Social justice in pandemic immunization policy: We’re all in this together

Abstract

Policy decisions regarding immunization during a pandemic are informed by the ethical understandings of policy makers. With the possibility that a vaccine might soon be available to mitigate the deadly COVID-19 pandemic, policy makers can consider learnings from past pandemic immunization campaigns. This critical analysis of three policy decisions made in Alberta, Canada, during the 2009 H1N1 influenza pandemic demonstrates the predominance of distributive justice principles and the problems that this created for vulnerable groups. Vulnerable groups identified in Alberta include rural and First Nations populations. We propose a social justice approach as a viable alternative to inform pandemic immunization policy and invite debate.

Keywords

Pandemic immunization policy social justice

Introduction

As populations around the globe experience the deadly COVID-19 pandemic, the prospect of relief through immunization brings hope that the disease might be mitigated. Vaccine administration, however, is a complex and ethically nuanced challenge.^1

–4 The immunization campaigns to combat the 2009 influenza pandemic (pH1N1) brought these challenges to the fore as immunizers attempted to deliver the vaccine on a scale never attempted in the past.⁵ Lessons learned, and further insights from these past experiences, could prove valuable for policy makers contemplating COVID-19 pandemic immunization campaigns.

In Canada, nurses are the largest group of healthcare professionals involved in front-line pandemic responses⁶ and in Alberta, public health nurses (PHNs) were the primary administrators of pH1N1 vaccine.⁷ As a contribution to nursing practice, this commentary is constructed by nurses with experience in, and/or knowledge of, pandemic immunization, public health, rural health, and the ethical underpinnings that inform nursing care in these contexts. To accomplish this critique, we analysed pH1N1 immunization policy decisions of the Alberta provincial government leaders as documented by the Health Quality Council of Alberta.⁷ This government commissioned, expert review of the province’s pH1N1 health responses, provided a comprehensive account of immunization decisions. We analysed ethical issues of vaccine delivery pertaining to the first 10 days of when the immunization campaigns and vaccine delivery started in the province. Based on our analysis, we concluded that policy decisions regarding immunization delivery were fraught with issues of power and based on a distributive justice framework. Our analysis, therefore, was guided by a postmodernist world view,⁸ a feminist theory of relational ethics,⁹ and a social justice ethical stance.¹⁰ Predominate features of these approaches include inclusivity and shared decision making.

Over a 10-day period of immunization policy making in 2009, the provincial government made three pH1N1 immunization policy decisions: to offer vaccine only through mass immunization clinics, to open those clinics to anyone who wanted to be vaccinated, and then; to severely restrict vaccine distribution to at-risk individuals.⁷ This fast moving and conflicting direction was confusing for health professionals and the public alike, particularly when there was evidence that the Public Health Agency of Canada provided officials in Alberta with a listing of risk factors for pH1N1 illness that could have guided vaccine distribution from the start.⁷ Through discussion of the problems associated with the Alberta experience, particularly for vulnerable populations, we believe our analysis can support policy and decision makers as they begin to grapple with immunizing Canadians when a vaccine becomes available for COVID-19.

Assumptions

The Health Quality Council of Alberta⁷ reported an absence of an agreed upon ethical framework for policy makers to refer to at that time. Of further concern, personnel interviewed in their review process did not speak to the value of such a framework. The first two policy decisions made in 2009, appeared however, to be based on an egalitarian form of distributive justice. In this form of justice, community members were considered morally equal and thus deserving of an equal share of material goods.¹¹ The policy decisions to provide free vaccine through mass immunization clinics, and to open the clinics to anyone that wanted it, demonstrated congruence with these principles. Described as impersonal and top-down in process,¹² distributive approaches may have appeal in their simplicity and the inferred understanding that experts know what is best. The decision to allow open attendance was short-lived, however, when after 5 days of operation, crowding at mass immunization clinics and concerns about insufficient vaccine supply prompted its discontinuation.⁷

