiler, 2005) – underscoring the important role that ethical review should play in pandemic preparedness planning in particular, as well as in policy analysis more generally (Amy, 1984; Ladd, 1973). As Lynn (1999) notes, ‘‘Policy analysis is contextualized craft, fueled by intuition and argument and ethical promptings, clearly associated

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with the world of political action, both normative and prescriptive, often identified with interests otherwise unrepresented at the table.’’ Indeed, we argue that the policies prescribed in the plans demand distinct attention to the ‘‘interests otherwise unrepresented at the table’’ – for while pandemic influenza poses dangers to every population, it represents an especially dire threat to disadvantaged groups. These groups vary by country and region; disadvantage may stem from a variety of individual and group characteristics, including socioeconomic position, place of residence, gender, religion, race, ethnicity, and/or sexual orientation. Past influenza pandemics have disproportionately impacted disadvantaged populations, and without particular attention future pandemics will likely follow suit ( Cummings, 2007; Mamelund, 2006; Murray, Lopez, Chin, Feehan, & Hill, 2006). Only one previous analysis (Kayman & Ablorh-Odjidja, 2006), however, has specifically examined the plans from a social justice perspective, in which particular emphasis is placed on the ramifications of pandemic preparedness and response for disadvantaged groups. To borrow a phrase from Eakin and Luers (2006), social justice ‘‘demands assessments in which values are made explicit, entitlements are reviewed and questioned, and new mechanisms for addressing existing inequities are implemented.’’ Recognizing the demand for such assessment, we conducted a review (Uscher-Pines, Duggan, Garoon, Karron, & Faden, 2007) of 37 national pandemic preparedness plans. Our analysis revealed a pronounced lack of consideration of disadvantaged populations. None of the plans explicitly referenced disadvantaged groups as such, and the plans paid scant attention to the particular needs and interests of disadvantaged individuals and populations. Here, we elucidate those findings via critical discourse analysis of the same plans, together with WHO guidance documents. As Fairclough (2006) notes, the lives of poor and disadvantaged people are represented through different discourses in the social practices of government, politics, medicine, and social science, as well as through different discourses within each of these practices corresponding to different positions of social actors. In this paper, we scrutinize the discourses that emerge within and among the plans, illuminating how and why the plans represent particular populations. These representations are based on key assumptions – namely, that pandemics (and consequentially preparedness for them) are ‘‘equal opportunity’’ and global in nature. We argue, to the contrary, that pandemics manifest locally and particularly, giving rise to differential and non-deterministic outcomes. We contend that while the plans’ fundamental assumptions and representations provide support for their prescriptions, they also elide inequalities that – left unanticipated, unacknowledged, and unaddressed – could seriously and disproportionately harm disadvantaged populations in every phase of a pandemic. By drawing on concrete historical and contemporary examples, our analysis moves past what Eakin and Luers (2006) term ‘‘generic descriptions of inequities in resource distribution and

opportunity,’’ connecting the discourses analyzed to specific issues and outcomes of concern for disadvantaged groups. This paper thus has two primary aims: The first is to show how the discursive structuring of the plans leads them to neglect disadvantaged populations. The second is to concretely illustrate the potential implications of this disregard for disadvantaged populations before, during, and after a pandemic. The methodology: Critical discourse analysis Discourse analysis has received widely contrasting definitions. Some researchers adopt an archaeological approach, concentrating on the structures and systems of thought reflected in the texts of interest; others engage genealogically, analyzing ‘‘the way in which texts themselves have been constructed in terms of their social and historical situatedness’’ (Cheek, 2004). As our aim is to show how the planning documents operate, rather than how they have been historically and socially constructed, we employ the archaeological approach – taking the individual planning document as our analytic unit. We follow Fairclough (2001) in defining discourse as ‘‘particular ways of representing particular aspects of social life,’’ and Bourdieu (1972/1977) in taking a universe of discourse as the apparently exhaustive range of discourses addressing some given aspect(s) of social life. The order of a universe of discourse is the hierarchy of discourses within their universe; as Fairclough (2001) comments, ‘‘some ways of making meaning are dominant or mainstream in a particular order of discourse, others are marginal, or oppositional, or ‘alternative’.’’ When certain discourses dominate a universe of discourse, the truths those discourses establish can and often do seem ‘‘natural’’ or ‘‘normal,’’ particularly in contrast to alternative truths (Fairclough, 2006). Yet as Fairclough (2006) also observes, while discourses may ‘‘become part of the legitimizing common sense which sustains relations of domination, [that] hegemony is always open to contestation to a greater or lesser extent.’’ Critical discourse analysis provides a methodological basis for such contestation, identifying the assumptions of ‘‘truth’’ or ‘‘normality’’ dominant in an order of discourse, and highlighting the ramifications of those assumptions. Our first analysis of the plans comprised a structured review of each of the 37 national preparedness plans. Three researchers conducted keyword searches of the plans. When the search identified a key term, the researcher evaluated its context, tagging only those elements relevant to disadvantaged groups. Each researcher then independently subjected each plan to close reading using constant comparison – giving particular attention to exceptional elements, which aided identification of the normative. We subsequently collaborated to identify emergent trends and deviant cases across and within plans, producing analytic memos that highlighted and extended areas of analytic convergence and divergence. These efforts led to our recognition that the national plans and WHO documents are linked discursive events.

