Teaching and Justice

Incorporating Social Justice into Infectious Diseases and Disaster Preparedness Education

by Terri Rebmann, Director, Institute for Biosecurity, Professor, Department of Epidemiology & Biostatistics

There are multiple definitions of social justice, but at the root of them all is the belief that all individuals have value and should have equal access to resources. As a Professor who studies and teaches infectious disease epidemiology and disaster preparedness within the College for Public Health and Social Justice at Saint Louis University, the issue of social justice goes much deeper than simply being part of the name of my academic unit. Social justice is part of my identity as an individual and as an instructor. I have a deep commitment to social justice and aim to instill that sense of justice and equity into my courses with the hope that my students will gain or enhance their own commitment to such principles. I intentionally incorporate social justice principles into my courses and program curricula in a thoughtful and meaningful way.

Within the field of infectious disease epidemiology, the concept of social justice is inherent. Health disparities are never more prevalent than when studying infectious diseases. Deadly sexually transmitted infections, vaccine preventable diseases, influenza, and vector-borne diseases all disproportionately affect society’s most vulnerable populations: very young infants, the elderly, pregnant women, individuals who are immunocompromised, those with low income, and ethnic minorities. Some of these groups, such as young infants and the elderly, are inherently more vulnerable due to physiological differences that put them at risk of becoming infected or having severe complications from the disease once infected. However, social determinants of health also play a major role in infectious disease epidemiology. Lack of access to health care, stigma, low income, overcrowded housing, lack of transportation, and other social factors all contribute to infectious disease morbidity and mortality. It is in the realm of social determinants of health where social justice principles are often addressed in my pedagogy. I encourage students to consider not only the unalterable physiological factors that affect health, but also the areas where intervention is possible. I then encourage students to contemplate how interventions can best be chosen and implemented to address these social determinants of health. For example, we discuss in class how to identify high-risk groups that should be prioritized to receive influenza vaccine when supplies are limited and how to distribute that vaccine in a fair way that ensures equal access to it among the prioritized groups. How do we distribute vaccine to individuals who lack transportation or access to health care? What interventions or programs can/should be in place to ensure that individuals around the world have access to vaccine versus only those who live in wealthier countries, such as the U.S.?

In addition to teaching infectious disease epidemiology, I also teach classes and manage academic programs related to disaster preparedness; more specifically, disasters involving infectious diseases, such as bioterrorism, outbreaks of emerging pathogens, and pandemics. Social justice is critical to disaster preparedness, because most often, our most vulnerable citizens are disproportionately affected by disaster. Individuals with low income may lack the transportation or resources to evacuate their home, immunocompromised individuals are more likely than those with functioning immune systems to become infected and have severe disease during a bioterrorism attack, pregnant women are at higher risk of hospitalization or death during emerging infectious disease outbreaks involving respiratory pathogens (such as SARS Co-V), and pandemic vaccines may be less efficacious among the elderly. During disasters, rapid response is essential to minimize morbidity and mortality and communities lack the resources to provide aid to all citizens. Therefore, decisions need to be made regarding how limited resources will be distributed. For example, during a future influenza pandemic, anti-viral medications will be needed to both treat those who are infected and given as prophylaxis to exposed individuals to prevent infection. One approach that has been suggested is to offer healthcare personnel pre-exposure prophylaxis (PReP) for the duration of each 6 – 8 week pandemic wave during times when a pandemic vaccine is not available; PReP would protect healthcare workers from infection and ensure that they are able and willing to continue working. However, the U.S. lacks sufficient anti-virals to both treat infected patients and give to healthcare personnel as PReP. Who then should be prioritized to receive the limited anti-virals? Social justice demands that a fair and equitable approach be used when making these challenging decisions to ensure that our most vulnerable populations are protected and ensure that our healthcare personnel are willing and able to continue working throughout the disaster response. How do we teach students to use an ethical and evidence-based approach to make these decisions?

In my classes, I use a variety of teaching approaches to engage students with social justice issues. Many students in my classes arrive at SLU with a deep commitment to social justice. For many, it is what drew them to the field of public health or disaster preparedness. However, they are often lacking knowledge about the scientific and social factors that contribute to health disparities. I deliver some information through readings and lectures to provide a foundation on the physiological differences that predispose individuals to infection and the social determinants of health specific to various diseases and conditions. I often use small group discussion to have students think through the complex issues involved in infectious disease epidemiology or disaster response. I have them use different points of view during the discussion, assuming the role of a parent, healthcare worker, public health professional, or disaster planner in the same scenario. This forces students to see the issue from multiple angles and (hopefully) gain a new perspective on how we can best intervene to limit health disparities. I also incorporate reflective essay writing into many of my courses. For example, I ask students to describe their past experience with an infectious disease or particular outbreak, either a disease they personally had or an infection of a friend or family member, and to reflect on how this disease/situation made an impact on them. Almost invariably, students describe social justice issues that arose with the disease/condition: lack of access to healthcare that led to more severe disease, stigma the person encountered when seeking screening or treatment, etc. Though my students do well on my quantitative tests and assignments requiring the calculation of morbidity and mortality rates, what they comment on most frequently in their course evaluation or communications with me is the impact that these reflective assignments and activities have made on their perspective as a future public health professional or disaster planner. I can receive no higher compliment than that.