The Social Psychological Decision Processes of Vaccine Allocation in the Event of a Pandemic Influenza Threat

The H1N1 pandemic of 2009 has served to highlight the health vulnerabilities on a global scale and need for a unified global response. The subsequent demand for flu vaccines however has highlighted disparities in health care access and has caused conflict between social groups because of prioritization in the distribution of the vaccines.  The comparative evaluation of change in vaccine allocation decisions with the change of the proximity of the health will show that the interest to protect ones own community is a primary consideration in decisions made. In studying the social psychological decision processes of vaccine allocation in the event of a pandemic influenza threat, the study will focus on how value systems are changed in the face of an imminent health threat as well as how they are being subsequently rationalized.

According to the World Health Organization (2009a), the threat of flu pandemic remains to be one of the biggest health risks, estimating the loss of life of as much as quarter of the worlds total population. The most recent threat has come in the form of H1N1 flu strain which received the WHOs fourth level of pandemic warning. Though there has been significant success in the development of the vaccines, access to it remains highly limited particularly in less developed countries (LDC) that are simply relying on donations of the medicines. However, the very nature of a pandemic is that as along as a population is infected or vulnerable to the infection, everyone else, regardless of their access to advance medical technologies, remains vulnerable (2009b).

Despite the recognition of this concern however, there is little public outcry to make vaccines more available to countries that cant afford them has not been evident as many people seem to be more concerned with getting the vaccines for themselves. The concern becomes even more critical as research show that the various influenza strains are evolving and adapting at a very fast rate. The implication is that unless there is wide access to vaccines worldwide, there is no assurance that even current vaccines will remain effective in deterring infection of pandemic flu threats.

Review of Related Literature
Pandemic Recognition and Response
Common influenza outbreaks naturally occur during colder seasons and fatalities are generally due to complications brought on by pre-existing health conditions. However, those that are considered to be pandemic threats are strains that show resistance to ordinary treatment, high rates of infection and communicability. In the case of the recent pandemic of AH1N1, popularly referred to as swine flu, is a strain of the common cold and proved highly resistant to existing vaccines and afforded little cross-reactive immunology. Virologist now theorize that the strain developed from an influenza strain among swine in Asia which transforming into a human strain which then spread into North America citing that mapping of the genome of the strain shows that it is a combination of known Eurasian and North American flu strains (Smith et al, 2009). A particular cause of alarm for scientists was the rate by the strain evolved and how widely it spread before being detected the initial symptoms were very mild but rapidly escalated when the viral infection was already spread significantly and worse, mutate at an unmanageable rate.

According to the U.S. based Center for Disease Control, in general, the virulence of the last pandemic strain was mild and had low mortality rates and attributes the loss of life to quality health care and lack of early detection capabilities.  However research developed by the Imperial College London has also shown that the 2009 H1N1 strain had the capacity infect deep lung cells causing more severe respiratory symptoms (The Swedish Research Council, 2009 AH1N1, 2010). The consensus seems to be that either patient only suffered mild or very severe symptoms, the latter representing most of the fatalities recorded. In developed countries, the average fatality rate was pegged at 0.03 but LDC rated as high as 2 of all diagnosed cases, representing a ten-fold difference. This has raised the concern for the WHO to increase access to vaccination to prevent another pandemic outbreak of not only the H1N1 strain but an emergent more fatal new strain (Nightingale et al, 2009).

In general, vaccine development for influenza viruses are being undertaken only by the largest pharmaceutical companies among them Novartis, Pfizer and Glaxo-Smith Kline among others and developed countries in Europe and North America (WHO 2009b). The 2009 flu pandemic vaccine has proven to have a high effectiveness of destroying infection or at the very least, weakening the infection to the level that patients immunological systems can deal with the infection. However, Keiji Fukuda of the WHO admits that further testing is still needed to ensure the vaccines effectiveness and safety (WHO, 2010). Another key concern in the course of the development of the vaccine were concerns that the strain was still evolving indicating that it is not yet stable or reached its maturity that would suggest that current vaccines will not be effective at all. However, despite o f this, orders for the first batch of vaccines that manufacturing pharmaceutical companies where given directives by the WHO to follow a prioritization list for the distribution.