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Each document reflects particular social activities and relations, times and places, and knowledge, attitudes, and values (Fairclough, 2006). Together, the plans form a constellation of meaning operating within and as part of an ordered universe of preparedness discourse. Pursuing this analytic insight, the first author (JPG) undertook a rereading of all 37 plans and the WHO documents, using the previous examinations of the plans as points of departure for identifying and analyzing the discourses as well as their ordering. These elements emerged both expressly (from homogeneous terms, phrases, and messages repeated within and across documents) as well as manifestly (from convergent observations and conclusions of each researcher within and across memos). As we aim to draw attention to discourse rather than to any particular plan, we have avoided using the name of the authoring country in citing plans. Instead, each plan is cited by a code comprising an abbreviation of the nation’s geographic region based on World Bank classification (World Bank, 2008) and an alphabetical index based on order of citation.

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Table 1 Frequency table: National Pandemic Influenza Preparedness Plans Number of Plans (%)a

Category b

Region (code) Africa (Afr) Americas (Amer) Asia and Pacific (AsiaPac) Europe and Central Asia (Euro) Middle East and North Africa (MeNa)

2 3 14 16 2

Income categoryb High Middle Low

15 (40.5) 18 (48.6) 4 (10.8)

Publication date 2003 or earlier 2004 2005 2006 Before publication of WHO 6-phase framework After publication of WHO 6-phase framework Unknown

4 2 26 3 9 26 2

a b

(5.4) (8.1) (37.8) (43.2) (5.4)

(10.8) (5.4) (70.3) (8.1) (24.3) (70.3) (5.4)

Percentages may not add to 100 because of rounding. World Bank (2008).

The texts The 37 national plans and the WHO documents analyzed here constitute a convenience sample. We obtained the plans in three ways: by reviewing websites that compile these documents (e.g., www.who.int); through Internet search engines, employing the terms ‘‘pandemic,’’ ‘‘influenza,’’ and ‘‘plan’’ (and synonyms) together with country names; and by requesting official national plans from each of 83 WHO National Influenza Centers. This search occurred between April 6 and June 28, 2006. The plans of internationally recognized countries and territories were considered ‘‘national’’ and thus eligible for inclusion. Plans were included only if they were available in English (originally or in translation). Plans that addressed only avian (i.e. not human) influenza were excluded. Application of these inclusion and exclusion criteria yielded 37 national plans, for which Table 1 presents summary frequencies. Making meaning and ordering discourse All of the documents share at least two goals: minimization of morbidity and mortality caused by the pandemic influenza strain, and limitation of social and economic disruption stemming from a pandemic. We identified six discourses that structure the plans’ pursuit of these aims: scientific, political, legal, cultural, social, and ethical. Within the ordered universe of discourse in which the plans operate, the former three discourses clearly dominate the latter trio. The scientific, political, and legal discourses are not only more prominent in the plans, but also frame the terms in which the plans consider the social, cultural, and ethical. While the plans differ in style and content, their representations of pandemic influenza preparedness converge; overall, the plans evince striking agreement on the truths underlying sound pandemic preparedness and response measures.

