What is Public Health? 

What is public health? There are many definitions. The World Health Organization (WHO) states that health is, “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 2023). This definition, however, doesn’t tell us what or who the “public” in “public health” are. Two ways we can define “public health” are:

1) Population-wide. Populations can be small or large. Population-wide public health measures can assess either:

1. The health of a specific group of people.
2. The distribution of health throughout a group of people.
3. Social and environmental conditions that affect everyone’s health.

2) Public also can mean “collectively accomplished” or something achieved by people as a group. Examples of public health activities accomplished collectively are:

1. The actions of many people and institutions together, whether governmental or nongovernmental.
2. The cooperation or involvement of the public.
3. The public’s joint involvement to realize health improvement. 

“Public health is “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” — CEA Winslow” (Centers for Disease Control and Prevention, 2021)

If you are interested in a career in public health, you might find employment in areas including:

1) Surveillance: collecting, analyzing, and interpreting health data.

2) Sanitation.

3) Food and workplace safety.

4) Disease prevention and control.

Public health professionals also function as educators, promoting healthy behavior. 

The illustration below shows the ten essential services provided by public health professionals. (Fig. 1.1) (Centers for Disease Control and Prevention, n.d.). These ten services are organized under three general categories:

1. Assessment–In Public Health assessment is used to evaluate data regarding incidents in the past as well as in the present. For example, data gathered from the 1918 “Spanish Influenza” pandemic has been used to make comparisons with the current COVID-19 pandemic.
2. Policy Development–Establish principles or rules guiding official actions regarding Public Health. As an example, public health agencies in many countries have developed smoke-free policies for public buildings, airports, and health care facilities.
3. Assurance–Active efforts to assure that communities are protected from health For example, it is the role of public health to inspect, regulate, and license restaurants to ensure the health and safety of those that eat there. Public health agencies also supervise the licensing of healthcare workers, ensuring that workers meet the accepted standards in terms of education and experience.
   

Public health professionals provide these essential services through local, regional, or national public health agencies. For example, during the COVID-19 pandemic, federal and local authorities made active efforts to promote the wearing of masks, social distancing, and other measures to limit the spread of the virus. 

At the center of Figure 1 is equity. The principle of equity, being fair and unbiased, is at the core of all activities and decisions in public health. Public health ethics address equity in issues that may arise across all essential public health services, particularly in areas where no specific guidelines governing traditional procedures exist. 

Access the appendix for a description of this image. 

(Centers for Disease Control and Prevention, n.d.)

Social Determinants of Health 

There have been many advances in access to healthcare and public health services. However, disease and the burdens that disease places on the healthcare system continue to exist throughout the world. This is true partly due to our individual genes and heredity. But that is not the only reason. People in different areas of the world are exposed to different levels of risk for exposure to viruses, bacteria, and other threats. Health risks differ from country to country, and from city to city. Surprisingly, most of the difference in risk doesn’t come from the presence of germs, much of it comes from social, economic, and political conditions where people live. These conditions include

1. Poverty.
2. The lack of education.
3. Discrimination against particular social groups. Some groups may be discriminated against because of long-standing prejudice and others because of issues in the organizational structure for delivering public health services.

Together, these three conditions are called “social determinants of health” ((Barrett et al., 2016) p.8).

The wide disparity in the availability of healthcare, regardless of the reason, causes a great deal of concern. It certainly feels unfair. Providing a way for all individuals to have access to health care can help.

When considering ways to accomplish an equal provision of healthcare it is important to understand the difference between the terms “health disparity” and “health equity”. “Health disparity” means simply that differences exist. The noticeable difference in levels of public health from one region to another is a fact. It doesn’t suggest that something should be done about it. Health disparities, however, can and frequently do reflect basic unfairness. When Public Health professionals use terms such as “inequity” and “unfair” they are using them as ethical terms that imply that we have a duty to do something about the injustice. The meaning of ethics in healthcare will be discussed in the next section of this chapter.

Justice for public health workers is about equal access to healthcare. Public health professionals ask questions such as:

“How can we distribute health benefits fairly?” and,

“How can we achieve better health outcomes in our communities or groups where healthcare is not available equally to everyone?” 

It is an established fact that some groups of people have more health problems and die sooner than others. To fix this, we can focus only on the groups that have historically not had good access to healthcare. Another approach is to work to improve health outcomes for everyone, while at the same time devoting special efforts to those most in need. It is generally accepted that everyone should have the same chance to be healthy and no one should be held back from being healthy if it can be helped. This means that changes need to be made to give everyone the best chance of having access to the information and services that will keep them healthy. Reducing the inequality of healthcare services will ultimately take the help of both governments and public health professionals working together.

