PUBLIC HEALTH AND PUBLIC HEALTH ETHICS *

Spectacular achievements in the health of individuals have not been matched by equivalent improvement in the health of whole populations. Indeed it is against the background of deterioration in levels of population health in some parts of the world and the emergence and re-emergence of infectious diseases in association with powerful globalizing forces that there has been a recrudescence of interest in ‘Public Health'. Here attention is drawn to the dominant values that have shaped our world, to the differences between broad and narrow definitions of public health, to some values that need to be promoted, and to an ethic of public health that considers both human rights and human needs.


Introduction
Spectacular achievements in the health of individuals as a result of the application of many major biomedical advances are the hallmark of medicine at the beginning of the 21 st century.New medical breakthroughs -both preventive and therapeutic in nature-are promised by the eventual clinical application of the revolution in molecular and cell biology and in genetics.
Despite these advances and their potential, it is noteworthy that there has been much less striking improvement in the health of whole populations.Indeed, in some parts of the world the health and life expectancy of billions of people have deteriorated in recent decades, especially since the re-emergence of infectious diseases in multi-drug resistant forms (for example tuberculosis and malaria), and the emergence of many new infectious diseases, of which HIV/ AIDS has been the most catastrophic.
At the end of the 20th century patterns of diseases and of longevity differ markedly across the world.Of the approximately 52 million people who die each year 17.5 million die of infectious and parasitic diseases (16 million of these -many in their youth -in the developing world), 10 million die of diseases of the circulatory system (4.5 million of these in the developing world) and 6 million die of malignant diseases (3.5 million of these in the developing world) (1).Among the poorest quintile of people in the world 55% die of communicable diseases, as compared with 5% of the richest.The WHO estimated that in 1998, 11 million children and young adults died of six infectious diseases that could have been prevented at the cost of $20 per life saved.Poor countries bear over 80 % of the global burden of disease in disability adjusted life years (DALYs).This burden is likely to increase as the epidemiological transition progresses, with added disability and suffering from non-communicable diseases such as vascular disease, malignant neoplasms (es-pecially of the lung associated with smoking), neuro-psychiatric disease, accidents and trauma.
Life expectancy at birth ranges from well over 70 years in highly industrialized countries to below 50 years in many poor countries.Wide disparities in life expectancy are also observed between rich and poor in rich countries.In sub-Saharan Africa gains in longevity achieved during the first half of the 20th century are rapidly being reversed by the HIV/AIDS pandemic.

Globalization and new threats to public health
Globalization is a complex and ambiguous concept with social and ecological manifestations that reflect a long, interwoven economic and political history in which peoples, economies, cultures and political processes have been subject to international influences.The pace of globalization has escalated during the past 40 years under the influence of advances in information and transport technology, decreasing barriers and homogenization of activities through the imposition of a set of ideas that accord higher priority to market transactions than to other human values and activities.Positive, and widely appreciated manifestations of progress associated with globalization include advances in science and technology; increased life-expectancy; enhanced economic growth; greater freedom and prosperity for many; improvements in the speed and cost of communications and transport; and popularization of the concept of human rights.About 20% of the world's population have benefited maximally from such progress.
Negative effects of globalization include widening economic disparities between rich and poor (within and between nations) and increases in both absolute and relative poverty.In addition to progressive widening of the economic division between nations, and growing external control over the economies of small countries through the 'debt trade' and markets that are increasingly global, other powerful global forces radically are disrupting the lives of many (2).These include new patterns of war and ethnic conflict, illicit trade in arms, money, drugs and people, toxic waste dumping, sexual exploitation and child labor and animal abuse on a wide scale.The trajectory of progress has thus excluded a large proportion of the world population from the benefits of globalization because the process fragments and divides as much as it unifies(3).
It is against this background of rapid and profound change, contributing to the creation of new ecological niches and to adaptive evolution of microbes, emergence of new infectious diseases and the recrudescence of multidrug resistant tuberculosis and malaria that the resurgence of interest in Public Health is so relevant.The recent SARS epidemic is a further reminder that the whole world is threatened by the ongoing potential for emergence of new, rapidly spreading infectious diseases.
If we contemplate the meaning of these developments it is not difficult to conclude that at the least we live in an amoral world.A harsher diagnosis is that our world, in which some live short miserable lives while luxuries for the few are favored over essentials for the majority, economic slavery is tolerated and sustained, gross abuses of basic human rights are ignored and threats to long-term self-interest are discounted, is morally depraved.We would surely also conclude that an economic system that generates vast wealth but increases poverty is unstable, that the risks of political and other terrorism are growing, and that the emergence of new infectious diseases and other biological threats together with environmental degradation are wake-up calls for new ways of thinking about our world and ourselves (4,5).
In this article I begin by outlining the dominant values that have shaped our world.Against this background I then address an evolving understanding of what we mean by public health by drawing attention to differences between broad and narrow definitions and to the fact that public health is 'at the crossroads' (6) The discussion proceeds with a description of public health ethics and its implications, a review of values that need to be promoted and some consideration of human rights and needs approaches to public health.I shall conclude by asking what prospects there are of making progress in public and population health.