The anatomy of vulnerability Most of the plans analyzed prioritize groups to receive medical countermeasures in the event of a pandemic. The majority of these plans frame prioritized groups in terms of ‘‘risk’’ or ‘‘vulnerability,’’ which the plans construct as the biological probability of a given individual succumbing to or transmitting the pandemic influenza strain. The plans present these constructs as the product of ‘‘medical/scientific consensus’’ (WHO, 2005a). While the plans differ on which groups to prioritize (with commonly prioritized groups including health care workers, pregnant women, children, the elderly, and the immunocompromised), they are consistent in representing each group as a homogeneous subpopulation – considering neither intra-group differences nor non-biological characteristics. Retrospective analyses of morbidity and mortality patterns during the 1918 influenza pandemic, however, reveal striking patterns of differential risks not readily reduced to proximate factors or biologically uniform populations. Economically and socially disadvantaged groups appear to have suffered significantly greater cause-specific fatality rates in the 1918 pandemic relative to better-off populations in both intra- and international comparisons (Murray et al., 2006). Mamelund (2006) provides evidence that nutritional status, size of residence, and the economic capacity to rest and recuperate after influenza infection significantly impacted mortality rates in a Norwegian community during the 1918 pandemic. These findings strongly suggest that risk of death in any future influenza pandemic would be determined by social vulnerability as well as the biological characteristics of agent and host. They also demonstrate the local and differential nature of pandemic influenza and, consequentially, responses to it (Mamelund, 2006; Murray et al., 2006). Failure to address social as well as biological vulnerability thereby poses the danger of repeating the differential

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trends in mortality observed in 1918 – meaning individuals and groups disadvantaged in the status quo ante would suffer a significantly disproportionate force of mortality. Thus, the plans’ apparently uncontroversial aim of minimizing morbidity and mortality should in fact raise critical questions: Whose illness? Whose deaths? Plan EuroA – one of the few plans to address such questions explicitly – takes a largely utilitarian tack, observing, A limited supply of vaccine will pose a number of medical and ethical problems. How does one choose between benefiting a small number of persons in a big way and benefiting a large number of persons in a small way? Is it best to give priority to increasing the remaining life expectancy of the young and middle-aged or to reducing mortality among elderly people with a short remaining life expectancy? In order to resolve these dilemmas, Plan EuroA continues, the expert medical communities will have to discuss the situation in hand and give expert advice. It is important to have the broad support of the medical communities for the chosen priorities, and thus lay the foundation for understanding among the general public for this prioritization. In this plan, as in all those analyzed, scientific experts are trusted to gain the understanding (and presumably acceptance) of the public, which plays a primarily receptive role in such communication. Moreover, the questions confronting the designated experts are constructed as objectified dilemmas. Answers to such questions are preframed: they are coined in scientific terms, and deal in the values of scientific authority, objectivity, effectiveness, and certainty – values assumed immanent in the medical/ scientific consensus. The plans, in turn, draw on these values in justifying their prescribed preparedness and response measures, including prioritization of medical countermeasures. As a result, these prescriptions themselves take on the veneer of authority, objectivity, effectiveness, and certainty. They are ‘‘normalized’’ within the universe of discourse, and alternatives are marginalized. As Cutter (2005) observes, however, the decision to prioritize biologically vulnerable groups is ultimately an ideological one. It seems ‘‘normal’’ only when considered within a particular universe of discourse. Scientific uncertainty, political prerogative The lack of certainty surrounding much of the science underlying pandemic preparedness should challenge this assumption of normality. While all of the plans highly value a scientific evidence base for preparedness and response measures, most also recognize that consensus still eludes scientific and medical authorities within many areas of pandemic influenza research. In a differently ordered universe of discourse, scientific uncertainty might serve as an impetus to development of preparedness and response measures that address the social and cultural heterogeneities that complicate uniform assumptions of biological