The World Health Organization (WHO) defines health equity as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically” (World Health Organization, n.d.). Remediable differences are those that can be cured. 

Stakeholders

Community Solidarity

Public health is only successful in a community if three things occur. First, public health must gain the community's trust and respect its values. Second, the community must accept, cooperate, or participate in the public health interventions. Third, public health must recognize the network of relationships and emotional bonds that are shared when people live together in an organized community. This third aspect is commonly referred to as solidarity.

Community solidarity is the idea that an inspired, caring community can create social change to improve its situation. It forms the basis of social life and action in a community. For a public health initiative to be successful, it must be understood that everyone in the community shares in the obligations and benefits of the initiative.

Successful public health initiatives supported by community solidarity are everywhere. You may have heard stories of communities sewing masks for their healthcare workers, organizing food drives for the less fortunate, or artists giving concerts to raise money for local charities. These are all examples where the public health sector gained the community's trust, and the community participated and supported the public health initiatives. 

Ethics 

Ethics is about right and wrong. However, people’s ideas about what is right or wrong can differ. People's beliefs can be shaped by their environment, culture, or by their religious faith. Some share the idea that whatever feels good is right, and this can be different for anyone. Others share religious beliefs with accepted laws or practices about what is right and wrong.

Ethics are different from morals. Morals are ideas of what is good and bad. Ethics is a set of rules that tell people what they can and cannot do. Some groups, like doctors and lawyers, have their own set of ethical rules that they must follow. These rules help them act in a way that is generally considered correct and moral. 

Introducing ethics to public health issues presents two special challenges:

1) Public health ethics is a relatively new field that combines public health and practical ethics. Because it is a more recent idea, it needs to be explained. Healthcare ethics are changing rapidly, which makes it difficult to define.

2) The concept of health ethics began in the West, However, public health concerns are global. A second challenge, then, is to develop ethical guidelines that are specific enough to provide clear guidance to public health workers, but at the same time are flexible enough to adapt to widely different cultures around the world. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in following accepted values and standards of right and wrong. 

“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” (Centers for Disease Control and Prevention, 2022).

Ethics for Public Health Educators

Public health professionals do a tremendous service and have a responsibility to help society. A Public Health Code of Ethics is a set of rules for public health professionals to follow to ensure they are doing the right thing. Public health professionals have a responsibility to follow these guidelines, even when following these rules presents difficult choices. For example, when there is a public health emergency, doctors and nurses provide help immediately, regardless of how it impacts their personal lives and activities. They put the needs of the community first. Each country has its own code of conduct for public health workers, and it can be different based on the environment, culture and values of that country. The following code of ethics used by several countries worldwide is one example.

Society for Public Health Education Code of Ethics

(Society for Public Health Education, n.d.)

Ethics and Morals 

Ethics and morals relate to “right” and “wrong” conduct. While they are sometimes used interchangeably, they are different: ethics refer to rules that guide conduct in workplaces or principles in religions. Morals refer to an individual’s own principles regarding right and wrong. 

Ethical challenges generally occur during extreme situations or when

guidelines are not in place, are changing, or competing. Some examples could be emergency operations, severe budget shortages, or new areas of technology that force people to decide to prioritize or cut programs.

Ethical Theories: 

What are ethical theories? There are many different ways to think about what is right and wrong conduct. Some theories focus on the person who is doing the action, some focus on the action itself, and others focus on the results of the action. 

1. Agent-based theory Agent-based theory is an approach that focuses on the moral character of the person or agent and their interactions. It emphasizes that virtues are determined by common-sense and that observers judge them as admirable traits in others. It says that good character translates into good actions that inspire others to do the same, which leads to success in social or professional settings. An “agent” can be a person or organization that can assess a problem or situation and take actions based on its perception of the potential consequences

Agent-based models are useful in public health because they can be used to study the emergence of patterns that would be difficult to predict otherwise. An example would be tracking the progression of a specific disease. Agent-based models are especially useful for tracking infectious diseases since this type of disease is spread through interactions between people or “agents”. This theory can help us to understand how the actions of single individuals can lead to the emergence of a global crisis such as the HIV/AIDS epidemic in the 1980s. Agent-based models can simulate and predict the behavior of complex systems, which can be useful in preventing crises that affect public health.

