Genomics and the public health code of ethics

We consider the public health applications of genomic technologies as viewed through the lens of the public health code of ethics. We note, for example, the potential for genomics to increase our appreciation for the public health value of interdependence, the potential for some genomic tools to exacerbate health disparities because of their inaccessibility by the poor and the way in which genomics forces public health to refine its notions of prevention. The public health code of ethics sheds light on concerns raised by commercial genomic products that are not discussed in detail by more clinically oriented perspectives. In addition, the concerns raised by genomics highlight areas of our understanding of the ethical principles of public health in which further refinement may be necessary.     

Is the Canadian health care system fiscally sustainable?

Current concerns over escalating health care costs and the sustainability of the Canadian health care system are based on analytical concepts and models that have their own limitations and deficiencies. Measuring health care costs across subsectors over the long-term period, the authors argue that Canada's health care costs, especially those under the direct control of provincial governments, are relatively stable. Using appropriate measures of sustainability, there is no indication that Canada's public health care expenditure is unsustainable. Nor is there any indication that Canada's public health care expenditures are out of line with those of its main trading competitors, including the United States.     

Professionalism and ethics in the public health curriculum

As the public's health-care needs increase in complexity, renewed attention is being given to the ethical dimensions of public health decision-making and the development of public health ethics as a bounded area of teaching and research. This article provides an overview of approaches to public health ethics and decision-making, and suggests ways to incorporate the professionalism competencies into the teaching of public health practice. The teaching of ethics language, concepts, and tools for decision analysis helps to prepare students for the inevitable ethical choices they will have to make in their professional practice. The teaching of ethics and professionalism and the experiences of professionals enrich each other and foster the critical link between education and practice.     

Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada

Despite Canada's reputation as a leader in health promotion and population health concepts, actual public health practice for the most part remains wedded to downstream strategies focussed on behaviour change. In Canada's largest province this has led to the implementation of a heart health promotion approach focussed on diet, activity and tobacco use. This is so despite increasing evidence that these approaches are generally ineffective, particularly for those at greatest risk. In addition, these strategies appear to divert public and governmental attention away from addressing the broader societal determinants of health. Examples of Ontario public health units that have begun to address societal determinants of health provide a counterbalance to the dominant paradigm that frames health as an individual responsibility. These new approaches focus attention upon the health-threatening effects of governments' regressive social and economic policies in a manner consistent with the best principles of health promotion.     

Public health ethics: informing better public health practice

Public health ethics has emerged and grown as an independent discipline over the last decade. It involves using ethical theory and empirical analyses to determine and justify the right thing to do in public health. In this paper, we distinguish public health ethics from clinical ethics, research ethics, public health law and politics. We then discuss issues in public health ethics including: how to weigh up the benefits, harms and costs of intervening; how to ensure that public health interventions produce fair outcomes; the potential for public health to undermine or promote the rights of citizens; and the significance of being transparent and inclusive in public health interventions. We conclude that the explicit and systematic consideration of ethical issues will, and should, become central to every public health worker's daily practice.     

The promise of public health: ethical reflections

Public health is in the spotlight of public and political concern, providing a unique window of opportunity for its revitalization and restoration as a pillar of the Canadian health care system. The establishment of a Federal Public Health Agency is a critical first step. The public health community has identified key challenges toward this renewal. However, public health ethics have received little attention and, when addressed, have focussed almost exclusively on communicable diseases. The ethical issues inherent in public health transcend infectious diseases and are distinct from clinical and research ethics. Identifying and addressing ethical issues at the heart of public health, including the public interest and the common good, as well as fundamental issues related to the core functions of public health will be essential if this revitalization of public health is to be achieved. While legal and regulatory reforms are necessary, they will not be sufficient to adequately address fundamental questions of the valuing of public health or the ethical issues in public health. Elements of a research agenda on the ethical foundations of public health reform are identified here.     

Ethical issues in public health

The significance of the binomial "ethics" and "public health" is firstly described. Several definitions are given. A few characteristics making bioethics (concerning mainly individuals) different from ethics in public health (concerning populations) are described. The authors point out how bioethics has been investigated more deeply than public health ethics. Synergy between the two is desirable and efforts should be made in order to promote integration. The importance of research and training in public health ethics and of data exchange with other branches of learning are underlined. A list of national and international institutions dealing with public health ethics is given.     