vulnerability. Instead, however, the plans avoid addressing this lack of certainty – and the challenges it presents to their prescriptions – by recourse to political (and, concomitantly, legal) authority. Plan EuroB, for example, notes, The priority in an influenza pandemic is to reduce the impact on public health (i.e. reduce illness and save lives). Interventions will therefore be applied where they will achieve maximum health benefit. However, they may also be needed to help maintain essential services. Should there be a conflict between these two aims, political decisions will need to be made about priorities for the use of interventions [emphasis added]. Similarly, Plan EuroA states, As the pandemic increases in scope as regards sickliness or death, the point will finally be reached where it will be more important for the country as a whole to vaccinate key persons in order to be able to look after essential community functions. In [this] instance, the choices of strategy and priorities are political and have to be made by the political authorities [emphasis added]. The plans thus draw a sharp distinction between the scientific and political; they portray the medical/scientific consensus as apolitical, in contrast to decisions made by political authorities. This dichotomy preserves the apparent normality of the plans’ prescriptions – but it is false, and belies the mutuality of scientific and political dominance of the plans. Policy decisions based on scientific consensus are no less (or more) political than those made in the face of scientific uncertainty. This becomes apparent in the plans’ consideration of non-pharmaceutical preparedness and response measures. The WHO (2005a) has reviewed such measures according to pandemic phase, applying scientific criteria to evaluate the value of each. It found a variety of ‘‘social distancing’’ measures ‘‘not necessary’’ in any phase, including (among other measures) entry screening for international travelers, restrictions on intra-national travel, establishment of a cordon sanitaire, and wearing of masks in public places. Such measures obviously carry political ramifications. Quarantine, travel restrictions, curfews, and traffic blockades are potentially quite unpopular with the public. At the same time, however, they provide the populace with evidence that the government is taking steps to protect the public’s health. This poses a conundrum to governments: while the scientific value of these measures is controversial at best, the political value may be quite substantial. In fact, the clear majority of plans at least consider implementation of one or more of the non-pharmaceutical measures that the WHO judged scientifically unnecessary. Even among those plans published after the WHO document, only a few disclose the WHO’s determination of the efficacy of such measures. Plan EuroC, for example, explicitly endorses ‘‘early and immediately drastic public health measures,’’ including restriction on travel to and from the nation, refusal of visas for travelers from affected countries, local traffic blockades, and bans on public gatherings. Plan AsiaPacA allows for similar measures, as do plans MeNaA and AmerA.

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Even plans that explicitly recognize the likely ineffectiveness of certain measures authorize their use: Plan AsiaPacB, for example, as well as Plan AsiaPacC, which states, though not all of these are effective. [s]uch measures are permitted provided that they cause no harm and do not have major impact and burden on resources and will not cause serious and economic disruption. Moreover, the WHO approves of at least some politically driven decision-making. With regards to entry screening, for example, it comments, ‘‘due to lack of proven health benefit, practice should be permitted (for political reasons, to promote public confidence) [emphasis added] but not encouraged’’ (WHO, 2005b). Law and socioeconomic order The importance of public confidence to effective pandemic preparedness and response is incontrovertible. Much more questionable, however, is how the plans define their ‘‘public.’’ In delineating the formal structure of authority for the implementation of preparedness and response measures, for example, Plan EuroC calls for delegating the operational conduct of the governmental action to the Minister of Health. [but if] the issues of civil defence, law and order or continuity of socio-economic life [emphasis added] prevail over the organisation of medical care, there is the possibility of transferring the conduct to the Minister of the Interior. ‘‘Continuity of socio-economic life’’ aptly captures the plans’ approach to the social. The plans closely and frequently identify the social with the economic; most follow the WHO (2005b) in coupling the two as they aim to minimize social and economic disruption. This disruption is generally construed as the breakdown of what the WHO (2005a) terms ‘‘essential services,’’ which, according to the organization, ‘‘are responsible for those processes that keep a society running’’ (WHO, 2005a). The plans present the maintenance of such services – and thus of social and economic order – as dependent on the exercise of authority by the national government. This authority (founded on scientific, political, and legal bases) governs what is construed as an undifferentiated spectrum of national social ‘‘activities and functions.’’ Most plans go no further in considering the complexities of social spaces or geographies. Plan EuroC is a notable exception; it stresses the importance of social ‘‘solidarity’’ during a pandemic, calling for ‘‘preservation of the conditions of life of people at home, through a proximity organisation based on solidarity between neighbours and consolidated by local communities [and] preservation of civil behaviour and of social cohesion around the institutions and the authorities.’’ Social solidarity in the event of an influenza pandemic will almost certainly depend upon the full range of capital (social, cultural, and economic) that any given community can mobilize. As Middaugh (2008) comments, ‘‘maintaining interpersonal bonds and social discourse in the midst of overwhelming tragedy may prove to be the most effective preparedness planning for the next influenza