The third policy direction aimed to support a needs-based form of distribution justice, by vaccinating according to risk.¹³ It appears the approach originally suggested by the Public Health Agency of Canada was revisited when problems arose, however, it was modified to a slow release of vaccine according to a hierarchy of risk factors. For example, on one day nurses were immunizing pregnant women, then on the following day access was expanded to include pregnant women and children under the age of three, and so on. This gradual release left some vulnerable people at risk while they waited for their turn. It was also problematic when, for example, family groupings presented to mass immunization clinics for immunization. Notably, Smith et al.¹⁴ found that some pandemic preparedness health policy makers in Canada defaulted to this kind of needs-based approach as the only option for deciding who might get vaccinated first. Significantly, these authors were interested the role of social justice in public health policy making. Their findings highlighted a dominance of the principles of distributive justice in the minds of some pandemic-focussed public health policy makers, leading them to question why social justice might not be applied to a pandemic immunization campaign. We share this view.

Given the assumption that the three policy decisions regarding vaccine delivery in Alberta during pH1N1 were based on a distributive justice approaches, and that they were problematic in some ways, our analysis seems warranted. The apparent lack of committed ethical approach to policy in Alberta in 2009, and the suggestion that social justice could inform pandemic responses furthers the impetus for analysis. We approach this analysis with the following thesis statement and description of the philosophical underpinnings that inform it.

Thesis statement

We suggest public health ethics¹⁰ and rural health ethics,¹⁵ both informed by social justice, are alternative perspectives that may better inform policy making in a pandemic response. These perspectives suggest that individual autonomy is of lesser importance than the social realities that situate individuals in communities. In a pandemic, individual autonomy must at times be constrained to support the common good. Social inequalities in society constrain equality in opportunity and access for some groups. In addition, to achieve an effective and fair response to a community crisis, meaningful inclusion in policy making is not only possible, but necessary. Health equity^16

–20 is an important concept that informs these perspectives. Health equity is achieved when populations that are defined socially, economically, demographically, or geographically do not experience differences in health outcomes as a result of modifiable system structures such as health policy.¹⁹ These ethical approaches, and their focus on health equity, are consistent with the goal of achieving health for all.

Our thesis, therefore, is that social justice can, and ought to, inform vaccine delivery during a pandemic. We cannot allow some individuals to be invisible to policy makers as they may belong to vulnerable groups that lack the resources to compete fairly with the privileged.^10,21
–23 We define vulnerable groups as those at risk of serious health complications or death from a pandemic illness as a result of intersecting determinants of health.²⁴ Examples of determinants of health that compound risk when they intersect in individuals or groups include gender, age, race, ethnicity, social class, socioeconomic status, disability, and geography.^24
–26 We will demonstrate how social justice can be enacted during a pandemic by first describing the philosophical, theoretical, and ethical stances that support it. Our aim is to advocate for thoughtful reflection and debate on how future pandemic immunization policy could evolve to include vulnerable groups.

Philosophical stance

Postmodernism

A postmodernist world view embraces the notion that our understanding of the world is a construction of social and political environments.^8,27 It is, therefore, a constructivist view in which subjective, contextual factors such as social groups, and group decision making, determine what is true or right in a certain time and place. The process of policy making in this world view is primarily bottom-up as it presumes dialogue and inclusion, reinforcing the idea that even though we are all different people, we are all in this world together.²⁸ The interests of groups, over that of individuals, is evident in this perspective. In addition, outcomes, though important, are of lesser importance than the process of decision making in this world view.

Other world views, such as modernism, prioritize the autonomy of the individual, their separateness from groups, and their personal responsibility in pursing health.^22,28 The pursuit of individual wealth and happiness, globalization, privatization of public services, and a pursuit of efficiency are tied to this world view.^28,29 Haddow³⁰ provided a description of the long history of government policies in Alberta addressing cost cutting or privatization of public services in favour of free market economics. It not surprising, therefore, in assessing the strategic plan of Alberta Health Services (AHS) in 2009, to find the following values congruent with a modernist world view: valuing each other and each client as individuals, and; encouraging/supporting people to take responsibility for their own health.³¹ This rugged individualist stance seems to be so engrained in Alberta culture that it has become an unchallenged or unexamined norm.

