The US Public Health System and Ethics
Abstract and Keywords
The public health enterprise is responsible for the protection and promotion of population health across the United States. Approximately 2,800 local health departments join state and territorial health agencies, federal agencies, and other government organizations in constituting the core of the governmental public health system in the United States. Spending on governmental public health accounts for less than 3 percent of the nation’s multi-trillion-dollar health budget. Yet it is responsible for health improvement, infectious disease control, pandemic planning, chronic disease control, environmental health, maternal and child health, and more. This chapter reviews the genesis and structure of the public health system. It examines the implications of that organizational structure for the many and varied ethical considerations that arise in the practice of public health.
(p. 63) What Governmental Public Health Is and What It Does
Governmental public health is among the least well-known aspects of the broad, complex web of public and private organizations that constitute America’s health system (Bradley and Taylor, 2013). The public tends to hear about public health during a disease outbreak, when food safety issues arise, or when questions of government paternalism are topics of conversations in the media (Novick, Morrow, and Mays, 2007). Where health care organizations focus mostly on direct patient care, governmental public health agencies have long been charged with the health of entire communities (CDC, 2010; IOM, 1988). Moreover, while the tools of a clinician might involve a surgical or medicinal intervention, the tools of public health are outbreak investigation, taxation, enforcement, and health education, among other population-oriented activities (Hearne et al., 2015). In some jurisdictions, where populations lack good access to health care, health departments have also long provided direct-care services in addition to population-oriented ones.
This chapter will characterize the mission of public health; describe the governmental public health system infrastructure in the United States and explain how it strives to meet the mission of public health; demonstrate the centrality of ethics to public health systems; outline the types of ethical considerations that arise in the work of public health; and consider a case study to show how ethical concerns arise and may be resolved in the complex, multilevel system of governmental public health.
“Public health” represents the means by which society can protect and promote the health of the population, as well as subpopulations of interest (Faden and Shebaya, 2010; Hardcastle et al., 2011). It focuses on “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988, 140). Health departments historically provided (p. 64) a small set of services to the populations they served related to surveillance, outbreak investigation, and infectious disease control, as well as some basic safety-net clinical care such as immunizations and clinics (Cutler and Miller, 2005; Nelson and Williams, 2007). There was also a significant emphasis on sanitation to minimize disease incidence and spread. This movement of “public health” began in earnest in the United States in the 1800s in urban areas, eventually working its way to the vast rural and frontier areas of the United States. Formalized public health systems and infrastructure began to arise through the creation of state and local health departments, which quickly became charged with providing additional services and protections, including environmental health, chronic disease control and prevention, and maternal and child health1 (IOM, 1988).
In the late 1980s, the Institute of Medicine (now the National Academy of Medicine of the National Academies of Sciences, Engineering, and Medicine) recommended that health departments allow private providers and community health centers to provide safety-net clinical services. However, as of 2013, most local health departments (LHDs) have not fully divested their clinical services. LHDs still provide a number of direct clinical services to patients, including vaccinations, clinical screening, and treatment for infectious disease, with some providing primary care directly. Overall, only 5 percent of LHDs provide no clinical services at all (NACCHO, 2014). While LHDs within states have tended to be funded to do similar things (e.g., provide clinical services), intrastate variation was (and is) also substantial (NACCHO, 2014; Parker et al., 2012). The profound variety in the organization and delivery of governmental public health services occurred mainly due to public health’s assurance function as a provider of last resort, as well as a lack of other providers—public or private—in many smaller, rural communities (Corso et al., 2000; Handler and Turnock, 1996). Each community had different needs, as well as a different history, legal framework, and funding basis for its LHD. As such, each LHD has come to look a bit different from its neighbor. Moreover, LHD infrastructure has grown in dramatically different directions. Where rural LHDs tend to be smaller and provide more clinical services, a number of the nation’s largest LHDs have grown to more closely resemble state health agencies in their size and focus (Harris et al., 2016; Leider, Castrucci, et al., 2015; Meit and Knudson, 2009). Just 5 percent (N=137) of health departments in the United States cover 50 percent of the population. The largest 1 percent covers 15 percent, or over 45 million people (Leider, Castrucci, et al., 2015). The budget of the nation’s largest local health department exceeds $1.4 billion—larger than most state health agencies’ budgets (ASTHO, 2014; Merrill and Francisco, 2016).
