People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility for their (...) health; responsibility sensitive health policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

Despite numerous initiatives and significant resource investment, violence remains a pervasive threat to public health. The burgeoning field of epigenetics may offer an exciting new possibility for violence prevention efforts by illuminating the mechanisms of gene-environment interactions. In particular, it may improve our ability to design more effective primary interventions, facilitate improved intervention tailoring, and better position communities to be active agents in their well-being. However, without attention to the distinction between awareness, self-efficacy, and agency, it risks (...) encouraging a false sense of individual accountability for violence, a perception that may perpetuate or increase existing inequities. Thus, embracing epigenetic insights in public health raises new opportunities but also new concerns. Ultimately, I argue public health should embrace epigenetics’ potential, but only with an equal commitment to state responsibility and systemic justice. (shrink)

The Public Health Law Association’s grant proposal described the problem of accessing public health law information, and the charge for this paper, as follows:The last decade has witnessed a renaissance in public health law. An array of forces have given rise to new model acts, important litigation developments and a growing body of academic research in the field. While there have been some initial attempts to collate important materials, practitioners in the field lack access (...) to “real world” documents and practice guides. If public health law is to remain an organic and growing field and, more importantly, if the fruits of this renaissance are to have lasting practical effect, practitioners in multiple fields must have access to this body of knowledge. (shrink)

This article focuses on the initial reactions to the Zika epidemic by national and international public health agencies. It presents and analyzes some responses public officials made about sexual and reproductive health at the inception of the epidemic. It also describes the different challenges and obligations faced by local and international public health agencies, as these have not been clearly outlined. The article argues that these agencies have different obligations and should fulfill them despite (...) existing obstacles. While international agencies should honor their leadership role and make recommendations at a meta-level, local agencies should provide, in the case of Zika, a framework for empowerment and grant women the freedom to achieve sexual and reproductive health so that they can avoid the consequences of this epidemic. (shrink)

“Public health legal preparedness” is a term born in the ferment, beginning in the late 1990s, that has led to unprecedented recognition of the essential role law plays in public health and, even more recently, in protecting the public from terrorism and other potentially catastrophic health threats.The initial articulation of public health has not kept pace with rapid evolution in the concept and in practical development of public health preparedness itself. (...) This poses the risk that legal preparedness may fall behind construction of general readiness in the public health system—and may, in fact, undercut achievement of comprehensive public health preparedness for massive threats to health in both the United States and world-wide. Inadvertent results might include both negative health impacts and infringement on individual rights. (shrink)

The COVID‐19 pandemic has infected millions around the world. Governments initially responded by requiring businesses to close and citizens to self‐isolate, as well as funding vaccine research and implementing a range of technologies to monitor and limit the spread of the disease. This article considers the use of smartphone metadata and Bluetooth applications for public health surveillance purposes in relation to COVID‐19. It undertakes ethical analysis of these measures, particularly in relation to collective moral responsibility, considering whether citizens (...) ought, or should be compelled, to comply with government measures. (shrink)

Food security policy, programs, and infrastructure have been incorporated into Public Health and other areas of the Provincial Government in British Columbia, including the adoption of food security as a Public Health Core Program. A policy analysis of the integration into Public Health is completed by merging findings from 48 key informant interviews conducted with government, civil society, and food supply chain representatives involved in the initiatives along with relevant documents and participant/direct observations. (...) The paper then examines the results within the context of historic and international trends and theoretical models of food policy, community food security, and applied policy research. Public Health re-emerged as a driver of food security in BC—both as a key player and in positing the public’s health as a driver in food security and food systems. While Public Health’s lead role supported an increase in legitimacy for food security in BC, interviewees described a clash of cultures between Public Health and civil society. The clash of cultures occurred partly as a result of Public Health’s limited food security mandate and top down approach. Consequently civil society voice at the provincial level was marginalized. A social policy movement toward a new political paradigm—regulatory pluralism—calls for greater engagement of civil society, and for all sectors to work together toward common goals. A new, emerging policy map is proposed for analyzing the dynamics of food security and health promotion initiatives in BC. (shrink)

Background: Expanded newborn screening generates incidental results, notably carrier results. Yet newborn screening programmes typically restrict parental choice regarding receipt of this non-health serving genetic information. Healthcare providers play a key role in educating families or caring for screened infants and have strong beliefs about the management of incidental results. Methods: To inform policy on disclosure of infant sickle cell disorder (SCD) carrier results, a mixed-methods study of healthcare providers was conducted in Ontario, Canada, to understand attitudes regarding result (...) management using a cross-sectional survey (N = 1615) and semistructured interviews (N = 42). Results: Agreement to reasons favouring disclosure of SCD carrier results was high (65.1%–92.7%) and to reasons opposing disclosure was low (4.1%–18.1%). Genetics professionals expressed less support for arguments favouring disclosure (35.3%–78.8%), and more agreement with arguments opposing disclosure (15.7%–51.9%). A slim majority of genetics professionals (51.9%) agreed that a reason to avoid disclosure was the importance of allowing the child to decide to receive results. Qualitatively, there was a perceived “duty” to disclose, that if the clinician possessed the information, the clinician could not withhold it. Discussion: While a majority of respondents perceived a duty to disclose the incidental results of newborn screening, the policy implications of these attitudes are not obvious. In particular, policy must balance descriptive ethics (ie, what providers believe) and normative ethics (ie, what duty-based principles oblige), address dissenting opinion and consider the relevance of moral principles grounded in clinical obligations for public health initiatives. (shrink)

