A tranquil Saturday morning in Cambridge, and the conflicting goals of public health & clinical ethics.

It was a tranquil Saturday morning in Cambridge, Massachusetts…I was reading the news sitting at the kitchen table when I heard a noise, as of something falling. A moaning and grunting sound followed. I stood up and went to the window to to check the cause of the noise, expecting to see a dog or another animal. What I did not expect to see was a half dressed man, lying flat on his back in the internal courtyard, arms widespread, and blood coming out of his mouth.
As it turned out later, he had fallen, most probably hungover from a party, from the third floor balcony. What does this has to do with the goals of public health? (By the way, against all odds of falling down from a balcony on the third floor, the guy turned out to be ok). Public health’s main goal is supposed to be the protection of, as a matter of fact, the health of the public, ie of the population. In order to reach this goal, public health policy makers build appropriate infrastructure, make sure that the water we drink is clean, take care of the roads we drive in, and so on and so forth. Public health promotion includes also bans, such as smoking prohibitions, junk food bans, and no drink & drive regulations. To what extent should interventions aimed at limiting dangerous behaviors for the individuals be limited? Does the promotion of health population include prohibiting drinking parties on private homes’ balconies? Would such interventions be legitimate?

According to Ron Bayer (Mailman School of Public Health, Columbia University), speaker at the 6th International Bioethics Conference on New strategies in health promotion, (Harvard, Boston, April 28-29, 2011), the answer is a definite YES.
Ron Bayer, who is also associate editor for the Journal of Public Health Ethicsdiscussed the aims of public health, and the necessity to distinguish them from the aims of clinical ethics. As put by Bayer, John Stuart Mill and the harm principle is not a good place to start reasoning, when thinking about public health (though it is a place that needs to be acknowledged). Indeed, the aims of public health are not to respect the individual autonomy, but to advance the health of population. Ethics, as emerged in clinical ethics, is strongly autonomy focused and Mill-based, and focuses on the individual. Public Health ethics instead is focused on population. According to Bayer, the problems arose when clinical ethicists migrated to public health ethics and tried to apply to the latter the same principles that they were using in the former. That couldn’t possibly work, as when dealing with populations the focus needs to be elsewhere, not on the autonomy. Elsewhere meaning the health of the population, which requires utilitarian reasoning and paternalist justifications in order to be accomplished. Along these lines, the starting point when discussing the goals and ethics of public health is to acknowledge that paternalism is an important element in public health, contrary to clinical ethics. Then, taking that element as a starting point, the question to address in public health becomes: what level of coercion and of public intrusion are we prepared to take in order to enforce public health paternalist policies, as complete smoking bans in public places (as the one enforced in NYC), or parties on private houses’ balconies in Cambridge?

Acknowledging the paternalistic element, though, only opens up the ethical discussion, as other elements need to be taken into account, one being acknowledging Mill’s principle and the autonomy of the patient. Respecting the autonomy of the patient while promoting the health of the population may turn out tricky. In this sense, the goals of clinical ethics and of public health may be conflicting, and as spelled out by Jon Wolff (Director of the Centre for Philosophy, Justice and Health, University College London) in the concluding ethical remarks of the Harvard conference, it is not clear yet what the goals of the health promotion strategies are: promoting individual autonomy, or promoting population health? Without making clear which one of the goals should take precedence, it becomes difficult to spell out what are the “ethical pitfalls” (as the title of the conference reads) of the incentives (be them carrots or sticks), and how to “steer” clear of them.

Further reading

An article by Christian Munthe on the JPHE and titled “The Goals of Public Health: An Integrated, Multidimensional Model” touches a similar point. As put by Munthe, while promoting population health (1) has been the classic goal of public health practice and policy, in recent decades new objectives in terms of autonomy (2) and equality (3) have been introduced. These different goals may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in different contexts. You can read the article by Christian Munthe here.

The issue of July 2009 of the journal of Public Health Ethics explores the issues revolving around the role of political philosophy in public health ethics. You can read the editorial by Angus Dawson here, or see the table of contents of the July 2009 issue.

New policies for Health Promotion: examples from the NYC Bloomberg administration. Too much “in your face”?