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pandemic.’’ Communities that lack such resiliency are likely to suffer the most in a pandemic. Yet the plans (including EuroC) do not address such communities – or, in fact, acknowledge any differentiation within or among communities whatsoever. Instead, the social units with which the plans engage are indistinguishable – ‘‘solid,’’ as Plan EuroC phrases it. Within these units, an idealized, homogenized social life is imagined. The plans neither recognize how individuals and families might differ within neighborhoods or communities, nor allow for how neighborhoods and communities might vary across a nation. In all of their deliberations on the ‘‘social distancing’’ measures detailed above, for example, none of the plans consider the relative burdens such measures might impose on various subpopulations. Members of socially vulnerable groups would almost certainly be less able to adhere to highly restrictive measures such as quarantine (Etzioni, 2002). In the 1918 pandemic, Mamelund (2006) notes, individuals of higher socioeconomic status were far more likely to have the capacity to absent themselves from work and social obligations than those in more disadvantaged positions. Today’s disadvantaged populations are no more able to forego the few resource-generating opportunities available to them, even in disaster situations. In the event of a pandemic, access to cash, food, health care, and other necessary goods and services would be far more difficult for socially and economically disadvantaged groups – not only due to their lower financial resources, but also because of their more tenuous ties to both public and private institutions as well as familial and social networks. School closures, for example, would not only confront single-parent households with the challenge of balancing income generation and child care, but would also potentially cut off school programs that feed a considerable number of low-income children (Ingelsby, Nuzzo, O’Toole, & Henderson, 2006). Structural inequalities – including those due to ethnic and religious discrimination – likely would also intensify during a pandemic. All of these dynamics were observed in the aftermath of Hurricane Katrina. The disproportionate impact of Katrina on New Orleans’ disadvantaged populations (primarily poor and black) is now well documented (Atkins & Moy, 2006; Cutter, 2005). Notably, researchers have found that members of these groups cited not simply poverty, but also lack of transportation, lack of support, fear of leaving valuables behind, lack of trust, and racism as obstacles to their evacuation from New Orleans and subsequent living arrangements (Cigler, 2007; Elder et al., 2007). As Strolovitch, Warren, and Frymer (2006) observe, the experience of Katrina forcefully demonstrated that even in high-income settings, natural disasters are not, in fact, ‘‘equal opportunity’’ events. Katrina serves as a stark example of the failure of preparedness and response measures designed under the assumption that the rising tide of uniformly targeted government measures would lift all boats. The government’s actions failed not only broadly, but also narrowly, with disproportionate ramifications for those already disadvantaged. The Katrina experience thus directly challenges the assertion that the government’s role in disaster preparedness is to preserve existing political and

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economic systems so as to assist all groups, disadvantaged or otherwise. As Alexander (2006) observes, such a stance ‘‘hark[s] back to an earlier time when civilian disasters were tackled in a paramilitary way under the assumption that the principal problem was how to restore law and order, rather than how to restore health, safety and dignity to the affected population.’’ This is, however, exactly the plans’ assumption. They aver the authority and objectivity of broad, undifferentiated policies grounded in a legal discourse. The plans consider legislative frameworks, like medical/scientific consensus, as apolitical; appeals to the law are not seen as ideological. The WHO (2005a) describes the plans’ need for a legislative framework (as well as for ‘‘medical/scientific consensus’’ and ‘‘political decision-making’’) as essential components of pandemic influenza preparedness planning; ethical considerations are merely ‘‘desirable’’ (WHO, 2005a). Moreover, while the WHO asserts legal structures will ‘‘ensure transparent assessment and justification of the measures that are being considered,’’ it describes ethical deliberation in explicit contrast as ‘‘part of the normative [emphasis added] framework that is needed to assess the cultural acceptability of measures’’ (WHO, 2005a). The plans follow suit. Plan AmerB, for example, notes, efforts should be made to encourage all jurisdictions to adopt the national recommendations on priority groups at the time of a pandemic in order to facilitate equitable access and consistent messaging. in the absence of any conclusive data, [public health authorities] will be making recommendations for the purpose of facilitating consistency between jurisdictions, which is considered to be valuable during the response phase. This explicitly frames a perspective manifest in many plans, in which preparedness and response measures are conceived as consistently applicable to a relatively homogeneous target population. Such consistency and uniformity is presumed to render the measures ‘‘equitable.’’ Once again, the plans’ prescriptions are ‘‘normalized’’ within the order of discourse: because the combined political and legislative frameworks are assumed authoritative, objective, consistent, transparent, and equitable, so too are the preparedness and response measures grounded in them. These assumptions both reflect and reproduce the popular image of the egalitarian and arbitrary natural disaster (Strolovitch et al., 2006). Yet laws are not necessarily (or even usually) objective, transparent, or equitable, even if consistently and uniformly applied. As Strolovich et al. (2006) argue, apparently nondiscriminatory or ‘‘equal opportunity’’ legislation often represents the institutionalization of past and present national prejudices. In the case of Katrina, assumptions that existing disaster legislation and policies would provide protection for all proved deeply flawed. Indeed, there is now evidence that enforcement of prevailing legal provisions at times hindered provision of aid to those most in need (Smith N., 2006a). All pandemics are local: Lessons from SARS The SARS outbreak of 2003 provides another concrete example of how national (and international) preparedness