An example of this theory would be a worker who shows up to work on time and does everything he is supposed to do because he believes he should be reliable. Other virtues may include being honest, courageous, modest, and trustworthy.

2. Deontology. Deontology is a philosophy and ethical theory that states that certain actions are morally right or wrong based on a moral duty or rule, regardless of their consequences. In other words, it holds that some actions are inherently right or wrong and that their morality does not depend on their consequences. Laws and rules should be obeyed and people should do their duty because it is the right thing to do, even if the results are negative.

This way of thinking comes from religious beliefs and philosophical principles, such as the belief in human dignity and the statement “First, do no harm,” which is found in the Hippocratic Oath taken by some physicians. Sometimes, doctors make promises, or oaths, when they first start practicing in their industry, these promises are made to uphold ethical standards. Deontological ethics is often contrasted with Utilitarianism, which says that the morality of an action does depend on its consequences. 

A person telling the truth even if it leads to negative results for someone else, is an example of deontology. Following the rules or standards of a person’s religion, is another example of deontology.

3. Utilitarianism. Utilitarianism is a philosophy and ethical theory that states that the best action is the one that maximizes overall happiness or pleasure and minimizes overall unhappiness or pain. This approach is often used to make moral or ethical decisions by weighing the potential consequences of different actions and choosing the one that is likely to produce the greatest overall benefit for the most people. Utilitarianism determines if something is morally right by the outcome. If the outcome is positive for everyone, then it is good or morally correct.

One difficulty with this theory is that it can involve difficult judgments that must be made regarding the relative value of each outcome. Because the utilitarian approach seeks to determine and promote the collective good based, it lends itself to justifying public health interventions. Such interventions can become highly controversial as people may disagree with governmental actions. This occurred when some individuals and groups were upset at government actions during the COVID-19 pandemic.

An example of utilitarianism would be if a new road needed to be built to help a growing community, but there is one house that is in the way. The utilitarian view might say that the house needed to be moved because it would only inconvenience one family and the road would help thousands of people in the community. For someone practicing utilitarianism, it would be the best decision because it would be a greater good for more people. 

Table 1.1 Ethical Theories

Differences Between Clinical and Public Health Ethics 

Clinical ethics is about what's best for one person, while public health ethics is about what's best for a group of people. Sometimes, the two overlap, but they are not the same thing. The table shows that the same rules, like being fair and doing no harm to others, still apply in public health, but they need to be applied differently because public health affects more people and is more complex. This means that public health workers need to think about things like working with other groups and making decisions together and that these decisions are influenced by the culture and government of the area. Overall, public health is more complex than clinical ethics because it affects more people and has more factors to consider. 

Three-Step Approach to Public Health Decision-Making

Step I: Analyze the Ethical Dimensions of the Public Health Issue and Context

• What are the risks, harms, or concerns?
• What are the appropriate public health goals?
• What is the scope and validity of legal authority, and which laws and regulations apply?
• What are the rules people think are important in a situation, and how important are they? ((Barrett et al., 2016) p. 28)
• Are precedent legal or ethical cases relevant for identifying the presumed rules of morality?
• Which social, cultural, or historical issues are relevant?
• Do professional codes of ethics provide guidance? 

Step II: Plan Alternative Courses of Action and Evaluate their Ethical Dimensions

• What are the short- and long-term options, given the assessment of the public health issue and the context in Step I?
• What are the ethical dimensions and tensions of each option?
– Utility: Does the public health action produce the best balance of benefits over harms and other costs?
– Equity and Justice: Is health equity improved? Are the benefits and burdens distributed fairly (distributive justice)? Is there appropriate involvement from the public, including the interactions of affected parties (procedural justice)?
– Respect for Individual and Community Interests: Does the public health action respect self-determination and human rights, as well as civic roles and community values? (e.g., trustworthiness, solidarity) ((Barrett et al., 2016) p. 29)

• Other Moral Considerations in Public Health: Are there other moral considerations in public health that are important to consider? (For example, cooperation, solidarity, protecting privacy and confidentiality; keeping promises and commitments; or disclosing information and speaking honestly, sometimes grouped as transparency.) 

Step III: Provide Justification for a Particular Public Health Decision
• Effectiveness: Is the public health action likely to be effective?
• Proportionality: Will the probable benefits of the action be better than the violated moral considerations?

