Public Health

1. Overview 2. Public Health and Moral Debates The following text is the transcript from the video: Welcome to Unit 4, Lesson 10, Public Health Part 1. This is the last unit of this course. We will discuss public health in both a Canadian and global perspective in this unit. Public health deals with anything that affects the health of populations that can be addressed through collective or government action. It is often contrasted with clinical medicine or health care, segments of health care that we have discussed in the previous lessons. So, in a way, we are stepping into a new domain in this unit. Public health, despite frequently being discussed in abstract terms or statistics, is extremely relevant to each of us. For example, the global pandemic of COVID-19 is a public health crisis that affects many aspects of people’s lives, in addition to their health. Public health has two important features. First, the patient in public health is not an identified individual like someone in a hospital bed. Instead, the “patient” is a large population or a community as a whole. Second, the decision makers are not the individual patient or their family. The decision makers are, in the case of public health, usually a department of the government—federal, provincial, or municipal—deciding on a policy that will affect many people. The moral debates in public health normally centers around the following two questions. First, how to address the conflict between an individual’s rights or freedoms and the well-being of other members of the community or population? Second, how to balance harms and benefits to determine which programs will benefit the greatest number? © 2 © May not be copied or duplicated without the permission of the owner. Which programs are most fair and just? Surrounding these questions, our lesson revolves around four topics: One, collective action problems, two, medical screening, three, harm reduction programs, and four, inequalities in health prospects amongst different groups of people. In this lesson, we will discuss topics 1 and 2, in the next lesson, we will discuss topics 3 and 4.

1. Collective Action Problems 2. Collective Action Problems (Part 1 of 4) Now let’s turn to collective action problems. In order to understand the problems of collective action, we need to first understand a pair of concepts. There are generally two types of goods: the excludable and the non-excludable. Excludable good is a good that people can be prevented from benefiting from without great cost. For example, private hospital beds are excludable—we can simply refuse to admit certain people to use them. A non-excludable good is one where people can be stopped from consuming it only at great cost. For example, blood collected by Canadian Blood Services is not excludable; it is considered as common-pool goods—we can’t deny someone blood transfusion because they never donated blood. 3. Collective Action Problems (Part 2 of 4) Another example is getting vaccines—by getting the vaccine, the person consumed a private good. At the same time, this person’s risk of infecting others is also reduced. When enough individuals are vaccinated, we may achieve a collective “herd” immunity. When that happens, everyone benefits from the immunity the majority of the population has attained and this good is non-excludable, even for those who refuse to get vaccinated. The people who do not get vaccinated in this case are considered “free riders”; they benefit from or consume a good without contributing sufficiently to its production or continued existence. © 2 © May not be copied or duplicated without the permission of the owner. Therefore, vaccines are both a private and excludable good in the sense of it benefits the person vaccinated and non-excludable good since the herd immunity, if achieved, benefits everyone. 4. Collective Action Problems (Part 3 of 4) Wearing masks during the COVID-19 pandemic is similar; the good brought by cautious measures is non-excludable. It benefits everyone, even those who act recklessly. In this case, the people who refuse to wear masks but benefit from others wearing masks are considered “free riders.” 5. Collective Action Problems (Part 4 of 4) Even though both are non-excludable goods, there are some major differences between blood transfusion and getting vaccinated: most of us think that donating an organ or blood is a nice thing to do, but nothing we are morally required to do. We do not harm others unjustly by not donating. Not being vaccinated, however, is different. Anyone not vaccinated risks infecting others. They risk wrongly infringing on the rights others have not to be harmed