It is important, however, to be aware of, and be transparent about, the world views that influence what, and how decisions are made. We propose that nurses, in rural, public health contexts, might embrace a postmodernist world view. This assumption comes from our analysis of the Canadian Nurses Association’s code of ethics³² and statement on social justice,³³ the definition of public health as adopted by the Canadian Public Health Association,³⁴ and the recent conceptualization of rural health ethics by Simpson and McDonald.¹⁵ Doane and Varcoe,³⁵ and Doane and Pauly,³⁶ scholars in public health, nursing, and ethics, argue that a postmodernist world view could be embraced by nurses in these contexts. These authors describe social and political structures as essential components to health care delivery with wording such as social justice, organized efforts of society, place, community, relationships, and health for all. Consistent with these scholars, we argue that a health threat as encompassing as a pandemic requires rural PHNs be guided by a postmodernist world view. Such a perspective best supports a collaborative and inclusive approach to intervention rather than one that leaves individuals on their own to navigate their survival.

Theoretical stance

Relational ethics

If we suppose that groups, context, dialogue, and inclusion are what matter in our world view, an ethical framework that details how these values could be operationalized is beneficial for policy makers. Baylis et al.⁹ offer this in their relational ethics framework. Based on the values of relational personhood, relational solidarity, and social justice, their model veers away from individualistic interests that are featured in other frameworks. The concept of inclusiveness in this framework rejects othering of people in any way, reinforcing a vision that we are all in this together.^9,10,37,38 Concurrently, there is acknowledgement that people are members of groups and that these groups can occupy spaces of privilege or disadvantage. The cornerstone of this framework is that policy ought not to put groups in a position where their interests, and larger society interests, compete for public goods such as pandemic vaccine. The underlying assumption of this statement is that disadvantaged groups cannot compete fairly with the privileged, so they ought not be put in such a precarious position.

Notably, this framework is proposed for public health practice at all times, not just during a pandemic.⁹ Indeed, the community development that comes from collaboration, increased awareness of vulnerable groups, and increased creativity in service provision, could facilitate effective pandemic responses. In contrast, Moodley et al.³⁹ argue that public health emergencies are special situations that require distributive justice approaches to vaccine distribution by virtue of scarcity of vaccine. Social justice, therefore, is suggested as appropriate only in times of less urgency and demand. Our objection to the default to distributive justice is that it shifts the focus to individuals, prioritizes equality over health equity, and is predominately a top-down process. Alarmingly, a distributive justice approach may also justify prioritization of vaccine to those deemed most essential to economic and social functioning, or, promote vaccination of individuals against their will.³⁶ A consistent commitment to relational ethics could be a long-term remedy to the health inequalities that vulnerable groups experience and, ensure that they are not forgotten, or disrespected, when emergencies arise.

Ethical stance

Social justice

Social justice is achieved when the burdens and benefits associated with living in a community are equitably shared.⁴⁰ Deepening our understanding of social justice as it translates to service delivery, Smith et al.⁴¹ identify two important underlying assumptions: first, that social justice will not be achieved if systemic inequities exist in a community that favour some members of a community, while oppressing others, and; second, power, resources, and individual access to these amenities are inevitably inequitable. For nurses, particularly public health and rural practitioners, we suggest that these assumptions align with the reality of the unique characteristics of a rural place that make rural populations more vulnerable to health inequities during a pandemic.^42,43 The features that contribute to this increased vulnerability include sparse health service resources, large geographical areas to service, lower levels of education, limited employment opportunities, increased rates of poverty and, a higher prevalence of chronic disease.^7,44
–46 Furthermore, we expand the understanding of vulnerability when we consider the effects of colonialism on First Nations peoples and how this contributes to vulnerability during a pandemic. First Nations peoples are consistently shown to be disproportionately affected by pandemic illnesses.^{5,9,47

–50} We also consider the vulnerability of developing nations²³ if a social justice approach informs policy decisions on macro levels. If contextual factors are not taken into consideration with policy making, rural populations, First Nations peoples, or any vulnerable population on a global level, will be challenged to equitably receive their share of community resources.

The values in a social justice approach to policy making proposed by Powers and Faden¹⁰ include respect for others, personal security, attachment to others, facilitating reasoning capacity and self-determination in pursing one’s destiny. To complement, rural health ethicists Simpson and McDonald¹⁵ suggest the values of place, community, and relationships are of central concern. Both these perspectives are relational, group-orientated, and concerned with inclusiveness. In a pandemic situation there are going to be challenges with shortages of supplies, and difficult decisions will need to be made. A process that is inclusive, with a balance of input from the bottom and top, is more likely to root out the unique challenges of service delivery for different groups, to foster creativity in service provision, and to improve acceptance of these difficult decisions.

