Public Health: Healthy Communities versus Individual Rights?

1. Public Health: Healthy Communities versus Individual Rights? Don Miller, Pharm.D., Professor and Chair, Pharmacy Practice

2. Definitions The Institute of Medicine defines the mission of public health as “fulfilling society’s interest in assuring the conditions in which people can be healthy.”1 The World Health Organization defines health as physical, mental, and social well-being, not just the absence of disease or infirmity. 1. NEJM 2009;360:2493-5

3. Why Public Health? • Clinical care to improve health takes much effort and attention to help one person at a time. • Interventions that change people’s environment are far more efficient and successful at helping large numbers of people and society in general. • Not only can public health interventions often be delivered at low cost; they are often cost saving because of their preventive nature. • Works synergistically with medical care.

4. Public Health Includes • Preventing disease (e.g. obesity, high blood pressure) and injury • Promoting healthy behavior • Assuring quality and accessibility of health services • Anticipating and responding to disasters to promote rapid recovery of health

5. The Public Health System Police EMS Corrections MCOs Health Department Churches Community Centers Philanthropist Nursing Homes Home Health Parks Doctors Schools Elected Officials Hospitals Mass Transit Environmental Health Civic Groups CHCs Fire Tribal Health Employers Laboratory Facilities Economic Development Drug Treatment Mental Health

6. Public Health Agencies • State and local public health agencies monitor community health status, investigate and control disease outbreaks, educate the public, do inspections and enforce public health regulations. • Federal public health agencies include the Centers for Disease Control and Prevention (CDC), FDA, NIH, HRSA, Agency for Health Care Research and Quality (AHRQ), all with the Department of Health and Human Services. • Local safety net providers (e.g. Family HealthCare Center)

7. Most Public Health Interventions are Preventive in Nature • Sanitation • Vaccinations • Reducing exposure to environmental toxins such as second hand smoke • Reducing exposure to drunk drivers • Morbidity and mortality from chronic disease may be as preventable as infectious disease. • At a time of staggering medical costs, preventing disease, lowering medical costs, and improving wellness is not just attractive but essential.

8. Most Public Health Interventions are Preventive in Nature Protective factor

9. Healthy People 2020 • Four overarching national goals: • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; • Achieve health equity, eliminate disparities, and improve the health of all groups; • Create social and physical environments that promote good health for all; and • Promote quality of life, healthy development, and healthy behaviors across all life stages. • Healthy People 2020 tracks approximately 1,200 objectives organized into 42 topic areas, each of which represents an important public health area. • http://www.cdc.gov/nchs/healthy_people/hp2020.htm

10. What Determines Health of the Public? • Biological • Infectious agents, chronic degenerative disease, etc. • Medical care for acute and chronic disease • Environmental • Pollution, sanitation, natural disasters • Behavioral • Smoking, seat belt use, diet, use of illicit drugs • Social • Poverty, disability, lack of insurance

11. What Determines Health of the Public? • Part of public health requires investigation of natural and biological phenomena, and we are generally very supportive of this aspect because it fits with the medical model of health. • Environmental and social determinants of health may be strongly influenced by public policy and laws. This where controversy occurs.

12. Examples of Public Health Policy • Regulation of prescription drugs and medical devices • Workplace safety • Health screening programs • Automatic External Defibrillators (AEDs) in public locations • Traffic rules (e.g. speed limits, seat belts)

13. Health Policy Issue • The speed limit on I-94 and I-29 through Fargo is 55 mph. • Should persons have the right to drive faster through the highways in Fargo? • If so, 75 mph? Higher??

14. Health Policy Question • Should new born infants be screened for rare genetic diseases such as thalassemia? • What if each screening test costs $70 and only 1 in 10,000 infants is affected? • Would cost $700,000 for each case detected and would increase your insurance premium. • (but the disease causes severe disability without early treatment)?

