Potential Harm in Public Health Practice

WHO Training Manual Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care Learning Objective 3.1 Identify possible harm and benefit to individuals and communities resulting from public health practice and surveillance

Outline 1. Writing Exercise 1 2. Introduction a) Potential Benefits & Harms b) Minimising harms 3. Writing Exercise 2 4. Reading and discussion Swine flu 5. Case Study sexually transmitted infections 6. Summary 0-5 (5 min) 26-30 (5 min) 101-105 (5 min) Suggested time (total 105 min) Activity 6-25 (20 min) 31-35 (5 min) 36-50 (15 min) 51-60 (10 min) 61-70 (10 min) 71-100 (30 min) Group discussion Class discussion Slide presenta tion Writing and discussion introducti on Writing Reading Case study and discussion Summary and conclusion L.O. 3.1

Harm in public health Often viewed as a tension between the individual and the population. For example, the harm of violating privacy must be weighed against the benefit of public health. Ethical justification usually requires an estimation of the probability and magnitude of the resulting harm. L.O. 3.1

Identifying harm If harm is something that negates or diminishes health, the WHO definition of health suggests that harm could be: Physical Mental Social L.O. 3.1

Psychosocial aspects Elaborate on the potential types of harm that could arise within each of these three areas of health. What other dimensions of a person are included within the psychosocial model of human well-being? The following diagram provides one answer: L.O. 3.1

material biological social well-being spiritual emotional cultural mental Adapted from Williamson & Robinson, Intervention 2006;4(1):4-25 L.O. 3.1

Psychosocial harm Public health and humanitarian responses have traditionally focused on medical, biological and material needs. As psychosocial needs are increasingly recognised and addressed, the potential for psychosocial harm needs to be acknowledged and responded to. Use the Case Study to identify examples of various types of psychosocial harms based on the previous slide s diagram. L.O. 3.1

Moral harm The violation of ethical principles, moral virtues and an individual s conscience can lead to what is called moral distress. The sort of harms arising from mishandled ethical dilemmas could include: Injustice Dishonesty Distrust Loss of respect, either for self or others Debilitating guilt L.O. 3.1

One final harm Predicting and balancing the potential harms of various options is always difficult. However, a decision not to act, or to allow the status quo to continue, also runs the risk of allowing harm. L.O. 3.1

Indeed, it remains our ethical obligation to use the data we collect for public health benefit; not using the data for improving health must be justified. Lee et al. American Journal of Public Health 2012;102(1):42 What could be the harm in not using such data? L.O. 3.1

Minimising harm in surveillance Collect the minimum amount and simplest data to meet the surveillance goals. Engage early with the individuals, families or communities, especially with sensitive data or vulnerable populations, including on communication strategies for findings. Use rigorous data protection procedures. Act on new evidence as soon as possible. Promote transparency, inclusiveness and openness. L.O. 3.1

Intervention Ladder Eliminate choice, e.g. quarantine. Restrict choice, e.g. make specific vaccinations compulsory. Guide choices through disincentives, e.g. making vaccination a requirement for children before enrolment in school. Guide choices through incentives, e.g. offering free health screening along with vaccination. Guide choices through changing the default policy, e.g. requiring questions about vaccinations at primary care visits. Enable choice, e.g. provide public programs or facilities. Provide information, e.g. public information campaign. Do nothing or just monitor the situation. Adapted from Nuffield Council on Bioethics, 2007 L.O. 3.1

Case Study Records from the sexually transmitted infection (STI) clinic at the largest general hospital in a southern African country indicate that the segment of the population self-ascribed as coloured has twice as many cases of STIs as the segment that is self-ascribed as black . By contrast, for almost all other conditions seen in the hospital s outpatient department, the number of cases of a disease in each racial and ethnic group is proportional to that group s percentage of the general population. Even after controlling for socioeconomic status, this distinction in the distribution of STIs remains. Before the country s independence, government officials assigned individuals to one of four racial categories black, white, coloured, and Asian. Since independence, an individual s membership to one of these racial groups, or a new alternative, other, is self-ascribed. Authorities may investigate an individual s self-categorization if they suspect them of self-identifying to a racial group to accrue some particular benefit. L.O. 3.1

Case Study Dr Chingana, director of the STI clinic, believes that the disproportionate rate of cases in people who have identified themselves as coloured , compared with those who have identified as being black , reflects differences in each group s biological susceptibility to these diseases: he is, however, unsure of the underlying mechanism responsible. Dr Chingana develops a survey designed to link STI symptoms with a variety of risk factors, including race and ethnicity. He presents his protocol to his institution s research ethics committee for approval. Ms Johnson, a community representative on the committee who self- identifies as coloured, objects to the inclusion of race as a targeted factor in the survey. She contends that a finding of higher rates of STI cases in the coloured population will only serve to reinforce these deeply held prejudices. Further, she is sceptical of the notion that being coloured might increase one s risk of contracting an STI and probes for further explanation. Do the bacteria behave differently in coloured people? Is their anatomy different? L.O. 3.1

Case Study Dr Chingana argues that this question is critical to the study. Moreover, the findings might point to further research that could aid in the development of programmes for STI control aimed at reducing the high rate of infection among coloured people. As used here, race refers to a group of people connected by common descent or origin. Ethnicity here refers to the culture and/or collective identity shared by a group of people of common descent or origin. Source: Cash R, Wikler D, Saxena A, Capron A, eds. Casebook on Ethical Issues in International Health Research. Geneva: World Health Organization, 2009, p. 62. . L.O. 3.1

For Discussion How might the different types of harms identified in the Case Study be minimised? How could (or should) these different types of harms be prioritised in public health surveillance? L.O. 3.1

Sources Cash R, Wikler D, Saxena A, Capron A, editors (2009) Casebook on Ethical Issues in International Health Research. Geneva: World Health Organization; 62 (http://whqlibdoc.who.int/publications/2009/9789241547727_eng.pdf). Lee LM, Heilig CH, White A (2012) Ethical justification for conducting public health surveillance without patient consent. American Journal of Public Health 102(1):38-44. Nuffield Council on Bioethics (2007) Public health: the ethical issues. London (http://www.nuffieldbioethics.org/public-health). Williamson J, Robinson M (2006) Psychosocial interventions, or integrated programming for well-being? Intervention 4(1):4-25. L.O. 3.1

Acknowledgements Chapter author O Math na, D nal, School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland L.O. 3.1