Healthcare Policy

Healthcare Policy 9(Special Issue) October 2013 : 14-25.doi:10.12927/hcpol.2013.23587
Population Health and Equity

The Pandemic Subject: Canadian Pandemic Plans and Communicating with the Public about an Influenza Pandemic

Laena Maunula

Abstract

In this paper, I examine the goals for pandemic public communication as outlined in two Canadian plans for pandemic planning and infection control. I critique these strategies by drawing on Foucault's notions of governmentality and biopower. My argument is that the public health communication campaign goals reviewed rest upon a particular conceptualization of health in the context of pandemic planning as an individual/family duty, and that scientific/medical expert knowledge is most appropriate for guiding pandemic planning. This study contributes to a sociological understanding of how pandemic preparedness and infection control are represented in Canadian pandemic plans, how public health shapes pandemic communication messages in Canada, and the implications of those messages for subjectivity and notions of citizenship.

In order to reduce infection and death during influenza pandemics, public health agencies worldwide have developed comprehensive pandemic public education campaigns. The Canadian pandemic public education plans strongly advocate infection control practices at the level of the individual and family, such as hand-washing, vaccination and respiratory etiquette, to prevent infection and stop further transmission. From a social and political perspective, this focus is problematic owing to the implications of defining ourselves in relation to moral categories associated with infection control techniques (e.g., be a good parent and have your children vaccinated), while disregarding the social and structural factors affecting the severity of influenza pandemics (e.g., poverty and inadequate housing on First Nations reserves causing an H1N1 crisis). Thus, the ways in which pandemic flu is represented in official pandemic education messages shape the way we view pandemic scenarios and ourselves, collectively and individually, within them.

In this paper, I consider the ways in which the messages developed for Canadian pandemic influenza public education are dangerous. I first examine the goals for pandemic public communication as outlined in two Canadian pandemic plans, exploring how pandemic planning and infection control are invoked within those texts. Drawing on Foucault's notions of governmentality and biopower, I then engage in a theoretical critique of those public communication strategies.

My argument is that the public health communication campaign goals reviewed rest upon a particular conceptualization of health in the context of pandemic planning as an individual/family duty, and that scientific/medical expert knowledge is most appropriate for guiding pandemic planning. To close, I discuss the pandemic subjects made possible in the context of those pandemic public communication messages. My goal is to open up public communication to theoretical critique – to ask what ideas about pandemic influenza are rendered unthinkable, and therefore, what pandemic planning questions are rendered unaskable.

Preparing the Public for a Flu Pandemic

The influenza viruses responsible for seasonal flu outbreaks are subject to antigenic mutations that allow new viral strains to develop. Cyclically, a strain develops to which the population has little or no immunity, and a global epidemic or "pandemic" can occur. Although experts in the health fields anticipate periodic pandemics based on history, they are unable to forecast exactly when and where these may happen.

It is extremely difficult to predict the virulence and severity of a novel influenza strain to which the population has little or no resistance. The devastation and great loss of life recorded during key pandemics of the last century, however, serve to caution us as to the immense potential damage that influenza pandemics can bring. Given that these pandemics arise with little warning and have a major national and international impact, emergency planning and response are needed.

Communicating with the public is a key aspect of pandemic preparation and response, and Canadian pandemic plans place considerable emphasis on communication utilizing multiple channels. Communications developed by the Public Health Agency of Canada (PHAC) and the Ontario Ministry of Health and Long-Term Care (MOHLTC) have included web-based resource pages (PHAC 2011a), weekly bulletins (PHAC 2011b), an online campaign of Google and Facebook advertisements, and multiple posters and fact sheets, five million of which were distributed in 23 languages in 2006 alone (MOHLTC 2008a).

In a number of informational pamphlets developed for the public on PHAC and MOHLTC websites, individual- and family-level infection control actions are strongly promoted. These behaviours include vaccination ("flu shot"), hand hygiene, respiratory etiquette (e.g., the "sleeve sneeze"), self-isolation (e.g., limit travel, stay home when ill), social distancing (e.g., avoid close contact with others), monitoring one's health, assessing and reporting suspected illness (MOHLTC 2008b).