We identified two groups already incorporating social justice in pandemic planning, one in the state of Minnesota⁴ and the other in the country of New Zealand,⁵¹ and their approaches provide valuable insights. Vawter et al.⁴ demonstrated a collaborative approach to how to ethically distribute vaccine in a worst-case scenario pandemic when they engaged a variety of community groups in discussions. Through this consultation process, they found that social cohesiveness was the preferred value with which to judge between possible policy options. Consensus, therefore, appears to be an important component of the process. Indeed, Schwartz and Yen⁵² contend that consensus-based decision making among government and non-government persons, though difficult, is a promising strategy for future pandemic responses. They argue, and we agree, that governments have not managed previous pandemics well, and that the meaningful participation of community groups in the process could remedy this.

The other leader in promoting social justice is the Ministry of Health in New Zealand.⁵¹ The Ministry’s initiatives demonstrated how populations impacted by colonialism were included in the pandemic planning for their country. Significantly, they describe a robust ethical framework that includes words such as open, inclusive, respect, fairness, neighbourliness, and unity. There is, therefore, precedent for adopting a social justice perspective in pandemic responses. Such an approach is different from traditional ways of delivering vaccine, however, a pandemic is a unique situation that puts global populations at risk. The problems with vaccine distribution in Alberta in 2009, described below, will illustrate this.

Alberta’s immunization policy in 2009

It is important to note contextual elements that may have influenced pandemic decision makers in 2009. As already mentioned, advice from the Public Health Agency of Canada regarding risk factors for pH1N1 did not result in immunization according to risk in the initial stage of the campaign,⁷ suggesting others had more influence over policy decisions in Alberta. The Health Quality Council did not identify who these others were, noting only that direction came from a high-level person or persons.⁷ Extensive restructuring of health services started in April of 2009, mere months before vaccines became available. Musto et al.⁵³ suggest that this restructuring may have contributed to some of the misguided decision making about pH1N1 vaccine delivery. Indeed, in evaluating the 18 recommendations from the Health Council review, it is evident that communication, role clarification, and collaboration among stakeholders were challenging. All these contextual factors had potential to complicate the pandemic response. Significantly, a central theme in the Council’s report was that ‘…the pandemic was not the emergency. Rather, the challenge was managing the immunization clinics (p.37)’.⁷ Our analysis of the following immunization policy decisions concurs with this assessment We offer critique of the three policy decisions that started the immunization campaign from a nursing perspective, and using a social justice lens, next.

Offer vaccine only through mass immunization clinics

PHNs were the sole providers of vaccine when pH1N1 immunization started, and mass clinics were the only venues of administration.⁷ This decision limited access to vaccine to persons that could physically get to a mass clinic, and then stand in line for many hours. Consequently, many vulnerable community members were faced with barriers to receive vaccination. For example, elderly persons in communal living situations, the disabled, and those without the economic means to leave work or travel to a clinic, were left without access. Uscher-Pines et al.⁵⁴ refer to this as a Darwinian, or, a survival of the fittest, approach to vaccine delivery. This approach is individualistic, competitive, and, it appears, made by top-down authorities that lacked an understanding of the scope and complexity of vaccine delivery in a pandemic. Although mass immunization clinics are cost-effective, efficient, and safe,^55,56 they cannot be the only strategy employed in a pandemic response. This simply is not socially just.

Anyone wanting vaccine will be accommodated

If community members in Alberta could get to the mass clinic, they were not to be turned away.⁷ This decision could have been surprising and confusing for public health professionals, and members of the public, since it is standard practice to identify those in a community who are at most risk to contract a vaccine preventable disease and then define them as eligible for vaccine.^57

–60 Although a social justice approach would identify high-risk groups over individuals to receive vaccine first, there has always been an attempt to roll out vaccine gradually due to the logistical challenges of vaccine supply chains, maintaining refrigeration of the vaccine, and the limited numbers of skilled practitioners that can safely inject vaccines. Not surprisingly, community members observed problems with the mass clinics. The media reported dis-satisfaction with the crowding and long queues^61,62 and reports of a professional hockey team receiving vaccinations in a private mass clinic created an uproar about queue jumping.⁷ It was obvious that demand for vaccine was high at the time; resources, such as immunization personnel, were limited; and that those with privilege could get special accommodation.