Dominant Values
Understanding the dominant values driving behavior in the modern world can assist our understanding of how our polarized world has developed.Firstly, there is great faith in the belief that many of the problems we face will be ameliorated though scientific progress.For example, the solution to the specter of millions of starving and sick people in the world is seen in the development and use of genetically engineered crops and in the application of new genetic technology through vaccines and novel treatment (7), (although the threats as well as the promises of biotechnology have been recognized( 8)) This emphasis on acquiring new knowledge distracts us from applying knowledge we already have.In relation to the above example the focus could profitably be broadened to include improved means of distributing the excess food produced in the world (much of which is wasted), and making essential drugs and health care more widely accessible.
This shortcoming is amplified by a second idea in which much faith is placed: namely that economic growth is the answer to poverty.Sadly not enough attention is given to how massive economic growth in recent decades has failed to alleviate poverty in the absence of fair reward for work and greater justice in the redistribution of resources towards those in most need.
A third 'belief' that aggravates this situation is the exclusive focus on 'human rights' as a modern civilizing moral agenda.While the human rights approach has great potential this is much diminished by a narrow focus on uninhibited individual freedom with little sincere attention paid to the whole range of human rights as an indivisible whole, as described in the Universal Declaration of Human Rights (9,10).
Finally, the disproportionate belief in the pursuit of short-term self-interest, fostered by market fundamentalism, emphasizes production of goods for consumption by individuals while long-term interests and the production of public goods are undervalued.

What is Public Health?
The 'crossroads' in public health described by Beaglehole and Bonita(6) 'lead in two directions: a broad direction, addressing the sociocultural foundations of health, and a narrow direction, focusing on more proximal risk factors' (11).The modern biomedical approach to medicine, described as a model that 'uncouples the etiology of disease from its social roots', has spawned a narrow definition of public health with its practitioners focusing on statistics, epidemiology and measurable risk factors.As a result public health has become increasingly divorced from practice, and public health workers have become 'tame counters of events' rather than professionals 'doing' anything to improve public health (12).
Because of the shortcomings of such a focus a broad definition is currently advocated.The Institute of Medicine's definition is 'What we as a society do collectively to assure the conditions for people to be healthy(13)'.Public health in the United Kingdom is defined as 'the science and art of preventing disease, prolonging life and promoting health through organized efforts of society(14)'.The report 'Healthy People 2010'(15) describes four constructs: a healthy body, high-quality personal relationships, sense of purpose in life, and selfregard/resilience.Further it is argued that a broad definition is necessary 'because public health cannot be separated from its broad socioeconomic context,' and public health professionals cannot silently witness such egregious social injustices as poverty, discrimination, inequality and violence (11).Clearly it is necessary to acknowledge that now, more than ever, addressing upstream causes of widening disparities is essential in confronting public health issues.'Compared with the narrow perspective of public health, the broad perspective has intellectual merit because it identifies the fundamental causes of many public health problems, providing more complete and parsimonious explanatory models' (12).

