Public Health Ethics: Social Health Justice

Public health ethics involves a systematic process to clarify, prioritize and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information.

Social justice is defined as

• “justice in terms of the distribution of wealth, opportunities and privileges within a society,” according to the New Oxford American Dictionary. Ensuring social justice is, therefore, one component to achieving health equity and maintaining public health ethics. 

According to Paula Braveman and Laura Gottlieb in a 2014 article in Public Health Reports:

• Social justice in health means no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged. Social justice in health is also considered as health equity. Health disparities are the metrics that are used to measure progress toward achieving health equity. A reduction in health disparities (in absolute and relative terms) is evidence that we are moving toward greater health equity and sustaining social justice in health. 

Importance of Social Justice in maintaining a Healthy Society

1. According to Aristotle, society's obligation to maintain and improve health rests on the ethical principle of “human flourishing” i.e. the ability to live a flourishing, and thus healthy, life.
2. It is important in allowing individuals to exercise a range of human rights – both civil and political (e.g. physical integrity, personal security, political participation), social and economic (e.g. employment, education and family life).
3. Health is necessary for well-functioning societies so is justice in health. If a population does not have a decent level of health, it is very difficult to ensure economic prosperity, political participation, collective security and so forth.
4. Social health justice gives special moral importance to health capability: an individual's opportunity to achieve good health and thus to be free from preventable morbidity and mortality.
5. When there is harmony in health and social justice, then health burden and problems are lessened with the reduction in health disparities.

Click health for Notes on Components of Social Justice in Health

Bibliography

1. https://www.cdc.gov/od/science/integrity/phethics/index.htm
2. http://www.who.int/healthsystems/topics/equity/en/
3. http://www.who.int/bulletin/volumes/89/1/10-082388/en/
4. BENJAMIN, G.C. Health Equity and Social Justice: A Health Improvement Tool
5. Peter, F., Anand, S., Sen, A. “Public Health, Ethics, and Equity” (2004).
6. Ruger, Jennifer Prah. “Health and Social Justice.”(2004).

Components of Social Justice in Health

The components of social health justice are as follows:

• Equity, Equality, Fairness, Inclusion, Opportunity, Rights
• Moral agency, action
• Equal treatment as natural law
• Removing barriers
• Impartiality

                                         

• Equity, Equality, Fairness, Inclusion, Opportunity, Rights

Health equity cannot be concerned only with health, seen in isolation. Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities, therefore, involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms.

Equality is guaranteeing people or groups are not treated contrastingly/differently or less favorably, on the basis of their specific characteristics, including areas of age, race, sexual orientation, gender, religion or belief, disability, etc.

Understanding the difference between equity and equality is a key component in the effort to reduce health disparities among vulnerable populations. Thus, equality is not equitable.

Example of Equality	Example of Equity
All mothers are provided with the same amount of transportation incentive after institutional delivery.	Considering geographical locations and transportation condition, mothers are provided with transportation incentive after institutional delivery respectively: Himalayan region  : Nrs. 1500 Hilly region            : Nrs. 1000 Terai region           : Nrs. 500

• Moral Agency, action

Moral agency in terms of health is also considered as enacted justice. It is an individual's ability to make moral judgments, based on some commonly held idea of right and wrong and to be held accountable for these actions; to become increasingly capable of making decisions and taking action themselves. A moral agent is a being who is capable of acting with reference to right and wrong. For e.g. If a patient is referred for physical therapy treatment, then there should be some kind of coherence between therapist and patient. There should be freedom for exercise choice and opportunity for change.

• Equal Treatment as Natural Law

Natural Equality is found among all humans solely by the constitution of their nature. Equal treatment as natural law is the principle and foundation of liberty. It is clear according to natural law that one must value and treat other people as so many individuals who are naturally equal to oneself. For example, one can demand preferential services, and must not claim more than others but, on the contrary, allow them to enjoy equally the same rights that one assumes for self.

• Removing Barriers

Removing Barriers mainly aims advocacy, understanding, collaboration on inclusion and diversity within the healthcare system. We advance social justice when we remove barriers that people face because of age, gender, ethnicity, race, religion, culture or disability.

• Impartiality

Impartiality as such is not a virtue. It assumes its morally worthy nature in the context of rights and duties. Furthermore, impartiality in relation to equity is something more than and other than the mere consistent application of rules of behavior. Actions, in order to be good ones, must treat persons appropriately as persons. This is the base of all good actions and, therefore, of all good just actions.

Bibliography

1. https://www.cdc.gov/od/science/integrity/phethics/index.htm
2. http://www.who.int/healthsystems/topics/equity/en/
3. http://www.who.int/bulletin/volumes/89/1/10-082388/en/
4. BENJAMIN, G.C. Health Equity and Social Justice: A Health Improvement Tool
5. Edwards, I., et al., Moral Agency as Enacted Justice: A Clinical and Ethical Decision-Making Framework for Responding to Health Inequities and Social Injustice. Physical Therapy, 2011. 91(11): p. 1653-1663.
6. McLachlan HV Justice and the NHS: a comment on Culyer Journal of Medical Ethics 2005; 31:379-382.
7. Peter, F., Anand, S., Sen, A. “Public Health, Ethics, and Equity” (2004).
8. Ruger, Jennifer Prah. “Health and Social Justice.”(2004).

