Research Article
No access
Published Online: 25 September 2014

Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security

Publication: Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
Volume 12, Issue Number 5


In today's global society, infectious disease outbreaks can spread quickly across the world, fueled by the rapidity with which we travel across borders and continents. Historical accounts of influenza pandemics and contemporary reports on infectious diseases clearly demonstrate that poverty, inequality, and social determinants of health create conditions for the transmission of infectious diseases, and existing health disparities or inequalities can further contribute to unequal burdens of morbidity and mortality. Yet, to date, studies of influenza pandemic plans across multiple countries find little to no recognition of health inequalities or attempts to engage disadvantaged populations to explicitly address the differential impact of a pandemic on them. To meet the goals and objectives of the Global Health Security Agenda, we argue that international partners, from WHO to individual countries, must grapple with the social determinants of health and existing health inequalities and extend their vision to include these factors so that disease that may start among socially disadvantaged subpopulations does not go unnoticed and spread across borders. These efforts will require rethinking surveillance systems to include sociodemographic data; training local teams of researchers and community health workers who are able to not only analyze data to recognize risk factors for disease, but also use simulation methods to assess the impact of alternative policies on reducing disease; integrating social science disciplines to understand local context; and proactively anticipating shortfalls in availability of adequate healthcare resources, including vaccines. Without explicit attention to existing health inequalities and underlying social determinants of health, the Global Health Security Agenda is unlikely to succeed in its goals and objectives.

Get full access to this article

View all available purchase options and get full access to this article.