Widespread obesity poses a serious challenge to health outcomes in the developed world and is a growing problem in the developing world. There has been a raft of proposals to combat the challenge of obesity, including restrictions on the nature of food advertising, the content of prepared meals, and the size of sodas; taxes on saturated fat and on calories; and mandated “healthy-options” on restaurant menus. Many of these interventions seem to have a greater impact on rates of obesity (...) than does simply providing information about health risks and healthier lifestyles. The more interventionist policy options have, however, been implemented only slowly, in large part because of criticisms that they are unjustified infringements on the liberty of consumers. Food industry groups, free-market think tanks, and the popular press regard measures that incentivize or penalize particular food and lifestyle choices as unjustifiable state regulation of purely self-regarding behavior. To counteract the liberty-oriented position, those who favor a more interventionist role for the state have recently argued for labeling obesity as a public health emergency. By labeling obesity as a public health emergency, policy-makers could override concerns about individual liberty in order to pursue more interventionist policies designed to guide consumer choices toward healthier lifestyles. In this paper, we argue that, contrary to initial appearances, obesity possesses some of the morally relevant features of public health emergencies, though we do not argue that it actually constitutes one. (shrink)

In the last decade the public health movement has bolstered efforts to prevent interpersonal violence through bringing social policy attention and needed dollars to prevention initiatives. Features in a public health approach to prevention include an evidence-based conception of the risks and so-called ?protective? factors associated with the unwanted problem and the use of sophisticated evaluation tools to monitor prevention efforts. This article critically reviews public health prevention methodology as applied to interpersonal violence (...) prevention at the primary level through drawing on findings from a qualitative inquiry into the moral dimensions of violence prevention education. It examines the premise that an empirical evidence base can determine what is desirable in relationships, together with the assumption that expert violence prevention educators can use this evidence to teach others about relationship desirability. In relying on a scientific and empirical evidence base, it is argued that the public health prevention model fails to recognize important moral dimensions of human relationships. (shrink)

This paper provides an overview of recent US Department of Health and Human Services initiatives and efforts — under the leadership of the General Counsel, the Secretary, and the President — regarding legal preparedness for public health emergencies. In addressing this topic, the paper focuses on four core elements comprising public health legal preparedness:effective legal authorities to support necessary public health activities;competencies of public health professionals to know and then to (...) apply those laws;coordination of the application of laws across jurisdictions and across multiple sectors; andinformation and best practices in public health law. (shrink)

Public Health Science and practice expanded during the course of the 20th century. Initially focused on controlling infectious disease through basic public health programs regulating water, sanitation and food, by 1988 the Institute of Medicine broadly declared that “public health is what we, as a society, do collectively to. assure the conditions for people to be healthy.” Commensurate with this definition, public health practitioners and policymakers today work on ;in enormous range of (...) issues. The 2002 policy agenda of the American Public Health Association reflects positions on genomics’ role in public health; national health and safety standards for child care programs; sodium in Americans’ diets; the health and safety of emergency rescue workers; and war in Central Asia and the Persian Gulf. (shrink)

In recent years there has been increased recognition of the global burden of mental disorders, which in turn has led to the expansion of preventive initiatives at the community and population levels. The application of such public health approaches to mental health raises a number of important ethical questions. The aim of this collection is to address these newly emerging issues, with special attention to the principle of prevention and the distinctive ethical challenges in mental (...) class='Hi'>health. The collection brings together an interdisciplinary group of experts in bioethics, mental health, public health, and global health. (shrink)

Pandemics challenge the law and often highlight its strengths or expose its limits. The novel strain of influenza A virus that emerged in the spring of 2009 and rapidly spread around the globe was no exception. The H1N1 pandemic prompted the first significant application of a number of international legal and policy mechanisms that have been developed in the last decade to respond to this kind of event. Furthermore, it presented a considerable test for public health systems at (...) all levels, from global to local.Although initial predictions forecasting high morbidity and mortality from this virus overestimated its eventual impact, the human toll of the pandemic was nevertheless significant. The World Health Organization reported approximately 1.5 million people were infected worldwide in 214 countries, resulting in over 25,000 confirmed deaths, but the actual health impact of the outbreak was certainly much higher. (shrink)

Background Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it (...) presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. Main body The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. Conclusion Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice. (shrink)