Medical Ethics and Public Health Ethics
The traditional concept of medical ethics is centered on standards of professional competence and conduct broadly outlined by formal codes of practice to which individual medical practitioners and medical organizations claim allegiance (16).Training in medical ethics has, until recent decades, relied almost exclusively on apprenticeship.Its practice was dependent on the conscience of individual practitioners and on exhortation through professional associations and various codes.Role modeling served to pass professional norms from one generation to the next.Although the emphasis was on medical etiquette, two major principles of medical morality were also propagated: 'to do good and no harm to others' and 'to respect human life and the dignity of the individual.'These, combined with compassion and confidentiality, have formed the basis for the desired relationship of trust between patient and doctor and the investiture of authority in medical doctors by society.Ethics was considered largely from the perspective of the duties of physicians.
The focus of much of the bioethics discourse over recent decades, driven by the dominant value placed on individualism and autonomy in the USA, has been on reshaping the nature of the health professional-patient relationship.Narrowing the power gap in decision-making has empowered patients to over-ride dominating medical decisions made from within what has been pejoratively labeled paternalistic medicine.An approach based on autonomy allows for a wide range of patient perspectives, and has been widely advocated and adopted especially in the Western world.
The understandable focus on ethical issues at the interpersonal level has undoubtedly eclipsed ethical issues that need to be addressed in dealing with public health issues.Widening disparities in health, the HIV pandemic and possibilities for improving health that are opening through new genetic biotechnology remind us of the limitations of such an approach and the need to extend our perspective beyond individual health to include the health of whole populations.In a globalising world, perhaps best described as a de-territorialising world, in which boundaries are becoming blurred and the lives of geographically disparate people are more intimately interconnected than ever before, it is necessary to re-evaluate traditional ideas of what it means to be an ethical professional (17).
We have suggested that achieving improvements in human life and health globally will require a broader moral agenda that includes, but goes beyond, interpersonal ethics and civil and political rights.Extension of the ethics discourse beyond the doctor-patient relationship should include considerations of order and fairness within institutions that serve the communities in which individuals are socially embedded and in which medical practice is 'constructed' (4,18) The responsibility of physicians here must be viewed more broadly to include concern for equitable access to health care, for improved public health and for the allocation of scarce resources in ways that promote the common good.This calls for an understanding of what the public good is and for a balance between individual rights and the common good -both of which pose the intellectual and social challenges of how to strike a balance between the rights (and needs) of individuals and the common good of societies (19).
In a world in which individual health is increasingly linked to population health, both within countries and between countries, there is thus a need to develop a scholarly and coherent account of Public Health Ethics.A start has been made and eloquent arguments have been offered in favor of a language of public health that "speaks to the reciprocity and interdependence that characterize community" (20).A broad outline of the terrain of public health has also been offered 'without suggesting that there is a consensus about the methods and content of public health ethics' (21).The latter account, however, is not designed to be a universal public health ethic but rather a focus on public health ethics in the particular setting of the United States.In my view it is vital to understand that in a globalizing world public health ethics should extend well beyond parochial considerations to include considerations of global social justice and the nature of the 'social contract' within a broader interdependent global society struggling to achieve sustainable development.How these considerations and the conflicts of interest that accompany them will impact on the physician/patient relationship will also need attention as the ethics discourse is broadened to encompass the ethics of public health and of professional responsibilities to society.While the focus on individual rights is vital and necessary for the well being of individual persons, such a focus is not sufficient for the achievement of improved public health (22).
The American Public Health Association's Public Health Code of Ethics, describing 12 Principles of ethical practice of public health, is supported by an explanation of the values and beliefs underlying the code and notes on the individual ethical principles(23).Several ethical principles have been proposed for the discourse on public health -especially in relation to constraints that may have to be imposed on individual liberties to prevent the spread of infectious diseases (21,24).The 'effectiveness principle' requires demonstration of the effectiveness of a measure in improving public health if other moral considerations are to be infringed.The 'necessity principle' requires that there is no other method that would conflict with other moral considerations.The 'proportionality principle' calls for a positive balance between benefits and adverse effects.The 'harm principle' states that the only justification for restricting the liberty of an individual or group is to prevent harm to others.The 'least restrictive means principle' requires that less coercive means (for example, education, facilitation and discussion) must first be tried before it can be justified to use the full force of state authority.The 'reciprocity principle' requires that the state should assist individuals to meet their public responsibilities through support and compensation for time and income lost in the process of so doing.The 'transparency principle' refers to the decision-making process, requiring that it be as clear and accountable as possible and free of political interference.The importance of these principles became ap-parent in dealing with the SARS epidemic in Toronto recently 1 .
Achieving an improved balance between the needs and rights of individuals on the one hand, and the requirements for advancing public health on the other, will require a shift in mindset away from strong individualism towards respect for individuals within the context of a sense of duty towards the community.Essential steps will include: firstly, acquiring deeper insight into the upstream causal factors influencing public health; secondly acknowledging the need for a new balance between individual and population health; thirdly, developing the political will to undertake ambitious projects (for example, seeking ways of reducing poverty and dependency and of increasing access to health care); and, finally, placing high value on the longer term economic and social justice required for meaningful and sustainable progress.
The dilemmas regarding public health ethics will be greatest for those societies that are intolerant of any infringement of individual liberties in the name of the common good.The challenge for societies more oriented towards the common good is to avoid excessive infringements of individual rights in the pursuit of public health goals.Realistically a middle ground will have to be forged, because the choice is not between polar extremes but rather about achieving an optimal balance between competing goods (25).