Defining the Terms and the Mission of Public Health
Public health provides a mechanism to protect and promote the health of society. Many modern definitions of public health have been offered, arguably beginning with Charles Winslow’s definition, which is both functional and aspirational:
Public health is the science and the art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.
(Winslow, 1920, 30)
Winslow’s definition held for over sixty years. Since then, major national and international organizations, such as the Institute of Medicine and the World Health Organization (WHO), have offered their own definitions (IOM, 1988; WHO, 1994). Faden and Shebaya (2010) offer four characteristics that distinguish public health from other public and private entities—characteristics that begin to define the ethical issues faced by public health practitioners: (1) public health is a public or collective good, (2) its promotion involves a particular focus on prevention, (3) its promotion often entails government action, and (4) it involves an intrinsic outcomes-orientation. How health is defined has important implications for the mission (and proper role) of governmental public health (Powers and Faden, 2006). For the WHO, health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1994, 1). Since “complete” well-being extends beyond the scope of somatic or behavioral health, adoption of this definition of health broadens the role of governmental public health beyond the primary prevention of disease to addressing all determinants of health and well-being. Other major definitions of health tend to focus more on physical and/or mental status of individuals, as compared to holistic measures of well-being (Kindig and Stoddart, 2003). Governmental public health in the United States tends to focus more on safety and health improvement, although there has been a recent push to incorporate public health systems and systems thinking into nonhealth sectors, such as housing and urban planning, transportation, and education (Wernham and Teutsch, 2015).
Public health concerns not just the health of individuals, but also health within and across groups and communities. As such, scholars have offered a number of definitions of “population health.” Kindig and Stoddard (2003, 381) outline the most prominent definition: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Beyond a mere aggregation of individuals’ health status, Kindig and Stoddard’s definition includes a distributional component. Social justice scholars have highlighted this consideration when enumerating ethical issues in public health practice.
Public Health Infrastructure in the United States
Governmental public health in the United States operates within a system of federalism. Practically, this means that while the federal government has broad authority over (p. 66) health issues (especially those with interstate and intercountry ramifications), many public health powers are retained by the states. There is substantial variation in public health infrastructure state to state because of this home rule philosophy.
The United States has a flagship federal public health agency, the Centers for Disease Control and Prevention (CDC). In addition, several agencies conduct public health activities or otherwise influence population health. These include the Health Resources and Services Administration (HRSA), the Food and Drug Administration (FDA), the Environmental Protection Administration (EPA), the Department of Agriculture (USDA), and other agencies within the broad Department of Health and Human Services (HHS) (IOM, 2012). There is one state health agency (SHA) per state, and approximately 2,800 local health departments across the United States (ASTHO, 2014; NACCHO, 2014). There are also territorial and tribal health agencies, which tend to be smaller, integrate health care and public health activities, and emphasize health care services (IOM, 1988; Mays, Halverson, and Scutchfield, 2003).
Public health is financed through a complex web of federal, state, and local funds (Leider, 2016). State funds were once the largest single source of revenue for health departments, but the Great Recession that began in 2007 resulted in cuts in state and local dollars to health departments. Coupled with modest increased federal investment in specific areas like bioterrorism and all-hazards preparedness, federal sources surpassed others in the late 2000s. This has allowed the federal government to significantly dictate the types of programs and services that state and local health departments provide (Leider, 2016). On the one hand, the increased standardization of activities has resulted in access to certain public health protections that is more equal. On the other hand, fewer funds are available to address community-specific needs. It is an open question as to whether this approach is equitable.
The federal government has long had a substantial impact on the nation’s health. As Table 7.1 shows, federal policies have addressed both direct care and population-oriented activities for over 200 years, though the United States’ public health infrastructure has solidified just in the past 100 years. Historically, the federal government exercised regulatory and enforcement oversight related to public health protections, whether from infectious disease, environmental hazards or pollutants, unsafe working conditions, or hazardous consumer goods. In the mid-twentieth century, the federal government became a large-scale funder of the nation’s health, both through health care reforms (e.g., Medicare and Medicaid) and the creation of federal public health infrastructure.