Preemption is a powerful strategy used by special interest groups to undermine strong, local public health standards. Currently, 20 states in the U.S. have preemption ordinances in place related to clean indoor air initiatives. These preemption laws are the direct result of an ongoing and aggressive campaign of tobacco companies to thwart clean indoor air initiatives, which ultimately, according to tobacco industry internal documents, cause significant reductions in their annual revenues. Clean indoor air policies have arisen (...) from a greater understanding of the documented health risks associated with exposure to secondhand smoke and action by local government to protect the public from these hazards. The efforts of the tobacco industry undermine local authority and seek to shift policy action to the state and federal levels, where the industry has greater political influence. (shrink)

The stigmatization of some groups of people, whether for some characteristic they possess or some behavior they engage in, will initially strike most of us as wrong. For many years, academic work in public health, which focused mainly on the stigmatization of HIV-positive individuals, reinforced this natural reaction to stigmatization, by pointing out the negative health effects of stigmatization. But more recently, the apparent success of anti-smoking campaigns which employ stigmatization of smokers has raised questions about whether (...) stigmatization may sometimes be justified, because of its positive effects on public health. Discussion of the issue so far has focused on consequences, and on some Kantian considerations regarding the status of the stigmatized. In this article, I argue that further Kantian considerations regarding the treatment of the general public (the potential stigmatizers) also count against any public health policy involving stigmatization. Attempts to encourage stigmatization are likely to fail to appeal to the rational decision-making abilities of the general public, and the creation of stigmatized groups (even if they are stigmatized for their voluntary behavior) is an obstacle to the self-improvement of members of the general public. (shrink)

The diversity of state confidentiality laws governing public health data presents a significant challenge for public health initiatives. This challenge is further complicated by the array of confidentially laws that are relevant within a state as disclosure and usage standards vary depending upon data holder, type, and source. These laws often have not been updated to address modern confidentiality risks such as unlawful data linkage or breach, leaving many public health organizations without clear (...) guidance in the contentious area of individual privacy. To address these challenges, public health organizations have increasingly turned to the science of de-identification, but whether de-identification adequately meets the many and varied state confidentiality legal requirements remains an unanswered question. (shrink)

While the realm of bioethics has traditionally focused on the rights of the individual and held autonomy as a defining principle, public health ethics has at its core a commitment to the promotion of the common good. While these two domains may at times conflict, concepts arising in one may also be informative for concepts arising in the other. One example of this is the concept of a “right not to know.” Recent debate suggests that just as there (...) is a “right to know” information about one's genetic status, there is a parallel “right not to know” when it comes to genetic information that if communicated, could be detrimental to an individual's social or psychological well-being. As new genetic technologies continue to change the nature of genetic testing and screening, it is crucial that normative frameworks to guide and assess genetic public health initiatives be developed. In this context, the question of whether a “right not to know” may also be said to exist for populations on a public health level merits attention. (shrink)

Why do some global health initiatives receive priority from international and national political leaders while others receive minimal attention? We propose a framework for analyzing this question consisting of four categories of factors: the strength of the actors involved in the initiative, the power of the ideas they use to frame the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself.We apply this framework to the case of a global initiative (...) to reduce maternal mortality, launched in 1987. Using a process-tracing methodology commonly employed in qualitative research, we conducted archival research and interviewed actors involved in the initiative. We find that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's twentieth anniversary year, 2007, presents opportunities to build political momentum. To generate political priority advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue that convinces political leaders to act.We draw on the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, a subject that has attracted much speculation but little scholarship. (shrink)

COVID-19 continues to dominate 2020 and is likely to be a feature of our lives for some time to come. Given this, how should health systems respond ethically to the persistent challenges of responding to the ongoing impact of the pandemic? Relatedly, what ethical values should underpin the resetting of health services after the initial wave, knowing that local spikes and further waves now seem inevitable? In this editorial, we outline some of the ethical challenges confronting those running (...) health services as they try to resume non-COVID-related services, and the downstream ethical implications these have for healthcare professionals’ day-to-day decision making. This is a phase of recovery, resumption and renewal; a form of reset for health services.1 This reset phase will define the ‘new normal' for healthcare delivery, and it offers an opportunity to reimagine and change services for the better. There are difficulties, however, healthcare systems are already weakened by austerity and the first wave of COVID-19 and remain under stress as the pandemic continues. The reset period is operating alongside, rather than at the end, of the pandemic and this creates difficult ethical choices. ### Balancing the greater good with individual care Pandemics—and public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective …. (shrink)

The, Police Executive Research Forum is completing a major initiative that encourages police chiefs to formalize working relationships with emergency medical personnel. The effort is sponsored by the U.S. Department of Justice, Bureau of Justice Assistance as a demonstration with the goal of preventing recurring violence that eventually leads to homicide. The initiative originally involved a consortium of emergency room clinicians, emergency medical service personnel, as well as police executives. The collaboration initially focused on arguably preventable dimensions of domestic violence (...) and homicide. However, after “9/11” and the ensuing anthrax crisis, the project developed into a three-step draft interactive protocol for earlier police intervention in situations involving possible deaths and mass casualties. With this shift in the project, Police Executive Research Forum’s principal collaborators shifted from emergency clinicians to public health practitioners. (shrink)

