ETHICAL AND RISK COMMUNICATION DILEMMAS FACED BY DECISION MAKERS DURING THE H1N1 2009 PANDEMIC: A MIXED METHODS ANALYSIS

Purpose:

During the 2009 H1N1 pandemic, decisions surrounding resource allocation posed several ethical and risk communication dilemmas. Persons prioritized for vaccine in early phases of the pandemic differed from the usual protocol; specifically, the elderly were not included and youth were prioritized based on epidemiological information about contagion and morbidity.  However, when doses of vaccine became abundant, the elderly were encouraged to get immunized. This required health message modifications that created confusion and uncertainty. Analysis of the H1N1 vaccine allocation process has raised significant ethical and risk communication problems that merit consideration.

Method:

In this mixed-method study, we interviewed 30 public health and health care decision makers and legal/ethical advisors in Mexico, Canada and the six US states most heavily impacted by H1N1. In addition, surveys were collected from more than 1,000 public health, health, and behavioral health professionals. The ethical dilemmas faced, solutions considered and implemented, and possible best practices guidelines are presented in this study.

Result:

One controversial theme is the growing reluctance to design and implement prioritization algorithms even if there are valid epidemiological data in support of such decisions.  The H1N1 experience has “converted” many in our sample to the view that vaccines should be distributed on a first-come, first-served basis. The blurring between at-risk and not at-risk groups is substantial and the confusion created by trying to create rigorous queuing for vaccine distribution is pragmatically and socially costly. Backlash from non-prioritized groups such as the elderly and police officers translated into non-compliance with public health recommendations. Further, the impact of tiered resource allocation on the relationship between the public and government health agencies hindered public health efforts and might have failed to produce the predicted benefits.

Conclusion:

The approach to resource allocation during an emerging and ongoing pandemic presents significant challenges. These include judgment and risk perception, risk communication, and ethical decision making under uncertainty.  H1N1 2009 revealed that some early and well-intended resource allocation decisions lead to negative and unintended consequences. Decision theory can prove especially helpful in analyzing these problems and to inform future pandemic planning.