Of interest, a resource that was not limited, over the long term of the immunization campaign, was vaccine.⁷ In fact, at the end of the immunization campaign, just over one million doses of vaccine were left over.⁷ There was great concern, however, that there could be a shortage of vaccine among decision makers in Alberta.⁷ Although hindsight proved this concern over a vaccine shortage was unsubstantiated, the issue of who gets vaccine first is revealed as one that could not be avoided simply by opening clinics to anyone that desired it. A social justice approach to vaccine delivery acknowledges that resources can be limited in a variety of ways, and, suggests that groups at high risk of illness or death ought to be prioritized to receive vaccine first. If the unfortunate circumstance presents where all who want vaccine cannot be immunized due to limited resources, at a minimum least we can claim we targeted those at most risk of illness or death.

Gradually release vaccine according to high risk

The decision to reopen clinics to high risk groups, phased in over several weeks was problematic. High-risk groups were narrowly defined by age (under 4 years, and, under 65 years with underlying health conditions), occupation (health care workers), pregnancy status, and on-reserve indigenous persons.⁷ This ranking is more individualistic than group-oriented, exclusive, and privileged health care workers.

To illustrate the problem with focusing on individuals, consider families, a natural grouping in communities, as they presented to clinics only to discover some individuals were ineligible for vaccine that day.⁷ In order to protect all family members, multiple visits to mass clinics over several weeks was required. This unfairly burdened those with long distances to travel, lower economic resources, and, perhaps, resulted in angst by leaving some household members at risk for disease while others were protected. Simultaneously, PHNs were discarding unused vaccine at the end of the clinic in fear of criticism or dismissal for allowing queue jumping.⁷ Vaccine was also being discarded rather than have rural PHNs travel long distances to return vaccine to central depots.⁷ By prescribing such a strict, and thus slower, programme of vaccine delivery, one could conclude that vulnerable groups not only experienced more burdens in receiving vaccine, but that they were also subjected to unnecessary risk of disease. A social justice approach to vaccine delivery would recognize vulnerable groups, not individuals, at higher risk of complications or death and thus, enable the flexibility to gear services provision in ways that create health equity. By framing vaccine delivery towards those most at risk of dying, a social justice approach could also resolve the issue of trying to determine who is more essential in a community than others. Our stance is that we are all in this world together, we all have value, and as a collective we can make difficult decisions.

Discussion

There is no doubt that shifting away from a familiar and deeply entrenched way of delivering vaccines is difficult. Indeed, the release in 2016 of an Alberta ethical decision-making framework for pandemics illustrates this.⁶³ Concerned that a national framework was not available for adoption, and perhaps feeling pressured by the 2010 recommendation of Health Quality Council of Alberta to develop such a framework, the authors drew heavily on the province of British Columbia’s ethical framework to create their document.⁵⁹ While the framework mentions public health ethics as the guiding principle, the wording references the supremacy of individuals over groups, and includes numerous bioethical terms more appropriate to interactions with individuals. Involvement of community members in the decision-making process around pandemic responses is exclusively qualified by the words ‘when possible’.

Although this movement is encouraging, we believe more can be done to ensure vulnerable populations are not forgotten in pandemic immunization responses. Perhaps the first step in moving towards social justice during a pandemic would be to shift our perceptions of health care from that of an expense of government to that of an investment in community. Practical implementation strategies include surveillance of groups who are at disproportionate risk of complications or death during a pandemic. Details such as age, gender, ethnicity, race, place of residence, place of employ, income and education level could bring these groups into focus. As we have witnessed during pH1N1 and COVID-19, vaccine development and production takes time. This time could be effectively used to fully describe and build relationships with affected groups. If a social justice approach occurs outside of emergency situations, these relationships might already be fostered and in place. A partnership approach to decision-making, employing strategies that promote consensus and social cohesion would also advance social justice. Strategies to offer vaccine where people live, work, or go to school could promote a more socially just option to exclusively immunizing in large, mass clinics. These examples are not meant to be prescriptive but illustrative of the range of possibilities available when a relational, predominately bottom-up process, informs policy making.

