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

2 What Motivates Modern Public Health? b Social Justice Health People 2010Health People 2010 b Integrated Delivery System NIH Future of Public Health StudyNIH Future of Public Health Study b “Our Patients” Unnamed State Health DirectorUnnamed State Health Director

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

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

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

6 Essential Public Health Services Enforce laws and regulations that protect health and ensure safetyEnforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailableLink people to needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public health and personal health care workforceAssure a competent public health and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health servicesEvaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problemsResearch for new insights and innovative solutions to health problems

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

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

9 Parens Patriae b "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 DictionaryBlacks Law Dictionary b The King as Father b The Country as Family

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

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

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

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

14 Police Power v. Parens Patriae b 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)Addington v. Texas, 441 U.S. 418 (1979)

15 Philosophical Differences b Parens Patriae The Individual Is FirstThe Individual Is First Society is just the Sum of the IndividualsSociety is just the Sum of the Individuals b Police Power Ecological ModelEcological Model Society is a Complex OrganismSociety is a Complex Organism

16 Practical Differences b Parens Patriae Driven by Individual Medical NeedsDriven by Individual Medical Needs Individual Lives Trump Statistical LivesIndividual Lives Trump Statistical Lives Protect Yourself From DiseaseProtect Yourself From Disease Informed Opt-Out AllowedInformed Opt-Out Allowed b Police Power Driven by Community ProtectionDriven by Community Protection Stresses Statistical LivesStresses Statistical Lives Protect Others From DiseaseProtect Others From Disease

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

18 Individual Liberties Law b Bill of Rights Based Limited Balancing of Individual vs Societal RightsLimited Balancing of Individual vs Societal Rights b Examples Privacy LawPrivacy Law Tort LawTort Law Informed Consent and other Medical Law DoctrinesInformed Consent and other Medical Law Doctrines

19 The Physician-Patient Relationship b Trust is Fundamental b Fiduciary Obligations Informed ConsentInformed Consent Informed RefusalInformed Refusal HMOs HMOs b Patient’s Interests are Primary Drug Testing Pregnant WomenDrug Testing Pregnant Women Involuntary CommitmentInvoluntary Commitment

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

21 Medical Police Problem b Public Health Issues Reporting, Contact Tracing, WarningReporting, Contact Tracing, Warning Coercive ActionsCoercive Actions Vital StatisticsVital Statistics b Criminal Law Issues Child AbuseChild Abuse Drug UseDrug Use b “Not On Our Patients” Problem

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

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

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

25 Disaggregate Public Health Services b Personal Medical Services b Core Public Health Food and Water SanitationFood and Water Sanitation Infectious Disease ControlInfectious Disease Control Vermin, Animal Control, and other NuisanceVermin, Animal Control, and other Nuisance b Wellness b Injury Prevention

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

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

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

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