• Necessity: Is the action necessary (i.e., will rejecting a conflicting ethical norm achieve an important public health goal)?
• Least Limiting: Is the public health action the least restrictive means available?
• Public Justification: Can decision-makers offer public justification in the political and cultural context that stakeholders, the public, and those most affected find acceptable? 

Public health is people taking action to improve the health of others. Public health is a meaningful and important field, one that can help a person feel that they are making a real difference in people’s lives–not just the quality of life, but in some cases making the difference whether a person remains alive at all. The health of individuals is impacted not only by disease carriers, such as viruses, but also by where they live and the conditions surrounding them. There are clinical as well as social factors that affect health. Public health workers often act as public educators. When providing healthcare education in a community, or when making decisions regarding actions that need to be taken to keep people healthy, public health professionals must be guided by ethics. Ethics are the principles that, when followed, can ensure that a public health professional can be confident that they are doing the right thing at the right time in the right way.

References

Barrett, D. H., Ortmann, L. W., Dawson, A., Saenz, C., Reis, A., & Bolan, G. A. (Eds.). (2016). Public health ethics: Cases spanning the globe. Springer.

Centers for Disease Control and Prevention. (n.d.). 10 Essential Public Health Services. Centers for Disease Control and Prevention. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

Centers for Disease Control and Prevention. (2021, January 22). Introduction to Public Health. Centers for Disease Control and Prevention. https://www.cdc.gov/training/publichealth101/public-health.html

Centers for Disease Control and Prevention. (2022, August 5). Public Health Ethics. Centers for Disease Control and Prevention. https://www.cdc.gov/os/integrity/phethics/index.htm

Society for Public Health Education. (n.d.). Code of Ethics for the Health Education Profession Preamble. SOPHE. https://www.sophe.org/careerhub/ethics/

World Health Organization. (n.d.). Health Equity. World Health Organization. https://www.who.int/health-topics/health-equity#tab=tab_1

World Health Organization. (2023). Health and Well-Being. World Health Organization. https://www.who.int/data/gho/data/major-themes/health-and-well-being

Case Study: Public Health Approaches to Preventing Mother-to-Child HIV Transmission

Case Study Background

The pursuit of global public health takes place in an unjust world, demanding that its practitioners judge when and to what extent to compromise their ideals and standards in order to remain effective. (Wikler and Cash 2009)

Mother-to-child transmission (MTCT)—also known as vertical transmission—is the primary cause of HIV infection in children under 10 years of age (Interagency Coalition on AIDS and Development 2011). Each year, more than 600,000 infants become infected with HIV from prenatal transmission during pregnancy, labor and delivery, or breastfeeding, primarily in under-resourced countries (Centers for Disease Control and Prevention 2012; Interagency Coalition on AIDS and Development 2011; Mnyani and McIntyre 2009).

For women who are HIV-negative, breastfeeding is the preferred child survival strategy. It is linked to a lower risk of various health problems for babies, including a reduction in the risk of death from diarrhea and malnutrition (World Health Organization 2007; O’Reilly et al. 2012). However, the risk of an HIV-positive woman transmitting the virus to her baby in the absence of any intervention ranges from 15 to 45 % (De Cock et al. 2000; World Health Organization 2015). Avoidance of breastfeeding (use of replacement feeding) reduces the risk of neonatal transmission to 20 % (Interagency Coalition on AIDS and Development 2011). Modified feeding, also known as mixed feeding (liquids or solids), results in a risk of transmission of about 30–35 % (Coutsoudis et al. 1999). The safety of replacing breastfeeding depends on access to clean water, a reliable supply of formula, and availability of instruction. Thus, use of mixed feeding techniques can be a challenge in many middle- or low-income countries (World Health Organization 2007; O’Reilly et al. 2012).

To help reduce the risk of babies becoming infected with HIV and to ensure quality services across the different levels of the health system, the World Health Organization (WHO) released revised guidelines in 2010 for use by managers of national HIV and AIDS programmers, as well as local managers and health care providers. The guidelines emphasize treatment for pregnant, HIV-infected women. Those with stage 3 or stage 4 disease (CD4 count ≤350 cells/μL) require lifelong three-drug antiretroviral therapy (ART) to treat their own HIV infections and for prevention of mother-to-child transmission of HIV (PMTCT). For women with less-advanced disease, WHO recommends a country- or program-level choice between Option A (maternal zidovudine during pregnancy and infant nevirapine [NVP] throughout breastfeeding), and Option B (maternal three-drug ART regimens throughout pregnancy and breastfeeding) (WHO 2010). Mutations of the virus can occur when the required course of treatment is not followed (Interagency Coalition on AIDS and Development 2011).