1. The Measles and Free Riders 2. “The Measles and Free Riders” by Katharine Browne (Part 1 of 4) Now let’s turn to the required reading. In The Measles and Free Riders: California’s Mandatory Vaccination Law, Katharine Browne discusses the issue of “free riders” in the Disney measles outbreak. Browne argues that collective action problems reveal the presence of an incentive to free ride—to benefit from the efforts of others. Therefore, she considers that the states are justified to overcome the free rider incentive and improve compliance with vaccination requirements. Browne bases her argument on the case of the measles outbreak linked to Disneyland in California, which led California to pass legislation to eliminate all nonmedical exemptions for school-mandated vaccines. According to this new legislation, children who do not receive school-mandated vaccines and who do not have a medical excuse will be prohibited to attend schools, public or private. 3. “The Measles and Free Riders” by Katharine Browne (Part 2 of 4) To understand the context, we need to take a look at a few concepts first. You may have heard of the term “herd immunity” in the news during the COVID-19 pandemic frequently, but what exactly is it? “Herd immunity” is when the majority of a population is immune to a particular illness. Further spread of the illness is minimized because there are fewer transmission points. Achieving herd immunity protects the vulnerable members of the community who cannot be vaccinated (infants, individuals with certain health issues). 4. “The Measles and Free Riders” by Katharine Browne (Part 3 of 4) Depending on the illness, normally, herd immunity is achieved when somewhere around 90% of the population is vaccinated against an illness. For measles, which is highly contagious, the percentage is higher; it is 96%–99%. 5. “The Measles and Free Riders” by Katharine Browne (Part 4 of 4) © 2 © May not be copied or duplicated without the permission of the owner. The World Health Organization (WHO) estimates US national averages of vaccination against the measles to be 91%. In 2013–2014, 92.3% of kindergarten children in California were vaccinated against measles. The Disneyland incident revealed a vaccination rate of 50%–86%. Why not vaccinate your children? For those who refuse to vaccinate their children, their behavior is a lot of times considered selfish, ill-informed, and irrational. However, is that really the case? Browne argues that it can actually be a rational and calculated decision when we consider the free rider incentive with the perspective of game theory. “The Measles and Free Riders” by Katharine Browne Scenario (Part 1 of 3) Let’s consider the following scenario. In the table, in the first column, are the options a patient faces: to vaccinate or not to vaccinate. In the second and third column are two scenarios she may face—namely, whether the community she resides has achieved herd immunity or not. In the third column, when herd immunity is not achieved and less than 96% of the population is immune to measles, it makes more sense for her to get vaccinated since without it, she faces a high risk of getting the measles. “The Measles and Free Riders” by Katharine Browne Scenario (Part 2 of 3) The second column is when herd immunity is achieved, namely, that more than 96% of people and their children have already received the vaccine. In this case, there is a very low probability for the measles to spread. Patient A is very unlikely to get it, even if she does not get vaccinated. If she doesn’t vaccinate, she gains the benefit of the other 96% of population being vaccinated without any cost. She can free ride on the benefit of herd immunity without facing the risks that is associated with the vaccine. 3 © May not be copied or duplicated without the permission of the owner. In this scenario, it is actually rational for her to not get vaccinated. “The Measles and Free Riders” by Katharine Browne Scenario (Part 3 of 3) Of course, we can immediately see the problem here. With a broader scope, if everyone wants to free ride on the 96%, there will not be a 96% for them to free ride on. We will not have herd immunity in a community consisting of free riders. We can describe the free rider incentive as a free ride on the herd immunity achieved by the majority of others getting vaccinated. For this reason, Browne suggests that the heavier-handed interventions may be needed and justified to ensure vaccination compliance, even though voluntary compliance would be most desirable.

1. Direct-to-Customer Genetics and Health Policy “Direct-to-Consumer Genetics and Health Policy” by Timothy Caulfield (Part 1 of 4) Next, we will consider the second topic of this lesson: screening for disease. In particular, we will look at genetic screening that is made available to people by companies such as 23andMe. If you recall, in the previous lesson on genetic screening, we discussed that genetic testing in professional labs can, at best, predict the probability or likelihood of one developing certain diseases; it cannot predict whether one will get it for sure or not, nor can genetic tests tell us when will one get the disease and how severe the symptoms may be. In this article by Timothy Caulfield, he outlines the problems of the direct-to-consumer genetics tests, the ones—such as 23andMe—that claim to provide useful health information. “Direct-to-Consumer Genetics and Health Policy” by Timothy Caulfield (Part 2 of 4) In this article, Caulfield examines the phenomenon of the popular and highly profitable direct-to-consumer (DTC) genetic testing service. This is not to be confused with the kind of genetic tests a specialist performs and interprets for a patient. For DTC, individuals can directly purchase this service and the results are directly delivered to the consumer. You may have heard of 23andMe, or Navigenics, or may know people who have done these tests before. Indeed, DTC receives a lot of attention and even was awarded the 2008 Invention of the Year by Time Magazine. These services are highly marketable, and the public are interested in them because they think these services can provide very useful health information particularly to them as individuals, and is of great health value. However, this is not necessarily so. © 2 © May not be copied or duplicated without the permission of the owner. According to Caulfield, these tests provide little useful health information and doesn’t provide any real health value. Let’s review his arguments. “Direct-to-Consumer Genetics and Health Policy” by Timothy Caulfield (Part 3 of 4) Caulfield points out that, first of all, individuals who use these services tend to ask help from their doctors to interpret the results. These health care providers (HCPs) do not have the skills or knowledge to interpret the tests. More importantly, this is considered a waste of medical resources since individuals are paying private companies then accessing the publicly financed system for interpretive help. And even if the patients directly purchased interpretive service from private companies, the data they purchase is of only marginal value. “Direct-to-Consumer Genetics and Health Policy” by Timothy Caulfield (Part 4 of 4) Caulfield then considered the possibility that such tests may motivate healthier diet or behaviors such as regular exercise; however, studies don’t seem to support that a single test can motivate long-term behavior change. As a matter of fact, there might be an opposite impact, namely, that once an individual thinks they are more likely to develop a disease, they feel that the disease is expected and inevitable, and their inaction is justified; they may resort to fatalistic inaction. Caulfield then goes on to suggest that facing the rising of DTC genetic testing, what we should do is to have widely disseminated independent information about genetic tests to lower public expectations about them. Wrap-Up In this lesson, we discussed a number of questions. We started off with discussing what public health is and the differences between clinical health care and public health. Both the patients and the decision makers in clinical health care and public health are very different. 3 © May not be copied or duplicated without the permission of the owner. We then discussed the collective action problems in health care; in particular, we explored Browne’s article on the measles and free riders. Browne showcased that we face the problem of free riders when aiming to achieve herd immunity. Lastly, we investigated medical screening in the case of DTC genetic testing. Knowledge Check: Introduction Now that we are at the end of the lesson, please try to answer these questions. Again, whether you answer them correctly will not affect your grade in the class, but you will need to complete them for the unit to be marked as “complete.” If you have questions about them, don’t forget to bring them to the office hour, or ask your TA about them via email.