15. Social Factors • Social class is a more important determinant of heart health outcomes than blood pressure, cholesterol, diet or smoking status combined.1 • Prevalence of diabetes among US adults without a high school diploma is 13.2% vs. 6.4% among those with a bachelor’s degree. Similar disparities for some other medical conditions.2 • Families with financial insecurity face hardships that take priority over health concerns. They tend to eat poorly, forgo exercise, and skip medications. They live in insecure neighborhoods and have more limited access to health care. • Even middle-class individuals have a lower life expectancy than those who are wealthy.2 Rose G, Marmot M. Br Heart J 1981;45:13-19 Woolf SH. JAMA 2011;305:1902-3

16. Social Factors • It is easy to forget that social reforms were a big part of conquering even early public health problems such as infectious disease (chimney sweeps -1788). • Social factors have long been recognized as important - cultural and religious rules traditionally contributed to public health through prohibitions on dietary and sexual practices. • Since we no longer commonly share these localized cultural factors, government (mostly local, state) becomes a default common denominator and social institution for influencing behavior.

17. Spending on Public Health • In the U.S. less than 5% of all health expenses go toward public health, and spending on public health varies considerably within states and communities (most funds come from local sources). • There is a good correlation between spending by local public health agencies and preventable causes of death. Mays GP, Smith SA. Health Affairs 2011;30(8):1585-93

18. Why Don’t We Spend More? • Individualized clinical medicine is more personal, stories of heroic doctors and patients are flashy and emotionally appealing. But when public health interventions work well, nothing happens – and its taken for granted! • Most payment for clinical medicine comes from patients or their insurance companies, while almost all funding for public health comes from tax dollars through various levels of government. • Costs occur today while the benefit occurs in the future. • Benefits accrue to unknown persons – and more often to disenfranchised persons. Advocacy needs a face.

19. Why Don’t We Spend More? • Those with the most to gain from public health are the most vulnerable in society – a group with little political clout, and who live in communities with less to spend on public health. • Those who are well-off and better educated are in position to make better choices for health and also can obtain care easily when illness does occur, so the need for public health interventions does not resonate. • Costs and other burdens of public interventions may fall on specific groups – tobacco companies, energy companies, the food industry, etc., and/or on the taxpayer. • Public health interventions may clash with personal freedom or the philosophy of personal responsibility.

20. Public Health vs Freedom? • Public health goals often clash with social conservative principles because that which aids a group collectively may harm or impair autonomy of some individuals (vaccines an example). • Passage of, and Supreme Court affirmation of, the Patient Protection and Affordable Care Act (ACA) has placed public health in the spotlight. The ACA itself is essentially public health legislation, and included many items to directly and indirectly support public health nationwide.

21. The ACA • The ACA included money for direct expansion of public health programs, including more community health centers, yet this money was the first target for cutting by the opposition. • The opposition would have also reduced CDC funding, and eliminated funding for Agency for Healthcare Research and Quality (the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care in the US).

22. Specific Policy IssuesLet’s Discuss

23. Lead Exposure • Lead is a known neurotoxin, especially to children. Policies have been enacted to ban leaded paints, leaded gasoline, and toys with lead. By reducing lead in the environment we reduce the probability that children will be exposed to the toxin. • Is this a good thing? Are there drawbacks?

24. Quarantine • Under constitutional police powers, authorities have always had the right to quarantine persons who are public threats in passing on infectious diseases such as tuberculosis, typhoid fever and smallpox. • Is this good policy? Doesn’t it violate personal freedom?

25. A Balancing Act Autonomy vs. Collective Interests Risks - Benefits

26. Tobacco Control • Many jurisdictions have banned smoking in all public places (including NDSU) because smoke contains many known carcinogens and toxins. • Is this rational? Are there drawbacks? • Is there a societal interest in limiting tobacco use that trumps personal freedom? • Health • Saves health care expenses • Societal norms

27. Tobacco Control • The federal government still subsidizes the growing of tobacco! • Is this rational public policy?

28. Seat Belts • Seat belts in automobiles are generally required by states (as are child restraints). • Saves lives • Saves medical costs • How is this different than requiring a change in how soft drinks are sold?

29. Public Policy and Health • Laws and regulations assure that health professionals are qualified and licensed, that consumer products are safe, violent behavior is punished, restaurants are sanitary, etc. • We now live in a very complex, global society, so public policy necessarily becomes more complex as well. • Also consider that health care costs are NOT paid directly by most people. It is society – either through health insurance premiums or taxes – that pays. • In other words, almost everyone who gets sick (or merely uses the health care system at all) costs you and me money. And health care costs continue to rise more rapidly than inflation. Therefore, society at large has a great stake in creating policies that protect its interests and reduce long term spending on health care.