Infection control behaviours are positively framed in these communication materials through association of these behaviours with such qualities as courtesy, responsibility, good parenting and preparedness. For example, covering one's cough is called "good respiratory etiquette" (Health Canada and PHAC 2006). Parents are exhorted to "take care of yourself and your family" (MOHLTC 2007a) and "be a good role model" (PHAC 2006a) by ensuring children are vaccinated and taught proper hand hygiene. Readers are urged to encourage others to follow similar behaviours: "Make sure family members get a flu shot too!" (PHAC 2006a). For healthy travel during a pandemic, one is advised to compile a travel health kit, purchase supplementary insurance, and then once home, disinfect footwear and monitor health for 14 days (MOHLTC 2007b). Several pamphlets instruct the reader to "be prepared" by considering the state of pandemic contingency plans in their communities and workplaces (MOHLTC 2007c).

What ideas about pandemic influenza, public health and citizenship underlie these messages? To address this question, I will explore stated goals for communicating with the public about pandemic influenza in the Canadian Pandemic Plan (CPIP), the Ontario Health Plan for an Influenza Pandemic (OHPIP) and public communication guidelines from the World Health Organization (WHO).

Canadian Pandemic Influenza Plan

At the federal level, the Canadian Pandemic Influenza Plan for the Health Sector delineates recommended pandemic control strategies and procedures, and serves as a guide for planning at the federal, provincial, territorial, municipal and organizational levels (PHAC 2006b: 1–2).

Plans devoted to communications surrounding a pandemic are detailed in CPIP's Annex K. These plans are detailed and complex – they include a breakdown of the roles and responsibilities of Canada's health partners concerning communications before, during and after an influenza pandemic.

Ontario Health Plan for an Influenza Pandemic

Chapter 12 of the Ontario Health Plan for an Influenza Pandemic (OHPIP) covers the communications aspect of pandemic planning at the Ontario provincial level (MOHLTC 2008c). It begins with a stirring quote from historian John M. Barry writing about the 1918 pandemic, highlighting the need for public health authorities to retain the public's trust (MOHLTC 2008c: 1).

The provincial public communication strategy is threefold: to educate, to reassure and to be accountable (MOHLTC 2008c: 1, 2). The OHPIP elaborates on the content of the public education messages according to the three pandemic phases:

  • Interpandemic and pandemic alert phases: to "raise awareness" of pandemic risk, to inform people of and "reinforce the importance of good hand and respiratory etiquette" and to "encourage cooperation and compliance with FRI screening and other precautions …" (emphases added) (MOHLTC 2008c: 2, 3).
  • Pandemic phase: provide up-to-date pandemic information through a variety of communication channels, advising the public on "what to do" (MOHLTC 2008c: 3).

The emphasis on trust, compliance and self-protection seems to fit with the expected "role of the public" during an influenza pandemic, as stated in Chapter 2 of the OHPIP. The public is expected "to actively participate in efforts to reduce the spread of the influenza, to comply with any public health measures and to participate in their own care in a pandemic" (emphases added) (MOHLTC 2008d: 5).

Public Communication Recommendations from the World Health Organization

Both the CPIP and OHPIP make mention of their cooperation and need for consistency with WHO pandemic planning recommendations for communication strategies (PHAC 2006b; MOHLTC 2008c). Within the Communications Annex, the CPIP specifically notes that the PHAC will utilize risk communications frameworks from the WHO (Annex K: 5). While those particular frameworks are not cited, it is useful to look at several WHO documents that outline steps for public communication during public health emergencies.

The strategies detailed within the outbreak communication guidelines (WHO 2005a) and the field guide, Effective Media Communications During Public Health Emergencies (WHO 2005b), clearly advocate communicating a message of trust in public communication messages. The WHO's recommendations for accomplishing this include citing "credible third parties," scientific research and published studies in particular, and demonstrating compliance with professional and scientific standards (WHO 2005b: 40).

