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Public Health I: Goals and Tools Mapping Public Health and Public Health Concerns/Issues Public Health What is Public Health?
A. Society's obligation to assure the conditions for people's health; or B. Public health is what we, as a society, do collectively to assure the conditions for people to be healthy (IOM definition).
Promote physical and mental health; prevent disease, injury, and disability
A. Assessment assemble and analyze community health needs B. Policy Development informed through scientific knowledge C. Assurance services necessary for community health
A. Narrow focus proximal risk factors (e.g., infectious disease control) B. Broad focus distal social structures (e.g., discrimination, homelessness, socioeconomic status)
Epidemiology and biostatistics, education and communication, leadership and politics
a) The idea of 'Public Health' Historically traces back to John Snow and the cholera crisis in London, and has undergone significant change throughout the 20th century as a result of three main factors: (1) modern change in mortality causes and mortality rates; (2) longer life spans, resulting in greater emphasis on illness management as opposed to death prevention; and (3) shifting conceptions of health from being 'diseasefree' to being 'illnessfree'. Taken together, this resulted in shifting conceptions of medical laws. Most definitions of public health share the premise that the subject of public health is the health of populations---rather than the health of individuals---and that this goal is reached by a generally high level of health throughout society, rather than the best possible health for a few. Verweij and Dawson's approach conceptualises public health as 'collective interventions' that aim to promote and protect the health of the public. Within their conceptualisation are the following aspects:
1. public health is focused on populations (not just individuals);
2. much public health work is preventive rather than curative; and
3. most public health improvements cannot be brought about by individuals on their own: the attainment of public health ends requires collective efforts. Why is it then that 'Public Health' is under appreciated both publicly and politically? Gostin raises the following reasons: (1) the rescue imperative we like to save lives with names, not statistical lives; (2) the technological imperative public health solutions less appealing than genetic or high
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tech solutions; (3) the invisibility of public health when it works, we don't notice it; and (4) the culture of individualism society values personal goods over public goods more these days. b) The scope of 'Public Health' A. Epstein's Approach Scholars and practitioners are conflicted about the "reach," or domain, of public health. Some, like Epstein, prefer a narrow focus on the proximal risk factors for injury and disease. This has been the traditional role of public health---exercising discrete powers such as surveillance (e.g., screening and reporting), injury prevention (e.g., safe consumer products), and infectious disease control (e.g., vaccination, partner notification, and quarantine). In favour of this approach, Epstein argues that: 1
There is no relevant market failure for public health to correct the 'old' public health was aimed at solving issues which bargaining and the common law were not suited to solve e.g. disease control. Chronic diseases like obesity etc. should not be within the domain of public health because they do not generate the same kind of market failure that infectious diseases do. Accordingly, regulation of socioeconomic aspects of society under the umbrella of 'public health' is not appropriate.
Counter: (1) If market failure is defined differently (i.e. a different comparator model is adopted), then the argument could be made for regulation of obesity etc.; and (2) even if Epstein's model of market failure is adopted, there needs to be reason for why obesity is not considered a market failure (because from the looks of it, the market is not able to internalise the issue). Surely a deepened understanding of the causes of obesity show that some factors cannot be managed by individuals alone acting through private transactions; and (3) his argument based on market failure begins with a baseline model of a market which is supplanted by moral premises that are not justified e.g. Epstein takes aim at unprotected and risky sex, but not consumption of risky unhealthy foods, seeing the former as a kind of market failure, but not the latter.
4. The additional regulations result in decreased social welfare the 'new' public health has a wider scope, which undermines the creation of opportunity and wealth by overregulating areas which need not be so strictly regulated, creating moral hazards, and diverting resources from other areas. For example:
in the quarantine and AIDS context, regulations are borderline overkill at the moment, treating AIDS as a contagious disease, when it is not. Specific AIDS antidiscrimination norms, whilst capable of helping people while they are down, has the effect of cross
subsidising the cost of engaging in risky behaviour, and preventing people from avoiding AIDS carriers. The provision of antibiotics to AIDS sufferers results in there being a wider window of time during which the virus can spread and/or develop immunities.
in the vaccination context, the modern legal position re negligence and product liability has resulted in an increase in the price of vaccines, and a concomitant reduction in the availability of vaccines.
in the governmental regulation context, where an increased focus on illness management has resulted in the adoption of policies that private insurers would never even consider, and the provision of treatment which may be wasteful (e.g. end of life care).