Making Progress -expanding the discourse on ethics and human rights as a first step
Morality is about right and wrong in relationships.Ethics is the branch of philosophy that examines the basis for right and wrong or good and bad.Morality and ethics are usually considered between individual persons -interpersonal ethics-or within groups such as families and religious groups.We have proposed that the discourse about relationships should be extended to relations within institutions (institutional or public health ethics) and between nations (ethics of international relations).Similarly the discourse on human rights needs to be extended beyond civil and political rights to include social, economic and cultural rights as well as environmental rights and the right not to be exploited at the level of international relations.The process of extending the bioethics discourse will require promotion of several crucial values (18).

Concern for the common good
Constructing new and acceptable ways of achieving economic redistribution is the key to resolving many global problems (26).Widespread appreciation is needed for the likelihood that further widening of disparities in wealth and health, beyond the already grotesque differences that currently characterize our world, is a guaranteed recipe for disaster.If the privileged care progressively less for the lives of those whom they consign to living under inhumane conditions, the lives of the privileged will become meaningless and inhuman to the underprivileged masses.This global trap, in which neither rich nor poor care if millions of the other group should die, is the precursor to conflict and loss of life on a grand scale.If rational selfinterest plays any role in human life, it should not be difficult to agree that such conflict must be avoided.
Achieving widespread access to such public goods as education, basic subsistence needs and work requires collective action, including financing, to make sure they are produced, and good governance to ensure their optimum dis-tribution and use.The current international system is very effective at stimulating the production of private goods (e.g., the role of WTO in promoting international trade) but not at the production of public goods -for example education for all children, equitable access to health care and the realization of labor rights and human rights (19,26,27).
While economic equality is an impossible goal, narrowing the current gap is surely well within our grasp.Fair trade rules, debt relief, various forms of taxation, such as the Tobin tax on currency trades across borders (that could generate US$100-300 billion per year) and environmental taxes, have been suggested as ways of facilitating the development of the solidarity required for peaceful co-existence in a complex world (5,27).It should also be acknowledged that greater value needs to be placed on such non-economic aspects of life as a sense of personal worth and dignity.

