Balancing the Needs of Society and the Individual Patient

Introduction

The COVID-19 pandemic has brought to light the conflict between public health policies and individualized patient care. Individual patients are lost in the dust of government dictates that are not necessarily based on data. Overnight, politicians and the media have been accepted as medical experts. This set of circumstances leads to an important question: is modern-day public health truly concerned with the public’s health? Have the American people been given guidelines to preserve their safety, or are these guidelines tactics to gain more control over the practice of medicine and day-to-day life?  Daniel Webster once said, “Good intentions will always be pleaded for every assumption of authority….”¹

While sometimes good intentions are just what they seem, our concern for society must not supersede individual rights. Public health must proceed with caution, least we fall prey to the ideology of Nazi doctors, who stated that the health of the Volk (people as a whole) stands above the health of the individual.²

Public and Population Health Defined

In 1920, the founder of the Yale School of Public Health, Charles-Edward A. Winslow, defined public health as “[t]he science and art of preventing disease, prolonging life, and promoting physical health and efficiency through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.”^3,4

The American Public Health Association (APHA) makes the distinction between individual health interventions. A medical professional treats patients who are sick or injured, while those in public health try to prevent people from illness or injury and promote wellness by encouraging healthy behaviors. Unfortunately, this definition conjures up the image of a turf war and demeans the role of the private physician in their patients’ overall wellness.

Population Health

Population health is a subset of public health that emerged as a topic of discussion in the year 2000. Population health deals with the health of a specific group of individuals, categorized by race, age, location, or disease. Officials then devise policies for these specific groups of people. Officials look for non-medical factors that may influence a patient’s health status, such as socioeconomic situation, education and literacy, unpleasant employment environment, housing, neighborhood safety, lack of adequate nutritious food or water, or occupational exposure to risk factors. These “social determinants of health” (SDOH) are now an ICD-10-CM code modifier “Z”. A common error when looking through the lens of public health is reducing a patient to the sub-group to which they may belong. This view of a patient leaves no room for individual needs, or individual health concerns that may not align with the group to which they belong.

The Role of Public Health

The role of public health is to recognize health problems and identify factors associated with the problems. Second, they are to report the problems to the public. Third, the officials must limit the exposure and spread by developing interventions to control or prevent the problems. The interventions guide choice through disincentives (e.g., taxes on health-harming goods, such as sugary beverages), incentives (e.g., tax breaks on health-promoting goods), or selected information, such as food labeling or media campaigns. Fourth, the officials assess the effectiveness of interventions.

The government is not supposed to practice medicine; however, the rules change in an emergency – which the Secretary of Health and Human Services (HHS) defines. This gives the government an inordinate amount of power over medical practice. The government can make clinical decisions, control medications, food, water, and commerce.

Public Health Achievements

As far back as the 1300s, the public was able to link travel through Asia with the spread of the bubonic plague. Accordingly, officials instituted and effectively utilized quarantine and isolation. In the 1700s, soldiers in tight quarters spread typhus to each other. During the Industrial Revolution, the population density and environmental toxins wreaked havoc on the health of many, leading to improvements in ventilation and sanitation. In 1798, Congress authorized formation of the U.S. Marine Hospital Service, the forerunner of the Public Health Service. The father of immunology, Edward Jenner, a physician, developed the first smallpox vaccination in 1796.

In the 1800s, public health was advanced by the establishment of the first U.S. system for recording births, deaths and marriages. Additionally, this system developed a standard nomenclature for disease; a system for recording mortality data by age, sex, occupation, socioeconomic level, and location. Eventually, government officials were able to apply the data gathered regarding school health, smoking, and alcohol abuse to their standardized recommendations. The 20^th century, public health officials began educating the public about the correlation between lung cancer and smoking, as well as lifestyle contributors to cardiovascular disease.  In sum, public health has had major achievements in sanitation, vaccinations, and lifestyle modifications such as smoking, heart health, workplace safety, and motor vehicle safety.⁵

Issues with Public Health

Public health is far from new. However, we have now entered a new era of public health. Five key issues are apparent with our public health system. First, public health relies on government action backed by the force of law. The HHS can declare an emergency and exercise police powers in the interest of general welfare. Examples include isolation, quarantine, community vaccination, and changing licensing rules for professionals.

Second, public health officials can be non-transparent regarding their data and conclusions.^6,7 Additionally, public health officials often dismiss the input of practicing clinicians. Consequently, many far-reaching solutions are based on erroneous assumptions.

