Strategies of Health Promotion Unit 8 Article Review

The Decline and Disorganization of Public Health in the United States Social Implications

William W. Darrow

Abstract

Public health in the United States has lost its edge. It made a significant impact on human well-being, capacities, and potential in the late nineteenth and early twentieth centuries. Now it takes a backseat to biomedical research and therapeutic medicine. Population health with its traditional emphasis on preventing harm has been displaced by an exorbitantly expensive and continually expanding medical care system devoted almost exclusively to restoring or rehabilitating the health of patients – no matter the cost. The failure to control the spread of human immunodeficiency virus (HIV) in the United States can be attributed to adherence to an inadequate biomedical model that ignores the social. Social quality theory, designed to further social justice, solidarity, equal value, and human dignity, can contribute to identifying and correcting deficiencies in biomedical approaches to HIV prevention and other public health problems that continue to plague the people of the United States.

Keywords: biomedical model, disease prevention, health promotion, human well-being, social quality, structural interventions, treatment as prevention

Almost 100 years ago, C.-E.A. Winslow (1920: 188) characterized public health as, “The science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts and informed decision making.” Much more recently, the Centers for Disease Control and Prevention (CDC) Foundation (2015) defined public health as “the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention, and detection and control of infectious diseases.” In the same year, the Association of Schools and Programs of Public Health (2015) left out both the science and the art in its action-oriented definition: “Public health protects and improves the health of individuals, families, communities, and populations, locally and globally.” These three different definitions reflect different emphases by members of different organizations in different eras. The concerns and strategies of the public health profession have changed as societies and the people who live in them have confronted new challenges affecting their population’s health.

In contrast to private physicians and other clinical providers in the United States, public health professionals try to prevent health problems from happening or recurring

International Journal of Social Quality 5(2), Winter 2015: 29–45 ISSN: 1757-0344 (Print) • ISSN: 1757-0352 (Online) © Berghahn Books 2015

doi:10.3167/IJSQ.2015.050203

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by designing, developing, and implementing educational interventions; formulating, enacting, and monitoring public policies, delivering specific services, and conducting epidemiologic and other kinds of applied research (CDC Foundation 2015). Since public health is concerned with the health of entire populations and not any one patient, it seeks to eliminate health disparities by promoting health-care equity, quality, and accessibility. Private medicine, on the other hand, focuses primarily on treating individuals after they become sick or injured. It involves the delivery of medical services to a diseased or disabled patient in exchange for monetary fees. These fees are to be paid by the patient, the patient’s family, or a private insurance company and may be supported wholly or in part by contributions from local, state, or national governments. Private medicine is a privilege, not a right of all citizens, and should be contrasted with universally available “socialized medicine.” In the United States, vested interests have successfully opposed having the federal government significantly involved in the control and delivery of medical care (Pescosolido et al. 2001).

Both professions – public health and private medicine – are devoted to fostering human well-being. Well-being has been defined as “a state of being with others, where human needs are met, where one can act meaningfully to pursue one’s goals, and where one enjoys a satisfactory quality of life” (Wellbeing in Developing Countries 2007). It is a multidimensional concept that combines a desirable end-state with process and has both objective and subjective dimensions. Efforts to assess well-being and understand the processes that affect it typically recognize various aspects, such as the material, the relational, and the affective and cognitive (Gough and McGregor 2007). Since it involves how people think and feel about their lives, thoughts about human well-being might include perceived needs, life goals, and subjective experiences (McGillivray 2007). In an international Gallup survey, five elements were discovered to be essential: (1) social, (2) financial, (3) physical, (4) career, and (5) community well-being (Rath and Harter 2010).

The aims of this article are to compare and contrast the public health and private medical professions in the United States, examine biomedical and alternative conceptual models for the prevention and control of HIV/AIDS, and explore social quality theory as a means of assessing current approaches to HIV control and achieving human well-being. Since 1985, the federal government of the United States has invested heavily in biomedical research to develop better diagnostic tests, safe and effective antiretroviral therapies, a safe and effective vaccine, and a cure for HIV/ AIDS. To an ever increasing extent, it must support medical care for growing numbers of men and women who become infected with HIV each year and must receive expensive medical care for the rest of their lives. Little money is devoted to implementing, evaluating, and improving structural interventions that address the underlying causes of HIV transmission or to effective health education and prevention programs that serve to interrupt continuing viral spread in states, municipalities, and vulnerable communities of the United States. Social quality theory might provide a way of correcting deficiencies in the prevailing “Treatment as Prevention” strategy adopted by the Obama administration to prevent and control HIV infections in the United States (White House Office of National AIDS Policy 2010).