According to the subsequent study developed by the Board on Global Health (BGH) (2009), during the first half of the 2009, experts were still arguing regarding whether the new strain warranted the status of a pandemic. The argument for those against it pointed out that infection rates did not differ significantly from the usual incidence of influenza. However, with the development of statistics that show its potential as a contagion and its potential for greater virulence, pharmaceutical companies, motivated significantly by the WHO, to start production of the vaccine. The vaccines were made available by the fourth quarter of 2009. By November of 2009, the WHO indicated that 65 million inoculations were completed and adverse reaction was only reported at 0.15. Reported adverse reactions included bleeding and Guillain-Barr syndrome (GBS), side-effects already recognized for influenza vaccines of other strains (Stark et al, 1999).

Social Reaction and Response
With the availability of vaccines limited and highly controlled, there were questions regarding how prioritization was being developed. The general consensus was vaccination was the best means of deterring the spread of the strain though there still limited data to substantiate the claim (Ellis, 2009)  In most countries that did have access to the vaccines, priority was given for health workers, children, the elderly and those who had compromised immunological conditions (Jordan  Hayward, 2009). There was a number of controversy regarding how the rest of the vaccines were distributed pointing out that big corporations were had greater access to the supply while public service hospitals were already indicating that their current supplies were insufficient to serve the people queuing up for the inoculation (Rubin et al, 2009). Concerns grew that the issue would become a source of serious social conflict particularly in the US where health reforms were garnering significant debate or to actual violence in countries where fatalities where high and supplies were even more scarce (Franklin, 2009).

Though many have argued that demand for the vaccines was in part being exacerbated by the media, there was no denying the mass reaction that at times bordered on hysteria (Davidson, 2009 Lantier, 2009). After the initial distribution of the vaccines in developed countries, significant efforts were made to widen distribution as asocial response and as extension of disease management objectives (Nieburg, 2009). In the case of North America, Canada and the US diverted much of its excess vaccines to Mexico which was among the hardest hit by the outbreak (Smith, 2010). However, there are some critics that this was only done after there was indication that incidence of H1N1 were in decline and after significant lobbying from the WHO as public interest groups. White (2010) point out also that unless the US and other leading countries are able to convince pharmaceutical companies to offload current surplus, the scarcity in the vaccines will likely rise again with the next flu season.

Considering these opinions, the implication seems that when an outbreak again occurs, access to the vaccines will again be limited to more developed countries. This can have underlying implications to the future effectiveness of disease management since pandemic outbreaks often begin in less medically advanced countries then quickly spreads to more developed countries by commerce or transportation (BMJ-British Medical Journal, 2009). To mitigate wider production of the vaccines and to make them more accessible, the European Union has authorized the licensing of the production of vaccines, a move that has been considered to be a departure of its previous protective stance of proprietorship (Cook, 2009).

Social Psychology Perspectives
Franklin (2009) point that the recent fears regarding the threat of pandemics has brought to a global scale the social and political challenges of quality health care. The process of prioritizing alone reveals the perceived social value of people or professions in society. DeWall (2009) also points out that the issue has also revealed the how much the fear regarding the pandemic has impacted spending, behavior and perceptions. These have ranged from the demand for personal sanitation and hygiene products, demand in health care services and opinions who should be prioritized for vaccination. Ultimately, both authors recognize such reactions that would likely receive censure at any other time. The situation also creates significant animosity for public institutions they are often become the object of censure for not focusing on the development of flu vaccination capabilities though the issue may never have figured as critical health concern of the public before the outbreak (Research Australia, 2009). At the same time, individual countries response to the issue comes under strong scrutiny and even on an intimate level or injury. As seen in the case in the criticisms for how China prioritized vaccination which minimized the inclusion of foreign nationals (Sociologist backs controversial Beijing decision on flu vaccinations, 2009).

Hewitt (2009) the majority of the observed response and behavior as part of a collective survival instinct. Pandemics always have a social component because they are communicable diseases. In these situations, Hooker (2010) often is seen not only as primary care givers but also as mediators and often is excluded from the debates of prioritization. However, the ranking of prioritization beyond these groups becomes the source of debate. On one level, intimate social groups would work collectively to emphasize its value for prioritization and see any action that may diminish such value as a threat. Thus, when the Chinese government was criticized for not including foreign nationals in its vaccination prioritization but sociologists supported the validity of the Chinese governments decision to protect its citizens first. The response to the recent pandemic threat also cannot be considered as a specific reaction to the recent pandemic threat. Previous experience with the SARS epidemic of the late 1990s, where there were accusations regarding where the disease originated and who would be responsible for developing response to control the spread of the disease (Kay, 2003).