Tools for thoughtful action: the role of ecosystem approaches to health in enhancing public health

The intimate interdependence of human health and the ecosystems in which we are embedded is now a commonplace observation. For much of the history of public health, this was not so obvious. After over a century of focus on diseases, their biologic causes and the correction of exposures (clean water and air) and facilitation of responses (immunizations and nutrition), public health discourse shifted to embrace the concept of determinants of health as extending to social, economic and environmental realms. This moved the discourse and science of public health into an unprecedented level of complexity just as public concern about the environment heightened. To address multifactorial, dynamic impacts on health, a new paradigm was needed which would overcome the separation of humans and ecosystems. Ecosystem approaches to health arose in the 1990s from a rich background of intellectual ferment as Canada wrestled with diverse problems ranging from Great Lakes contamination to zoonotic diseases. Canada's International Development Research Centre (IDRC) played a lead role in supporting an international community of scientists and scholars who advanced ecosystem approaches to health. These collective efforts have enabled a shift to a research paradigm that embraces transdisciplinarity, social justice, gender equity, multi-stakeholder participation and sustainability.     

Bioethics and public health: epistemological convergences

This is a theoretical discussion about the epistemological statute of bioethics based on its convergences with public health, linked as scientific areas that came from the context of the second epistemological rupture, which questioned the critique to common sense inherent in modern science. The reapproximation with common sense in the second rupture means considering the determinants of environment and subjectivity in the methodology. Emerging from the second rupture, public health and bioethics include the social and subjective determinants in their analysis, with an enlarged and complex vision of human health and human actions involving environment, life and health. This requires a transdisciplinary focus in their approaches. What is the meaning of these premises for the epistemological statute of bioethics in its convergence with public health? As ethics, bioethics needs to be critical, but not aprioristic. The criticism of bioethics needs to come from the facticity of the social determinants expressed by the health iniquities. The only way to integrate criticism and facticity is hermeneutics, interpreting the significances constructed in the reality and become critical therefrom. This is the epistemological statute appropriate to bioethics in its convergence with public health.     

Quebec's approach to population health: an overview of policy content and organization

While Canada's international leadership in the area of health promotion has been widely acknowledged in the past, Quebec's approach could be better known. Canada's second largest province has indeed developed a comprehensive public health infrastructure and adopted a population health approach which features an integrated set of legislative, organizational and programmatic policy instruments. These instruments not only ensure the core functions of public health, but also foster public intervention on the social determinants of health. In addition, Quebec's policy is supported by a solid research infrastructure, networked expertise and a mobilized workforce among health professionals. In spite of the interest it represents for the larger public health community in Canada and elsewhere, this largely French-speaking province's approach remains little known because of language and cultural barriers between Quebec and Anglo-Saxon countries, and it has yet to be systematically discussed in the English-language literature. This article provides an overview of policies and administrative structures in Quebec to support public health and address socially determined inequalities in health. It analyzes the development of these policies over the past decade and offers insight to their core content.     

Ethics in American health 1: ethical approaches to health policy

I trace the evolution of ethical approaches to health policy in the United States and examine a number of critical unresolved issues pertaining to the current set of frameworks. Several themes emerge. First, fair procedures claim more attention than substantive and procedural principles. Second, in the case of public deliberation, more focus has been placed on factors such as procedural mechanisms than on understanding how individuals and groups value different aspects of health and agree on health-related decisions. Third, the nation needs workable frameworks to guide collective choices about valuable social ends and their trade-offs; purely procedural strategies are limited in illuminating overarching health policy and ethics questions. There is a need to integrate consequential and procedural approaches to health ethics and policy.     

The determinants of First Nation and Inuit health: a critical population health approach

Environmental dispossession disproportionately affects the health of Canada's Aboriginal population, yet little is known about how its effects are sustained over time. We use a critical population health approach to explore the determinants of health in rural and remote First Nation and Inuit communities, and to conceptualize the pathways by which environmental dispossession affects these health determinants. We draw from narrative analysis of interviews with 26 Community Health Representatives (CHRs) from First Nation and Inuit communities across Canada. CHRs identified six health determinants: balance, life control, education, material resources, social resources, and environmental/cultural connections. CHRs articulated the role of the physical environment for health as inseparable from that of their cultures. Environmental dispossession was defined as a process with negative consequences for health, particularly in the social environment. Health research should focus on understanding linkages between environmental dispossession, cultural identity, and the social determinants of health.     

