Balancing the Rights of Individuals and the Community

The plight of the individual versus the well-being of society is a common conflict noted throughout history. It creates division among modern politics, inspires debate among great philosophers, and is even manifested in public health.  

In the case of KIRK v. WYMAN, the rights of the individual versus the community were brought to trial.  The jury weighed both sides of this debate, ultimately ruling in favor of the individual.  The plaintiff, Mary V. Kirk, was diagnosed with anaesthetic leprosy, which the Board of Health believed to be contagious and a threat to the community. They initially requested voluntary sequestration, but after her incompliance demanded compulsory isolation.  Even still, Mary Kirk refused to comply, arguing that her form of leprosy was not proven to be highly communicable and the environment of forced isolation was unhealthy and inhumane.  The Board of Health suggested an alternative location, only to be met with further resistance and an injunction by Ms. Kirk. Ultimately, they ruled in favor for the individual, arguing that isolation was unnecessary for her relatively non-communicable case.  The Board of Health unsuccessfully tried to appeal.  

This case exemplifies the cruciality of this debate and both sides argue legitimate points.  The individualists view restriction by the government on the individual to infringe on personal freedom, thus contradicting the inalienable rights deemed in the Constitution.  However, protecting the community brings greater benefits for a larger amount of people: a seemingly utilitarian approach.  Furthermore, the individual has the potential to harm an entire community. As an ardent public health advocate, I support the rights of communities over those of the individuals in matters related to health.  Many personal behaviors effect the health of not only the individual, but also of those they encounter in the community.  This is exemplified in the case of communicable diseases, where people can easily infect those they encounter briefly and even indirectly.  To effectively protect the population, infected individuals must be either quarantined or isolated, restricting their rights in the process. In such cases, we are called to examine the ethics of the debate: is it moral to protect many individuals by sacrificing the freedom of one? 

The government is the entity responsible for defining instances where isolation and quarantine are ethical and should therefore enact laws to draw clear distinctions between the rights of individuals and those of the community in such instances. It is important when debating the issue of community versus individual in Public Health to differentiate between quarantine and isolation.  Quarantine is used when a person has been exposed to an illness and they have become susceptible to developing the illness.  Both share a common theme: ensuring the community remains unaffected by communicable diseases. However, forced quarantine or isolation should be a last resort.    Comfortable and humane living conditions must be provided for the patient, their pride and dignity cannot be sacrificed, and confidentiality must be maintained to avoid potential discrimination.

The individual will inevitably be connected to the community, and vice versa; but it is learning how to justly balance the rights of the two that will determine much of the future of public health. 

The Decline of Global Public Health

The article “The Challenges of Global Health,” published in Foreign Affairs, discusses the changes in development over the last century and the current state of global health.  Over the 20th century, aid has seen an increase in spending for health related programs. Increased spending on global health initiatives began with the HIV/AIDS epidemic, which revealed disparities in access to treatment for victims of low socioeconomic status. Healthcare professionals were appalled and caused an outcry, spearheading a, “larger global public health agenda.” Other recent incidences, such as the Avian Flu, have also increased funding for global epidemiological surveillance.  Furthermore, spending by wealthy nations has lead them to pressure developing nations do their share by allocating more of their national budget toward healthcare. The aid world is finally begging to realize that poor health impedes productivity and developmental growth.

Enormous sums of money are now given annually by private and government donators, each amount designated for a specific, narrow goal. This increase in donations has spurred an explosion of well-meaning NGOs dedicated to solving the world’s problems.  But, lack of coordination amongst these do-gooders may be doing more harm than good. The main problem facing health development is no longer lack of resources, but rather lack of coordination.  

Aid is ultimately failing because it is inefficient.  As money becomes tied up in bureaucracies and corruption, funds don’t end up supporting their intended purpose.  Inefficiency is also due to “stove-piping” funds by narrowing their focus to one specific disease or program.  Stove-piping reflects the priorities of donors, which is subject to their opinions, whims, and ideals. Improving efficiency can also be achieved by spending less on specific diseases prevention and more on improving the total health of the population, a more comprehensive approach. 

Donors and NGOs can even hinder the progress of global health with their well intended projects.  Spending by outside organizations and NGOs in developing nations can destabilize a nation’s economy by causing inflation and driving up costs of health higher than what people can afford.  This can only be avoided by the economic participation of local people. The article reaffirms this point stating, “If locals cannot profit, country will never be able to ween off its dependence of aid.” The donor system is also causing a “healthcare brain drain”--trained healthcare workers in developing nations are being lost to better funded projects or are practicing in wealthier nations where they can earn a better living.  In some cases, medical professionals are even being recruited by the very organizations who are trying to help. Ultimately, successful global health development will incorporate exit strategies and transfer control to local leadership.

