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Rethinking Public Health

Rethinking Public Health. Edward P. Richards, J.D., M.P.H. Professor of Law Executive Director Center for Public Health Law University of Missouri Kansas City http://plague.law.umkc.edu/cphl . What Motivates Modern Public Health?. Social Justice Health People 2010

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Rethinking Public Health

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  1. Rethinking Public Health Edward P. Richards, J.D., M.P.H. Professor of Law Executive Director Center for Public Health Law University of Missouri Kansas City http://plague.law.umkc.edu/cphl

  2. What Motivates ModernPublic Health? • Social Justice • Health People 2010 • Integrated Delivery System • NIH Future of Public Health Study • “Our Patients” • Unnamed State Health Director

  3. APHA • Vision: Healthy People in Healthy Communities • Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability

  4. Public Health • Prevents epidemics and the spread of disease • Protects against environmental hazards • Prevents injuries • Promotes and encourages healthy behaviors • Responds to disasters and assists communities in recovery • Assures the quality and accessibility of health services

  5. Essential Public Health Services 1-5 • Monitor health status to identify community health problems • Diagnose and investigate health problems and health hazards in the community • Inform, educate, and empower people about health issues • Mobilize community partnerships to identify and solve health problems • Develop policies and plans that support individual and community health efforts

  6. Essential Public Health Services 6 - 10 • Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure the provision of health care whenotherwise unavailable • Assure a competent public health and personal health care workforce • Evaluate effectiveness, accessibility, and quality of personal and population-based healthservices • Research for new insights and innovative solutions to health problems

  7. The Big Umbrella Problem • Different Skills Sets • Different Finance Models • Different Professional Paradigms • Different and Conflicting Legal Authority • Different Political Base

  8. Conflicting Legal Authority • Parens Patria • Police Powers • Criminal Law • Individual Liberties Law

  9. Parens Patriae • "Parens patriae," literally "parent of the country,”... It is the principle that the state must care for those who cannot take care of themselves, such as minors who lack proper care and custody from their parents. • Blacks Law Dictionary • The King as Father • The Country as Family

  10. Modern Parens Patriae Powers • Child Welfare • Indigent Care • Wellness Programs • Mental Health Care

  11. Why do Lawyers and Law Professors Like Parens Patriae? • Helping the Downtrodden • Empowering the Individual • Distrust of the State • Lots of Money in Suing for Individuals • Not Much Money in Representing the State • No Money or Private Practice in Public Health Law

  12. Police Power • Right of Societal Self-Defense • Right of the State to Protect Itself • Right of the State to Protect Its Citizens

  13. History • From English Common Law • Core of Colonial Government • Key Power Reserved to the States • The Key Public Health Law Doctrine until the 1980s • Still the Doctrine Used by the Courts

  14. Police Power v. Parens Patriae • The state has a legitimate interest under its parens patriae powers in providing care to its citizens who are unable because of emotional disorders to care for themselves; the state also has authority under its police power to protect the community from the dangerous tendencies of some who are mentally ill. • Addington v. Texas, 441 U.S. 418 (1979)

  15. Philosophical Differences • Parens Patriae • The Individual Is First • Society is just the Sum of the Individuals • Police Power • Ecological Model • Society is a Complex Organism

  16. Practical Differences • Parens Patriae • Driven by Individual Medical Needs • Individual Lives Trump Statistical Lives • Protect Yourself From Disease • Informed Opt-Out Allowed • Police Power • Driven by Community Protection • Stresses Statistical Lives • Protect Others From Disease

  17. Criminal Law • Subset of Police Powers • Moral/Religious Overlay • Prospective Deterrence • Core Difference • Allows Retrospective Punishment • Special Constitutional Protections

  18. Individual Liberties Law • Bill of Rights Based • Limited Balancing of Individual vs Societal Rights • Examples • Privacy Law • Tort Law • Informed Consent and other Medical Law Doctrines

  19. The Physician-Patient Relationship • Trust is Fundamental • Fiduciary Obligations • Informed Consent • Informed Refusal • HMOs • Patient’s Interests are Primary • Drug Testing Pregnant Women • Involuntary Commitment

  20. Administrative Conflicts • Personal Medical Services • Very Expensive • The Demand for Services is without Limit • The Providers are Expensive • The Emotional Pull is High • Contrast with Public Health • Resource Capture

  21. Medical Police Problem • Public Health Issues • Reporting, Contact Tracing, Warning • Coercive Actions • Vital Statistics • Criminal Law Issues • Child Abuse • Drug Use • “Not On Our Patients” Problem

  22. Skills Set Problem • Why School of Public Health Do Not Work • Too Many Different Skills to Train in One Educational System • Academic and Grant Pressures Devalue Core Public Health • Limits Admissions Requirements • MPH Tells You Almost Nothing About Public Health Knowledge

  23. Community Support Problems • Core Public Health • Food, Water, Nuisance, Communicable Disease Control • Indigent Care • Drug Addicts and the Mentally Ill • Not Just Different, but Conflicting

  24. War in the Big Tent • Health Directors who Do Not Believe in Public Health • Confusing Patient Interests with Public Interests • Individual Liberties Law is not Public Health Law • Undermines Agency Authority • Increases Agency Costs

  25. Disaggregate Public Health Services • Personal Medical Services • Core Public Health • Food and Water Sanitation • Infectious Disease Control • Vermin, Animal Control, and other Nuisance • Wellness • Injury Prevention

  26. Rethink Schools of Public Health • Require Core Public Health Training in the MPH • Concentrate on the Special Skills of Public Health • Do Not Duplicate University Departments • Privilege the Workers • Do not Try to Save the World • Bring Public Health to Medicine

  27. Focus on Community • Ecological Model • Community as More than the Sum of Individuals • Duties, as well as Rights • Use Fear Constructively

  28. Emerging Infectious Diseases • Demand Surveillance • Case Finding • Swift Action in the Face of Uncertainty • Protect Individuals Against their Will • Must Sometimes Sacrifice Individual Rights to Societal Protection • Same Issues in Bioterrorism

  29. EID Control Depends on the Police Power How do We Restore the Police Power to Public Health?

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