Balancing the Precepts of Public Health and Medical Professionalism Sheila M. Rothman, Ph.D. Professor of Public Health Columbia University Peking University health science center October 21, 2008

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 2 Medical Professionalism and Public Health Sources of conflicts between physicians and public health in the United States: Physicians committed to patient confidentiality Fear that violations of privacy will lead patients to give misinformation or avoid care Physicians, therefore, object to mandatory disclosure of patient name and contagious disease to public health officials.

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 3 Public Health Officials and Confidentiality Public health officials Fear a dedication to confidentiality will fuel epidemics Regard mandatory reporting as a powerful tool to reduce transmission These conflicts have increased because The boundaries of what is considered public health has expanded The authority of public health has enlarged

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 4 The Origins of Public Health Reporting, Koch identifies the tubercle bacillus as the cause of tuberculosis (1882) Tuberculosis is spread person to person Reducing contacts between sick and healthy can prevent disease transmission

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 5 New Public Health Reporting Policies The findings led public health officials to enact new policies to reduce transmission Mandatory reporting by physicians of those diagnosed with tuberculosis Ongoing surveillance of persons with tuberculosis by sanitary inspectors Confinement of the newly diagnosed patients to sanatoriums

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 6 Physicians’ Objections The policies violate a key principle of medical professionalism: doctor-patient confidentiality Surveillance leads to social discrimination Surveillance leads to economic discrimination (loss of employment, housing)

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 7 Public Health Officials Recognize Danger but insist on Reporting Herman Biggs, New York City Commissioner of Health, 1898 “The government of the United States is democratic, but the sanitary measures adopted are sometimes autocratic and the functions performed by sanitary authorities paternal in character.” BUT: “We are prepared, when necessary, to introduce and enforce, and the people are ready to accept, measures which seem radical and arbitrary, if they were not plainly designed for the public good and evidently beneficent in their effect….Friends of patients often declare that they prefer to expose themselves to the chance of infection rather than have their dear ones banished…but this is sheer nonsense.”

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 8 A New Public Health Consensus, Physicians more willing identify persons with contagious diseases The Polio Epidemics of the ’s Scientific discoveries reduce the number and scope of epidemics

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 9 The Challenge of AIDS Public Health officials see AIDS as a Plague “For every case of reported AIDS in the United States there are about 100 or more carriers…Once infected, infected for life…We see a wave of devastating disease approaching.”

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 10 The Challenge of AIDS, continued To reduce transmission, public health officials propose: Compulsory testing of high risk groups Reporting by name of every person diagnosed with AIDS Closing down public bathhouses

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 11 AIDS Advocates Respond Public Health is discriminating against a stigmatized group They resist: Reporting their names to the Department of Health (make testing anonymous) Mandatory testing for HIV

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 12 Physicians Divide on the Issue Some are sympathetic to the AIDS community demands More want to protect themselves and the public

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 13 First Resolution: AIDS Exceptionalism At first, AIDS community wins: Persons with HIV must consent to HIV testing In most states, physicians did not report AIDS patients by name

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 14 Current Situation AIDS loses its Exceptional Standing: Why? Changing Demography of the Epidemic New cases of HIV more often minorities The availability of effective treatment

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 15 New Policies Testing now part of routine health care- written informed consent no longer necessary Mandatory testing for some populations (pregnant women, prisoners, military)

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 16 The New Public Health Threats Multidrug resistance Tuberculosis Bioterrorism Emerging infectious global diseases (West Nile Virus, Avian Flu)

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 17 Medical Responses to the Threats Respect for patient confidentiality remains a strong value But in situations of epidemics, support public health mandates Will report individual patients Will test without patient consent

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 18 Physicians Recognize the Value of Privacy but Elevate Public Health If the outbreak of an epidemic is hidden, it will spread more quickly and be more devastating Elevate public health over own convenience Elevate public health over objections from their institutions

Sheila M. Rothman Balancing the Precepts of Public Health and Medical Professionalism 19 Implications for Professionalism Physicians should respect the wishes of their patients and others who might want to restrict their freedom to report contagious diseases But: A physician’s commitment to health not only for their patients but for their community must take precedence.