Table 7.1 History of Select US Health Policies with Implications for Public Health and Population Health
1798: Federal hospitals for sick/disabled seamen (Marine Hospital Services)
1862: Forerunner to Food and Drug Administration created
1921: Indian Health Services created, first Maternal/Child Health grants
1871: Surgeon General appointed
1924: Veteran’s Bureau
1878: National Quarantine Act
1891: Marine Hospital Services responsible for screening immigrants
1966: Community Health Centers launched
1930: Forerunner to National Institutes of Health created
1990: Ryan White HIV/AIDS Program funded
1938: Federal Food, Drug, and Cosmetic Act
1997: SCHIP (Children’s Health Insurance Program)
1946: Forerunner to Centers for Disease Control and Prevention created
2003: Medicare Modernization Act (Part D—Prescriptions for Seniors)
1971: National Cancer Act
2010: Affordable Care Act
1993: Vaccines for Children Program
Governmental health departments in the United States perform a variety of services, mostly governed by what is funded and what is required by local, state, or federal law (IOM, 2012). Federal and state agencies tend to conduct high-level regulatory, surveillance, and primary prevention efforts, whereas LHDs tend to be the “boots on the ground,” delivering immunizations, doing food safety inspections, conducting health outreach campaigns, and so on (see Table 7.2). National surveys of public health activity largely confirm this theoretical division of labor. In addition to governmental entities, many nongovernmental organizations (NGOs) perform public health activities, especially related to health education and outreach. (p. 67)
Table 7.2 Services Most Frequently Provided Directly by US State and Local Health Departments
Local health departments
State health agencies
Surveillance: Infectious disease
Surveillance: Behavioral risk factors
Adult immunization provision
Surveillance: Infectious disease
Child immunization provision
Surveillance: Reportable disease
Primary prevention: HIV
Surveillance: Environmental health
Primary prevention: Nutrition
Food establishment inspection
Primary prevention: Tobacco
Immunization vaccine order management (Vaccines for Children)
Food safety education
Lab services: Bioterrorism agent testing
Primary prevention: Nutrition
Lab services: Foodborne illness testing
Schools/daycare center inspection
Lab services: Newborn screening
Surveillance: Vital statistics
Screening: Other STDs
Childhood immunization registry
Surveillance: Foodborne illness
(p. 68) Whereas regulation and enforcement are within the sphere of government, other activities are bolstered by private efforts. Moreover, about three dozen state-level public health institutes and ten public health training centers provide technical assistance to state and local health departments in the United States (Leider, 2016). The institutes and centers are often affiliated with universities (public or private), and they help connect practitioners with evidence-based practices.
Official estimates place the size of the governmental public health workforce at about 300,000 strong across federal, state, and local levels (Beck, Boulton, and Coronado, 2014). However, only about 17 percent of the government workforce has formal training in public health (Leider, Harper, et al., 2015). This has important implications for formal public health education, including ethics. The public health system comprises numerous public and private organizations (see Figure 7.1). Governmental public health is at the center of this system (CDC, 2010). Government action, and inaction, thus creates core challenges for public health ethics.
Ethics and the Public Health System
Professionals working in the public health system routinely confront ethical issues. Indeed,
[t]he mandate to ensure and protect the health of the public is an inherently moral one. It carries with it an obligation to care for the well-being of communities and it implies the possession of an element of power to carry out that mandate. The need to exercise power to ensure the health of populations and, at the same time, to avoid abuses of such power are at the crux of public health ethics
(Thomas et al., 2002, 1057).
(p. 69) Ethical issues pervade all aspects of the work of public health, from the macro level of policy development and large-scale planning to the micro level of day-to-day decision-making.
For example, policies governing disease reporting for public health surveillance must balance protection of the public’s health with protections for privacy and confidentiality. Poignant micro-level dilemmas also arise when health department personnel receive reports about, for example, the HIV status of colleagues or friends. In addition, public health interventions routinely limit liberty—consider fluoridation of water, motorcycle helmet laws, and prohibitions on smoking in restaurants. State newborn screening programs engender debates about whether parental consent should be required for screening, not only for research using blood spots. Moreover, social justice issues extend throughout the work of public health, including concerns about reducing health disparities, improving access to health services, reducing the potential stigma of public health campaigns on, for example, tobacco or obesity, and environmental justice issues such as lead in housing or water in low-income communities.