Verbal autopsy presents the opportunity to understand the disease burden in many low-income countries where vital registration systems are underdeveloped and most deaths occur in the community. Advances in technology have led to the development of software that can provide probable cause of death information in real time, and research considering the ethical implications of these advances is necessary to inform policy. Our research explores these ethical issues in rural Nepal using a public health ethics framework. We considered (...) the burdens and benefits of VA and giving cause of death information to families of the deceased through qualitative research with VA interviewers, community members, national policy stakeholders and international academics. Burdens can be experienced differently, and it is important to balance the emotional burden of VA with utilization of the data to inform planning and increased access to health services. The training, support and supervision of VA interviewers should be prioritized if VA is taken to scale. Initial and ongoing community engagement is recommended in addition to engaging ethical, legal, health and policy personnel in developing protocols and systems. Integrating rigorous research while cautiously moving forward is recommended to ensure systems and responses to concerns are relevant to contexts. (shrink)

What happens when the scientific tradition of openness clashes with potential societal risks? The work of American toxic-exposure epidemiologists can attract media coverage and lead the public to change health practices, initiate lawsuits, or take other steps a study’s authors might consider unwarranted. This paper, reporting data from 61 semi-structured interviews with U.S. toxic-exposure epidemiologists, examines whether such possibilities shaped epidemiologists’ selection of journals for potentially sensitive papers. Respondents manifested strong support for the norm of scientific openness, but (...) a significant minority had or would/might, given the right circumstances, publish sensitive data in less visible journals, so as to prevent unwanted media or public attention. Often, even those advocating such limited “burial” upheld openness, claiming that less visible publication allowed them to avoid totally withholding the data from publication. However, 15% of the sample had or would, for the most sensitive types of data, withhold publication altogether. Rather than respondents explaining their actions in terms of an expected split between “pure science” and “social advocacy” models, even those publishing in the more visible journals often described their actions in terms of their “responsibility”. Several practical limitations (particularly involving broader access to scientific literature via the Internet) of the strategy of burial are discussed, and some recommendations are offered for scientists, the media, and the public. (shrink)

Stigma can influence the prevention and identification of fetal alcohol spectrum disorder, a leading cause of developmental delay in North America. Understanding the effects of public health practices and policies on stigma is imperative. We reviewed social science and biomedical literatures to understand the nature of stigma in FASD and its relevance from an ethics standpoint in matters of health practices and policies. We propose a descriptive model of stigma in FASD and note current knowledge gaps; discuss (...) the ethical implications of stigma based on two distinct criteria ; and describe two cases and the concerns associated with inadvertent stigmatization by public health initiatives for FASD. We recommend further empirical and ethical analyses to examine whether public health policies and practices inadvertently stigmatize and impact the success of public health initiatives and programs for FASD. (shrink)

Background Bioethical debates about privacy, big data, and public health surveillance have not sufficiently engaged the perspectives of those being surveilled. The data justice framework suggests that big data applications have the potential to create disproportionate harm for socially marginalized groups. Using examples from our research on HIV surveillance for individuals incarcerated in jails, we analyze ethical issues in deploying big data in public health surveillance. -/- Methods We conducted qualitative, semi-structured interviews with 24 people living (...) with HIV who had been previously incarcerated in county jails about their perspectives on and experiences with HIV surveillance, as part of a larger study to characterize ethical considerations in leveraging big data techniques to enhance continuity of care for incarcerated people living with HIV. -/- Results Most participants expressed support for the state health department tracking HIV testing results and viral load data. Several viewed HIV surveillance as a violation of privacy, and several had actively avoided contact from state public health outreach workers. Participants were most likely to express reservations about surveillance when they viewed the state’s motives as self-interested. Perspectives highlight the mistrust that structurally vulnerable people may have in the state’s capacity to act as an agent of welfare. Findings suggest that adopting a nuanced, context-sensitive view on surveillance is essential. -/- Conclusions Establishing trustworthiness through interpersonal interactions with public health personnel is important to reversing historical legacies of harm to racial minorities and structurally vulnerable groups. Empowering stakeholders to participate in the design and implementation of data infrastructure and governance is critical for advancing a data justice agenda, and can offset privacy concerns. The next steps in advancing the data justice framework in public health surveillance will be to innovate ways to represent the voices of structurally vulnerable groups in the design and governance of big data initiatives. (shrink)

Médecins Sans Frontières is not morally required to continue providing the same therapeutic and preventative interventions for lead poisoning in Nigeria in the face of conditions that negatively impact on the achievement of their objectives. Nevertheless, Médecins Sans Frontières may have reasons to revise their objectives and adopt different interventions or methods.