Third, public health can be corrupted and political. Studies are often designed not to test the hypothesis but to prove the desired outcome. Public health authorities are in the position to highlight the topics that advance a certain agenda. For example, public health officials often emphasize the safety and the perceived necessity of abortions. However, the public health system says little to nothing of the risks, complications, and ethical problems that go along with abortion. If aborted lives were counted as others are, abortion would be in the top two causes of loss of human life, coming in a close second (629,898 deaths in 2019) to heart disease (659,041 deaths in 2019).^8,9

Fourth, the number of issues that have achieved public health status is concerning. This is due to the latitude afforded to government entities to declare various issues a public health concern.  Public health has been the basis for HHS to modify property law during the COVID-19 emergency. Other areas under the public health umbrella include guaranteed wages, voting laws, terrorism, incarceration, financial lending, among many other things. Finally, the United States has taken some moral wrong turns in the name of public health.

Eugenics and Forced Sterilizations

Eugenics gained popularity in the U.S. in the early 1900s. Eugenics is any human action whose goal is to improve the gene pool, especially by selective breeding. In the U.S., public health eugenics proponents insisted that it was our social responsibility to create healthier, stronger, and more intelligent people. They asserted that eugenics saved resources, and would lessen human suffering by eliminating “defectives.” The focus on lessening human suffering drew in many physicians.¹⁰ As time went on, eugenics proponents determined that selective breeding worked better with cattle than humans. Eugenics leaned more toward segregation of populations, family planning, forced sterilization, and abortion.^11,12,13,14

Many see Margaret Sanger as a public health hero as the founder of the American Birth Control League, the precursor to Planned Parenthood. In fact, her writings revealed a darker side to her ideology. She opposed charitable efforts to uplift the downtrodden.¹⁵ She referred to lower classes as “human waste” and that “defective stocks” and “human weeds” should be exterminated in the name of public health. Her definition of “defective stocks” was not just based on genetics, but also on race and national origin. She believed the weak should be allowed to die off.¹⁶

Population control went beyond family planning to include forced sterilization. Starting with Indiana in 1907 to the 1930s, 38 states had forced sterilization laws. The so-called “socially inadequate” included the feebleminded, insane, criminalistic, epileptic, inebriate, diseased, blind, deaf, deformed, and dependent (this included orphans, ne’er-do-wells, tramps, the homeless and paupers).⁷ Forced sterilization was mainly used in institutions, and heads of psychiatric institutions were free to sterilize anyone they considered social misfits.

One such law that made history was Virginia’s Eugenical Sterilization Act, part of a cost-saving strategy to relieve the tax burden of public institutions. Carrie Buck, a 17-year-old unwed mother who was the daughter of a prostitute was chosen as the first person to be sterilized.¹⁷ Before starting a mass sterilization program, the superintendent of Carrie’s institution filed a lawsuit to test the constitutionality of the law. At the trial, the institution’s superintendent testified that: “These people belong to the shiftless, ignorant, and worthless class of anti-social whites of the South.”¹⁸ The judge concluded that Carrie should be sterilized to prevent the birth of other “defective” children.¹⁹

In the 1927 case, Buck v Bell, Justice Oliver Wendell Holmesdelivered these cringeworthy words: “[Carrie Buck’s] welfare and that of society will be promoted by her sterilization. It is better for all the world if, … society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. . .Three generations of imbeciles are enough.”¹⁹

Forced sterilizations in the furtherance of public health went beyond the mentally challenged. Hispanic people and Black people were easy targets, particularly in the 1970s after Medicaid-funded family planning service offered sterilization. Some patients were bullied into consenting with threats of having their welfare benefits or medical care taken away. Tubal ligations during Cesarean sections or other surgeries unbeknownst to the patients became known as “Mississippi appendectomies.”²⁰ The Indian Health Service was equally deplorable, particularly because this organization held a captive audience. Between 1973 and 1976, some three thousand four hundred Native American women—including minors—were sterilized without permission or with defective consent forms. Between 1909 and 1979, over twenty thousand government-funded forced sterilizations were performed. In total, there were sixty-four thousand forced sterilizations in the United States, the last one being recorded in 2010.^21,22

The Tuskegee Syphilis Experiment

The “Tuskegee Study of Untreated Syphilis in the Negro Male” lasted from 1932 to 1972. The U.S. Public Health Service used 400 mainly poor, illiterate, Black sharecroppers with syphilis as lab subjects. The public health establishment stood by to observe the course of syphilis as a “natural experiment.” Informed consent consisted of being told they had “bad blood,” but not that they were actually suffering from a serious disease. In exchange for having their lives ruined, the men received free medical exams, free meals, and burial insurance.