Promoting LGBT health and wellbeing through inclusive policy development

In this paper we argue the importance of including gender and sexually diverse populations in policy development towards a more inclusive form of health promotion. We emphasize the need to address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population health, the social determinants of health (SDOH), and public health goals, in light of the lack of recognition of gender and sexually diverse individuals and communities. By first acknowledging the unique health and social care needs of LGBT people, then employing anti-oppressive, critical and intersectional analyses we offer recommendations for how to make population health perspectives, public health goals, and the design of public health promotion policy more inclusive of gender and sexual diversity. In health promotion research and practice, representation matters. It matters which populations are being targeted for health promotion interventions and for what purposes, and it matters which populations are being overlooked. In Canada, current health promotion policy is informed by population health and social determinants of health (SDOH) perspectives, as demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the challenge of ensuring that diverse populations are equitably and effectively recognized in public health and health promotion policy.     

Getting serious about the social determinants of health: new directions for public health workers

International interest in the social determinants of health and their public policy antecedents is increasing. Despite evidence that as compared to other wealthy nations Canada presents a mediocre population health profile and public policy environments increasingly less supportive of health, the Canadian public health gaze is firmly - and narrowly - focused on lifestyle issues of diet, physical activity and tobacco use. Much of this has to do with Canada being identified as being driven by a liberal political economy, a situation shared with a cluster of other developed nations. Reasons for Canada's neglect of structural and public policy issues are explored and ways by which public health workers in Canada and elsewhere can help to shift policymakers and the general public's understandings of the determinants of health are outlined.     

Public health ethics: teaching survey and critical review

The last decade has witnessed development of the new field of public health ethics, as well as growing emphasis on the importance of ethics education to both students and graduates of the health care professions. Using a topic-based interpretation of public health ethics this paper presents a questionnaire survey of the nature and content of teaching of public health ethics to medical undergraduates and public health postgraduate students in the United Kingdom. Completed questionnaires were returned by 76.9% (20/26) of medical schools and 76.7% (23/30) of institutions teaching postgraduate public health courses. Public health ethics was described as being taught in 75% of medical schools and 52% of institutions providing postgraduate education. However, in both types of location the content and nature of teaching was patchy and often minimal.If medical schools and postgraduate institutions are serious about improving the discussion and teaching of ethical issues in public health, there will need to be considerable investment and commitment, accompanied by creativity and imagination. In parallel, the debate about the meaning of, and approaches to, public health ethics needs to be broadened and enriched. The topic-based interpretation of public health ethics has limitations. Alternatives are explored and critically reviewed.     

Ethical issues in epidemiologic research and public health practice

A rich and growing body of literature has emerged on ethics in epidemiologic research and public health practice. Recent articles have included conceptual frameworks of public health ethics and overviews of historical developments in the field. Several important topics in public health ethics have also been highlighted. Attention to ethical issues can facilitate the effective planning, implementation, and growth of a variety of public health programs and research activities. Public health ethics is consistent with the prevention orientation of public health. Ethical concerns can be anticipated or identified early and effectively addressed through careful analysis and consultation.     

Canada: a land of missed opportunity for addressing the social determinants of health

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organization's Commission on Social Determinants of Health. In this regard, Canada's recent performance suggests a bleak prognosis. Canada's track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canada's capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.     

Raising the profile of public health ethics in Australia: time for debate

This paper argues for greater dialogue on public health ethics. There has been little discussion in Australia about the significant ethical dilemmas in this field, and there is no agreed framework for analysing and responding to these challenges. We highlight concerns about the suitability of biomedical principles-based ethics for public health, and encourage public health professionals in this country to reflect on ethical challenges in public health research. A focus on research ethics concerns will deliver concrete examples demonstrating the need for a public health ethics framework. Recommendations are offered for how public health ethics promotion may occur locally.