Conclusion

Pandemics have been rare but potentially devasting events for populations.^64
–66 As technological advancements allow for mass production of vaccines, policies to ensure their just delivery are desired. We have demonstrated that a lack of ethical awareness and a tendency to apply distributive justice principles could be problematic for vulnerable groups seeking immunization. These problems arise from a predominantly top-down approach that neglects the relational reality of human existence. We suggest a viable alternative lies in a social justice approach to policy making, and that the work in public health and rural ethics can move this transition forward. Through dialogue, inclusiveness, and a recognition that social positioning impacts risk of complication or death during a pandemic, we might ensure that none are rendered invisible in the efforts to prevent illness and maintain health.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Carmen Torrie

Lisa Howard

References

Barr

Macfarlane

Macgregor

, et al. Ethical planning for an influenza pandemic. Clin Med 2008; 8(1): 49–52.

Bennett

Carney

. Law, ethics and pandemic preparedness: the importance of cross-jurisdictional and cross-cultural perspectives. Aust N Z J Public Health 2010; 34(2): 106–112.

Kotalik

. Preparing for an influenza pandemic: ethical issues. Bioethics 2005; 19(4): 422–431.

Vawter

Gervais

Garrett

. Allocating pandemic influenza vaccines in Minnesota: recommendations of the Pandemic Influenza Ethics Work Group. Vaccine 2007; 25(35): 6522–6536.

Low

McGeer

. Pandemic (H1N1) 2009: assessing the response. Canadian Medical Association Journal 2010; 182(17): 1874–1878.

Devereaux

. Pandemic influenza: an evolutionary concept analysis. J Adv Nurs 2015; 71(8): 1787–1796.

Health Quality Council of Alberta. Review of Alberta’s response to the 2009 H1N1 influenza pandemic, 2010, https://d10k7k7mywg42z.cloudfront.net/assets/53222ca04f720a1df5000238/H1N1_OfficialReport_December_2010.pdf

Pesut

Johnson

. Philosophical contributions to nursing ethics. In: Storch

Rodney

Starzomski

(eds) Toward a moral horizon: nursing ethics for leadership and practice. Toronto, ON, Canada: Pearson, 2013.

Baylis

Kenny

Sherwin

. A relational account of public health ethics. Public Health Ethics 2008; 1(3): 196–209.

10.

Powers

Faden

. Social justice: the moral foundations of public health and health policy. Cary, NC: Oxford University Press, 2008, http://ebookcentral.proquest.com/lib/uleth/detail.action?docID=728780

11.

Lamont

Favor

. Distributive justice. In: Stanford encyclopedia of philosophy [Internet] . Stanford, CA: Stanford University, 2017, https://plato.stanford.edu/entries/justice-distributive/

12.

Shanner

. Bioethics and health law: theoretical foundations and moral points of view. In: Gervais

(ed.) Canadian health law practice manual. Markham, ON, Canada: LexisNexis, 2008. pp. 1–5.

13.

Hope

Osterdal

Hasman

. An inquiry into the principles of needs-based allocation of health care. Bioethics 2010; 24(9): 470–480.

14.

Smith

Thompson

Upshur

REG

. Public health as social justice? A qualitative study of public health policy-makers’ perspectives. Soc Justice Res 2019; 32(3): 384–402.

15.

Simpson

McDonald

. Rethinking rural health ethics. Cham: Springer, 2017, http://ebookcentral.proquest.com/lib/uleth/detail.action?docID=4947093

16.

Anand

. The concern for equity in health. J Epidemiol Community Health 2002; 56: 485–487.

17.

Braveman

. Health disparities and health equity: concepts and measurement. Ann Rev Public Health 2006; 27: 167–194.

18.

Sen

. Why health equity? Health Econ 2002; 11: 659–66.

19.

Starfield

. Equity in health. J Epidemiol Commun Health 2002; 56(7): 483–484.

20.

Whitehead

. The concepts and principles of equity and health. Health Promot Int 1991; 6(3): 217–228.