30. General Principles for Change • Use interventions that make better choices easier (by education, provision of encouragement or rewards), rather than punitive or coercive, whenever possible. • Interventions best conceived and implemented at community level. • If laws and regulations necessary, must be narrowly tailored to achieve the objective. • Coercion may be in the eye of the beholder. By limiting the size of a sugar-sweetened soft drink at McDonalds, or by putting taxes on such beverages, you don’t stop anyone from drinking as much as they want, but you make it less convenient.

31. Health and Policy Issues • To what extent is health a public versus private commodity?? • Do people have a rightto be protected from foreseeable health hazards? • In the majority of countries around the world, the “right to health” is considered a moral and legal imperative. • It is enshrined in the constitution of over 100 countries and in the International Covenant on Economic, Social and Cultural Rights, to which the USA is a (unratified) signatory, and other international treaties. Friedman EA, Adashi EY. JAMA 2010;304:2639-40

32. Health and Policy Issues • Of the 25 wealthiest nations, only the US does not provide universal health care coverage. Even many mid-income countries (e.g. Mexico) now do.1 • Universal is not the same as single payer. • Apart from moral drivers, good health is seen by many countries as a driver of economic development, since healthy people are more productive. • Provides all with the freedom to pursue their potential. 1. Lancet 2012;380:861-2

33. Health Insurance • Does society have an interest in making sure that everyone pays their fair share of medical costs, or should society be happy to carry “freeloaders”? • Is the health care reform law good policy? • Is a mandate morally justifiable? • “Near the center of the court's marble steps, pastors knelt on black pads with Bibles open on the ground as they prayed for the law to be struck down”. (AP report June 29, 2012)

34. Rationing • Is it good policy to ration health care? • What if rationing is done by limiting access to certain expensive or ineffective procedures for all? • What if rationing is done based on the ability to pay? • Isn’t failing to expand Medicaid eligibility a form of rationing? • Improving access to Medicaid does improve persons’ health and reduces mortality! • http://www.medscape.com/viewarticle/766749?src=mp&spon=38 • http://www.nejm.org/doi/full/10.1056/NEJMsa1202099

35. Addressing Personal Responsibility • Should persons have the right to avoid vaccinations or laws on seat belt use, motorcycle helmets, etc. if it violates their personal beliefs, but causes a harm to others?

36. Addressing Personal Responsibility • Should a physician have the right to opt out of being vaccinated for influenza (if there is no contraindication) even if this puts the physician at risk of transmitting flu to his/her patients?

37. Analogy to Treatment Decisions • The supremacy of decision making by individuals and families is not limited to public health. • When it comes to active treatment for cancer, autism, or whatever condition, people and advocacy organizations put their own interest first, and resist attempts to consider value to society in limiting health care expenditures.

38. Public Policy CAN make a Difference! • Reducing availability of sugary snacks in schools is associated with less adolescent weight gain(Pediatrics 2012;130:437-46). • Michael Bloomberg has been called America’s first public health mayor. • Under his leadership life expectancy in New York boroughs has increased much more than the national average and he has taken tough public stands on everything from removing whole milk from public schools, to banning trans fats in restaurant's cooking, providing information and services to prevent teen pregnancy, attracting vendors of fresh fruit and vegetables to poor areas, improving asthma management in schools, and controlling HIV(Lancet 2012;379-80)

39. Supplemental Slides

41. Morality • Real morality should be concerned with the reality of human suffering and efforts to alleviate it. • One way to gauge the moral quality of a person is see how they treat the less powerful and those with no power.

42. Diet • Iodine is added to dietary salt to prevent goiter from dietary deficiency, and fluoride is added to drinking water to prevent dental cavities. • Many schools have prohibited or limited availability of pop in vending machines. • Some jurisdictions of limited use of trans-fats in cooking. • What are the pros and cons of these decisions?

43. Denialism and Public Health • An approach to undermining public health initiatives is denialism – use of arguments to create doubt and give the appearance of unresolved debate about matters generally considered to be settled by the scientific community. • Alleging conspiracies (to place doubt about consensus) • Arguments with logical flaws (but which sound plausible) McKee M, Diethelm P. BMJ 2010;341:1309-12

44. Denialism and Public Health • Absolute perfection required for evidence (why no randomized clinical trials on smoking and cancer?) and perfect certainty for action • Highly selective use of citations • Buying “experts” to undermine good science, to plant doubt, or publish contradictory findings • Misrepresentation of scientific findings, including information out of context and straw man arguments