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The Evolution of Public Health and Expansion of Private Medicine

“Public health in the United States did not begin as a systematic, rational, centrally directed activity following a coherent plan,” write Fee and Brown (2002: 32) in their historical overview, “but rather as a fitful, episodic, and necessity-driven response to immediate local threats.” The American Civil War (from 1861 to 1865) marked a major turning point. Reform efforts led to the “sanitary science” movement and creation of the American Public Health Association in 1873. Initially, physicians provided strong support and leadership for the “practical application of public hygiene.” Waves of immigration generated an interest in “progressive” ideas that “combined the new sciences of bacteriology, chemistry, sanitary engineering, and industrial toxicology with political, economic, and humanitarian principles” (Fee and Brown 2002: 36). Progressives “sought a middle ground between the cutthroat principles of entrepreneurial capitalism and the revolutionary ideas of contemporary socialists.” They saw a need for governmental authority that emphasized “public need over private greed.”

“By the early twentieth century, public health was seen as cost-effective as well as useful,” notes Nancy Kass (2001: 1776), “and more money was directed to public health programs.” After the armistice of the Great War (from 1914 to 1918) was signed, however, the American Medical Association disproportionately increased its influence (Fee and Brown 2002). Conservative private physicians opposed federal programs as examples of “creeping socialism.” Public health in the United States was “relegated to a secondary status,” observed Paul Starr (1982: 197), “less prestigious than clinical medicine, less amply financed, and blocked from assuming the higher- level functions of coordination and direction.” The surge of interest in public health that crested in the Progressive Era crashed with the global economy in 1929 (Fee and Brown 2002). The Democratic administration of president Franklin D. Roosevelt tried to pick up the pieces with its “New Deal” in the 1930s, but World War II, the Cold War with the Soviet Union, and McCarthyism diminished all attempts to establish a national health service in the United States.

Post–World War II public health branched along two major paths: evidence-based medicine and epidemiologic research into the deleterious effects of lifestyle (Berridge 2011). Generous amounts of federal funds were allocated to hospitals and a specialist system of tertiary care (Brandt and Gardner 2000). Traditional public health (and its focus on prevention) lost out in terms of power, prestige, and financing to technology- based medicine (and its focus on treatment). Instead of reforming the practice of medicine, evidence-based medicine sought to improve biomedical outcomes through cohort studies, the randomized clinical trial, and other empirical methods. Changing patterns of disease led to studies of chronic diseases with quantitative statistical techniques to identify distal “risk factors” instead of immediate causes. Programs to modify behavior through the persuasive use of mass media drew attention to “individual responsibility” for health. Support for community health initiatives virtually disappeared in the 1980s as neo-liberal critics in the United Kingdom as well as the United States opposed “social engineering” and objected to “the nanny state” dictating the proper way to live one’s life (Berridge 2011).

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The distancing of medicine from public health in the twentieth century was not merely due to self-interest (Brandt and Gardner 2000). The profession of medicine gradually coalesced around a rigorous scientific perspective and the fundamental worldview of logical positivism, an abiding commitment to personal care and treatment, and an ideological conviction about the sanctity of the biomedical paradigm. Physicians had come to rely on an understanding of disease and its cure that made public health’s broad social and environmental agenda superfluous. Many doctors believed that public health could best be served by the medical care and treatment offered by practicing physicians to individual patients. The reductionist biomedical model minimized the role of societal, behavioral, and environmental factors in the therapeutic physician–patient relationship. “Issues of socioeconomic status, ethnicity, race and culture, personal psychology, and gender were no longer considered significant factors in disease causation as individuals became patients in an expanding tertiary health care system. Indeed, the very nature of the biomedical paradigm was to uncouple disease from its societal roots and to focus research and education on specific diseases” (Brandt and Gardner 2000: 711).