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Counter: (1) Does regulation necessarily mean a decrease in welfare? In making this claim, is Epstein discounting the new information we have learnt in modern times about the socio
economic causes of diseases? If one were to take those into account, would there still be a perceived decrease in welfare? Surely an epidemiological change in health care concerns requires a corresponding change in public health ethics; and (2) in the context of public health, is it necessary or appropriate to measure welfare in an economic/monetary sense?
One general criticism of Epstein's approach is that he ignores the complex scientific and political causalities at play when it comes to public health policy making. He thinks something is either a cause of something, or not, and that policymakers should intervene or restrain accordingly. An example is his acceptance of social factors as causes of the AIDS epidemic, in conjunction with his dismissal of their relevance for obesity and its health consequences. "Sinful" bathhouses, excesses of "associational freedom," and failure of monogamous commitment are causal factors and appropriate targets of legal intervention, he holds. But corporate promotion of fattening foods and couch potato habits is not responsible for obesity (in either the scientific or legal sense); individuals bring it upon themselves, through their consumptive choices. B. Gostin's Approach Others, like Gostin, prefer a broad focus on the socioeconomic foundations of health. Those favouring this position see public health as an allembracing enterprise united by the common value of societal wellbeing. Similarly, the field is interested in "social capital" because social networks of family and friends, as well as associations with religious and civic organisations, are important factors in individual wellbeing and community functioning. In favour of this approach, Gostin argues that: 1
Theory of human functioning health is an intrinsic and instrumental value for individuals, communities and entire nations. People aspire to achieve health because it is foundational to so many of the other things people want to achieve in life, both individually, and as a community.
Counter: (1) People can have just as fulfilling lives when suffering from disability; and (2) Although good health underlies many other goods, other factors underlie good health, meaning it is not as foundational as made out to be. Both of these are fairly weak counters because (1) every person strives for their best possible health, even in face of ailment, and (2) whatever factors are identified as underlying good health ultimately feed from a necessary base of good health to begin with. One may need to concede that good health is not the only foundational aspect, and that it is sustained via other aspects which operate in tandem.
5. Theory of democracy people form governments to protect them against natural and manmade hazards, things which they cannot secure alone (hence, national defence, security and welfare). Public health is a classic case of a good which cannot be secured by individuals alone but which all individuals in a community have a vested interest in, and so the government acts as an agent to solve the collective action problem.
Counter: (1) Just how far does the theory of democracy take you down the path to justifying public health intervention, or the broad definition of public health? Why does the theory of democracy promote this broad version of public health as opposed to the narrow Epstein version?
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Ultimately, the field is interested in the equitable distribution of social and economic resources because social status, race, and wealth are important influences on the health of populations. However, this gives rise to the problem of excessive breadth, the problem of expertise, and the problem of political support: 1
Excessive breadth Almost everything human beings undertake impacts the population's health, but this does not justify an overly inclusive definition of public health. The field of public health appears less credible if it overreaches.
6. Expertise Public health professionals do not possess all the skills necessary to intervene on behavioural, social, physical, and environmental levels (e.g., competence in behavioural and social sciences, economics, and engineering).
Many of the determinants of health are normally the province of other agencies. Furthermore, much of the behaviour that public health agencies try to change (e.g., exercise and diet) is not subject to direct legal regulation at all. At the same time, many of the institutions that affect the public's health are outside government, such as managed care organisations, business and labor, communitybased groups, and academic institutions.