Two rates that can be used as markers of healthcare development: reduced maternal mortality and increased life expectancy, trends that show an overall improvement in the health of populations.  It is more beneficial to focus on these factors rather than improvement of mortality rates by specific diseases.  Death rates from specific diseases will will only show narrow progress, because diseases can be controlled independently of the nation’s general health, as in the case of HIV.  Furthermore, life expectancy also incorporates death by preventable diseases, thus broadening the focus of aid efforts.  Diseases and causes of death are interconnected, demanding a comprehensive approach that addresses them all simultaneously. Integrated efforts that deal with many variables at once through interconnected, community based interventions will be more effective than tackling each problem individually.  The article discusses the importance of maternal mortality and life expectancy, claiming “If mothers thrive, it means the health-care system is working, and the opposite is true,” and “life expectancy is a good surrogate for child survival and essential public health services”  

The efforts of donors and NGOs are also unintentionally worsening the state of certain illnesses, such as AIDS and Multi Drug Resistant Tuberculosis (MDRTB).  Many developing nations don’t have sufficient healthcare infrastructure in place and are not equipped to effectively battle AIDS and other infectious disease.  Having multiple donor groups is resulting in uneven distribution of aid and incoordination between efforts.  This has lead to many bad effects, such as the failed recognition of connection between AIDS, malaria and MDRTB.  Ultimately, lack of coordination amongst donors results in repetition of interventions.  The state of global health can be improved through dialogue and coordination between organizations and donors who are focusing on the same goals.  Coordination needs to be lead by a visionary leader, something which global health is currently lacking.

Immunity at Risk

American children and parents in the 21st century are naive to many infectious diseases.  Thanks to vaccinations, populations have seemingly forgotten about smallpox, measles, polio, pertussis, and many others.  This lack of knowledge and recognition of diseases has left us vulnerable to these reemerging illnesses.  Pertussis (aka Whooping Cough) is reemerging in California, as described in the article, “Whooping Cough Makes a Comeback,” featured in the Washington Post. 

Bordetella Pertussis is the bacteria responsible for Whooping Cough.  There are two vaccines currently available for Pertussis: whole cell (deactivated pertussis bacteria) and acellular (purified pertussis proteins).  Since the 1940s, the whole cell vaccine has decreased the pertussis infection rate by 99%. In the 1970s, the vaccine shifted to acellular, due to rare but severe side effects from the whole cell.  This change, along with three other factors have lead to the reemergence of pertussis: bacteria are mutating, effectiveness of vaccines are in dispute, and parents are opting to refuse vaccination. 

Fear is the main factor compromising immunity.  Parents are opting out of vaccination due to popular misunderstandings concerning vaccines, as they are uninformed and fall susceptible to rumors (i.e. the MMR vaccine causes autism).  Scarred parents then rely on herd immunity to protect their vulnerable children from infectious diseases. Herd immunity is the concept that not every person needs to be immunized for a population to be protected from a disease. When the majority of a population is protected, an illness’ infectivity deceases, lessening the opportunities for the bacteria or virus.  Thus, even those not inoculated are inadvertently protected. 

However, when too many parents rely on this theory, herd immunity fails.  If too few children are vaccinated, the threshold drops bellow effective levels, allowing the bacteria or virus to spread rapidly through a population.  This trend is observable in many wealthy communities, where parents are less likely to subject kids to vaccines due to a false sense of security. Consequences of this decision can be detrimental, causing an upsurge in cases and increasing risk for immunodifficient children.  Despite all the popular beliefs, there is one truth: benefits of vaccination far outweigh the potential risks.  

Fearful parents are not the only obstacles, as physicians, pharmaceutical companies, and the healthcare system share the blame.  Health care providers need to inform their patients of the actual risks of vaccines, correcting any preconceived beliefs. Pharmaceutical companies are becoming reluctant to developing vaccines because they face legal implications over risks associated with vaccines.  Furthermore, there is only a small return on investment, so vaccines are not profitable for the company to continue to produce and innovate.  Finally, due to access disparities in healthcare, children of lower socioeconomic status tend to have lower rates of vaccination.  Only through eliminating this access disparity and by inoculating these children can any population be effectively protected against infectious disease.  

There are many approaches the public health sector can take to tackle the reemergence of Whooping Cough: mandating boosters to ensure continued immunity, screening those who are at highest risk, educating the community about the truth of vaccination, providing children with equal access, and incentivizing the pharmaceutical sector to continue production of vaccines.  Appropriate public policy must be implemented to ensure these changes. 

The Innocent Victims of Second-Hand Smoke

Both of my parents grew up in the houses of heavy smokers.  The daily exposure to cigarette smoke compromised their household environment and long term health.  Even today, they continue to feel the consequences of long term exposure to smoke.  Exposure to second hand smoke is serious, as it effects innocent nonparticipants including family, friends, and any one who breathes the same air.  A study, “Non smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan.” revealed just how serious passive exposure to smoke truly is. 