A New Perspective, New Public Health, and Health Promotion

Against the view of many disease entities partitioned into separate silos, there were mounting concerns about escalating costs and limited societal benefits, especially in countries that had established national health services (Berridge 2011). Canadian minister of national health and welfare Mark Lalonde (1974) noted that the underlying factors that influence susceptibility to disease lie in the social environment, physical environment, genetic endowment, and the biological and behavioral responses of individuals to potentially harmful agents. This “new perspective” divided the determinants of health into four fields: lifestyles, environment, human biology, and health-care organization. “A significant proportion of health care is ineffective, inefficient, inexplicable, or simply unevaluated,” argued Evans and Stoddard (1994: 39), “We are reaching the limits of medicine.” They systematically developed a more comprehensive model for making wide-ranging policy decision about health. “Well- being, the sense of life satisfaction of the individual … should be the ultimate objective of health policy,” they argued (p. 47), “the ultimate test … is whether or not it adds to the well-being of the population served.”

Growing interest in evidence-based medicine and the effects of lifestyle in the United States and elsewhere also led to conceptualizations of a “new public health” and “health promotion” (Kickbusch 2003). Since the mid-1970s, the term “new public health” had been recognized and defined in various ways by health professionals working in different parts of the world. Tulchinsky and Varavikova (2010: 26), working in Israel and the former Soviet Union as well as the United States, defined it as follows:

The New Public Health [NPH] is an integrative approach to protecting and promoting the health status of both the individual and the society. The dimensions of the NPH include conceptual, methodological, scientific, political and moral factors recognizing the

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interdependency and interrelationship of the health of people, communities, and nations. As outlined at the Alma-Ata conference of 1978, the NPH encompasses a wide range of essential preventive, curative, and rehabilitative factors crucial to the health and well-being of a society.

Tulchinsky and Varavikova go on to say that the New Public Health is new in that it links “health promotion” with health-care access; it is an integration of transdisciplinary and multi-organizational efforts. The mission of the New Public Health is to maximize human health and well-being and to help redress societal and global inequities. “Above all,” declare Tulchinsky and Varavikova (2010: 28), “the New Public Health is concerned with action.”

Health education in the United States, especially in the 1950s and 1960s, had been used to motivate “at-risk” individuals by encouraging personal responsibility for behavior change (Minkler 1989). A broader approach to stimulating action accompanied visions of a new public health. The World Health Organization conceived of health promotion as “a process of enabling people to increase control over and to improve their health.” The process of empowerment represented “a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health.” The concept of health promotion was based on the moral principles of an open society concerning the rights and dignity of all human beings, respect for diversity and dissent, and with increasing social justice and self-determination.

This new idea of health promotion, with its focus on empowerment and health as a resource for living, challenged the prevailing biomedical model of doctor knows best (Breslow 1999). Attempts were made to subvert the new discipline of health promotion with its far-reaching consequences for social change (Berridge 2011). Funding was a major issue and hospitals, doctors, and drug companies demanded the lion’s share of it for research and medical care. Multidisciplinary research would be encouraged, especially if it complemented evidence-based medicine and the biomedical model, but always under the condition that the health-care industry controlled the purse strings. Revolutionary ideas about “a new public health,” “health promotion” rather than “disease prevention,” and “healthy cities” projects scattered around the globe were unable to survive for very long in the United States due to the unfavorable political climate of “privatization,” “deregulation,” and “downsizing government” that arrived with the presidential election of Ronald W. Reagan in 1980.

Modern and Postmodern Public Health

The New Public Health with health promotion at its core held promise for replacing the “incomplete, obsolete, and misleading framework” of biomedicine with a more expansive biopsychosocial view of the underlying determinants of health (Evans and Stoddard 1994: 59). Hopes were dashed when community intervention trials and Healthy Cities Projects were transformed into “politically innocuous, inexpensive, highly visible, and relatively ineffective” campaigns for individual behavior change (p. 44). Van der Maesen and Nijhuis (2000) reacted against the trend to co-opt the

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new public health movement by making distinctions among “traditional,” “new,” and “modern” public health.

Traditional epidemiologic methods, based on simplistic notions of causality, “are too blunt to dissect the complexities of today’s health problems,” argued van der Maesen and Nijhuis (2000: 134). They cannot help us understand the societal dynamics of health and disease or lead us to interventions to bring about meaningful change in population health. Contemporary public health, “with epidemiology as its scientific core and rooted in Paretonian thought, is not logically orientated towards understanding societal conditions that improve or undermine health and prevent ill health” (p. 140).