An earlier study developed by King (2003) highlight that the communicability of pandemic diseased directly impact the collective sense of security. Thus, it is recognized as security threat and elicits a reaction not dissimilar to how one would react to a terroristic or criminal threat. This is seen to really have the capacity of reducing reactions to primitive, protective and even defensive stances. These are all indications of social stress and often become reflected to individual reactions. As seen in the case of the recent pandemic, though even at the height of its infection fatality remained low, as low as the fatality for the common cold public demand for vaccination was already growing. At the same time, the sale of personal antiseptics and hygienic products resulted into periodic stock outs. Interviews of consumers at the height of the pandemic indicate significant amount of purchases diverted for this purpose as a precautionary measure. Personal review of acquaintances at that time indicated that their concern for the issue was very real but remained to be precautionary than the perceptions of any actual direct threat.

An individuals sense of security is intimately connected with the threats that he perceives his community faces. This research will show that the response of an individual for a threat on the scale of a pandemic disease can significantly impact what he perceives to be an appropriate social response. In these situations, sociologist suggests that what may be considered as self-serving are sociologically sound (Sociologist backs controversial Beijing decision on flu vaccinations, 2009 Hewitt, 2009). Using a survey and interactive exercise, the study will test the following hypotheses
Perceived scarcity of a resource will impact an individuals perception of equitable allocation
Perceived scarcity does not impact an individuals perception of equitable allocation
In the course of testing this hypothesis the research will determine how scarcity can impact ones perception of the vulnerability of ones own society, particularly in the way it engages protective and survival instincts. The valuation will not delve into whether the perception of risk is valid or not.

Respondents to the study will consist of individuals aged between twenty and thirty years old who will be selected through a selection survey which will limit the survey participants to individuals who already have a significant knowledge about the issue regarding the flu vaccination issue that rose from the 2009 H1N1 pandemic. Participants should also have sufficient English language competency to be facilitate answering of materials and the completion of activities. Aside from the age constraints stated, there will be no discrimination regarding the demographic characteristics of the respondents. In the case of psychographic characteristics, no distinct discrimination will be made. The actual study will consider a minimum of twenty respondents who will be asked to accomplish two activities that will measure the validity of hypotheses of the study.

The study will have two main instrumentations. The first will be the qualifying survey that will determine the actual participants of the study. The second will be materials that will be used in the actual testing of the hypothesis.

Qualifying Survey
The first part of the study, a non-random paper and pen survey, aims to be able to select activity participants who have sufficient knowledge or awareness regarding the issues associated with the H1N1 pandemic and the distribution of vaccines.

Research Activity
For the research activity, materials will be used to stimulate the allocation and distribution of vaccines into a number of seven social groups
the participants community,
a neighboring more affluent country,
a neighboring less affluent country,
a neighboring country of identical affluence,
a far-away more affluent country,
a far-away less affluent country,
a far-away country of identical affluence,
Each of these groups will be represented by a bowl labeled accordingly into which the participants will place marbles, a hundred in total, representing the allocation of vaccines.

As mentioned, the study will have two main phases the qualifying phase and the actual research activity to test the hypothesis of the study. The qualifying survey will be distributed to first a group of fifty people aged twenty to thirty that will be shortlisted to twenty research activity participants. There is minimal discrimination to demographic and psychographic characteristics of participants to support the idea that opinions to be gathered are that of common people. The negative and positive response to the questions will have no discrimination for either yes or no answers and valuation will be pegged on the number of dont know answers will be used to determine the level of awareness the prospective activity participant has about the research issue. In the event that, the first batch of qualifying survey will not yield a sufficient number of prospective activity participants, another batch of qualifying survey is to be conducted. The criteria for the qualifying survey will be as follows
Prospective activity participant indicated willingness to participate further in the study
Prospective activity participant did not give a Dont Know response for more than half of the questions responded to

Final list of prospective activity participant represents the twenty respondents with the least number of Dont Know responses

For the actual research activity, the participants will be asked to distribute the marbles which represent the current supply of H1N1 vaccines still available. For the purpose of the study, other than the allocations made by the participants, there is currently no other source of vaccines other than new batch which will cost three times the prevailing price of vaccines. Each of the marbles will only represent a 5 guarantee of immunity but regardless of this, the probability of infection from neighboring countries is 50 and 25 from far away countries (see proposed set up in Appendix B). It will be emphasized to the client that his decision will be considered as representative of his community. The participant will also be given the option of saving all of the vaccines for his community as a safeguard in the event that someone does become ill in the future. There will be two scenarios given to the participants which will measure factors affecting the allocations made of the participant

The first scenario states that the community of the respondent has not been affected by the H1N1 virus but reports have of infection have been reported everywhere else. The results will be tabulated by the researcher and the participant will be interviews briefly on how the decision process he used for determining the allocations.