response measures had unintended consequences, especially for disadvantaged populations in the affected regions. When SARS emerged in 2003, lack of scientific understanding of the virus and its transmission forced the authorities to act under substantial scientific uncertainty (MacDougall, 2007). In many cases, the resultant political responses generated considerable contention both among public health officials and within civil society (Smith R.D., 2006b). Central governments implemented strict social distancing measures, and the WHO itself issued a travel advisory for Toronto (MacDougall, 2007; Smith R.D., 2006b). Yet after systematically reviewing the handling of the epidemic in Toronto, Canada’s National Advisory Committee on SARS and Public Health (NACSPH, 2003) issued the ‘‘Naylor Report,’’ declaring, outbreaks are fought at the local level. SARS was not contained by Health Canada; it was contained by local public health agencies and health care institutions. With our vast geography and cultural heterogeneity. a federal law may be ineffective if general and more harmful than helpful if unduly prescriptive. Comparing Toronto’s experiences with SARS and the pandemic of 1918 – and drawing lessons from both – MacDougall (2007) concurred with the Naylor Report, concluding, ‘‘local health departments are the foundation for successful disease containment, provided that there is effective coordination, communication, and capacity.’’ Indeed, Ingelsby et al. (2006) suggest that pandemic influenza preparedness in the United States ignores the importance of strengthening local public health infrastructure to its own detriment. MacKellar (2007) extends their point, asserting, ‘‘governance problems, such as the fragility of health systems, represent structural weaknesses and are not best addressed by crisis-mentality preparedness planning.’’ Governments already straining to adequately provide primary health care face critical resource allocation challenges when pressed to engage in vertical or ‘‘siloed’’ pandemic preparedness planning. The demand for funds and personnel by what Rosenberg (2008) might term ‘‘the virtual pandemic’’ is a potential threat to many nations’ ability to deal with current health challenges – posing particularly dire consequences for marginal populations already disadvantaged vis-a`-vis access to health care. The obverse also holds: improvements in primary health care may also ameliorate the situation of disadvantaged populations in the event of a pandemic, since those most socially vulnerable are also those most likely to rely upon local public health care services in case of disaster (Avery, 2004). Many plans do assign specific powers to regional and local authorities – but those powers are almost always dependent on national oversight and decision-making (Ingelsby et al., 2006). As Hodge, Gostin, and Vernick (2007) note, such provisions can lead to usurpation of ‘‘traditional subnational public health activities’’ by national authorities – which, the authors observe, could ‘‘potentially exacerbate preparedness disparities nationally.’’ As the Naylor Report notes, cultural and geographical heterogeneity are critical mediating factors in preparedness for and response to infectious disease outbreaks (NACSPH, 2003). The examples of both SARS and the

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pandemic of 1918 demonstrate the importance of flexible local response to local challenges.

The uses of culture Successful local response largely depends upon the establishment of responsive or even reflexive communication at multiple levels (MacDougall, 2007; NACSPH, 2003). Such communication would necessarily be open to contestation by various stakeholders, including local officials, specific interest groups, and the general public. Notably, several plans call for transparent and culturally appropriate communication strategies. Initially, then, communication appears to be one area in which the plans recognize the diversity of their target populations, and the consequent need for a particularistic approach to preparedness and response measures. Upon closer examination, however, it becomes apparent that the plans do not in fact present a cultural discourse on its own terms. Rather, they subordinate it to overriding concerns emerging from the dominant scientific, political, and legal discourses. Plan AmerA, for instance, notes, ‘‘Timely and transparent dissemination of clear, accurate, science-based, culturally competent information about pandemic influenza and the progress of the response can build public trust and confidence.’’ As noted above, public confidence is undoubtedly essential to effective pandemic preparedness and response. Again, however, questions emerge regarding how the plans conceive of their ‘‘public.’’ The plans’ framing of the cultural – as of the social – essentially effaces the diversity found within and among the various groups that the general population comprises. The plans primarily view cultural differences as barriers that must be overcome in order to assure effective implementation of preparedness policies and programs: differences in sociolinguistic patterns, for example, or (as in plans MeNaA and AsiaPacC) funerary ceremonies. The plans’ goal is to merge culturally diverse groups into the public fold vis-a`-vis pandemic preparedness measures and objectives. Even in the rare plans (e.g., AmerB and AsiaPacD) that do call on cultural groups to provide feedback to planning authorities, the roles of these groups are circumscribed, and little attention is given to issues of culture per se. Culture is thus rendered instrumental in the plans, reduced to a set of knowledge that must be mastered and mobilized so that preparedness efforts can succeed. Such a hypostatic framing of culture ignores the irreducibly heterogeneous and dynamic relations and processes that culture comprises. The plans thus risk ignoring the complex and particular ways in which pandemic influenza preparedness (as well as a pandemic itself) may exacerbate existing inequalities in subgroups in which cultural differences and disadvantage are often superposed. This is particularly evident in those plans that address indigenous populations that fall under national jurisdiction. The plans label the issues surrounding these groups ‘‘cultural,’’ but emphasis is not placed on how membership in a particular cultural group might mediate the experiences or impacts of a pandemic. Rather, the plans focus on issues of oversight and legislation, concentrating on