In their original conceptualization, van der Maesen and Nijhuis (2000) used the adjective “social” in a non-theoretical way. Since then, social quality scholars theorized anew the noun “social” and also its adjective. It is a result of the dialectic between processes of self-realization of human beings and the formation of collective identities. The outcomes refer to the consequences of the current production and reproduction relationships of people. They will appear as “societal outcomes.” In the context of this theory the traditional non-theorized use of the adjective “social” refers in this theory to societal phenomena. Also the adjective “public” in “public health” refers in this theory to a “societal phenomena” and not to an equation of common aspects of individual people. In the reference to van der Maesen and Nijhuis that follows, the adjective “social” should be read as “societal.”

“Mainstream epidemiology increasingly serves as a tool of molecular biology,” van der Maesen and Nijhuis continued (2000: 134); therefore, it cannot serve as “the scientific cornerstone of modern public health.” “Most of the collectivist elements … in the Ottawa Charter vision, with its emphasis on promoting health through state policy intervention, action [g]roups (rather than individuals), involvement of lay persons (rather than professionals) and the creation of environments that make healthy choices easy choices, was lost in favo[u]r of strategies aiming at individual behavior change” (p. 135). A new socio-ecological model is needed “to generate knowledge concerning the [a]etiology of patterns of population health, disease, and well-being” (p. 134).

In the conceptualization of a “modern public health” proposed by van der Maesen and Nijhuis (2000: 135), “public is synonymous with larger social configurations (communities) of subjects that interact. The reciprocity between social structures and individuals is crucial. The social, political, economic and cultural conditions for interaction are in a sense given, but the result of the interactions in turn also changes the conditions.” The challenge for a modern concept of public health is to connect a behavioral approach to individuals with a systems approach to societal-based structures. In this vision of modern public health, societal aggregates should be the unit of analysis and they should be assessed in terms of “social quality.”

Van der Maesen and Nijhuis (2000) point out that medical policy is not public health policy. “Modern public health needs a new orientation, distinct from the old public health (biological hygiene) and from the recent or new public health approaches (individualistic health promotion). Modern public health means considering modern problems of socio-political, socio-cultural and socio-economic relationships, new

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forms of inequalities, exclusion and the marginalization of many groups of urban inhabitants” (p. 139). Modern public health offers three strategies: (1) improving societal conditions that stimulate health, (2) preventing societal conditions that threaten health, and (3) neutralizing existing societal conditions that cause ill health. “Growing individualization is a consequence of modern economic relations,” according to van der Maesen and Nijhuis (2000: 140), “not a result of so called postmodern philosophy as a deliberately chosen cultural shift.”

As the twentieth century was coming to a close, Inglehart (1997) described a “postmodern shift” in advanced industrial societies away from religious and secular authority to individual autonomy in the pursuit of subjective well-being. In contrast to concerns about “inequalities, exclusion, and marginalization” expressed by van der Maesen and Nijhuis, Inglehart drew attention to the high levels of economic security and welfare attained within the past few decades by some nation-states. In these countries, support for democratic principles was rising along with distrust of political authority and big government. People living in these countries were more likely to turn to self-help remedies and less likely to believe that governmental actions could solve problems. Modernization was marked by a rational and legal worldview, faith in scientific expertise, subordination of the individual in bureaucratic organizations, and an “apparently inexorable growth of the economic, political, and social role of government.” Post-modernization, according to Inglehart (1997), means a declining respect for authority and governmental interventions, less faith in scientific advances to help humanity, and doubts that technology will make our lives better. As some societies move further into this postmodern phase of development, what are the implications for biomedicine and “modern public health?”

Human Well-being and the Quest for Social Quality

Public health and private medicine have coexisted in the United States because both professions were able to make their case for improving the quality of human life, one by looking out for the well-being of the entire community and the other by looking out for the well-being of the individual patient. Their professional interests diverged when it came to competing for scarce resources to accomplish their respective missions. Public health sought support to maintain health and prevent disease and injuries as private medicine required more and more resources to restore health and treat disease and injury. The rivalry intensified as medicine disproportionately increased its share of revenue while funds to support public-health services continued to dissipate. Toward the end of the twentieth century, public health realized that it had been overtaken by the medical profession, declared the field to be in “disarray” (Institute of Medicine 1988), and pleaded for finances to support essential public-health services.

Table 1. The Essential Public Health Services in the United States (1994) 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems.

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5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care

when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health

services. 10. Research for new insights and innovative solutions to health problems

The Essential Public Health Services describe the public health activities that should be undertaken in all communities (Centers for Disease Control and Prevention 2014). They provide a working definition of public health and a guiding framework for the responsibilities of local public health systems in the United States.