Questions concerning the scope and appropriate boundaries of governmental public health also have ethical significance. How far do the obligations of the public health system extend? As noted above, if health is defined broadly, as the WHO recommends, then the responsibilities of public health encompass the promotion of well-being. Even if health is defined in more limited ways, the scope of public health may extend beyond the common services enumerated in Table 7.2. For example, growing research documents that Americans with lower levels of education face higher levels of risk for chronic illness and premature death (VCU CSH, 2015). Do educational programs fall within the mission of public health? What about jobs programs, affordable and safe housing, or other social programs that may significantly impact health by addressing social determinants of health? An impressive body of research demonstrates the significance of social determinants of health (Marmot, 2005). How does this affect the responsibilities of the public health system? Does it mean the public health system should partner with other governmental systems to implement such programs with an eye toward promoting benefits to health? Should it affect the way public health professionals are trained?
Ethical Issues in Pandemic Influenza Planning
It may be useful to consider how to apply an ethical analysis to a particular topic in terms of how public health systems respond to a particular threat. The example of pandemic influenza planning implicates governmental public health across national, state, local, and tribal systems, and also raises many ethical challenges. Aggressive surveillance and data sharing across governmental agencies can help to protect the public’s health, but it can also compromise privacy. Interventions geared toward limiting the spread of infection, such as isolation, quarantine, and other social distancing interventions like closing schools, infringe on personal liberty and can compromise personal well-being by, for example, undermining access to school meals programs. Resources such as vaccines or antiviral medications may be scarce during a pandemic, necessitating ethical guidance (p. 70) for rationing. The ability of health systems to provide care may be dramatically strained, raising questions about the permissibility of compelling health professionals to work, and thus take on potentially significant risk to themselves and their families. These are a few of the many issues that arise due to the complexities of pandemic planning.
One especially pressing challenge for pandemic preparedness concerns health disparities. In particular, socially disadvantaged groups consistently fare worse than more privileged groups in terms of morbidity and mortality during influenza pandemics (see, for example, Blumenshine et al., 2008; Patterson, 1986; Hutchins et al., 2009). Differences across populations in exposure and susceptibility to illness, and in access to care, appear to account for influenza-related health disparities. Members of socially disadvantaged groups tend to be less able to protect themselves from exposure to illness; for example, they may lack resources that would allow them to avoid public transportation, or the employment flexibility to allow telecommuting to work, and they may therefore be unable to adopt recommended social distancing strategies. Socially disadvantaged groups also tend to be more vulnerable to illness, given their higher rates of comorbid chronic conditions that can increase influenza risks. In addition, those who are socially disadvantaged may have poorer access to care (Blumenshine et al., 2008; Quinn et al., 2011). Disparities in influenza morbidity and mortality are thus linked to other health disparities and social inequalities more generally.
Given their persistence—and thus predictability—these disparities in influenza-related morbidity and mortality should be addressed in pandemic plans across public health systems. Indeed, addressing disparities fits centrally with the core mission of public health, given their impact on population health. Moreover, the Principles of the Ethical Practice of Public Health, often referred to as the Public Health Code of Ethics, emphasizes that “[p]ublic health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all” (PHLS, 2002, 4). Nevertheless, questions remain about the implications these fundamental commitments have for the particular systems that make up public health. What then must public health professionals do to meet their obligations to address health disparities in the context of pandemic planning?
To begin, public health systems at the state and federal levels need to gather data so that groups who are at higher risk can be identified (Bellagio Meeting, 2006; DeBruin, Liaschenko, and Marshall, 2012). Historical risk-factor data can predict which groups are likely to be at particular risk so that relevant preparations can be made. During a pandemic, event-specific data will be needed to capture the burden of disease associated with the particular strain of pandemic influenza. Public health officials should consider the best approach to gathering data on at-risk populations, as certain sources of data may fail to adequately reflect their situation. For example, hospitalization data may not capture rates of morbidity and mortality in populations lacking adequate access to care. Local and tribal public health systems may be able to provide guidance about approaches to data gathering, given their understanding of their particular communities.
(p. 71) Admittedly, more severe pandemics will impose a greater strain on public health agencies’ ability to collect data. Does this potentially limit the obligation to reduce disparities, or does the strength of the obligation demand action in the absence of strong data? Once at-risk groups are identified, further questions arise concerning how to provide services or allocate resources such as vaccines. For example, if members of the public at high risk of death from influenza are prioritized for vaccination, but the vaccine is distributed across geographic areas (e.g., across regions in a given state) in amounts proportional to area population rather than to risk, priority groups may not be reached as needed (DeBruin, Liaschenko, and Marshall, 2012). This further complicates the efforts needed to address disparities, and it heightens questions about the strength of this obligation. Do these difficulties limit, to any extent, the duty to address disparities rather than simply work to reduce morbidity and mortality in the broader population?