In many countries, the social stigma, or fear of the risk of discrimination, rejection, and violence can crushthwart a woman’s intention to have an HIV test, take antiretroviral drugs, or substitute breast milk (Interagency Coalition on AIDS and Development 2011). Such obstacles arise in part from traditional beliefs and values and from unfamiliarity with the practice of biomedicine. In some cultures, a woman is viewed as responsible for her own HIV infection and that of her child, and she may suffer emotional or physical abuse at the hands of her family if her HIV status is discovered. However, it can be important for her family to be aware of her HIV status, as they are often the ones who advise her on child feeding practices. Dealing with a woman’s fear of being exposed as an HIV-positive mother is a challenge inherent in programs that focus on PMTCT.

Case Description

In a sub-Saharan African country, Dr. Charles directs a rural health clinic that an international organization funds. Funding requires the clinic to follow new WHO guidelines for the PMTCT. The guidelines specifically recommend using antiretroviral drugs throughout the breastfeeding period by HIV-positive women (WHO 2010). The district health office is also requiring Dr. Charles to develop guidance for his clinical staff on how to carry out the guidelines in a way that takes the values and beliefs of the community into account. Implementing the guidelines poses a major challenge for Dr. Charles because of the country’s weak health infrastructure, the small number of paid staff in his clinic, and an inadequate facility with limited general supplies. However, his facility boasts a lab, and he has received some funding to support the PMTCT program.

Recently, a woman in labor came to the clinic and told Dr. Charles she was HIV positive. She wanted to know how she could breastfeed without awakening suspicions of her HIV status. This womanShe was worried that if neighbors or family found out, her husband would abandon her, and she would have to support herself and the child in a hostile environment.

Authors

Margaret Henning, MA, PhD and Indira Nair, MSc, PhD

Affiliations

1 International Health Systems Program, Harvard T. H. Chan School of Public Health, Boston, MA, USA

Email: ude.eneek@gninnehm

Health Science, Keene State College, Keene, NH, USA

Email: ude.eneek@gninnehm

Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA

This case is presented for instructional purposes only. The ideas and opinions expressed are the author’s own. The case is not meant to reflect the official position, views, or policies of the editors, the editors’ host institutions, or the authors’ host institutions.

References

Centers for Disease Control and Prevention. 2012. HIV for women. http://www.cdc.gov/HIV/risk/gender/women/facts/index.html. Accessed 23 May 2013.

Coutsoudis, A., K. Pillay, E. Spooner, L. Kuhn, and H.M. Coovadia. 1999. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South-Africa: A prospective cohort study. Lancet 354(9177): 471–476.

De Cock, K.M., M. Fowler, E. Mercier, et al. 2000. Prevention of mother-to-child HIV transmission in resource-poor countries: Translating research into policy and practice. JAMA 283(9): 1175–1182. doi:10.1001/jama.283.9.1175.

Interagency Coalition on AIDS and Development. 2011. HIV/AIDS: Mother-to-child transmission. http://www.icad-cisd.com/. Accessed 23 May 2013.

Mnyani, C., and J. McIntyre. 2009. Preventing mother-to-child transmission of HIV. BJOG: An International Journal of Obstetrics & Gynaecology 116(suppl 1): 71–76.

O’Reilly, C.E., P. Jaron, B. Ochieng, et al. 2012. Risk factors for death among children less than 5 years old hospitalized with diarrhea in rural western Kenya, 2005–2007: A cohort study. PLoS Medicine 9(7): e1001256. doi:10.1371/journal.pmed.1001256.

Wikler, D., and R. Cash. 2009. Ethical issues. In Global public health: A new era, ed. R. Beaglehole and R. Bonita, 249–266. Oxford: Oxford University Press.

World Health Organization (WHO). 2007. HIV transmission through breastfeeding: A review of available evidence. http://whqlibdoc.who.int/publications/2008/9789241596596_eng.pdf. Accessed 1 May 2013.

World Health Organization (WHO). 2010. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. http://www.who.int/hiv/pub/mtct/guidelines/en/. Accessed 1 May 2013.

World Health Organization (WHO). 2015. Mother-to-child transmission of HIV. http://www.who.int/hiv/topics/mtct/en/. Accessed 1 June 2015.