Public Health Service personnel indicated their lack of respect for these men as individuals by affirming that the study was more important than the patients. As John Heller, assistant of Dr. Vonderlehr, director of the USPHS Division of Venereal Diseases, bluntly stated in 1933, “They were subjects, not patients; clinical [research] material, not sick people.”²³

In 1947, when penicillin became the drug of choice for syphilis, researchers neither offered it to the subjects nor gave them the choice of leaving the study. Despite the establishment of the 1947 Nuremberg Code of bioethics, the United States Public Health Service continued to deny the right of informed consent to its patients. Once the study became public in 1972, it took a nine-person panel appointed by the federal Health Education and Welfare Department to decide that the study was ethically unjustified.²⁴

Resolving the Tension between the “Greater Good”  and Individual Care

Philosophers have stressed that society is a collection of individuals and that a free society must be based on respect for the individual. When individual rights are infringed under the pretext of public safety or the “greater good”, the individual can become a political tool to be manipulated or oppressed by the government or powerful institutions.

The Oath of Hippocrates provides foundational guidance. According to the oath’s ethical principles, physicians swear to give the best care possible to the patient before them, not to society at large. Physicians swear to maintain confidentiality (“holy secrets”) and to refrain from making value judgments regarding treatments or patients’ value to society or other non-medical characteristics—not social, racial, age-based, or disability-based. In line with the Oath of Hippocrates, the American Medical Association (AMA) code of ethics states that the duty to advocate for the needs of the individual patient is paramount.

First and foremost, physicians must follow their own moral compass. Ethicists from several disciplines have developed practical guidelines for public health dilemmas. General guidelines for engaging in public health studies instruct that the physician must, first, know the goal and ensure that it fits with their ethics; second, know the burdens (e.g., privacy, confidentiality, self-determination); third, determine that the process is fair and transparent; fourth, determine that the study will not cause harm to the patient (nonmaleficence); fifth, obtain informed consent.²⁵ Similar principles attach to engaging in a public health intervention. The proposed measure must achieve the goal, provide benefit when balanced against any harms, respect human rights and privacy, and confi- dentiality, and protect the sub-group from being marginalized and stigmatized.^26,27

Finally, there are guidelines to assist health professionals when patient confidentiality must be breached. It is ethically justified to disclose a diagnosis to public health authorities if the probability of a very serious risk to the public is high and the risk relates to an identifiable individual or group. Finally, if a confidence must be betrayed, health-care professionals must tell the truth to the patient.

Conclusion

Corporate-style medicine has opened the door to top-down control by public health authorities. However, public health is not the practice of medicine. Health care systems and public health would not be possible or effective without individual doctors and individual patients and the bond of trust between them.

Further Reading on Public Health Issues

• Climate change, https://www.wsj.com/articles/climate-change-to-be-treated-as-public-health-issue-11630315800.
• Property law, https://www.npr.org/sections/healthshots/2020/09/29/916972891/evictions-damage-public-health-which-is- why-the-cdc-has-banned-them-for-now.
• Racism, https://www.hsph.harvard.edu/news/hsph-in-the-news/racism-public-health-crisis-bassett/.
• Wages, https://www.minnpost.com/community-voices/2014/03/wages-are-public-health-issue/.
• Voting laws, https://harvardpolitics.com/wisconsin-voter-suppression/.
• Transportation, https://usdotblog.typepad.com/secretarysblog/2010/07/dot-doing-its-part-to-keep-kids-moving.html#.YbZD0y2caj0
• Terrorism, https://academic.oup.com/eurpub/article/28/6/986/5071711
• Crime, https://pubmed.ncbi.nlm.nih.gov/9532958/.
• Policing, https://sph.umich.edu/pursuit/2020posts/policing-is-a-public-health-issue.html
• Juvenile justice, https://latogether.org/2019/03/29/juvenile-justice-is-a-public-health-issue/
• Higher education, https://www.chronicle.com/article/higher-education-is-a-public-health-issue/
• Employment, https://academic.oup.com/ilj/article-abstract/50/3/467/6299605
• Incarceration, https://law.stanford.edu/press/in-san-francisco-incarceration-is-now-a-public-health-issue/
• Financial lending, https://www.frbsf.org/community-development/files/credit-scores-payday-lending-matter-to-health.pdf
• Identity theft, https://www.sciencedirect.com/science/article/pii/S2211335520300188
• Bullying, https://mphdegree.usc.edu/blog/how-bullying-is-a-public-health-issue/
• Gentrification, https://www.publichealth.columbia.edu/sites/default/files/pdf/cuessgentrificationas.pdf
• Human trafficking, https://link.springer.com/book/10.1007/978-3-319-47824-1
• Online poker, https://reason.com/2012/01/19/if-poker-is-a-public-health-issue-what-i/