From the pandemic communication plans and recommendations reviewed above, three main messages geared for the public seem readily apparent: (a) encouraging individual- and family-level infection control behaviours, (b) encouraging trust in authorities and compliance with their directives, which are (c) informed by expert scientific and medical knowledge.

There are numerous approaches to explore how the public interprets and responds to health and science communication, including critical and culturalist approaches to health and media studies (Zoller and Dutta 2008), the public understanding of science literature (Irwin and Michael 2003; Irwin and Wynne 1996) and within the Third Wave debate in science and technology studies (Collins and Evans 2002). However, in this paper I do not explore how pandemic influenza is constructed through particular messages or expertise claims, or how those messages are interpreted by the public – in other words, I don't address how well these communication approaches will "work." Instead, I raise the epistemological question of what kinds of pandemic subjects and citizens are made possible in the context of these specific pandemic public communication guidelines and goals. At this point, I turn to and briefly discuss several of philosopher and social theorist Michel Foucault's key theoretical concepts.

Foucauldian Concepts in the Context of Pandemic Public Education

Medical/scientific knowledge-power

The public communication goals and recommendations reviewed above emphasize adherence to and trust in the infection control techniques informed by a specific type of expert knowledge: that of scientific and (bio)medical experts. The tacit implication is that specialized scientific and medical knowledge is somehow more or most appropriate for guiding pandemic planning and response. Such an assumption about the legitimacy of scientific knowledge guiding public health and medical interventions would not be unique to the pandemic situation. Foucault traces the prominence of medicine in particular during the rise of those discourses of individuality and the body as privileged site of governmentality during the 18th century, and drawing from Foucault, O'Brien and Penna (1998), for example, have also noted the prominence of medical/scientific knowledge-powers more recently.

The individual as a medicalized subject

The emphasis on individually targeted self-protection techniques (e.g., instructing individuals to wash their hands in such a way that will stymie the spread of infection) perhaps is not surprising. Petersen (1997: 197) notes that a focus on the individual in the self-management of epidemiological risk is a key tenet of health promotion strategy – to empower through education. An example can be seen in smoking cessation campaigns that inform people about the risks of cigarettes so that they might make informed decisions and protect themselves from those risks (Brown 2000). The underlying assumption is that the information is being provided so that individuals are able to make the scientifically informed, risk-minimizing or risk-managing, correct choice – this approach is known as the "new public health" (Petersen 1997). These recommended infection control practices can also be understood as points of reference for individuals in constituting themselves as particular kinds of subjects (e.g., staying home when ill is considerate, responsible, doing my part, etc.) – in other words, Foucauldian technologies of the self.

The family as a medicalized subject

To a slightly lesser degree, but still noteworthy, public communication guidelines spotlight the family in pandemic infection control. Foucault perceived the family as becoming "the most constant agent of medicalization" and a "target for a great enterprise of medical acculturation" since the mid-18th century (Rabinow 1984: 280). Not that this in any way negates the consideration paid to individual bodies in attaining population well-being as discussed previously. It was through the family that individual bodies were to be reached – families became constituted as the major force, the channel through which individuals would be shaped into medical subjects (Rabinow 1984: 281).

Foucault connects this role as an agent of medicalization with the family's task of raising healthy children and the rise of discourses regarding what constituted "correct management" of the childhood stage (Rabinow 1984: 279). It became the family's designated mission to ensure that children would live to adulthood. Thus, hygiene, fitness, nutrition and other things linked to "care" were regulated as the domain and responsibility of the family (Rabinow 1984: 280). Foucault also notes the family's particular moral accountability for inoculation. With the family interpolated into this role, the way was made clear for "[a] 'private' ethic of good health as the reciprocal duty of parents and children to be articulated onto a collective system of hygiene and scientific technique of cure made available to individual and family demand by a professional corps of doctors, qualified, and as it were, recommended by the state" (emphases added) (Rabinow 1984: 281).