Watching the news about the Royal Wedding from the other side of the Atlantic when I could for the first year consider London my “homeplace” feels a little bit strange, but actually nice, as it is nice to be able to discuss Kate’s dress or William’s uniform with the other Londoners participants at the 6th Annual International Bioethics conference, pretending to be sad to be missing it, but actually being happy to be out of the chaos. Dan Wikler (Professor of Ethics, Harvard School of Public Health) was in charge of the opening remarks of the conference, organized by the Harvard University Program in Ethics & Health and sponsored by the World Bank, the Edmond J. Safra Center for Ethics and the Harvard Kennedy School of Law.
The focus this year was on new strategies for health promotion: carrots or sticks? As put by Nir Eyal (Assistant Professor of Global Health & Social Medicine at the Harvard Medical School) and one of the organizers of the event (together with Dan Wikler and Maureen Lewis of the World Bank), the very dense 2-day program -which put together around 40 speakers among ethicists, economists, policy makers, lawyers and regulators – aimed at raising ethical questions deriving from strategies aimed at implementing health, as such: when does an intervention count as too intrusive, or trumping individual’s autonomy? Which strategies are legitimate, and on which basis? What are the goals and principles of public health ethics, versus clinical ethics? And, how to resolve potential conflicts between the two?
Andrew Goodman, Deputy Commission, Health Promotion and Disease Prevention (NYC Department of Health & Mental Hygiene) opened the morning session, presenting examples of strategies aimed at “making newyorkers healthier”, and implemented under the Bloomberg administration. Most of those policies are tackling the tobacco and obesity epidemic. As to the former, the Smoke Free Air Act (SFAA), being a complete ban, ensures that smoking is prohibited even in public open spaces, such as gardens and parks. The rationales for the ban are based not only on the harms derived from passive smoking (an argument that becomes weaker in a public and open space), but also on the ‘repulsive garbage’ argument (i.e. too many butts on the streets), and on the supposed right of parents (or children, it is not clear whose right it is) of not having their children see the bad model purported by people smoking.
As to the latter, policies aimed at tackling the obesity epidemic with the associated increased heart risks, such as the augmented risk of coronary heart disease (CHR), the TransFat Regulation which was passed in December 2006 superseded a previously ineffective campaign aimed at educating people about the risks derived from food containing transfats. The current regulation prohibits the selling of transfat containing food (for a complete list click here) and has jurisdiction over restaurants and vending machines. Another campaign called NSRI (National Salt Reduction Initiative) aims at the gradual reduction in the food salt content, and at reducing risks derived from an excessively high arterial pressure. Around thirty companies are collaborating, and the number is increasing. But the most provocative policy presented by Goodman revolves around banning sugary drinks (basically all pop, soda, fizzy drink, or carbonated beverages). The NYC Department of Health & Mental Hygiene submitted last fall an application to the US Department of Agriculture (USDA) to allow a 2-year demonstration to cut soda & pop drinks, and a 360 degrees campaign on tv and other media has been implemented. Click here to watch one of the video of the “Pouring on the pounds” campaign to cut soda drinks, showing a man drinking fat. Quite effective in eliciting disgust, ain’t it?
Some have criticized NYC health promotion strategies implemented under the Bloomberg administration, as being way too direct, and intrusive of the private sphere. I will leave this issue aside for the moment, and note instead that all the policies described above are not directed at steering the individuals’ beahavior (at least not so directly), but are directed at regulating the food industry, the rationale being that in order to be effective such policies must act at the level of the social context in which the individuals are embedded. Plenty of data demonstrate indeed the ineffectiveness of policies aimed at educating the individual, of which the first campaign to cut transfat containing food is only an example. This line of reasoning is in agreement with the recent April 2011 editorial by the Journal of Public Health Policy . In here the editors Anthony Robbins (Tufts) and Marion Nestle (NYU)
encourage authors to come up with new strategies aimed at tackling the obesity epidemic, but focused on considering how to change the behavior of the food industry, not of the individuals.
As put by Robbins and Nestle, “We have come to believe that research studies concentrating on personal behavior and responsibility as causes of the obesity epidemic do little but offer cover to an industry seeking to downplay its own responsibility”. In other words, paraphrasing emeritus epidemiologist Geoffrey Rose, “Mass diseases and mass exposures require mass remedies”. Policies aimed at influencing only individual behaviors will not make the trick. NYC Bloomberg’s policies may do so. Even if they may be ‘too much in your face’. Yuck!

Further reading:

Chan, Sewell New Targets in the Fat Fight: Soda and Juice, New York Times, August 31, 2009.

Goodman, Andrew President Obama’s health plan and community-based prevention. Am J Public Health. 2009 Oct

Rose, Geoffrey. The Strategy of Preventive Medicine Oxford University Press, 1993.

Public Health Promotion

Last week I attended a conference on public health promotion. http://www.publicserviceevents.co.uk/event/overview.asp?ID=157 A day later I was nearly killed. Let me explain how the two are related.

The public health event was positive in spirit but narrow in focus; ‘promoting health and healthy living’ in practice meant ‘promoting exercise and better diet in order to reduce obesity’. Thus method after program was rolled out to encourage children/families/employees to increase activity/healthy eating/exercise.

There is a weird paradox about encouraging exercise; we have spent decades of investment and inventiveness discouraging exercise in the name of efficiency, by engineering it out of our lives – through building cars, elevators and escalators; through buying household machines to lighten every single task; and by making nearly any act possible with a mere click on the internet. Public health promotors – and individuals who try to live healthy lives – thus find themselves faced with a desperate task: reversing this trend, fighting not only the tide, but 50 years of built environment. In hotels and offices, for example, I often cannot even find stairs, having to resort to an elevator instead – never mind ‘personal lifestyle choices’.