In an article published in the first issue of the International Journal of Social Quality, David Phillips compared quality of life, social quality, and human development approaches to the individual and the social as understood in the social quality theory (Phillips 2011). “Quality of life” has collective as well as individual attributes. At the individual level, the concept includes subjective as well as objective elements (Phillips 2006: 242). Basic needs must be met and material resources must be sufficient to fulfill societal requirements. In addition, autonomy must be guaranteed to make informed choices to enjoy, flourish, and participate in the full range of societal activities. Collectively, quality of life requires socio-economic, socio-political, and socio-cultural as well as environmental sustainability, civic integration, integrity, synergy, extensive network ties, integrative norms and values relating to trust, reciprocity, other-regarding behavior, fairness, equity, social justice, and egalitarianism. Phillips (2011: 79) acknowledges that he has drawn from the work of Sen (1993, 2004), Nussbaum (2011), and others. An alternative approach is provided in social quality theory that “was developed from the mid-1990s onward as an antidote to the predominance of economic measures of quality of life.”

Social quality theory rests on the premise that people are essentially social beings (Phillips 2011). The “social” is defined by the productive and reproductive relationships manifested in structures, practices, and conventions (Lin et al. 2009). The theory recognizes a constitutive interdependency: the dialectic between the self-realization of individuals as social beings and the processes leading to the formation and re- formation of collective identities (Phillips 2011). Tensions between societal-level development and the development of individual human beings and between the formal world of systems, institutions, and organizations and the informal life-worlds of families, groups, and communities guide its examination and understanding of societal transformation and the quality of daily circumstances (Beck et al. 2012).

Social quality has recently been redefined as “the extent to which people are able to participate in social relationships under conditions which enhance their individual well-being, capacities, and potential” (Berting 2012: 93). It enables reciprocity between the operations of institutions or organizations (representing societal based structures) and the interaction of people (representing human agency) (van der Maesen and Nijhuis 2000). Social quality theory maintains that citizens must: (1) have access to a minimum level of economic security, (2) experience a basic level of

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social inclusion, (3) live in a community that exhibits social cohesion, and (4) be empowered to develop their competencies. It also includes four core values (social justice, solidarity, equal value of all humans, and human dignity) that align with the four essential conditions (Ward 2006; Ward et al. 2011). The long-term aim “is to enhance the social quality of people’s lives (especially vulnerable groups)” (Ward et al. 2006: 11). Social quality theory has relevance for public health, because the concept of “social quality” serves to link the collective “public” with the personal “health” (van der Maesen and Nijhuis 2000).

“Health related social quality refers to the conditions, circumstances, and societal based systems (institutions, organizations) that improve or undermine health” (van der Maesen and Nijhuis 2000: 136). With reference to medical policies, quality primarily refers to the efficacy and the ethical aspects of medical interventions for patients. With reference to modern public health, attention should be given to the social quality of living conditions, circumstances, and systems. Social quality aspects of health-care systems include a socially equitable distribution of services and their availability, accessibility, and capacity for empowerment. “The challenge of our modern enterprise of public health is to improve social conditions related to health. In doing so, we are in fact meeting our values and norms, in other words, the ethical questions of public health. In our opinion,” conclude van der Maesen and Nijhuis (2000: 141), “modern public health, based on a theory of which we have attempted to outline some principles, has to play an important part in this moral endeavor.”

The Decline, Disorganization, and Displacement of Public Health: The Case of AIDS

Acquired immune deficiency syndrome (AIDS) was first recognized in the United States by the CDC in summer 1981 (Valdiserri 2013). Epidemiological research into the source of the outbreak suggested that it might be a sexually transmissible pathogen, a previously unknown retrovirus was found to be the infectious agent, and an enzyme- linked immunosorbent assay was developed and patented in 1985 to test people for human immunodeficiency virus (HIV), “the virus that causes AIDS” (Darrow 1991). Following these discoveries, the United States Public Health Service began to formulate a response to AIDS that would rely primarily on biomedical research to explicate pathogenesis, improve diagnostic tests and clinical care, develop safe and effective therapies, deliver a safe and effective vaccine, and find a cure (Darrow 2013a).