Background The COVID-19 pandemic forced governments, multilateral public health organisations and research institutions to undertake research quickly to inform their responses to the pandemic. Most COVID-19-related studies required swift approval, creating ethical and practical challenges for regulatory authorities and researchers. In this paper, we examine the landscape of ethics review processes in Africa during public health emergencies (PHEs). Methods We searched four electronic databases (Web of Science, PUBMED, MEDLINE Complete, and CINAHL) to identify articles describing ethics (...) review processes during public health emergencies and/or pandemics. We selected and reviewed those articles that were focused on Africa. We charted the data from the retrieved articles including the authors and year of publication, title, country and disease(s) reference, broad areas of (ethical) consideration, paper type, and approach. Results Of an initial 4536 records retrieved, we screened the titles and abstracts of 1491 articles, and identified 72 articles for full review. Nine articles were selected for inclusion. Of these nine articles, five referenced West African countries including Liberia, Guinea and Sierra Leone, and experiences linked to the Ebola virus disease. Two articles focused on South Africa and Kenya, while the other two articles discussed more general experiences and pitfalls of ethics review during PHEs in Africa more broadly. We found no articles published on ethics review processes in Africa before the 2014 Ebola outbreak, and only a few before the COVID-19 outbreak. Although guidelines on protocol review and approval processes for PHEs were more frequently discussed after the 2014 Ebola outbreak, these did not focus on Africa specifically. Conclusions There is a gap in the literature about ethics review processes and preparedness within Africa during PHEs. This paper underscores the importance of these processes to inform practices that facilitate timely, context-relevant research that adequately recognises and reinforces human dignity within the quest to advance scientific knowledge about diseases. This is important to improve fast responses to PHEs, reduce mortality and morbidity, and enhance the quality of care before, during, and after pandemics. (shrink)

While many experts and organizations have recognized infertility as a public health issue, most governments have not yet adopted a public health approach to infertility. This article argues in favor of such an approach by discussing the various implications of infertility for public health. We use a conceptual framework that focuses on the dual meaning of the term ‘public’ in this context: the health of the public, as opposed to that of (...) individuals, and the public/collective nature of the required interventions. This analysis highlights the need for a comprehensive public health approach toward infertility, points to some initiatives that are already in place and demonstrates that prevention is currently a neglected—yet much needed——element. We move on to discuss the sensitive nature of prevention initiatives as a probable explanation for their scarcity. We illustrate the complexity of prevention through an analysis of an infertility prevention campaign previously conducted in the United States, which provoked significant controversy. We use a public health communication ethics framework to expose the strengths and the shortcomings of this campaign, and conclude that prevention initiatives targeting infertility can indeed be conducted in a sensible way that promotes autonomy while improving public health. (shrink)

Risk and crisis communication (RCC) is a current ethical issue subject to controversy, mainly due to the tension between individual liberty (a core component of fairness) and effectiveness. In this paper we propose a consistent definition of the RCC process in public health emergencies (PHERCC), which comprises six key elements: evidence, initiator, channel, publics, message, and feedback. Based on these elements and on a detailed analysis of their role in PHERCC, we present an ethical framework to help design, (...) govern and evaluate PHERCC strategies. The framework aims to facilitate RCC, incorporating effectiveness, autonomy, and fairness. It comprises five operational ethical principles: openness, transparency, inclusivity, understandability, and privacy. The resulting matrix helps understanding the interplay between the PHERCC process and the principles of the framework. The paper includes suggestions and recommendations for the implementation of the PHERCC matrix. (shrink)

Mathematical modelling has played an increasingly prominent role in public health responses, for example by offering estimates of how infectious disease incidence over time may be affected by the adoption of certain policies and interventions. In this paper, we call for greater research and reflection into the ethics of mathematical modeling in public health. First, we present some promising ways of framing the ethics of mathematical modeling that have been offered in the very few publications specifically (...) devoted to this subject. Second, to draw out some issues that have not yet been sufficiently considered, we bring in the case of mathematical modeling in voluntary medical male circumcision (VMMC) initiatives for HIV prevention in Africa. We argue that greater attention should be paid to ethical considerations in mathematical modeling, particularly as its use is becoming more widespread and its potential impacts are becoming greater in the ‘big data’ era, as witnessed during the COVID-19 pandemic. (shrink)