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the logistics of preparedness given indigenous peoples’ outstanding political and legal status. The plans are similarly silent on immigrants (including undocumented aliens and migrant workers). Considerable evidence points to the need for particular attention to immigrant populations in case of disastrous events such as pandemic influenza (Jones, 2005; Wynia & Gostin, 2004), and the recent experience of an outbreak of enteritidis among seasonal migrant workers in Norway provides a stark illustration of why such attention is warranted (Guerin, Vold, & Aavitsland, 2005). Yet only two plans (EuroK and AsiaPacB) mention provisions for immigrants in case of a pandemic. The invisibility of immigrant (especially in contrast to indigenous) populations is not surprising, however, when groups’ cultural identities are reduced to their political, legal, and economic status (Gilbert, 2007). This diminution is also evident in plans that address equitably compensating farmers for poultry destroyed in efforts to contain avian influenza. Several of these plans go into considerable detail regarding the political, legal, and economic dimensions of such compensation. None of the documents analyzed, however, consider that the poultry owned by both large- and small-scale producers may occupy a more culturally, socially, and ethically complex space than economic compensation can fill. In poor households, for example, backyard chickens may serve as a relatively cheap source of protein not easily replaced on the open market, even given compensation at ‘‘fair market value’’ (World Bank, 2006). Poultry-rearing and live markets often provide rare opportunities for socially vulnerable groups (most prominently, younger women) to earn both economic and social capital; moreover, slaughtering and gifts of poultry may play important roles in social and cultural events and activities (Constable, 2006; Roland-Holst, Otte, & Pfeiffer, 2006; World Bank, 2006). Such lack of attention to particular circumstances is in keeping with the plans’ economistic reduction of the cultural, social, and ethical. In the idealized market economy, agents (buyers and sellers) are anonymous, distinguishable only via their activities in exchange (Cunningham, 2005). Similarly, in the plans’ idealized, homogenized society, the distinguishing characteristics are social objects (services, activities, and functions) – not social subjects (i.e. the people who provide and rely on these services, activities, and functions). Blending the social and cultural into a uniformly economistic palette allows the pandemic influenza preparedness plans to cover a broad national (and even international) canvas. This scope comes at a cost, however: it paints over the crucial if micro-scale relations and processes that produce and reproduce an ethical and equitable (or, equally, an unethical and inequitable) social and economic order (Schoch-Spana, 2004). Given the plans’ economistic bent, it may seem surprising that an economic discourse does not emerge. This is, however, precisely because all of the discourses are embedded within a field that is manifestly economic. The economic field is doxa – that which is complementary to the universe of discourse, and which, as Bourdieu (1972/ 1977) notes, ‘‘is only fully revealed when negatively constituted by the constitution of a field of opinion, the locus of confrontation of competing discourses.’’ The economic

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can be nowhere only because it is really everywhere. It is because the economic assumptions of preparedness are implicit in the plans – because they literally go without saying – that an economic discourse is not identifiable.