21.

DeBruin

Liaschenko

Marshall

. Social justice in pandemic preparedness. Am J Public Health 2012; 102(4): 586–591.

22.

Gostin

Powers

. What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff (Millwood) 2006; 25(4): 1053–1060.

23.

Marmot

Friel

Bell

, et al. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization, 2008, https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf?sequence=1

24.

Hankivsky

Christoffersen

. Intersectionality and the determinants of health: a Canadian perspective. Critical Public Health 2008; 18(3): 271–283.

25.

Hawe

. The social determinants of health: how can a radical agenda be mainstreamed. Can J Public Health 2009; 100(4): 291–293.

26.

Reid

. The rural determinants of health: using critical realism as a theoretical framework. Rural Remote Health 2019; 19: 5184.

27.

Mitchell

. Postmodernism, health and illness. J Adv Nurs 1996; 23(1): 201–205.

28.

Rodney

Harrigan

Bashir

, et al. A further landscape: ethics in health care organizations and health/health care policy. In: Storch

Rodney

Starzomski

(eds) Toward a moral horizon: nursing ethic for leadership and practice. Toronto, ON, Canada: Pearson, 2013, pp. 358–383.

29.

McGregor

. Neoliberalism and health care. Int J Consumer Stud 2001; 25(2): 82–89.

30.

Haddow

Alberta: one-party dominance and neo-liberalism. In: Haddow

Klassen

(eds) Partisanship, globalization, and Canadian labour market policy: four provinces in comparative perspective [Internet] . Toronto, ON, Canada: University of Toronto Press, 2016, pp. 178–200.

31.

Alberta Health Services. Alberta Health Services strategic direction 2009 - 2012: defining our focus, measuring our progress, 2009, http://www.assembly.ab.ca/lao/library/egovdocs/2009/alahs/172555.pdf

32.

Canadian Nurses Association. Code of ethics for registered nurses. Ottawa, ON, Canada, 2017, https://www.cna-aiic.ca/en/∼/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive

33.

Canadian Nurses Association. Social justice: a means to an end and an end in itself. 2nd ed. Ottawa, ON, Canada: Canadian Nurses Association, 2010, https://www.cna-aiic.ca/∼/media/cna/page-content/pdf-en/social_justice_2010_e.pdf

34.

Canadian Public Health Association. Public health – community health nursing practice in Canada: roles and activities. 4th ed., 2010, https://www.chnc.ca/upload/membership/document/2016-07/publichealth-communityhealthnursingincanadarolesandactivities2010.pdf#upload/membership/document/2016-07/publichealth-communityhealthnursingincanadarolesandactivities2010.pdf

35.

Doane

Varcoe

. Relational Practice and Nursing Obligations. ANS Adv Nurs Sci 2007; 30(3): 192–205.

36.

Doane

Pauly

Brown

, et al. Exploring the Heart Ofethical Nursing Practice: implications for ethics education. Nurs Ethics 2004; 11(3): 240–253.

37.

Anderson

Rodney

Reimer-Kirkham

, et al. Inequities in health and healthcare viewed through the ethical lens of critical social justice: contextual knowledge for the global priorities ahead. ANS Adv Nurs Sci 2009; 32(4): 282–294.

38.

Yanicki

Kushner

Reutter

. Social inclusion/exclusion as matters of social (in)justice: a call for nursing action. Nurs Inq 2015; 22(2): 121–133.

39.

Moodley

Hardie

Selgelid

, et al. Ethical considerations for vaccination programmes in acute humanitarian emergencies. Bull World Health Organ 2013; 91(4): 290–297.

40.

Beauchamp

. Public health as social justice. John Wiley & Sons, 2012, https://ebookcentral-proquest-com.ezproxy.uleth.ca/lib/uleth/detail.action?docID=861648

41.

Smith

Baluch

Bernabei

, et al. Applying a social justice framework to college counseling center practice. J College Counsel 2003; 6(1): 3.

42.

Bushy

. Rural health care ethics. In: Warren

Smalley

(eds) Rural public health: best practices and preventative models. New York: Springer Publishing Company, 2014, pp. 41–54.

43.