The study focussed on the effects of second hand smoke on the wives of smoking husbands.  However, the wives themselves were nonsmokers. It was found that the rate of lung cancer increases with an increase in exposure to passive smoke, so that women in the first group had the highest rates of lung cancer. No correlation between passive smoking and other forms of cancer, such as cervical, breast, or stomach was found.  

The study also compared those living in urban versus rural areas and found that, surprisingly, those living on farms hard a higher rate of lung cancer.  It was deduced that this was probably a result of exposure; wives in urban settings on average spend less time with their husbands than do wives in rural areas.  Therefore, the latter group has greater exposure time to cigarette smoke, thus increasing their chance for lung cancer. 

This study was conducted as a cohort study, which provided it with many advantages.  Researchers were able to observe the development of its subjects over an extended period of time, thus better controlling for outside variables. Bias in studies sometimes cause a miscorrelation between association and causation.  However, this study minimized its bias by controlling for as many factors as possible.   Occupation, age, alcohol consumption and marital status were all considered during the study.  How heavy the husband smoked was also considered, so the subjects were divided accordingly into three groups: wives of heavy, moderate, or light/ex smokers.  They were then considered within the context of these groups.  Small sample size can also occasionally skew results, but this study avoided the problem by following a large group of women.  The results of this study can be confidently cleared of any suspicions of bias to ultimately reveal that second hand smoke is a cause of lung cancer.

Carcinogens from cigarette smoke in the air, present at any level in the environment, creates a risk for everyone.  Since clean air is a fundamental concern of environmental health, this poses a major concern. Of course, risk increases as exposure increases, so strict regulations must be established to decrease exposure and risk.  Smoking causes risk for not only those who are directly involved, but for everyone who breathes common air, which causes many innocent victims of lung cancer every year.  Toxins in the air from cigarette smoke can only be reduced through public health efforts, policy implications, and structural societal changes.  Only then will innocent victims, such as the Japanese wives, be spared from an unnecessary death from lung cancer. 

Globalization: The Connections of Disease

Globalization: connecting our world for better and for worse. 

Pros: improves economies, reveals similarities between cultures, and connects humanity. 

Cons: diminishes individual cultures, increases gap between social classes, and shares diseases.  

Prior to globalization, there existed a clear distinction between the illnesses of developed versus developing nations.  The wealthy were effected by noncommunicable diseases of “affluence”, typically obesity, whereas the third world suffered from infectious diseases related to poverty, such as cholera.  Globalization has since diminished these differences.  Now, noncommunicable diseases pervade all nations, rich and poor, and are the leading causes of death throughout the world.  This international shift in illness to preventable, noncommunicable diseases is discussed in the article “Global Noncommunicable Diseases - Where Worlds Meet,” published by The New England Journal of Medicine. 

The article attributes the changing health problems as a side effect of the increasingly globalized market, which has brought us mass production of cheap synthetic foods and the influence of media on impressionable consumers.  It has also brought us an unprecedented problem: for the first time in history, it is more affordable and accessible to purchase junk food than whole foods. These factors, as well as others, have made unhealthy lifestyles more acceptable, and in some cases the norm, in almost all regions of the world. 

High and low income nations share not only an unhealthy lifestyle and the same chronic diseases, but also the same risk factors. Almost all risk factors overlap between high, middle, and low income countries.  The most shared components include: high blood pressure, tobacco use, physical inactivity, high blood glucose levels, and high cholesterol levels.  Obviously, this overlap was brought about by globalization and its many facets.

The article not only discusses implications of noncommunicable diseases on health, but also on economic development.  Chronic disease will effect the prosperity of nations, as it reduces the productivity of its people on a long term scale.  And, since economic growth of a nation inherently depends on the health of its people, these persistent disease will result in economic decline.  The nations suggests that nations should unite in their common interest, prosperity, to recognize their common problems and solve them, This, combined with “levels of policy, health care delivery, health communication, and education,” are the only ways the public health crisis of noncommunicable can be overcome. 

Globalization cannot account for the prevalence of all noncommunicable diseases in developing and developed nations. Certain shared chronic diseases predate the our modern globalized society.  For instance, mental health illness (i.e. bipolar disorder) is a naturally caused occurrence and an inherent problem for all of humanity, superseding culture and effecting all communities.  However, what does vary is the culturally specific attitude towards these illnesses; some cultures hold a stigma regarding mental health problems, whereas others are more understanding.  For public health initiatives regarding mental health to be effective, they must be culturally specific, as an understanding of varying attitudes is integral. Once the culture is understood, the three levels of prevention can be implemented:

• Primary: educating communities about changing the pervading mindsets on mental health issues. 
• Secondary: providing those with predisposition to resources and teaching them to control their symptoms.  
• Tertiary: treating and counseling those individuals who are effected.  

Once policies are implemented, communities are educated, and the ill are treated, changes in mental health can occur.