In spite of failures to develop a safe and effective vaccine, find a cure, and reduce the average number of new HIV infections in the United States to less than 40,000 per annum, the United States Public Health Service remains resolute in its adherence to the biomedical model. With evidence from randomized control trials that virally suppressed patients rarely infect others, a “treatment as prevention” program has been launched to find, test, treat, and retain in care at least 90 percent of all persons infected with HIV in the United States (Bärnighausen et al. 2014). Increasing amounts of federal funds are being spent on maximizing outcomes in President Obama’s “HIV Care Continuum Initiative” as monies for social, structural, and behavioral interventions

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in the United States evaporate (Kippax and Holt 2009). Public-health programs designed to mobilize communities, establish “safer” norms, and interrupt HIV transmission have been displaced by biomedical programs designed to screen everyone between the ages of fifteen and sixty-five years, immediately treat everyone who is found to be infected and continue to do so for the rest of their lives, and prophylactically treat everyone who is uninfected but at risk of HIV infection (Darrow 2013b).

Very little if anything contained in President Obama’s National HIV/AIDS Strategy (White House Office of National AIDS Policy 2010) fits into the architecture of Social Quality Theory. None of the four constitutional factors – personal security, social recognition, social responsiveness, and human capacity – is addressed. None of the four conditional factors – socioeconomic security, social cohesion, social inclusion, and social empowerment – is addressed. None of the four normative factors – social justice, solidarity, equal value, and human dignity – is addressed. Suggestions to adopt a systems approach to HIV prevention and address the structural determinants of HIV transmission were overlooked in the original strategy created by the president’s advisers (Livingood et al. 2011). The 2015 update serves to reinforce the idea that the sturdy walls of the HIV/AIDS silo erected by biomedical scientists and their political allies shall remain intact (White House 2015).

Less than one year before his tragic death in the crash of Swiss Air flight 111, Jonathan Mann (1998: 118) presented a paper to the Institute of Medicine in which he described “a crisis of identity about the nature, roles, and responsibilities of public health” and called for “a creative renewal, a renaissance of modern public health.” He identified “social context” as the major determinant of health status, “Yet, paradoxically, public health has avoided addressing directly the societal conditions which largely determine the burden of preventable disease, disability, and death.” Public health must work for “societal transformation,” and Mann believed that human rights provided “public health with a more useful framework, vocabulary, and guidance for analysis and direct response to the societal determinants of health than any framework inherited from the past biomedical or public health tradition” (p. 120). President Obama’s national strategy is all about “widespread HIV testing,” “linkage to care,” “full access to pre-exposure prophylactic (PrEP) services,” “medication adherence,” “remaining engaged in comprehensive care,” and “universal viral suppression.” It has little to say about – and less to do with – the violations of human rights that racism, prejudice, and discrimination continue to cause those communities in the United States that are particularly vulnerable to HIV infection and related conditions.

The updated National HIV/AIDS Strategy based on “treatment as prevention” and other biomedical interventions is difficult to justify in terms of the “Principles of the Ethical Practice of Public Health in the United States” (table 2) or the “Ethical Framework for Public Health” proposed by Nancy Kass. Kass (2001: 1776) proclaimed, “Public health is the societal [not biomedical] approach to protecting and promoting health. Generally, through social, rather than individual, actions, public health seeks to improve the well-being of communities.” She proposed a six-step framework for analyzing the ethical implications of proposed policies and programs, such as President Obama’s “National Action Plan”: (1) What are the goals? – a major goal must be to improve the health status of a population; (2) How effective is the program in reaching

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its stated goals? (3) What are the known and potential burdens? (4) Can the burdens be minimized or are there alternatives? (5) Is the program implemented fairly? (6) How can the benefits and burdens of a program be fairly balanced?

Table 2. Principles of the Ethical Practice of Public Health in the United States (Public Health Leadership Society 2002) 1. Public health should address principally the fundamental causes of disease and

requirements for health, aiming to prevent adverse health outcomes. 2. Public health should achieve community health in a way that respects the rights of

individuals in the community. 3. Public health policies, programs, and priorities should be developed and evaluated

through processes that ensure an opportunity for input from community members. 4. Public health should advocate and work for the empowerment of disenfranchised

community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

11. Public health institutions should ensure the professional competence of their employees. 12. Public health institutions and their employees should engage in collaborations and

affiliations in ways that build the public’s trust and the institution’s effectiveness.

Kass (2001: 1779) believes that:

Health education is the ideal public health intervention since it is completely voluntary and seeks to empower people to make their own decisions regarding their health once they are equipped with accurate information. From an ethics perspective, education clearly is preferable to other preventive strategies, to the extent that they are equally effective, because it poses few, if any, burdens.