US Department of Health and Human Services. Global Health Security: Vision and Overarching Target. Accessed July 28, 2014.
Bernard KW. Health and national security: a contemporary collision of cultures. Biosecur Bioterror 2013;11(2):157-162.
US Department of Health and Human Services. Global Health Security Agenda: Toward a World Safe & Secure from Infectious Disease Threats. Accessed February 26, 2014.
Inglesby T, Fischer JE. Moving ahead on the global health security agenda. Biosecur Bioterror 2014;12(2):63-65.
Gronvall GK, Morhard R, Rambhia K, et al. Meeting Report: Improving Global Health, Strengthening Global Security. Center for Biosecurity of UPMC website; 2010. Accessed July 28, 2014.
US Department of Health and Human Services. U.S. Commitment to the Global Health Security Agenda: Toward a World Safe & Secure from Infectious Disease Threats. Accessed February 26, 2014.
Farmer P. Social inequalities and emerging infectious diseases. Emerg Infect Dis 1996;2(4):259-269.
Uscher‐Pines L, Duggan PS, Garoon JP, Karron RA, Faden RR. Social justice and disadvantaged groups. Hastings Cent Rep 2007;37(4):32-39.
O'Sullivan T, Bourgoin M. Vulnerability in an influenza pandemic: Looking beyond medical risk. Public Health Agency of Canada; 2010. Accessed March 23, 2014.
Global Report for Research on Infectious Diseases of Poverty. WHO; 2012. Accessed April 1, 2014.
Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva: World Health Organization; 2008. Accessed July 28, 2014.
Blumenshine P, Reingold A, Egerter S, Mockenhaupt R, Braveman P, Marks J. Pandemic influenza planning in the United States from a health disparities perspective. Emerg Infect Dis 2008;14(5):709-715.
Diderichsen F, Evans T, Whitehead M. The Social Basis of Disparities in Health: Challenging Inequities in Health: From Ethics to Action. New York: Oxford University Press; 2001.
Quinn SC, Kumar S, Freimuth VS, Musa D, Casteneda-Angarita N, Kidwell K. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic. Am J Public Health 2011;101(2):285-293.
Kumar S, Quinn SC, Kim KH, Daniel LH, Freimuth VS. The impact of workplace policies and other social factors on self-reported influenza-like illness incidence during the 2009 H1N1 pandemic. Am J Public Health 2012;102(1):134-140.
Dee DL, Bensyl DM, Gindler J, et al. Racial and ethnic disparities in hospitalizations and deaths associated with 2009 pandemic influenza A (H1N1) virus infections in the United States. Ann Epidemiol 2011 Aug;21(8):623-630.
Wenger JD, Castrodale LJ, Bruden DL, et al. 2009 pandemic influenza A H1N1 in Alaska: temporal and geographic characteristics of spread and increased risk of hospitalization among Alaska Native and Asian/Pacific Islander people. Clin Infect Dis 2011 Jan 1;52(Suppl 1):S189-S197.
Balter S, Gupta L, Lim S, Fu J, Perlman S. Pandemic (H1N1) 2009 surveillance for severe illness and response, New York, New York, USA, April-July 2009. Emerg Infect Dis 2009;16(8):1259-1264.
Levy NS, Nguyen TQ, Westheimer E, Layton M. Disparities in the severity of influenza illness: a descriptive study of hospitalized and nonhospitalized novel H1N1 influenza-positive patients in New York City: 2009-2010 influenza season. J Public Health Manag Prac 2013 Jan-Feb;19(1):16-24.
Tricco AC, Lillie E, Soobiah C, Perrier L, Straus SE. Impact of H1N1 on socially disadvantaged populations: systematic review. PLoS One 2012;7(6):e39437.
Rutter PD, Mytton OT, Mak M, Donaldson LJ. Socio-economic disparities in mortality due to pandemic influenza in England. Int J Public Health 2012 Aug;57(4):745-750.
Inglis NJ, Bagnall H, Janmohamed K, et al. Measuring the effect of influenza A(H1N1)pdm09: the epidemiological experience in the West Midlands, England during the ‘containment’ phase. Epidemiol Infect 2014 Feb;142(2):428-437.
Lowcock EC, Rosella LC, Foisy J, McGeer A, Crowcroft N. The social determinants of health and pandemic H1N1 2009 influenza severity. Am J Public Health 2012 Aug;102(8):e51-8.
Kumar S, Quinn SC. Existing health inequalities in India: informing preparedness planning for an influenza pandemic. Health Policy Plan 2012;27(6):516-526.
Tam K, Yousey-Hindes K, Hadler JL. Influenza-related hospitalization of adults associated with low census tract socioeconomic status and female sex in New Haven County, Connecticut, 2007-2011. Influenza Other Respir Viruses 2014 May;8(3):274-281.
Yousey-Hindes KM, Hadler JL. Neighborhood socioeconomic status and influenza hospitalizations among children: New Haven County, Connecticut, 2003-2010. Am J Public Health 2011 Sep;101(9):1785-1789.
Cardoso AM, Coimbra CE Jr, Werneck GL. Risk factors for hospital admission due to acute lower respiratory tract infection in Guarani indigenous children in southern Brazil: a population-based case-control study. Trop Med Int Health 2013 May;18(5):596-607.
Clemans-Cope L, Perry CD, Kenney GM, Pelletier JE, Pantell MS. Access to and use of paid sick leave among low-income families with children. Pediatrics 2008 Aug;122(2):e480-6.
Bureau of Labor Statistics. Access to and Use of Leave—2011 Data from the American Time Use Survey Table 1. 2012. Accessed June 16, 2014.
Villalba JA, Liu Y, Alvarez MK, et al. Low child survival index in a multi-dimensionally poor amerindian population in Venezuela. PLoS One 2013;8(12):e85638.
Cohen S, Janicki-Deverts D. Who's stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. J Appl Soc Psychol 2012;42(6):1320-1334.
Cohen S, Doyle WJ, Skoner DP. Psychological stress, cytokine production, and severity of upper respiratory illness. Psychosomat Med 1999;61(2):175-180.
