Reaching Special Populations: Marginalized Populations, Health Services, and Refusals

ADITI RAO: The next course theme we’ll explore is on reaching special populations. As we mentioned at the beginning of the lecture, the last 1% of the world’s communities affected by polio are socially, politically, and/or economically marginalized. They may experience conflict on migration, environmental hazards such as poor transport networks and flooding, or government persecution. These communities, already underserved by a health system, may be skeptical of disease-oriented programs, which deemphasize key health and economic priorities and come from distrusted state and non-state actors. This section will describe how polio eradication has engaged with and been affected by these forces and consider the intended and unintended consequences on the community demand for health services.

Populations with ongoing polio transmission are often the ones with reasons to distrust their own governments. Polio eradication’s independent monitoring board has noted that in Pakistan, polio cases often appear in isolated communities, tribal populations, and environments with extreme social and economic deprivation. These are people and places where trust in government is low. The report further notes one threat emerges from all the individual community level voices heard in Pakistan– a sense of deprivation and of disenfranchisement from rights and duties owed by the state to its citizens. The concept of citizenship may itself be in doubt here.

Refusal of the polio vaccine is not a mere gesture, rather it’s a distillation of the anger that communities feel when polio workers knock on their doors over and over again, in the absence of other governmental services. To better understand some of these issues, let’s look a bit at some theoretical frameworks which might then guide how we meet and address these barriers in implementing program activities. So what is intersectionality? Intersectionality recognizes that we’re all made up of many facets. It does not presume that one category of social identity is more important than another. When people meet or interact with us, it’s not just where the one part of us, but with us as whole people.

The theory assumes that health outcomes are always caused by factors of all of our intersections that are related to multiple social identities. And finally, it relates to the understanding of power dynamics among individuals, which are the result of the interplay of multiple social identities of these individuals. Having understood this, what are the intersecting identities affecting communities refusing polio vaccines in Pakistan? We can think about gender, race, class, sexuality, disability status, et cetera. The communities most at risk of polio were largely those with limited access to fresh water, poor sanitation, and the absence of public service infrastructure. And why is understanding this social position so relevant?

Acknowledging this sense of alienation in conjunction with the deep practical challenges of simple survival in contested contexts is crucial to understanding how and why people behave the way they do, and it is necessary to establishing how an extensive internationally backed polio vaccination campaign fits into that world and designs its policies and programs to align with it. I hope we’re now beginning to see how incredibly complex it can be to plan and implement such a program. It’s not as simple as here’s a solution, and here’s a population that needs the solution. Next, let’s look at a slightly more complicated framework by Diderichsen and Hallqvist.

The relationship between the social context and the way in which individuals are sorted into social positions is central to the issue of health inequities. What do we mean by these terms? Social context comprises of the structure, culture, and functions of systems, including education, economic, judicial, and political systems. Social position refers to an individual’s place within the society in which they live, which is derived by the social context and is linked to systems that generate power, wealth, or risks. The model explores how social contexts create social stratification and assign individuals to different social positions.

As we can see here, there are multiple mechanisms that play a role in stratified health outcomes, including the central engines of society that generate and distribute power, wealth, and risks and thereby determine the pattern of social stratification. At the individual level, this figure depicts the pathway from social position to exposure to specific contributing causal factors and onto health outcomes. As many different interacting causes in the same pathway might be related to social position, the effect of a single cause may differ across social positions as it interacts with some other goals related to one’s social position.

To dive into this further, social stratification of individuals to different social positions determine that differential exposure to health-damaging conditions and value in resources influencing risks and outcomes. Influencing social stratification– that is, policies that influence gaps in opportunities and resources– can be achieved via education; family welfare policies, including parental leave, subsidized childcare, early child care provision, et cetera; social and economic opportunities for women to address; economic opportunities; equal wages; et cetera, which impact the trend of social stratification. What is an example of this in the Pakistan-Afghanistan context? As we saw earlier, some people have access to clean water and high-quality health services, while others do not, based on how they have been stratified into a social position.

Social stratification also determines differential exposure to risks of ill health for more and less advantaged groups. Decreasing exposure that is reducing excess exposure to risk for those in lower social positions can be achieved via interventions such as HIV prevention among high-risk groups and vulnerable populations. Again, how might this work in the case of polio in Pakistan and Afghanistan? We can think about how exposure to poliovirus is increased in areas without good wash services due to poor sanitation practices. In conjunction with differential exposure, we might also consider a differential vulnerability to risks of ill health, not only how an individual’s position affects what they are exposed to but if and when exposed how vulnerable are they to disease or injury?

And what might enable them to withstand such devastation? Thinking about polio in Pakistan, Afghanistan, we know marginalized people are less likely to be fully vaccinated. The final piece of the model looks at differential consequences of ill health. So when you was unwell, in what ways and to what extent does it debilitate an individual? Preventing unequal consequences of ill health can be addressed by the provision of universal access to care to prevent catastrophic expenditure, social protection policies, rehabilitation funds, et cetera.

In the case of polio in Pakistan in Afghanistan, poor kids who get polio don’t have access to education, health services, et cetera that would help them become household providers in their adulthood, resulting in further debilitating conditions and perpetuating a cycle of poverty and disease. The Diderichsen-Hallqvist framework of the social production of disease allows us to unpack what we largely term as social determinants of health across the individual and community levels. And while complex, it is key to our understanding of challenges faced by marginalized populations and how we can address these issues in order to reach the vulnerable communities for more than just achieving the goal of polio eradication.

I would encourage you to take a pause and think about these questions. What are some inequalities that lead to ongoing polio transmission, in particular communities in Pakistan and Afghanistan? Can we explain how these inequalities might lead populations to be more or less likely to refuse the polio vaccines? And finally, what can be done about it?

Faced with the challenges outlined in this section, recently the GPI announced that they would begin an integrated services initiative to mobilize urgent help for deprived and polio vulnerable communities. UNICEF is proceeding by supporting a convergent package of basic health services in high-risk areas in Afghanistan and Pakistan. In addition to that, Rotary International and the Gates Foundation are supporting a number of important basic services projects, also in high-risk polio areas in Pakistan in the health and WASH sector. I’ll end this section leaving each of you with this question– do we think these efforts are enough, and what goal or purpose might it be serving?