To be a public health professional, one must be an unrelenting optimist. Public health interventions are subject to the political, physical and social environments in which they operate. Success is slow due to tenuous political climates, industry interference, anti-paternalistic views, and an overall lack of funding. Making lasting changes in systems is an uphill battle where we receive no praise for ‘reaching the top’ but we will receive derision if we fail. But after all, public health does not strive for praise and recognition. It strives for equity in all aspects of health.
Although this is probably most evident by how the current coronavirus pandemic is playing out worldwide, the politicization of public health is not a new phenomenon. When one looks at the early 1900s in the US, one can see that public health efforts succeeded or failed based on the system it was acting in. At the time, prevalent anti-communist and -socialist views prevented discussions about national health insurance from progressing (this was prior to Medicare and Medicaid)(1). On the other hand, paternalistic public health remedies were welcomed and seen as necessary to address the physical environment’s deterioration as a byproduct of mass industrialization and immigration movements to large cities. Traditional politics aside, attitudes of the time which held women at a lower regard than men, were demonstrated by the quarantine of ‘Typhoid Mary’. She was held against her will where other male breadwinner asymptomatic carriers were free (2). These historical examples offer modern-day parallels and demonstrate the complex systems that public health interventions operate within. Prevalent attitudes or politics of the time make certain paternalistic interventions impossible. It’s up to public health practitioners to navigate systems and find key leverage points that can cause cascades of positive actions. (3,4).
Regardless of the system one is acting in, public health professionals are charged with upholding human rights, clearly laid out in proclamations like the UN’s Declaration of Human Rights (5). These rights span the life course and are affected by all aspects of the human condition including the social determinants that we are born into, the health of our physical environment, and the political and cultural systems in which we operate. We are given these guidelines to operate within and must determine whether paternalistic interventions are warranted based on if we
- Believe the persons to be rational actors (e.g., are they fully informed?)(6),
- Think that there is or is not the presence of a quasi-coercive environment (e.g., are your alternative choices essentially unjust or unfair and you’re in a catch-22 situation)(7), and
- Trust that we are not impinging on the rights of the individual and we are providing the most good for the largest amount of people (8).
Human rights gives us our guidelines and goals, while ethics gives us the questions to ask ourselves before we can proceed. Although we try to use history to learn from past mistakes, the answers to these ethical questions are not clear-cut and cultural attitudes impact things like deeming what levels of paternalism are acceptable. These three areas, paired with a deep understanding of the social determinants of health and the complexity of systems, can help us in our fight for public health equity for all. Public health faces many challenges but it has at least equally as many opportunities. After all, “an optimist sees the opportunity in every difficulty.” (Winston Churchill)
- Physicians for a National Health Program. A Brief History: Universal Health Care Efforts in the US. https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/
- Leavitt, Judith Walzer. (1992). “Typhoid Mary” Strikes Back Bacteriological Theory And Practice In Early Twentieth-Century Public Health.” Isis. 608–29. https://pubmed.ncbi.nlm.nih.gov/1487413/
- de Savigny, D., Adam, T. (Eds). Systems thinking for health systems strengthening. Alliance for Health Policy and Systems Research, WHO, 2009. https://www.who.int/alliance-hpsr/resources/9789241563895/en/
- Meadows, D. (2014). Leverage Points: Places to Intervene in a System. http://www.donellameadows.org/archives/leverage-points-places-to-intervene-in-a-system/
- UN General Assembly. (1948). Universal Declaration of Human Rights. http://www.refworld.org/docid/3ae6b3712c.html
- Conly, S. (2013). Against autonomy: Justifying coercive paternalism. Cambridge, MA: Cambridge University Press.
- Daniels, N. (1985). Doth OSHA protect too much? Just Health Care. (140–179). Cambridge, MA: Cambridge University Press. https://doi.org/10.1017/CBO9780511624971.008
- Mill, J. S. (2001). On Liberty. Kitchener, Ontario: Batoche Books Limited. (Original work published 1859).