BackgroundIn response to COVID-19 pandemic, the Government of Uganda adopted public health measures to contain its spread in the country. Some of the initial measures included refusal to repatriate citizens studying in China, mandatory institutional quarantine, and social distancing. Despite being a public health emergency, the measures adopted deserve critical appraisal using an ethics and human rights approach. The goal of this paper is to formulate an ethics and human rights criteria for evaluating public (...) class='Hi'>health measures and use it to reflect on the ethical propriety of those adopted by the government of Uganda to contain the spread of COVID-19.Main bodyWe begin by illustrating the value of ethics and human rights considerations for public health measures including during emergencies. We then summarize Uganda’s social and economic circumstances and some of the measures adopted to contain the spread of COVID-19. After reviewing some of the ethics and human rights considerations for public health, we reflect upon the ethical propriety of some of Uganda’s responses to COVID-19. We use content analysis to identify the measures adopted by the government of Uganda to contain the spread of COVID-19, the ethics and human rights considerations commonly recommended for public health responses and their importance. Our study found that some of the measures adopted violate ethics and human rights principles. We argue that even though some human rights can sometimes be legitimately derogated and limited to meet public health goals during public health emergencies, measures that infringe on human rights should satisfy certain ethics and human rights criteria. Some of these criteria include being effective, strictly necessary, proportionate to the magnitude of the threat, reasonable in the circumstances, equitable, and least restrictive. We reflect on Uganda’s initial measures to combat the spread of COVID-19 and argue that many of them fell short of these criteria, and potentially limit their effectiveness.ConclusionThe ethical legitimacy of public health measures is valuable in itself and for enhancing effectiveness of the measures. Such legitimacy depends on the extent to which they conform to ethics and human rights principles recommended for public health measures. (shrink)

There is a growing focus on public health initiatives that prioritise well-being. The main question of our study is whether this, in its current form, can really represent a new response to the challenges of previous strategies, or whether there is a greater chance that it will essentially reproduce the problems associated with the paradoxical situation of public health. Based on a review, analysis and evaluation of the literature on well-being in public health, (...) we outlined the foundations of a new meta-theory of well-being and a possibility for its social application. In our view, well-being is seen as a social representation of a combination of positive and negative freedom of choice concerning the quality of everyday life, used in a positioning process involving both individual and collective aspects. Health is a particular aspect of the social representation and positioning of well-being, which encompasses aspects of the physical, psychological, social and spiritual functioning of individuals. The well-being meta-theory also opens up the possibility for more effective solutions to the social challenges related to well-being and salutogenetic health. It underscores the importance of the need for a dedicated social subsystem where the goals and organizational culture of the organizations involved are focused on well-being and health promotion. In our study, we consider this to be the Public Well-being System (PWS). (shrink)

During the COVID-19 public health crisis, market failures such as shortage of supplies and soaring prices of anti-epidemic materials – with masks as the core – have occurred. In essence, such anti-epidemic materials have the dual nature of necessities with low elasticity of demand and private products with positive externalities. This research explores the understanding of anti-pandemic materials and how different initiatives, and evaluation to increase availability of necessary resources can be effective in curbing a pandemic. Market (...) regulation results in a non-Pareto optimal allocation of resources and the difficulty of exerting the positive externalities of products. However, in China, the market failure of anti-epidemic materials was quickly resolved, due to the institutional advantages of socialism with Chinese characteristics, the social responsibility drive of domestic enterprises, and cultural genes that focus on equity and concern for the disadvantaged. The optimal allocation of anti-epidemic materials gave access to exerting efficiency and fairness effects, positive external effects, and public effects. (shrink)

This paper develops a general approach to how society should compensate for losses that individuals incur due to public health interventions aimed at controlling the spread of infectious diseases. The paper falls in three parts. The first part provides an initial introduction to the issues and briefly outlines five different kinds of public health interventions that will be used as test cases. They are all directed at individuals and aimed at controlling the spread of infectious diseases (...) (1) isolation, (2) quarantine, (3) recommended voluntary social distancing, (4) changes in health care provision for asymptomatic carriers of multi-resistant microorganisms, and (5) vaccination. The interventions will be briefly described including the various risks, burdens and harms individuals who are subject to these interventions may incur. The second part briefly surveys current compensation mechanisms as far as any exist and argue that even where they exist they are clearly insufficient and do not provide adequate compensation. The third part will then develop a general framework for compensation for losses incurred due to public health interventions in the infectious disease context. This is the major analytical and constructive part of the paper. It first analyses pragmatic and ethical arguments supporting the existence of an obligation on the part of the state to compensate for such losses, and then considers whether this obligation can be defeated by (1) resource considerations, or (2) issues relating to personal responsibility. (shrink)

We conducted and analyzed qualitative interviews with 12 persons working on the Healthy Public Housing Initiative in Boston, Massachusetts in 2001. Our goal was to generate ideas and themes related to the ethics of the community-based participatory research in which they were engaged. Specifically, we wanted to see if we found themes that differed from conventional research that is based on an individualistic ethics. There were clearly distinct ethical issues raised with respect to projects and individuals who engage in (...) community-based collaborations. The differences that arose from the interviews were seeking equality between the partners, the need for the community partner to defend the community, dealing with unflattering data, meeting community expectations and producing tangible benefits to the community. (shrink)