Health as a moral project

O'Brien and Penna (1998: 116) refer to the behavioural regimes made possible through institutional discourses as a "moral-political code." This resonates with the last point I will make about the public education plans: that the pursuit and protection of health in the event of a pandemic is positioned as a "moral" responsibility. I use the term "moral" in the same way I understand both O'Brien and Penna (1998) and Lupton (1999) to mean when arguing that subjects willingly take up recommended risk-minimizing health behaviours as a "moral enterprise relating to issues of self-control, self-knowledge and self-improvement"(Lupton 1999: 92–93).

Petersen (1997) claims that under the "new" public health system of individual-level health promotion strategies, a convergence between the public good and personal goals emerged. For our purposes, we can consider how the personal goal of avoiding infection and the public good of pandemic management are complementary. When merged, the two objectives form a mutually reinforcing moral project – practising self-protection at the individual level keeps me from becoming infected and protects others too, thus reducing infection levels in the population.

Several of the phrases taken from examples of current public education pamphlets, above, clearly illustrate this message of moral duty, particularly to one's community and family. There appears to be a tacit expectation that the individual will want to adopt behaviours that are positioned as prudent, responsible and good, and are in alignment with current scientific expertise.

How This Public Communication Is Dangerous

According to Foucault (2003: 172), "Critique does not consist in saying that things aren't good the way they are. It consists in seeing on what type of assumptions, of familiar notions, of established, unexamined ways of thinking the accepted practices are based." It is in this spirit that I will engage in a theoretical critique of the dangers of public education for pandemic flu. The danger lies not so much in the strategies themselves, but in the failure to examine the assumptions on which they are based. If we understand pandemic public communication plans as representative of and contributing to discourses on identity, the question then becomes: What kinds of pandemic subjects and citizens are made possible in the context of these pandemic public communication guidelines and goals?

What does a good citizen look like in the context of pandemic planning?

Higgs (1998: 189) argues that "governmentality locates itself within the idea of citizenship." Technologies of the self – in our case, self-protective behaviours such as hand-washing – "are ordered by techniques from which the model citizen can be created out of a composite of norms, values and statistics" (emphasis added). O'Brien and Penna (1998: 120–21) similarly speak of the "identity categories" that are "a normative basis of social and political order." The model pandemic citizen identity categories would certainly have moral implications as "signifiers of one's moral worth" (Petersen 1997: 198). What I mean is that the divide between vaccinated/unvaccinated, or those following/disregarding recommended behaviours (for whatever reason), translates into responsible/irresponsible, cautious/incautious, more/less risky people. If we consider the goal and guidelines for pandemic public communication within the reviewed texts, good pandemic citizens are those who comply with infection control directions, particularly by adopting self-protective practices, who trust in the direction of scientific and medical experts and who actively embrace these strategies and goals as their own.

A citizen who self-protects

An ideal pandemic citizen is one who, after seeking out information on pandemic flu and prevention tips, says: "This is my health. I am in control and I need to protect myself." Taking a cue from Foucault, such a stance towards pandemic influenza isn't necessarily a bad thing. The individual gains knowledge and, as the assumption goes, gains improved ability to protect his or her health. The follow-up Foucauldian question is then: What unarticulated, unquestioned premises is this assumption based on?

Above, I noted that governmentality depends on individual compliance with the needs of the state (Lupton 1999). This is not an instance of one group or individual controlling another, but rather of a mutual creation and mutual reinforcing of desires. It would be appropriate, then, to look at the ways in which an ideal pandemic citizen fits with the interests of the currently predominant neoliberal state.