As this discussion illustrates, public health professionals must often navigate ethical dilemmas in their work. This means they must be able to identify ethical issues as they arise. The ethical significance of some issues may seem obvious, such as questions about informed consent for newborn screening, or concerns about justice related to health disparities. However, not all ethical issues are so easy to identify. For example, as noted above, questions about the types of data to collect during an influenza pandemic have genuine moral relevance, but recognizing this requires that questions about data collection be explicitly connected to social justice concerns about health disparities. Even when identifying ethical issues seems simple, determining how to resolve these issues is typically far from obvious. Ethical issues tend to be quite complicated and often involve conflicts between values—like those between the value of promoting the public’s health, on the one hand, and concerns about privacy, confidentiality, and liberty, on the other.
Given the centrality of ethical challenges to the work of public health, the Council on Linkages Between Academia and Public Health Practice includes ethics among its Core Competencies for Public Health Professionals (2014). The Association of Schools and Programs of Public Health includes the ethical dimensions of public health in the critical content for MPH and DrPH degree programs (ASPPH, 2014a, 2014b). Similarly, the Public Health Accreditation Board’s latest standards (PHAB, 2013) include a requirement that public health agencies develop and support an infrastructure that promotes ethical decision-making. Thus, these sets of guidelines include explicit expectations concerning ethical practice. They also include responsibilities that are not explicitly framed in terms of ethics but that relate to moral norms, such as cultural competency, consideration of the effect of programs and policies on diverse communities, and solicitation of public input in decision-making (Council on Linkages, 2014; PHAB, 2013).
Given that few who work in governmental public health have formal public health training, it is likely that few have received education in public health ethics, even though (p. 72) ethics is widely recognized as being central to the work of public health. Of course, one does not need formal ethics education to deliberate about moral issues. However, ethics education can support explicit, informed, transparent, and systematic engagement with ethical issues, and thus promote accountability and trustworthiness of decision-making (NACCHO, 2014, Baum et al., 2007, CDC, 2016). To achieve accreditation, public health departments must develop and maintain an ethics infrastructure (PHAB, 2013). This may mean that the department formally adopts the Public Health Code of Ethics as a basis for ethical decision-making, or it may involve the creation of a more substantive ethics infrastructure such as an ethics advisory board (PHAB, 2013). The National Association of County and City Health Officials (NACCHO) recommends that health departments begin to develop their ethics infrastructure by having a leadership model and openly supporting ethical decision-making. Supports include providing training opportunities and other resources for staff (NACCHO, 2015).
It is critical that public health professionals receive the support they need to meet the complex ethical challenges that pervade their work. These challenges arise throughout the work of the governmental public health system, and range from systems issues concerning policy and planning to dilemmas confronting individual public health professionals in their day-to-day work. While it may be laudable for a public health agency to formally adopt the Public Health Code of Ethics as a basis for decision-making, doing so offers little real support for recognizing and resolving ethical challenges as they occur. After all, “[c]odes of ethics are typically relatively brief; they are not designed to provide a means of untangling convoluted ethical issues” (PHLS, 2002, 5). Convoluted ethical issues are not rare in public health. The discussion in this chapter illustrates the sorts of challenges that public health systems routinely encounter as they work to implement ethics guidance, such as the Public Health Code of Ethics, in the messy and detailed context of actual practice. Education programs and ethics advisory boards would provide more robust support than simply adopting the Code of Ethics, but they require political will and dedicated resources. These would be valuable investments in accountability and trustworthiness.
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(1.) By the mid-1990s, federal leaders outlined the ten essential services the public health system must provide: “(1) Monitor health status to identify and solve community health problems. (2) Diagnose and investigate health problems and health hazards in the community. (3) Inform, educate, and empower people about health issues. (4) Mobilize community partnerships and action to identify and solve health problems. (5) Develop policies and plans that support individual and community health efforts. (6) Enforce laws and regulations that protect health and ensure safety. (7) Link people to needed personal health services and assure the provision of health care when otherwise unavailable. (8) Assure competent public and personal health care workforce. (9) Evaluate effectiveness, accessibility, and quality of personal and population-based health services. (10) Research for new insights and innovative solutions to health problems” (CDC, 2010).