Not being able to design exercise back into the fabric of our lives, health promotors must encourage us to add it on. This takes time, commitment and difficult-to-achieve behaviour change, thus losing the efficiency we previously gained.

As a result I was more pleased than usual when I got out my bike the next day. I have found a way to beat the time’s curse: twice a day I spend 30 minutes cycling to work instead of 35 minutes on public transport. Thus I lose no time commuting (and save time otherwise spent in the gym), I save money (twice: once by saving the public transport fee and once by saving the gym fee), I get some exercise, improve my health, get some fresh(ish) air and increase my wellbeing. It’s a win-win-win for all!

Except that I nearly died. A bus overtook me so close and so fast that it only just missed me, its slipstream buffeting my bike, nearly dragging it into the bus.

Luckily I have a very stable bike. Luckily I am a big girl, cycling at considerable speed (which stabilises the bike even more). Luckily I have 20 years of daily cycling experience, and as a result, the cycling reflexes of a cat.

Luckily I have also developed almost complete immunity to fear and fright in traffic. For this was not the only near miss of the morning – just the closest. I was also cut off by a bus overtaking me when pulling into a bus stop; I got wedged between two buses in front of a traffic light (an extremely dangerous situation, but I had little choice as had to take a right turn); I was pushed out into the road by a bus pulling away from a bus stop, and I was nearly taken out by a taxi which was simultaneously overtaking me and taking a right turn. All in thirty minutes – and outside rush hour. If it had been rush hour, there would have been even more near-misses, and more of the problems would have been caused by cars. Overall, today’s trip was on the quiet side.

In principle, commuting by bike is – socially, ethically and environmentally – a quadruple edged sword. It gives you exercise, reduces air and noise pollution, has a low carbon footprint, and makes efficient use of the road (cyclists take up far less space than cars). In addition cycling is cheap, fast and time-efficient; I always beat public transport, average the same speed as cars in London, and can always get exactly where I want to be, when I want to be there.

In principle, getting people out on their bicycles could be the single best public health measure under the sun.

In practice, cycling in London is dangerous and terrifying. It requires superhuman amounts of courage, a delusional belief in one’s own skill and invulnerability, and incredible fitness and years of experience to have the reflexes and acceleration needed to be safe in traffic. I possess all these traits. But would I cycle when pregnant? No. Would I cycle with a child on my bike? No. Would I cycle when I approached middle age? No. Would I send family out on a bike? No.

Whereas, really, I should be able to do all these things. I could do them in a car in London (if I could afford one), but I should be able to do them on a bike – and in many other European capitals, I can.

And that is where the real link between my near-death and public health comes in. It is not that promoting cycling would be a good public health measure because it would encourage health; it is that my cycling experience this morning was a failure of public health – a failure of the state’s obligation to me, the citizen, to design a safe road.

In all our focus on diet, exercise and behaviour change, we forget that, once upon a time, public health was not about that. It was about design. It was about safety. And we forget that public health started not in the hand of doctors, but of engineers and regulators. Examples of public health measures are sewage systems and drinking water provisions to prevent disease outbreaks; road safety design; industrial emission regulation; and industrial and consumer good design safety. These did more for the health of the public than all health care combined. And, sadly, in many places in this world they are still lacking.

One of these places, it turns out, is London. When I go out on my bike, I go out into a hostile and unsafe environment that is the result of 50 years or more years of design, regulation and education – of road design and traffic rules that chose to and continue to facilitate motorised transport over cycling transport; road design and traffic rules that prioritises motorised transport efficiency over cycling safety; road users who have not been taught to check their inside mirrors for cyclists. It is not cycling that is inherently unsafe. It has been made unsafe by the way we designed our environments.

I should not have to put up with such an environment, and I should not have to put up with such risks – just as I should not have to put up with being exposed to asbestos in my workplace. Questioning what the government could do to promote exercise, takes attention away from the government’s failure to keep road users safe. Both are related to public health but the second, surely, should have priority.

PS – what does this mean in practice? Barclay’s cycle lanes are a nice effort (thanks Boris!), but laughable in terms of a safe cycling lane. If cycling is taken seriously, and decades of pro-car-bias to be corrected, London needs to close half its roads in the city centre to cars and sacrifice a lot of parking spaces , devote entire road lanes to safe (barrier-protected) cycle lanes, and have larger cycling boxes at the front of traffic lights that are accessible even when traffic starts piling up behind them. Cycling lanes should continue up to and through crossings, with cyclists going straight having priority over cars turning left. Crossing into a cycle lane or cycling box, and a taking a turn without looking should be a punishable (and enforced) offence.

This will, of course, severely hamper car traffic – but should we continue to favour car speed at the expense of cyclist’s safety, just because we did so for 50 years? Or should we equalise? For if we do, cycling will suddenly become safe and thereby attractive. I beat cars through London on a bike already. Make cycling safe and everyone will want to do the same – a public health double-whammy!