A neoliberal society values individuality, choice, free markets and a scaling back of government intervention. Numerous scholars trace the concurrent and mutually reinforcing discourses of individual responsibility for health and neoliberal ideology (Burchell 1996; Higgs 1998; Petersen and Lupton 1997). Lupton (1999: 86) asserts that contemporary governmentality and neoliberal ideologies are indeed complementary. Petersen (1997: 204) sees this as a new "politics of citizenship" based on duties, not rights. Higgs (1998) similarly argues that within neoliberal discourses, a new concept of citizenship has emerged; one that is not based on social security but on individual freedom and choice.

The work of these scholars sheds light on the link tacitly made within pandemic public communication plans between self-protection, individual responsibility and the population or community. Good neoliberal pandemic citizens are those who accept responsibility for and protect their own health through choosing to adopt individual techniques of the self, with the understanding that they cannot (and perhaps should not) expect to rely on state-sponsored healthcare if they fall ill.

A citizen who takes personal responsibility

It is important to note that any mechanism through which people might be held accountable for their adherence to or rejection of the desired behaviours in the event of a pandemic are undeveloped. Yet, from the CPIP and OHPIP we see an expectation of self-monitoring and self-surveillance (e.g., self-reporting of infection and self-imposed isolation when ill), which will comprise a major facet of outbreak management (PHAC 2006b, Annex N: 1–2).

Lupton (1999) notes that mass targeted media campaigns, in which we can include the pandemic public communication campaigns, are contingent upon individuals' engaging in self-surveillance, classifying themselves as being at risk (in our case, of pandemic virus infection), borne from a sense of responsibility. Good pandemic citizens fix their gaze on themselves as a potential vector of disease and take steps to become guardians of population health through their individual actions.

A focus on individual responsibility can redirect responsibility away from public health authorities and the state to protect citizens (if only in the eyes of the individual reader of public communication materials) (Brown 2000; Sacks 1996). Issues of state-level and agency-level responsibility for infection control and pandemic management are rendered less visible.1 However, as both those pandemic plans indicate in the breadth of their text, nearly all aspects of pandemic planning, including infection control, require collaboration across multiple sectors of government and medical, scientific and public health agencies. Although managing a pandemic outbreak requires action among multiple sectors of society and government, the goals directing pandemic public communication do not appear to reflect fully this complexity.

From a Foucauldian perspective, the emphasis on individual responsibility for infection control is significant because of its implications for subjectivity, and harkens back to governmentality critiques of the individualistic neoliberal state. Its emphasis on choice, free markets and reduced government intervention requires people to engage in their own vigilant self-governance, self-surveillance and self-evaluation, becoming "experts of themselves" (Rose 1996: 59) in order to keep from burdening society with illness that could have been prevented and managed without government interference (Petersen 1997). Neoliberal subjects must vigilantly monitor themselves in this way, for no "collective safety net" (Higgs 1998: 193) can be expected to catch them if they do become ill.

A citizen who trusts in the scientific/medical expert knowledge

This scenario assumes that a program of self-monitoring and self-protection will indeed result in protection from, or at least reduced chance of, infection. Embedded within is the presumption that even at the time of an influenza pandemic, control is to some degree in the hands of the individual (do your part, get a flu shot, wash your hands and your health can be protected), though the efficacy of recommended behaviours cannot be guaranteed. Communication messages that do not address scientific uncertainty may perhaps create unrealistic expectations of individuals' ability to protect their health during a pandemic and could lead to public mistrust. A more Foucauldian critique, however, would be to address the seeming unassailability of the scientific and medical expertise that informs such self-protective behaviours.