Meit

Knudson

. Why is rural public health important? A look to the future. J Public Health Manag Pract 2009; 15(3): 185–190.

44.

Bavington

. Rural public health. Can J Public Health 1994; 85(5): 295–297.

45.

DesMeules

Pong

How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa, ON, Canada: Canadian Institute for Health Information, 2006, http://publications.gc.ca/collections/collection_2013/icis-cihi/H118-91-2006-eng.pdf

46.

National Advisory Committee on SARS and Public Health. Learning from SARS: renewal of public health in Canada. Ottawa, ON, Canada: Health Canada Publications, 2003, http://publications.gc.ca/collections/Collection/H21-220-2003E.pdf

47.

Boggild

Yuan

Low

, et al. The impact of influenza on the Canadian first nations. Can J Public Health 2011; 102(5): 345–348.

48.

Hutchins

Fiscella

Levine

, et al. Protection of racial/ethnic minority populations during an influenza pandemic. Am J Public Health 2009; 99(Suppl. 2): S261–S270.

49.

Hutchins

Truman

Merlin

, et al. Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative. Am J Public Health 2009; 99(Suppl. 2): S243–S248.

50.

La Ruche

Tarantola

Barboza

, et al. The 2009 pandemic H1N1 influenza and indigenous populations of the Americas and the Pacific. Euro Surveillance 2009; 14(42): 19366.

51.

Ministry of Health. New Zealand influenza pandemic plan: a framework for action. 2nd ed. Wellington, New Zealand: Ministry of Health, 2017, https://www.health.govt.nz/system/files/documents/publications/influenza-pandemic-plan-framework-action-2nd-edn-aug17.pdf

52.

Schwartz

Yen

M-Y.

Toward a collaborative model of pandemic preparedness and response: Taiwan’s changing approach to pandemics. J Microbiol Immunol Infect 2017; 50(2): 125–132.

53.

Musto

MacDonald

Ulrich

, et al. Health services restructuring in Alberta and the 2009 pandemic influenza—An untimely concurrence. Healthcare Management Forum 2020; 33(4): 170–173.

54.

Uscher-Pines

Barnett

Sapsin

, et al. A systematic analysis of influenza vaccine shortage policies. Public Health 2008; 122(2): 183–191.

55.

Sander

Bauch

Fisman

, et al. Is a mass immunization program for pandemic (H1N1) 2009 good value for money? Evidence from the Canadian experience. Vaccine 2010; 28(38): 6210–6220.

56.

Weber

Hammer

. From chaos to control: implementation of mass influenza immunization clinics. AAACN Viewpoint 2013; 35(5): 4–8.

57.

National Advisory Committee on Immunization, Committee to Advise on Tropical Medicine and Travel. Canadian immunization guide. Ottawa, ON, Canada: Government of Canada, 2018, https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html

58.

Pan-Canadian Public Health Network. Canadian pandemic influenza preparedness: planning guidance for the health sector, vaccine annex, 2017, https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/cpip-pclcpi/assets/pdf/annex-d-2017-eng.pdf

59.

Immunization Program Standards and Quality. Immunization program standards manual. Edmonton, AB, Canada: Government of Alberta , 2017, http://www.albertahealthservices.ca/info/Page10802.aspx

60.

Tuite

Fisman

Kwong

, et al. Optimal pandemic influenza vaccine allocation strategies for the Canadian population. PLoS ONE 2010; 5(5): e10520.

61.

Bly

. Pandemic fear leaves many without flu shot. Lethbridge, AB, Canada: The Sunny South News, 2009.

62.

Luth

Jardine

Bubela

. When pictures waste a thousand words: analysis of the 2009 H1N1 pandemic on television news. PLoS ONE 2013; 8(5): e64070.

63.

Alberta Health. Alberta’s ethical framework for responding to pandemic influenza. Edmonton, AB, Canada: Alberta Health, 2016.

64.

Barry

. The great influenza: the story of the deadliest pandemic in history. New York: Penguin Books, 2009.

65.

Ghendon

. Introduction to pandemic influenza through history. Eur J Epidemiol 1994; 10(4): 451–453.

66.

Giles-Vernick

Craddock

(eds) Influenza and public health: learning from past pandemics. London: Earthscan, 2010.