In the second scenario, there are already reports of infection in the community of the respondent and health experts believe that the there will be more reported cases in the future. The results will be tabulated by the researcher and particularly attention will be made on how the adjustments were made by the participants particularly in consideration of the allocations for his own community. A brief interview will also be conducted to document the participants rationale for the adjustments, if any.

In the first scenario of the research activity, the research will be able to determine how participants decisions are influence by the health of his community, the proximity of possible threats and perceptions of wealth or capacity. In doing so, the research will be able to determine the value systems that are being utilized by the participants in the evaluating health issues. The differences in the allocations in the second scenario will determine how the existence of a health threat will affect the decisions made earlier. The research will also show how the threat or infection and scarcity of access will determine distribution of the vaccines, paralleling the prioritization measures that these undertaken with the first batch of vaccines in 2009.

Representing the group mind, the participants will be able to determine how their decisions changed and what if components of their decision making changed with the variation of scenarios. In terms of social psychology, it should be noted that the participants are not able to simply allocate for themselves vaccination but allocates it for groups. In this prospect, even if he allocates sufficient vaccines for his community and all neighboring communities, there is insufficient vaccine to immunize everyone thus, the threat remains. The real challenge for the participants is how they will secure their communities safety. It is likely that in the first scenario, the participants will display a high degree of liberalism in giving other communities some vaccine but the second scenario will certainly be more challenging particularly since there is the option of stockpiling. As pointed out, the strategy of prioritizing ones own survival is a basic logic of a society (Kay, 2003 Sociologist backs controversial Beijing decision on flu vaccinations, 2009 Hewitt, 2009).

Therefore, the most extreme response of the exercise, the participant taking all the allocations for his own community in view of the fact that his community is already reporting infection, may be considered to be morally reprehensible but may have sociological value. However, such an option will only have real value if access to a new batch vaccines is made by the other communities in the future of the disease absolutely runs through its course. Otherwise, the community will to be vulnerable to infection and even if they have access to vaccines, there is no assurance that it will continue to be effective if the virus again mutates.

During the course of the H1N1 scare, the concern for preventing infection caused a high degree of apprehension and even panic among the public. Despite efforts of the medical and scientific community to mitigate the concerns, the media and the public itself created outcry for vaccines and other health measures. On one hand, this reaction may have been instrumental in the management of infection risks since it made people more aware of the threat. However, more than anything else, the situation gave a good example of how much society as a collective impact social and political policies and how individual psychologies in turn reacted to the issue. More disturbingly, it showed how even a relatively manageable health threat can induce collective protective and survival instincts.

For health and social development managers or administrators, there is recognition of the intimacy of health in individual and group society which is the reactions to the issue is often visceral in nature. Thus, it is to be expected that reactions to health care on both individual and social levels can be considered selfish. However, it can also be easily recognized that such an approach is beneficial to the survival of a society. In the case of pandemics, the only real way that people can really be safe is if everyone receives vaccination. It has been proven that universal efforts to eradicate diseases are possible as in the case of small pox but this was only made possible with global immunization initiatives. In emphasizing this logic to the public, then there may be greater recognition of insuring global access to the influenza vaccines. By applying and extending this group think perspective on a global scale, then the concern for global access to vaccine can be realized. At the same time, since the market is a global one, companies may have a greater incentive to produce the vaccines at a more affordable rate.

Directions for Future Research
The application of this research can be extended first and foremost into understanding how greater global concern can be generated to solve highly infectious diseases in the world. These would include other strains of influenza, particularly the avian strain, commonly referred to as bird flu, which has already proven to be more fatal than H1N1. Another option for research is the reaction to an unknown strain that could be a highly communicable as swine flu but as fatal as the avian strain. The interest in these flu strains is due to the opinion of experts that as long as the access to treatment of these diseases remain anywhere in the world, there is no assurance that an individual, regardless of how wealthy or how much access he has to quality health care, can be absolutely safe. Other areas of research can also have a more theoretical approach such as the determination of how sociological value systems are developed in the development of health risks. More practical research can also be conducted to determine the viability of global health standards and systems.


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