Mind the Gaps Conclusion [8 of 8]
Mind the Gaps Applied: Individuals [6 of 8]
The following two scenarios reflect the application of how one might apply Mind the Gaps to promote inclusive action. The first scenario shows an administrator using the Mind the Gaps framework to consider how to address a conflict at the school. The second scenario demonstrates how a proposed government action was evaluated under the Mind the Gaps framework and illustrates the responsive action that sought to promote conscious, inclusive action for social change.
B. Institutional: Emergency Preparedness
In December 2005, the Center for Disease Control (CDC) hosted a teleconference proposing that local governments throughout the United States adopt “Community Legal Preparedness for Public Health Emergency” and expand the public health authority for an infectious disease outbreak, like avian flu. During the Questions & Answers, I inquired how this proposed scheme to broaden authority would address the needs and protect the rights of people from diverse communities, such as those who didn’t speak English; there was a long pause, and someone attempted to respond but didn’t actually address the question. I wondered what an inclusive preparedness plan would look like?
Public Health Authority is the power that government has over the people to protect the public’s health. The public entrusts discretionary power to the public health authority, and the proposal sought to broaden discretionary authority even further eliminating restrictions placed after historical episodes of misuse of authority over marginalized communities. I reflected on the response to my question about non-native English speakers and wondered who else might not be adequately included in a plan developed by people who aren’t thinking consciously about inclusion. Below are outlined some of the questions that I considered when thinking through how to make the CDC’s proposed course of action truly inclusive.
1. Gaps of Culture: Public Health
- What if the public health authority’s good intentions to protect the public good gets overrun by the politics of fear and discrimination in a time of panic and uncertainty?
- How does the public health authority intend to use their discretionary power?
- Is there concrete guidance on how to use discretionary power in difficult situations?
- What protections exist for the public, if we fail to meet our ethical aspiration to use our power well?
- What if the public does not trust the public health authority or it’s good intention?
– what if the public health authority is not as good as it presumes to be and what has been done to ensure that the good intentions are realized?
Having done a critical legal history of public health’s treatment of vulnerable populations during infectious disease outbreaks, I wondered whether the public health authority would be able to carry out its noble intention amidst the heavy political pressures that dominate, particularly in the initial stages of a public health disaster, when fear looms and science lags. I also wondered how those who do not trust the public health authority, or government in general, would be affected during a public health emergency and what the implications would be for the public’s overall health if some sub-groups did not follow the public health directives. I also considered that getting funding and support for preventative efforts and for marginalized communities is nearly impossible, and I considered that if there were a collective interest, it might facilitate funding for inclusive policies.
2. Gaps of GPSE: Public Health
- How might people from different GPSE be affected during the critical stages? (awareness/prevention, screening, treatment, vaccination, quarantine)
- How will geography play a part in an epidemic? With regard to limiting access to treatment and spreading disease?
- How will political status influence the public health authority efforts? What happens to non-English speakers, what happens to recent immigrants who are often scared to access public services in the US? What happens to prisoners? What happens to people who are not legal citizens?
- What social factors will influence the epidemic? What happens to the elderly? the elderly who are institutionalized in nursing homes? What happens to a child whose only parent may become ill?
- How might different economic status impact the public health authority plans? How will the homeless be contacted? How will the poor be impacted? Will the need to eat and fear of job loss lead people who work rather than stay under quarantine?
Relying on my historical identification of marginalized communities and scenarios from the SARS outbreak in Toronto, I developed 5 scenarios and used them to identify who might be impacted but might not be considered in the planning events.
I identified the following groups seemed the most likely to be omitted from the traditional planning strategies: homeless, poor, persons with disabilities, persons who are institutionalized (prisons, nursing homes), children, elderly, illegal immigrants/immigrants (incl. language access). These groups all have little political power and thus have minimal access to ensure that their interests are included in emergency preparedness endeavors and protected during times of crisis.
In an infectious disease outbreak, the personnel of transportation become key players in a variety of circumstances so paying attention to the geography of a situation remains important.
3. Gaps of Systems: Public Health
- Who is not adequately served by the current health care system?
- Will people who are illegal and fear deportation be afraid to come to the hospital during a pandemic?
- If the strategy is to use media to promote awareness and prevention, who will that miss? How will people who don’t speak English learn of this? people who cannot read? people who cannot afford a tv/radio? people who are homeless?
- How do public systems, such as public transit, affect who may come into contact with an infectious disease and how does it inform the way that disease may spread?
I considered that the public health system relies on three critical systems – the public health authority/government, the health care system, and the media. For people who have historically poor relationships with government, it is important to consider how they might respond/ignore the admonitions of government.
The government and health care system systemically alienate certain members of our community, particularly illegal immigrants. The fear that illegal immigrants have of government might prompt them to respond/ignore public health advisories in a way that would have significant implications to the overall health of the public. Considering the manner and degree to which this community is alienated from the health care system, I wondered what would be necessary to promote compliance and trust in the public health directives.
Most public health announcements are made through media channels, and I wondered what would happen to people who are not part of regular media. Homeless people who don’t have a radio/TV, deaf people who don’t listen to the radio, illiterate people who can’t read a flyer, and announcements made in English would miss a number of community members who don’t speak English.
4. Gaps of Power Perspective: Public Health
- How does this proposed action reflect assumptions of my power and privilege?
- Where and how can I use my power most effectively?
I saw the greatest contribution I could make to support the “vulnerable populations” I identified was to speak to the group that I was a “part” of and to use the tool of my training, law and ethics, to suggest ways to guide this very broad discretionary power. I developed an ethical argument to justify preventative policies that address the unique needs of vulnerable populations during a public health emergency. To see what an effort for inclusion on this issue looks like, I made that paper into a poster, Vulnerable Populations During a Public Health Emergency, that was presented at the CDC’s Public Health Law Conference in June 2005. When Hurricane Katrina hit three months later, the groups identified and the issues anticipated in the poster became a part of tragic history. It is my hope that if we endeavor to use these steps rigorously and consistently, we can promote inclusion action for social change.
The opportunity here that I did not undertake due to my position (a student writing a paper rather than a policy maker) would be to invite the now identified constituents into the problem solving process to ensure that any subsequent actions, such as the proposed preventative policies, were not based upon the power perspective of the problem solver.
In discussing this poster and working with people of diverse and vulnerable populations, I discovered that creating an inclusive space remains elusive, even for people who are committed to doing important work for social good. I offer a backbone for building capacity so that those who are committed to cultivating inclusive spaces might be able to realize their aspirations.
 Ettinger,K. A Critical Legal History of Public Health’s Treatment of Vulnerable Populations during a Public Health Emergency. (available from the author)
 This is not intended to indicate that this is the state of affairs at present. Though reports indicate, overall emergency preparedness planning is not well developed. As such, one wonders how much attention will be paid to the interests of marginalized communities in the time of a crisis and that was the purpose of this endeavor taking the focus that it did.
 Ettinger, KM. Vulnerable Populations During a Public Health Emergency, available at: www2a.cdc.gov/phlp/conferencecd2005/docs/kettinger.pdf