Belief in and promotion of all human rights (and duties)
"Human rights", as a secular concept for promoting human dignity, has the potential to transcend religions, national borders and cultures.In recent decades the human rights movement has flourished and more countries seem to be accepting universal human rights as a "civilizational" standard (28).Although human rights are widely accepted in the rhetorical sense, much argument continues about the nature and extent of rights.Since the early 1990s a complex debate has also emerged regarding the Western bias and origins of human rights.The extension of human rights from the West to the rest of the world, while superficially successful, must still be considered as largely 'unfinished business(29)'.
Today many countries consider access to basic health care as a basic human right that na-tion states should be committed to providing for their citizens.Some form of socialized and equitable health care is provided in all western European nations and in Canada.Regrettably the example of medical care (as a marketable commodity -albeit with considerable state assistance for the poor and the aged) set by one the wealthiest nations in the world (with damaging effects on that society that are increasingly being acknowledged in the USA(30)) has been followed by many developing countries.Such privatization of medical care, aided and abetted by structural adjustment programs promoted by the IMF and the World Bank, has adversely affected health in many poor countries.Acknowledging the need for, and the right to, universal access to a basic health care package and achieving this goal pose challenges for the future.The WHO's renewal strategy for health-for-all places emphasis on equity, solidarity and appropriate technical, political and economic strategies that could promote health and sustainable health care systems as central requirements for development (31).
The application of human rights must extend beyond civil and political rights to include social, cultural and economic rights and their close integration with the reciprocal responsibilities required to ensure that rights are honoured and basic needs are met.Just as the concept of 'political citizenship' requires nondiscriminatory enfranchisement of all, so the concept of 'social citizenship' requires access to the basic requirements for survival and potential flourishing -a requirement of modern democracy.Considerations of group rights to protect minorities add another layer of complexity (32).Protecting minorities is more than an extension of human rights and is an essential component of the quest for international peace and security.Much remains to be achieved if human rights are to become an integral aspect of global politics and law (33).
The different perspectives from which rights are discussed include consideration of rights as entitlements under law, rights as ethical standards and rights as aspirational ideals.Medical ethics is also addressed from a range of perspectives -including, but not limited to, deontological ethics, consequentialist ethics, casuistry, virtue ethics and caring.Medical ethics and human rights are linked indirectly and directly.Indirect links are evident from the concerns of health care professionals to improve the health and lives of individuals and of society, and to treat all patients with equal respect.Direct links include recent declarations to respect human rights and an increasing discourse about rights within bioethics.Human rights proponents and bioethicists share values regarding human dignity.However, these two sets of activities use different discourses and methods and have different implications.The scope of medical ethics or bioethics is more comprehensive than the human rights discourse, embracing concepts of duties and virtue, empathy, compassion and communication skills that cannot be dealt with through a rights approach.However, rights are powerful and have a specific role in medicine.For example the special role of health care professions in witnessing and responding to abuses of human rights provides the opportunity and the responsibility to act on these (34).
There are several ways in which health care professionals can protect or promote human rights: Firstly, by promoting commitment to high ideals in medicine through exhortation and other means of sustaining idealistic aspirations.Secondly, by promoting greater knowledge and understanding of the content of ethics and human rights through education.Thirdly, by implementing due process through international statutes and international law.Fourthly, by developing strategies to enlist assistance from national and international Medical Associa-tions.Finally by operationalizing ideals through the actions of Human Rights Commissions and other Non-Governmental Organizations such as Amnesty International.

Sense of solidarity with others
Solidarity is a complex concept the nature of which, its justifications and implications are all contested depending on how self-interest, the common interest and identity are conceived and balanced (35).However, the term seems to have special relevance in a dangerously polarized world.Developing a global state of mind about major global health problems is arguably the most crucial element in the evolution of global health ethics.Given the plurality of deeply held perspectives solidarity will also be difficult to achieve -as illustrated by the struggle to develop global alliances on the environment, nuclear deterrence, debt relief for highly impoverished countries, on the tobacco trade and on universal access to basic drugs.Its importance, however, is not diminished by such difficulty.

Long-term self-interest
While advocating for both the desirability and the necessity to develop a global mindset in health ethics, we do not suggest that this should be based solely on altruism.In addition there should be greater attention to enlightened long-term self-interest (18).In the past, the achievement of security has depended on striving for competitive advantage and on building fortresses for protection.With the progress of nuclear and other weapons of mass destruction it becomes evident that this approach is inadequate and could destroy all life on the planet.As all of our lives become increasingly dependent on environmental preservation and on the improved living conditions that could reduce the emergence of new infectious diseases, security will become increasingly dependent on co-operation within a mindset that allows us to see ourselves as intricately linked to the lives and well being of others globally. 2There may be no clearer example of self-interest, mutual interdependence and the need for co-operation than in facing the threat posed by the HIV/AIDS pandemic.Politicians are coming to recognize this, as illustrated by former President Clinton's declaration that HIV is a national security threat to the USA and the agreement at the 1999 meeting of Commonwealth Heads of Government that HIV/AIDS is a global emergency.