Monto AS, Ross H. Acute respiratory illness in the community: effect of family composition, smoking, and chronic symptoms. Brit J Prev Soc Med 1977 Jun;31(2):101-108.
Monto AS, Ullman BM. Acute respiratory illness in an American community. The Tecumseh study. JAMA 1974 Jan 14;227(2):164-169.
Rajatonirina S, Razanajatovo NH, Ratsima EH, et al. Outcome risk factors during respiratory infections in a paediatric ward in Antananarivo, Madagascar 2010-2012. PLoS One 2013;8(9):e72839.
Kumar S, Quinn SC, Kim KH, Musa D, Hilyard K, Freimuth V. The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the US. Health Educ Behav 2012 Apr;39(2):229-243.
Biggerstaff M, Jhung MA, Reed C, Fry AM, Balluz L, Finelli L. Influenza-like illness, the time to seek healthcare, and influenza antiviral receipt during the 2010-11 influenza season—United States. J Infect Dis 2014 Apr 13. ePub ahead of print.
Leon K, McDonald MC, Moore B, Rust G. Disparities in influenza treatment among disabled Medicaid patients in Georgia. Am J Public Health 2009 May 21;99(Suppl 2):S378-S382.
Checklist for Pandemic Influenza Preparedness and Response Plans. The Bellagio Meeting on Social Justice and Influenza; 2006. Accessed July 28, 2014.
Garoon JP, Duggan PS. Discourses of disease, discourses of disadvantage: a critical analysis of national pandemic influenza preparedness plans. Soc Sci Med 2008;67(7):1133-2242.
World Health Organization. Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. WHO; 2011. Accessed July 28, 2014.
World Health Organization. Pandemic Influenza Risk Management: WHO Interim Guidance. Geneva, Switzerland: WHO; 2013 . Accessed July 28, 2014.
World Health Organization. Pandemic Influenza Preparedness Framework: Partnership Contribution Implementation Plan, 2013-2016. WHO; 2013. Accessed July 28, 2014.
Global Health - Health Protection: What Is Integrated Disease Surveillance and Response (IDSR)? Centers for Disease Control and Prevention website. Updated January 25, 2012. Accessed June 23, 2014.
Kasolo F, Yoti Z, Bakyaita N, et al. IDSR as a platform for implementing IHR in African countries. Biosecur Bioterror 2013;11(3):163-169.
Lee BY, Brown ST, Cooley P, et al. Simulating school closure strategies to mitigate an influenza epidemic. J Public Health Manage Pract 2010;16(3):252-261.
Ferguson NM, Cummings DA, Cauchemez S, et al. Strategies for containing an emerging influenza pandemic in Southeast Asia. Nature 2005 Sep 8;437(7056):209-214.
Ferguson NM, Cummings DA, Fraser C, Cajka JC, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic. Nature 2006 Jul 27;442(7101):448-452.
Galea S, Riddle M, Kaplan GA. Causal thinking and complex system approaches in epidemiology. Int J Epidemiol 2010 Feb;39(1):97-106.
Kumar S, Grefenstette JJ, Galloway D, Albert SM, Burke DS. Policies to reduce influenza in the workplace: impact assessments using an agent-based model. Am J Public Health 2013 Aug;103(8):1406-1411.
Mabry PL, Kaplan RM. Systems science: a good investment for the public's health. Health Educ Behav 2013 Oct;40(1 Suppl):9S-12S.
Discovering influenza disease and economic burden. Centers for Disease Control and Prevention website. Updated December 5, 2013. Accessed April 30, 2014.
Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010 Oct 2;376(9747):1186-1193.
World Health Organization. Report of the WHO Pandemic Influenza A(H1N1) Vaccine Deployment Initiative. WHO; 2012. Accessed July 28, 2014.
Kumar S, Quinn SC, Kim KH, Hilyard KM. US public support for vaccine donation to poorer countries in the 2009 H1N1 pandemic. PLoS One 2012;7(3):e33025.
Seasonal Influenza (Flu): Influenza Division International Program. Centers for Disease Control and Prevention website. 2013. Accessed June 23, 2014.
Partnership for Influenza Vaccine Introduction. Task Force for Global Health website. Accessed May 4, 2014.

Information & Authors


Published In

cover image Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
Volume 12Issue Number 5September/October 2014
Pages: 263 - 273
PubMed: 25254915


Published online: 25 September 2014
Published in print: September/October 2014
Accepted: 25 June 2014
Received: 5 May 2014


Request permissions for this article.





Sandra Crouse Quinn, PhD, is Associate Dean for Academic Affairs, Senior Associate Director of the Maryland Center for Health Equity, and Professor, Department of Family Science, School of Public Health, University of Maryland, College Park. Supriya Kumar, PhD, MPH, is Research Assistant Professor, Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
Address correspondence to:Sandra Crouse Quinn, PhDAssociate Dean for Academic AffairsSenior Associate Director, Maryland Center for Health EquityProfessor, Department of Family ScienceSchool of Public HealthUniversity of Maryland2242CC SPH Building #255College Park, MD 20742-2611Email: [email protected]

Metrics & Citations



Export citation

Select the format you want to export the citations of this publication.

View Options

Get Access

Access content

To read the fulltext, please use one of the options below to sign in or purchase access.

Society Access

If you are a member of a society that has access to this content please log in via your society website and then return to this publication.

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

View options


View PDF/ePub

Full Text

View Full Text







Copy the content Link

Share on social media

Back to Top