Conclusions: Developing discourses of disadvantage The foregoing arguments do not mean that an ethical discourse does not emerge from the plans. It does – but subject to a complex assemblage of assumptions and abstractions that privilege biological vulnerability, aggrandize the political and legal, and homogenize social and cultural relations. This, in turn, places the ethical in a techno- and bureaucratic box – a box into which the lives, needs, and interests of disadvantaged populations cannot fit. Critical discourse analysis reveals the way in which the plans construct this box, via the dominance of a specific set of discourses. Lakoff (2006) argues that this ordering is inherent to preparedness as ‘‘both an ethos and a set of techniques,’’ asserting, for preparedness the key site of vulnerability is not the health of a population but rather the critical infrastructure that guarantees the continuity of political and economic order. And while preparedness may emphasize saving the lives of ‘‘victims’’ in moments of duress, it does not consider the living conditions of human beings as members of a social collectivity. It is important to recognize, however, that the objects and aims of Lakoff’s preparedness are contingent, not necessary. They are the product of a particular construction of preparedness within a specifically ordered universe of discourse. Critical discourse analysis can also help show how to deconstruct the box. While it is beyond (and indeed antithetical to) the aims of this paper to offer specific blueprints for alternative preparedness plans, the findings presented here do suggest possible ways forward. The examples discussed above highlight social and cultural heterogeneity as critical factors in both the responses of and ramifications for populations in the event of a disaster. They illustrate that while these complexities can be national and even global in character, they are ultimately rooted in the local. As Adger, Benjaminsen, Brown, and Svarstad (2001) argue, ‘‘since global discourses are often based on shared myths and blueprints of the world, the political prescriptions flowing from them are often inappropriate for local realities.’’ This suggests that to be truly effective and equitable, the plans’ political prescriptions should flow from local realities – highlighting the potential utility of collective action and of adaptive, dynamic policy solutions such as the ‘‘local performance regimes’’ of Clarke and Chenoweth (2006). Broad consultation among stakeholders before a pandemic should ideally lead not to a ‘‘Procrustean bed’’ of preparedness prescriptions (NACSPH, 2003), but rather a flexible framework in which local circumstances and concerns, including those of disadvantaged populations, can be duly considered and addressed. By embracing complexity and diversity – by drawing examples and conclusions

from the local and particular – the plans can move toward a more effective and equitable preparedness. Such an approach undoubtedly represents a challenge to pandemic influenza preparedness as currently conceived. It would require that plans venture upstream of the proximate determinants of pandemic-specific morbidity and mortality. In those murkier waters, the measures presented by the plans are open to critical challenges on social, cultural, and ethical grounds. By steering clear of such challenges, however, the plans occlude critical debates with significant ethical implications. As a result, there is no recognition that the policies, practices and programs the plans prescribe, while perhaps justifiable in an otherwise just context, would be quite unjust in a situation in which people are not, in fact, on even footing. In the face of a pandemic, aiming to preserve an unjust social and economic status quo ante raises the grave prospect of exacerbating pre-existing disadvantage in terms of biological, social, and economic outcomes. More perniciously, the plans currently convey a sense that they are, in fact, considering the relevant ethical dimensions of pandemic preparedness, when in fact their very parameters create potentially dire ethical ramifications in focusing on the preservation of order and the status quo. In order to properly address these ethical ramifications, the plans must first be recognized as operating within a universe of discourse dominated by what are literally governing ideologies. While it is not within the scope of this paper to address genealogically why the order of preparedness discourse is what it is, current WHO documents do seem to have had impact on the structuring of the plans. Almost all of the plans analyzed in this paper follow at least the general outlines the WHO provides – which, as noted, have emphasized the scientific, political, and legal, while adopting a markedly economistic perspective. The WHO does plan to provide further practical guidance to member states on incorporating ethical considerations into their pandemic influenza preparedness plans, and appears to have recognized the importance of the social and cultural and the values they convey (WHO, 2007). The structures and practices that emerge from those deliberations remain to be seen. Indeed, much greater attention needs to be devoted not only to the universe of discourse in which pandemic preparedness planning is situated, but also to its universe of practice. Particular mobilizations of discourse do not ineluctably determine practical means and methods. As Schoch-Spana (2006) observes, however, ‘‘Pandemic publications. serve as important rallying points for medical and public health stakeholders to advocate more forcefully on a number of concerns.’’ It is our hope that the findings presented here will provide the basis for keener, more critical understanding of the continuing processes of pandemic influenza preparedness planning – and, by extension, of preparedness writ large. Lacking such understanding, we run the risk of disastrously disadvantaging those already disadvantaged. Acknowledgements This article was funded by The Rockefeller Foundation. We are thankful to Michal Engelman, Ruth Faden, Amelia

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Greiner, Siba Grovogui, Ruth Karron, Lori Leonard, Lori Uscher-Pines, and Emma Tsui for their insightful comments and suggestions on earlier drafts. Lynn Lederer and Leslie Long also provided much-appreciated support during the writing of this paper.

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