In 1974, the Liberal government of Pierre Trudeau released a “green paper” known as the Lalonde Report, after the health minister at that time. The report formulated perspectives on health and the main concepts and ideas developed in it, particularly the concept of “lifestyle,” which became the foundation of public health policies in many different European countries and the United States. The concept of “lifestyle” connected personal behaviour and habits to the individual health condition; people (...) were not dying due to a lack of access to medical care but because they lived a life prone to personal risk taking. Furthermore, what is seldom discussed is that this report not only propagated the (neo)liberal view of citizens as autonomous rational actors (homo oeconomicus), with personal responsibility for their health, but it was a first step in the transformation of Medicare and went far beyond the question of health promotion. Health was no longer something that happened to a person but was created through personal choice and, therefore, one had to assume responsibility for one's behaviour. Using Foucault's definition of government as the “conduct of conduct,” we will demonstrate that the Lalonde report must be understood as a specific “technology of government” and contributed to a neoliberal transformation of health care despite the fact that the Canadian system of Medicare was based on the idea of universality, meaning citizens had equal access to health care independent of their socio‐economic situation. As we will demonstrate, the Lalonde report undermined this foundation and initiated a profound reorientation, not only of the healthcare system, but even more importantly, it radically changed the way we think about our behaviour around health‐related issues. We will also discuss how the making of the report contributed to the redefinition of politics and demonstrated a lack of concern with liberal‐democratic decision‐making processes. (shrink)

Measured against the gloomy pre-COVID-19 predictions, Africa has fared far better than most regions in managing the pandemic. This much, however, has received less attention. This paper answers the question: how have the new rituals of self determination in public health affected the successful management of COVID-19 in Africa, and how can the continent and the rest of the world build on such models/lessons in the post-pandemic era? I employ emancipatory theorising in reviewing literature on approaches to governance (...) of COVID-19. The rationale is to empower the grassroots and to accentuate the urgency for a decolonized local ownership of the governance of all public health crises. I argue that while traditional international cooperation is necessary for additional resource and expertise from the global North for sustainable health, the political will of Southern governments remains fundamental for any extraordinary success due to its grassroots/community orientation towards non-pharmaceutical interventions and initial pre-emptive rituals. The novelty in this paper is that it lays bare the ignored African responses and lessons and reveals how to harness protective communitarian ethos in solving future crises. The paper further provides population health as an ‘immune system’ policy framework for explaining and predicting how a scientific and human-centrered grassroots leadership can yield optimal outcomes in any future crisis. (shrink)

The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. (...) We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic ‘success’, and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets. (shrink)

Initiatives advocating for nature-based solutions, such as increased urban biodiversity, aim to promote public health as a part of creating sustainable cities. These initiatives are supported by a plenitude of scientific literature demonstrating the link between human health and nature contact. Despite these findings, positive human-nature interactions are declining worldwide, negatively effecting human development and health. We support an embodied approach to mental health. Taking this approach seriously illuminates how cities can be enhanced (...) by modifying environmental and social affordances and the ways in which urban dwellers interact with urban natural greenspaces. We argue that urban nature experiences can be used to promote mental health, but that indicators of environmental injustice need to addressed. (shrink)

The Turning Point Initiative is an initiative for which the Robert Wood Johnson and W.K. Kellogg foundations partnered in order to fund a group of states and a number of communities within each of those states to work through a planning process to look at ways to strengthen their public health systems at the state and local levels. Out of that process, the states and communities would come together at the national level to talk about what they had (...) been learning and what the issues were. There were a number of issues that resonated with all of the states. (shrink)

Contemporary biomedical ethics and environmental ethics share a common ancestry in Aldo Leopold's and Van Rensselaer Potter's initial broad visions of a connected biosphere. Over the past five decades, the two fields have become strangers. Public health ethics, a new subfield of bioethics, emerged from the belly of contemporary biomedical ethics and has evolved over the past 25 years. It has moved from its traditional concern with the tension between individual autonomy and community health to a wider (...) focus on social justice and solidarity. Public health has a broad focus that includes individual, community, and environmental health. Public health ethics attends to these broad commitments reflected in the increasing concern with the connectedness of health of individuals to the health of populations, to the health of animals, to the health of the environment; it is well situated to reconnect all three “fields” of ethics to promote a healthier planet. (shrink)

Social theory is developing in response to the coronavirus (COVID) crisis. Fundamental questions about social justice in the relationship of individuals to society are raised by Delanty in his review of political philosophy, including Agamben, Foucault and Žižek. However, the focus on the libertarian critique of authoritarianism is not enough. The social democratic critique of neoliberalism lies at the centre of the contesting responses to the COVID crisis. A social democratic perspective on public health, democracy and state action (...) is contrasted with the anti-statists of left and right. This is addressed in debates on the relationship between science and governance, the place of crisis in theories of change and the conceptualisation of alternative forms of social formation. The crisis initiated by the pandemic, cascading through society, from health to economy, to polity and into violence, includes a contestation between social democratic and neoliberal visions of alternative forms of society. (shrink)