President Obama’s national strategy is not molded around effective health education for HIV prevention. His “National Action Plan” may benefit the National Institutes of Health, CDC, and other federal agencies, the American health-care and pharmaceutical industries, academic researchers and the universities that receive reimbursement for indirect costs, state and local health departments, for-profit and not-for-profit AIDS service organizations, and, perhaps a few others, but there is very little chance that it will “improve the well-being of communities” suffering the most

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from the burdens of HIV/AIDS. Importantly, the incidence of HIV infection in the United States is not decreasing. In Florida, the number of reported HIV cases increased by 23 percent during the first six months of 2015 (3,555 persons newly infected with HIV) compared with the first six months of 2014 (Sweeney 2015).

Further Considerations

The influence of the public-health profession on national health policy has declined precipitously in the United States as the powerful interests of high-technology biomedicine and its political supporters have risen (Fee and Brown 2002). The Reagan administration set out to dismantle regulatory agencies and social programs in the 1980s and, subsequently, cut the budget for Health and Human Services by 25 percent, thus undermining early attempts to mount an effective preventive program against AIDS. “Health is about political choices,” acknowledges Ilona Kickbusch (2014: 83). The dynamics of health policy in the twenty-first century “will require facing a matrix of power, interests, institutions which reinforce unsustainable production and consumption patterns, unsustainable lifestyles and inequalities.” Unfortunately, the focus of health policy remains on expenditures to treat those who are sick rather than on investments to improve conditions for maximizing social, mental, and physical health outcomes of all who live in the United States. The world we want will not be the world we get without a new political and social movement that addresses the social, commercial, and political determinants of health.

According to former CDC director Bill Foege (2010), a major problem with the “dysfunctional” health-care system in the United States is that the marketplace that controls health care is concerned primarily with profit, not with quality of care. Treating disease is reimbursable, but preventing it is not. The US health system should be reformed to provide incentives to assure conditions for people to be healthy and to help people make healthy choices (Foege 2010). Jonathan Mann (1998: 119) agreed, “Public health must work for societal transformation,” and offered a few further recommendations. A shift away from biomedical traditions and toward modern human rights is required to identify, promote, and protect the societal pre-conditions for human well-being. Through its focus on societal determinants of well-being, human rights provides public health with a more useful framework, vocabulary, and guidance for analysis and direct response to the societal determinants of health than any framework inherited from the past biomedical or public-health tradition. Human rights have the capacity to change lives and the course of history.

The first public-health revolution dealt with the prevention and control of communicable diseases, the second with non-communicable chronic diseases, and the third with maximizing health as “a resource for living” (Breslow 1999). The concept of “health promotion” was introduced to advance considerations of health beyond disease prevention. “Health promotion has come to be understood … as a commitment to social reform and equity” (Kickbusch 2003: 384). Health professionals “should adopt a new mind set and ethos to enable, advocate, and mediate for supportive environments, community action, and reorienting health services away from costly

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treatments and towards cost-saving prevention.” The orientation should be holistic and ecological rather than reductionist and pathophysiological, the emphasis should be on health education (not on political propaganda and persuasive advertising), and the focus should be on the determinants of health in populations.

“Biomedical approaches, by themselves, may be inadequate to reduce HIV incidence,” admits Ronald Valdiserri (2014: 326). “HIV is a profoundly social disease, its causes and consequences deeply embedded in the social, cultural and political processes that shape national development, social institutions and civil society, interpersonal relations and everyday lives,” write Kippax and Holt (2009: 3). In contrast to the narrowly defined biomedical approach of universal testing, treatment, and retention of infected individuals in care adopted by the Obama administration, Jones and colleagues (2014) recently recommended an alternative “art in public health” approach. Their public-health approach recognizes and seeks to address the structural barriers of marginalization, stigmatization, and criminalization of key populations, provide people at high risk for HIV with access to consumer-friendly information and intensive community-based interventions, advance health equity, promote human rights, and prevent new HIV infections. “To effectively reach key populations and control HIV, far more engagement of communities and civil society is essential” (Jones et al. 2014: 275).