Eleven Strategic Policies for Prevention and Control of Non Communicable Disease (NCDs) in Nepal

Multisectoral Action Plan for the Prevention and Control of NCDs (2014-2020) by Government of Nepal has highlighted eleven strategic policies for prevention and control of NCDs. They are briefly described in the following way:

    1. High political commitment: 

Non-communicable Disease (NCD) multisectoral action plan will be connected to the head of state/his representative Chief Secretary Government of Nepal (GoN) to have high level of political commitment in line with country international commitment.

    2. Multisectoral response: 

Functional mechanism will be set for multisectoral partnerships and effective coordination in order to accelerate and scale up national response to NCD epidemic. Effective leadership, political commitment, and resources will be sustained for implementation of NCD action plan.

    3. Tobacco: 

Enforcement of and compliance to Tobacco product (control and regulatory) Act, 2011 will be strengthened and public awareness to hazards of tobacco use will be improved.

    4. Alcohol: 

Commercial and public availability of alcohol will be reduced and social mobilizing programs will be implemented to reduce harmful use of alcohol

    5. Unhealthy diet: 

Increased Consumption of fruits and vegetables will be encouraged with a reduction in consumption of salt, saturated fat and trans-fat.

    6. Physical inactivity: 

Improving built environment and promoting health beneficial physical activity through supportive policies in key settings

    7. Indoor air pollution: 

Communities and areas with poor indoor air quality as a result of the use of biomass fuels for cooking and heating will be taken care of and will be supported with alternative means of energy to reduce adverse health impacts.

    8. Essential NCDs (CVDs, COPDs, diabetes, and cancer): 

Health system competence will be strengthened, particularly the primary health care system to address common essential NCDs particularly CVDs, COPDs, diabetes, and cancer, along with the additional NCDs, and communities and individuals will be empowered for self-care.

    9. Oral health: 

Accessibility of essential oral health services will be enhanced through community-oriented oral health, focusing on preventable oral diseases and oral care.

    10. Mental health: 

Basic minimum care of mental health services at the community, competency for case identification and initiating referral at primary care level will be enhanced.

    11. Surveillance, research, monitoring, and evaluation:

Systematic data collection on NCDs and their risk factors’ situation will be strengthened. The information will be used for evidence-based policy and program development. Programs will be implemented for prevention and control of NCDs.

Epidemiology Relation with Public Health

“Epidemiology is the study of the patterns of diseases and factors that causes diseases in man.”

- Center for Disease Control, US Public Health Services

Thus Public health has itself defined epidemiology and epidemiology can be said as a key discipline of public health. It is also known as one of the core sciences of Public Health. It is also considered as the foundation methodology of Public Health Research.

In the mid-1980s, five major tasks of epidemiology in public health practice were identified: 

1. Public health surveillance
2. Field investigation
3. Analytic studies
4. Evaluation
5. Linkages. 

A sixth task, policy development, was recently added. In addition, Community health assessment, screening, intervention programmers, disease investigation are also the functions of epidemiology which have significant roles in Public health.

Also, according to John M. Last, 1988, Epidemiology is defined as “the study of the distribution and determinants of the health-related states or events in specified populations, and the application of this study to the control of health problems.” Relating this definition to public health:

• Epidemiology is concerned with the collective health of the people.
• Epidemiologic findings provide sufficient evidence to direct quick and effective public health control and prevention measures.
• Epidemiology uses epidemiologic information to promote and protect the public's health. Thus, epidemiology involves both science and public health practice.
• Epidemiological data directs public health decision making and aids in developing and evaluating interventions to control and prevent health.

Thus, it serves as the foundation and logic of interventions which fulfills the purpose of public health i.e. to prevent diseases, to promote health of people and to prolong their life.

Historical Evolution of Epidemiology

Disease prevention and health promotion are the main goals of public health, a multidisciplinary field that focuses on populations and communities rather than separate individuals. Epidemiology, one of the basic sciences of public health, is defined as “the study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems.” Epidemiology has played an important role in public health achievements of the last 400 years. Key historical figures and studies have included 

1. HIPPOCRATES (400 BC): “On Airs, Waters, and Places” –Hypothesized that disease might be associated with the physical environment, including seasonal variation in illness.
2. John Graunt (1662): He was first to employ quantitative methods which described population vital statistics. “Nature and Political Observations Made Upon the Bills of Mortality” –
3. James Lind discovered the cause and prevention of scurvy using an experimental study design in the 18th century;
4. William Farr(1839): He originated many modern epidemiologic methods which included a combination of numerator and denominator data;
5. John Snow (1849-1854): He demonstrated that contaminated drinking water. It was the mode of cholera transmission in the 19th century;
6. Members of the Streptomycin in Tuberculosis Trials Committee, who conducted one of the first modern controlled clinical trials in the 1940s;
7. Doll and Hill conducted case-control studies on smoking and lung cancer in the 1950s;
8. Frances et al. (1950) performed formal field trial of the Poliomyelitis vaccine in school children;
9. Dawber et al. (1955) used the cohort design to study risk factors for cardiovascular disease in the Framingham Heart Study;
10. Finally, during the 1960s and early 1970s application of epidemiological methods/interventions got succession in the eradication of smallpox worldwide in 1977.

In recent years the field of epidemiology has greatly expanded in scope, size, and influence. The 21st century poses even more challenging problems for epidemiologists like non-communicable diseases, mental health diseases, aging issues, disaster management, etc.. Like past public health achievements, the solutions to these problems are being studied with the huge contributions of epidemiology in the context of public health action.

Reference: 

Essentials of Epidemiology in Public Health by Ann Aschengrau, George R. Seage