While pandemic influenza certainly is a biomedical issue, it is not only a biomedical issue. It is also a social, cultural, political and ethical issue. Take, for instance, the sticky matter of providing "high-risk" groups with priority access to vaccines, which requires decision-making about which population groups should be given priority access to the influenza vaccine, a major component of the publicly funded healthcare intervention against outbreaks. Prevailing pandemic public communication guidelines emphasize the importance of scientific/medical expert knowledge and do not easily allow for questioning of that expertise, which renders questions about whether those without specialized medical expertise ought to contribute to pandemic planning largely unthinkable. Thus, decisions are made regarding issues that are explicitly positioned as being of a scientific/medical nature (infection rates, viruses) without equal attention (and, I suggest, perhaps without equal accountability) to their social, moral and political implications (e.g., fair resource distribution, housing, social justice). In another context, these issues might well be considered an appropriate matter of concern for the general public (and perhaps up for public debate or part of a political platform). In rendering it evident that scientific knowledge and biomedical methods ought to direct and inform pandemic planning, these expert knowledges have gained a legitimated dominance over planning and response for a complex and fundamentally social issue.

Although pandemic planners estimate that influenza pandemics will continue, it is difficult to gauge the virulence and pathogenicity of a virus to which the population has little or no immunity. It is perhaps more difficult to anticipate and manage the actions of populations that have not experienced a devastating, global epidemic of influenza in their lifetime. Yet this is what these pandemic public communication strategies aim to do: to teach self-protection for infection control, to reassure, to induce compliance to authority and trust in scientific and medical expertise – in short, to sell the public on the neoliberal goal of population well-being through individual action. These approaches indeed may result in decreased infection and death. In light of Foucault's cautions, however, the consequences of failing to investigate and make explicit the rationales for health promotion practices might have important social and political implications.

Recent decades have seen a violent upswing in the number of emerging infectious disease outbreaks – SARS, Ebola and MDR-TB, to name but a few. There is an urgent need for greater understanding of the ways in which infectious diseases are represented in public communication plans and messages, including the need to compare and explore the interrelationship between these and other national and regional pandemic plans. There is also a need to better understand the ways in which those representations are interpreted by the public and how various pandemic subject positions are taken up or resisted.

In this paper, I have attempted to open up Canadian pandemic public communication to theoretical critique. I have raised questions about the implications of those messages, challenged the unspoken assumptions on which they are founded, and in Harris's (1999: 27) lovely phrase, to "dislodge the certainties of the present." Our success in understanding and planning for future infectious disease outbreaks may depend upon our persistent willingness to do this.

 


 

La question pandémique: plans canadiens de lutte contre les pandémies et communication publique au sujet d'une pandémie d'influenza

Résumé

Dans cet article, j'examine les objectifs de communication publique de deux plans de communication canadiens visant la planification de lutte contre les pandémies et le contrôle de l'infection. Je critique ces stratégies à la lumière des notions de gouvernabilité et de biopouvoir définies par Foucault. J'avance que les objectifs de la campagne de communication en santé publique reposent sur une conception particulière de la santé, dans le contexte du plan de lutte contre les pandémies, où elle est considérée comme un devoir familial/personnel, alors que l'expertise et les connaissances scientifiques/médicales sont plus adéquates pour orienter un plan de lutte contre les pandémies. Cette étude apporte une compréhension sociologique de la façon dont la préparation à une pandémie et le contrôle de l'infection sont représentés dans les plans canadiens de lutte contre les pandémies, de la façon dont la santé publique donne forme aux messages des plans de communication canadiens et des répercussions de ces messages sur la subjectivité et la notion de citoyenneté.

About the Author

Laena Maunula, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

Correspondence may be directed to: Laena Maunula, Dalla Lana School of Public Health, 155 College St., Ste. 754, Toronto, ON M5T 1P8; e-mail: laena.maunula@utoronto.ca.

Acknowledgment

The author would like to thank Ann Robertson and two anonymous reviewers for helpful comments on an earlier version of this paper.

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Footnotes

1. Crowded conditions in industrialized poultry and swine farming are conducive to rapid spread and mutation of influenza viruses; ensuring hygienic practices in industrial factories is essential for control and prevention of pandemic influenza (Wiwanitkit 2010). As Link and Phelan (1995) state, the deregulation of food inspectors is an example of a "fundamental cause of disease" rooted in social and economic forces, which has led to the need for individual caution against disease. Thanks to the anonymous reviewer who pointed out this example.

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