From rights to needs and a broader moral agenda for public health
Inadequate attention has been paid to the fact that rights and duties are intimately connected -the conceptual logic of rights entails corresponding duties.Thus duty bearers need to be identified to ensure the realization of rights.If all claim rights but none are willing to bear duties, rights will not be satisfied.Our ability to enjoy rights is thus determined by our willingness to accept our responsibilities.The recently proposed Declaration of Universal Duties could further strengthen the rights approach(36).A focus on duties would expose the responsibility of developed nations not to act in ways that may abrogate the rights of people in developing countries.It could also promote recognition of the role developing countries themselves play in causing and perpetuating the misery of their peoples.
Both the Universal Declaration of Human Duties, recently offered as a supplement to the UDHR, and a detailed formulation of how rights and responsibilities (which are indeed inextricably related), can be reintegrated (37), illus-2 Much greater attention will also be required to the ways in which we use and abuse animals -creatures whose lives are more closely intertwined with ours than is currently appreciated trate how the power of human rights language could be enhanced.Of concern is that political discourse is impoverished by a human rights discourse in the US, which "far more than in other liberal democracies, is characterized by hyper-individualism, exaggerated absoluteness, and silence with respect to personal, civic, and collective responsibilities (37)."The reintegration of rights and responsibilities offers three advantages: (i) moving the human rights debate in the direction of who has to do what if these rights are to be realized, (ii) more focused and specific discussions of questions of priority among rights and other important social goals, and (iii) discussions of the inadequacies of the contemporary international political and economic order (38).A shift is required from an excessively liberal human rights paradigm to a social model of human rights that links benefits and entitlements with the acceptance of a series of responsibilities -the starting point for such rights being the principle of respect for all persons in the context of community (37).
While the necessity of the highly commendable rights approach should be acknowledged, it would be wrong to imagine that it is a sufficient moral agenda for the achievement of greater social justice.While rights language is effective in meeting some needs, and is thus a necessary component of the moral vocabulary, it cannot meet all.The language of needs is another essential means of pursuing progress towards achieving decent societies (39).'[It] provides a moral discourse for health promotion and the common good and would be conducive to 'a moral economy of interdependence' that goes beyond the individualistic oriented 'political economy,' takes account of the inherently 'political nature of need,' 'situates the definition and adjudication of needs in the common life of the community, and incorporates notions of reciprocity that go beyond the dichotomy of dependence and independence.A theory of human need provides the justifying framework for such an approach (40).

Conclusions
The world is changing rapidly, with new threats arising to human health at both individual and population levels, and new ideas are needed to make moral and social progress.While new ideas take time to impact there is now a glimmer of hope that advancement towards improved global health is possible.For example, the recent report from the US Council of Foreign Relations and the Milbank Memorial Fund acknowledges the relationships between health and social capital, political stability, the economy and war (41).This could facilitate deeper commitment by the USA and other nations to the moral and strategic importance of improving global health.The work of the Commission on Macroeconomics and Health (42) and the inauguration of a Global Health Fund(43) also reveal a deeper understanding of the importance of global health and an acknowledgement of the responsibility of developed nations to address this constructively.A recently proposed method of promoting a market in global public goods draws attention to how international institutions could promote the production of global public goods by steering a middle path to development between the goals of avid pro-globalization advocates and aggressive anti-globalization groups (44).
However, these are very modest beginnings and much more is required to build a moral global community (26).Public health is a complex notion.Justice and social justice are also complex notions.While there is no satisfactory theory of social justice that could improve public health, injustice is easy to recognize and much progress could be made through new scholarly approaches and the application of common sense conceptions of what could be done to reduce injustice.While achieving justice may be impossible, it is feasible to reduce injustice if we focus on global injustice and develop a public health ethics discourse capable of reshaping how we think and act (18).
While it may seem daunting to individual physicians to consider that they could make any impact on global problems of such magnitude several suggestions can be made.First, we should acknowledge our obligation to know about the impact of global forces on health.Second, we should become more introspective about our privileged lives.Third, we should appreciate that our personal skills, developed on the basis of labor and investment by previous generations, represent social capital and involve social obligations for us.Fourth, we should become a force in coupling excellent treatment of individual patients to national programs that improve public health within nations.Finally, we need to locate our activities within the global context described above and promote new ways of thinking about local and international activities that have the potential to improve well-being and health at the global level.If physicians, scholars and other influential persons (individually and collectively) were to accept these responsibilities there would at least be some hope of moving beyond the present impasse towards healthier and better lives for all.

1
Singer PA, Benatar SR, Bernstein M, et al.Ethics and SARS: learning lessons from the Toronto experience.British Medical Journal 2003; (in press)