7. Political support By espousing controversial issues of economic redistribution and social restructuring, the field risks losing its legitimacy. Public health gains credibility from its adherence to science, and if the field strays too far into political advocacy, it may lose the appearance of objectivity. If public health has such a broad meaning, then who engages in the work of public health? At the governmental level, public health has a significant jurisdictional problem. The breadth and variety of public health actors is a relevant practical and theoretical consideration. It matters a great deal in law and ethics to understand who is acting, with what authority, and with what resources. C. Fundamental tension within 'Public Health' The field of public health is caught in a dilemma. If it conceives itself too narrowly, then public health will be accused of lacking vision. It will fail to tackle the root causes of ill health and fail to utilise a broad range of social, economic, and behavioural tools necessary to achieve healthier populations. At the same time, if it conceives itself too expansively, then public health will be accused of overreaching and invading a sphere reserved for politics, not science. It will lose the ability to explain its mission and functions in comprehensible terms and, consequently, to sell public health in the marketplace of politics and priorities. There may be a deeper level of tension here. Public health is an arm of the state and a profession of public service. It must work within the bounds of the law and respect the judgments of elected officials. Yet, public health professionals often function as a voice of social conscience and a champion for the disadvantaged who disproportionately suffer from injury, disability, and disease. It is not always easy for public health officials to "speak truth to power." Public Health Law Gostin defines 'Public Health Law' as "the study of the legal powers and duties of the state, in collaboration with its partners (e.g., health care, business, the community, the media, and academe), to ensure the conditions for people to be healthy and of the limitations on the power of
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the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals." Public health law scholars, therefore, are interested in government authority to prevent injury and disease and to promote the public's health, as well as in the constraints on state action to protect individual freedom. Fundamentally, public health law is concerned with the tradeoffs entailed in the exercise of government power. Under what circumstances should government be permitted to act to achieve a public good when the consequence of that act is to invade a sphere of personal or economic liberty? Furthermore, is the requisite intervention proportionate and necessary? In determining an answer to this question, one must consider whether the rights of other individuals not implicated by the immediate threat are respected. The legitimacy of public health law turns on our perspective of the issue as to whether one's health is an individual matter or an issue in respect of which we owe a responsibility to ourselves and to others. The communitarian may favour the latter, whereas the libertarian the former. a) Stages of intervention Law, regulation, and litigation, like other public health prevention strategies, intervene at a variety of levels: 1
Individual behaviour government interventions are aimed at individual behaviour through education (e.g., health communication campaigns), incentives and disincentives (e.g., taxing and spending powers), and deterrence (e.g., civil and criminal penalties for risky behaviours).
8. Societal norms the law regulates the agents of behaviour change by requiring safer product design (e.g., safety standards and indirect regulation through the tort system).
9. Environmental conditions the law alters the informational (e.g., advertising restraints), physical (e.g., city planning and housing codes), and business (e.g., inspections and licenses) environments. The Nuffield Council has highlighted the importance of precaution when dealing with threats to public health, and referenced the European Commission Communication on the precautionary principle, which identifies five elements for consideration when developing responses to public health emergencies: (1) scientific assessment of risk, acknowledging uncertainties and updated in light of new evidence; (2) fairness and consistency; (3) consideration of costs and benefits of actions; (4) transparency; and (5) proportionality. Public Health Ethics Public health ethics seeks to understand and clarify principles and values that guide public health actions, offering a framework for decisionmaking and a means of justifying decisions. It is necessary to distinguish between three different types of public health ethics: Public Health Ethics Branch of Ethics
Ethics of Public Health i.e. Professional Ethics
A. Ethical dimensions of professionalism B. Moral trust society bestows on professionals to
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act for the common good
Ethics in Public Health i.e. Applied Ethics
A. Ethical dimensions of public health enterprise B. Moral standing of population's health C. Trade offs between collective good and individual justice D. Social justice: equitable allocation of benefits and burdens
A. Overriding value of healthy communities B. Serves interests of populations, particularly powerless and oppressed C. Methods: pragmatic and political
a) Ethics in Public Health AKA Applied Ethics Problems in public health often involve numerous risk factors, multiple stakeholders, and diverse perspectives on matters of individual liberty and population wellbeing. Since a principle aim of public health is to achieve the greatest health benefits for the greatest number of people, it draws from the traditions of consequentialism, which judges the rightness of an action on the consequences, effects, or outcomes that are produced. The "public health model" of ethical reasoning, argue Allen Buchanan and others, uncritically assumes that the appropriate mode of evaluating options is some form of costbenefit (or cost
effectiveness) calculation. Public health, according to this view, appears to permit, or even require, that the most fundamental interests of individuals be sacrificed in order to produce the best overall outcome. This characterisation is based on a misunderstanding or, at least, an oversimplified understanding of the public health approach. Public health does not simply aggregate benefits and burdens, choosing the policy that produces the most good and the least harm. Rather, the overwhelming majority of public health interventions are intended to benefit the whole population without knowingly harming individuals or groups. Certainly, public health focuses almost exclusively on one vision of the "common good" (health, not wealth or prosperity). And public health action can diminish personal and economic freedoms such as privacy or free enterprise. But, such individual sacrifices are not the salient characteristics of public health ethics. The field rarely sacrifices fundamental interests to produce the best overall outcome, except perhaps when individual behaviour threatens the equally fundamental interests of others to live in health and safety. a. Limitations on the traditional liberal approach to clinical medical ethics Traditional liberal approaches to medical ethics in the clinical context promote noninterference and a certain brand of attribution of responsibility. As regards the former, people's existing preferences
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