In May 2011, the Brazilian Ministry of Health announced the distribution of the first batch of locally produced generic tenofovir disoproxil fumarate (TDF) to support its program of universal and free access for the treatment of HIV/AIDS. The inclusion of TDF in the public health program illustrates what has been considered the ‘Brazilian model’ of HIV/AIDS response, as it illustrates the current phase of the Brazilian pharmaceutical economy. Brazil is known for having managed to control the expansion (...) of HIV/AIDS through a unique initiative combining the public health and the industrial production of generics. But, if at first local manufacturers could freely copy ARVs and produce cheaper generic versions that were delivered to the Ministry of Health, since the country started to grant patents on drugs in 1996, the sustainability of this policy has been challenged by the high cost of patented second-line HIV/AIDS treatments. In order to assure continuity of the local production of ARVs, and keep the program of public health alive, Brazilians are now forced to deal with conflicts of drugs' intellectual property rights in order to open the path to generic production. This article aims to describe the experiences surrounding TDF in Brazil and the unprecedented conflicts and challenges it has brought for our different interviewees. Blurring the frontier between the public and the private, the TDF case was driven at the same time by an ethic of drug access and regulation of drug quality, which has inspired Brazilians to intervene and transform the world they live in. (shrink)

Professor Gostin is a leading authority on health law, whose writing and teaching are among the most authoritative in the United States, as exemplified by his recent work, Public Health Law: Power, Duty, Restraint. Gostin's article in this issue of the Journal of Law, Medicine & Ethics pays homage to Jonathan Mann by expressing the debt he feels toward this extraordinary doctor and public health official with whom he had collaborated on several projects.As many will (...) remember, Mann held high-level positions at the Centers for Disease Control and worked on AIDS research in Central Africa before setting up the World Health Organization's Global Programme on AIDS, which he ran from 1986 to 1990. Thanks to his profound commitment and consummate communication skills, he achieved the unprecedented feat of raising the budget within two years to almost $100 million from the initial set-up of “himself, a secretary, and one typewriter,” as described by Daniel Tarantola. (shrink)

Irecall vividly my initial excitement at the accomplishments of the Human Genome Project. That excitement was short-lived and diminished steadily over the next decade as I came to realize that the HGP was just another nail to be hit by the metaphoric hammer of genome-sequencing technology. To this day, I see this trend in many other spheres of public health and biomedical science. I take responsibility for using this same approach of "hammer" and "nail" in my own research (...) program, where I use complex systems modeling to address pressing public health issues, such as adverse birth outcomes, food insecurity, and the opioid epidemic. But I am slowly yet surely shifting my ways by explicitly and slowly... (shrink)

In 2012, a law against hiring models with a BMI below 18.5 was passed in Israel. In addition, every photoshopped advertisement must have a visible subtitle that indicates that the picture was photoshopped. Dr. Rachel Adatto, the initiator of the law, states that the law is “a beginning of a revolution against the anorectic beauty model ideal,” and that its aim is to prevent eating disorders that may lead to death in the aspiration to lose weight, especially among the general (...) population of teenagers and young adults who are exposed to the thin role models in the media. Adi Barkan, a photographer and models’ agent, who was also involved in promoting the legislation, viewed it from a different angle.... (shrink)

Should the private sector concern itself with the health of the communities in which it operates? Should the community look to local businesses for collaboration in the effort to elevate the health of its citizens? Is there an opportunity between the public and private sectors to create shared value through the enhancement of public health? These are questions this paper explores and analyzes, using theoretical models that originate in disparate literatures.

Sometimes, offering someone beneficial care is likely to thwart the similar or more serious medical needs of more people. For example, when acute shortage is strongly predicted to persist, providing the long period on scarce intensive care that a certain COVID‐19 patient needs is sometimes projected to block several future COVID‐19 patients from receiving the shorter periods on intensive care that they will need. Expected utility is typically higher if the former is denied intensive care. A tempting initial account of (...) such cases is that consequentialism supports denying care to that patient and nonconsequentialism supports providing that care. This paper argues that the consequentialist case is more complicated than it may initially seem and that nonconsequentialism sides more readily with denial of the beneficial treatment. It also shows that when denying it would directly enhance public health by a lot, either ethical approach would normally recommend denying it. Practical implications are discussed, including how to address conscientious objection to this shared recommendation. (shrink)

Diphtheria is an acute toxin-mediated superficial infection of the respiratory tract or skin caused by the aerobic gram-positive bacillus Corynebacterium diphtheriae. The epidemiology of infection and clinical manifestations of the disease vary in different parts of the world. Historical accounts of diphtheria epidemics have been described in many parts of the world since antiquity. Developed in the late 19th century, the diphtheria antitoxin played a pivotal role in the history of public health and vaccinology prior to the advent (...) of the diphtheria-tetanus toxoids and acellular pertussis vaccine. One of the most significant demonstrations of the importance of DAT was its use in the 1925 diphtheria epidemic of Nome, Alaska. Coordinated emergency delivery of this life-saving antitoxin by dog-sled relay in the harshest of conditions has left a profound legacy in the annals of vaccinology and public health. Lead dogs Balto and Togo, and the dog-led antitoxin run of 1925 represent a dynamic illustration of the contribution made by non-human species towards mass immunization in the history of vaccinology. This unique example of cooperative interspecies fellowship and collaboration highlights the importance of the human-animal bond in the one-health initiative. (shrink)