Conceptualizations of health and its determinants are strategically important because they determine the kinds of interventions that might be considered and chosen (Fielding et al. 2010). Biomedical interventions narrowly address specific risk factors or pathophysiologic causes of injury and disease. Comprehensive public health interventions, on the other hand, more widely attempt to assess and modify policies, institutional practices, community capacities, interpersonal interactions, and harmful behaviors as well as biologic factors. The medical model cannot create healthy communities, yet as much as ninety-seven cents out of every health dollar in the United States continues to be spent on biomedical research and health care. State and local governmental agencies must perform the ten essential services of public health with very little support. Many of the 2,794 local health departments in the United States are sparsely staffed and under-resourced; their ability to carry out necessary functions is severely hampered. Marketing forces and commercial interests have stoked individual desires at the cost of the common good. A major paradigm shift away from the medical model is needed to design and support interventions and policies that provide the greatest return across the full spectrum of health (Fielding et al. 2010).

Complex systems abound in public health (Luke and Stamatakis 2012). These systems are characterized by nonlinearity, threshold events, and chaotic behavior. They consist of many heterogeneous elements that interact with one another. The interactions produce an emergent effect that is different from the effects of the individual elements. This effect persists over time and adapts to changing circumstances. To capture emergent effects, it is necessary to study the system as a whole, rather than to decompose it and study its various parts. Traditional study designs and analytic tools are inappropriate for studying complex public-health systems. Systems science study designs, such as computer simulation models and network observation studies, have the ability to assess the influence of context on health behaviors.

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Poverty-trap models that require a breadth of scientific methods and draw upon the ecology of complex systems are an example of this kind of thinking (Ngonghala et al. 2014). Biophysical and biosocial processes often play fundamentally important roles in the structure of extreme poverty, but these processes are complex and include nonlinear feedbacks. Developing poverty-trap models can provide a general framework for exploring the effects of poverty on quality of life and can inform potentially promising interventions with social as well as public-health implications.

Conclusion

Social quality theory was formulated in the mid- to late 1990s to provide a vision of a united Europe pulling together disparate strands of public policy based on principles of social justice and democratic decision making (Beck et al. 2001). The social quality initiative rejected “turbo capitalism” and the traditional approach that subordinated all areas of public policy, including public health, to economic policies and imposed a top-down form of governance. It required governments to provide minimum levels of socio-economic security, social inclusion, social cohesion, and social empowerment to participate in community decision making. It advanced a new interpretation of “the social” as an outcome of the dialectic of processes of individual self-realization and of the formation of collective identities. It rejected the traditional duality between “the social” and “the economic,” the “individual” and “social structures.” Modern public health as a concept was based on the nature and consequences of this dialectic.

Instead of a focus on short-term profits, “dog-eat-dog” competitiveness, and “winner-take-all” market mechanisms, the social quality approach brought people together by enabling a large number of people and interest groups to be involved in deliberations, decision making, consensus building, program implementation, and the monitoring and modification of public policies. A social quality approach to public health might provide an excellent opportunity for Americans to examine shortcomings in the current HIV “treatment as prevention” strategy promulgated by biomedical elites, consider more viable (and less costly) approaches to health promotion for HIV prevention, and achieve better quality of life circumstances, especially in vulnerable communities of the United States that continue to suffer the most. This will happen by taking onboard the dialectic between people’s self-realization and the collective identities they are part of. The reduction to the mainstream “individualism” as a neo- liberal proposition rejects the adage that people are in essence “social beings,” a final outcome of this dialectic. The adjective “public” in traditional “public health” suppositions misses a theoretically founded meaning and is at the end of the day an individualistic-oriented health approach. Such is the case with the current biomedically driven “Test and Treat” approach to HIV prevention.

William W. Darrow began his career in public health with the New York City Department of Health in 1961, conducted social, behavioral, and epidemiologic research on HIV/AIDS and other sexually transmitted diseases with the Centers for Disease Control and Prevention in Atlanta until 1994, and currently serves as a

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professor of public health in the Robert Stempel College of Public Health and Social Work at Florida International University in Miami. He teaches graduate-level courses on ethical issues in public health, health promotion program planning and evaluation, and the history and foundations of public health.

Acknowledgment

The author gratefully acknowledges the assistance of Professor Laurent J. G. van der Maesen in providing helpful updates on recent developments in social quality theory. No financial or other support for this work was sought or obtained from the Centers for Disease Control and Prevention, National Institutes of Health, Bill & Melinda Gates Foundation, Gilead Sciences, or any other for-profit corporation, public agency, or private foundation. The author has no conflicts of interest to report.

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