Madison, Wisconsin / USA - April 24th, 2020: Nurses at Reopen Wisconsin Protesting against the protesters protesting safer at home order rally holding signs telling people to go home.

The Consequences of Public Health Law Vacuums

By Daniel Goldberg

Pandemic planning documents and materials from the early 2000s to the present anticipated a great deal of what the U.S. has been experiencing during the COVID-19 pandemic. The best of such plans documented exactly what be required to manage, respond, and control a pandemic spread by a highly communicable respiratory virus like SARS-CoV-2.

What the plans did not account for was what we are now experiencing: That governments would simply refuse to govern.

Few truly accounted for the possibility that the very entities charged with regulating for the health, safety, and welfare of their residents and citizens would simply decline to do so, choosing instead the public health law vacuums in which we find ourselves at the present time. Read More

Waitress wears face mask and face shield, cleans table with alcohol and wet wipe at restaurant.

The Problem with Individual-Level Interventions to Curb the COVID-19 Pandemic

By Daniel Goldberg

The failure to control the COVID-19 pandemic in the United States rests, in part, on the individualist nature of our public health responses.

Public health simply does not work well when we base our interventions on the individual level. This is known as “methodological individualism,” and the evidence suggests it is both ineffective and can expand existing health inequalities. It is problematic in any public health context, but especially in pandemic response and control.

Take, for example, the ongoing debate over mask mandates. Multiple governors have refused to issue mask mandates, instead simply requesting that people don masks. The objection, interestingly, is not to the idea of masking as a public health intervention, but to the existence of a mandate itself.

Yet a model of public health which consists of nothing more than pleading with individuals to avoid behaving in ways injurious to public health would be an abject failure. Imagine if, instead of imposing minimum requirements for clean water, we simply asked regulated industries to avoid polluting watersheds. Or perhaps instead of passing laws discouraging or even criminalizing obviously harmful behavior, we simply asked people to avoid driving drunk.

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supervised injection site

NIMBYism continues to factor into supervised injection site policies

As a major tool in harm reduction policy connected to opioid and substance misuse, more than 30 states have implemented syringe exchange programs, or SEPs.

Surmounting or, in many cases, bypassing the considerable legal and political obstacles has proved a challenge for states, whether they succeeded in enacting SEPs or not. While, given the opioid crisis, SEPs are more important than ever, they do have limitations.

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Concussions, the N.F.L., & the Manufacture of Doubt

{SHAMELESS SELF-PROMOTION ALERT}

A new article of mine is out in the Journal of Legal Medicine entitled “Mild Traumatic Brain Injury, the National Football League, and the Manufacture of Doubt: An Ethical, Legal, and Historical Analysis.”  I’ve written on the subject before, but in case anyone is interested, here is the Abstract of the current paper:

This paper integrates legal, historical, and ethical approaches in analyzing the National Football League’s conduct regarding the risks its players face of experiencing concussions and the long-term neurodegenerative pathologies to which such injury is linked.  Given that millions of children and adolescents play American football, and that the NFL concedes its behavior is a strong determinant of football culture, concussion issues are crucial matters of population health.  Examining over 500 pages of testimony generated during Congressional hearings in 2009 and 2010, the paper links claims issued by leading NFL representatives to past efforts by industrial actors to manufacture doubt.  The paper therefore argues that the history of public health is crucial to framing just public health policy in the present.  The paper applies two frameworks drawn from public health ethics to argue first that a robust process of public reason is stymied by the NFL’s insistence on privately holding information relevant to its attitudes, practices and beliefs regarding concussions, and second, that the unequal distribution of ‘football prevalence’ exposes already disadvantaged groups such as African-Americans to higher risks of concussions and neurological disease.  The paper concludes that this latter possibility may contravene mandates of social justice, and, if so, would be ethically suboptimal.

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The Oregon Health Study and the Medicalization of Health Policy

According to the website, the Oregon Health Study “is the first randomized controlled  experiment to examine the causal effects of having some type of insurance coverage versus having no insurance at all.”  The findings, released a few days ago, have unleashed a storm of commentary on what the investigators did and did not find in terms of links between coverage and health outcomes.  Writing  over at The Incidental Economist, Harold Pollack quotes Joseph Newhouse for the notion that the “Oregon Medicaid experiment ‘is a Rorschach test of people’s views on the ACA.’”  After the jump, I am going to try to defend that claim, although likely not in the way that good readers of Bill of Health might expect.

So here’s the funny thing: even though I am an attorney, an historian, and a bioethicist who researches health inequalities, stigma, and social justice, I actually am less of an expert on the delivery of health care services than virtually every blogger here, and likely a goodly portion of the readership, too.  When interviewing for a job as a prawf some years ago, I was asked for my opinion on the fate of the ACA (then still in Congress), and I had to shrug and say that I really was not up to date on all of the provisions of the bill nor of its likely passage, nor of its potential impact.  (No, I did not get the job!).

This is not because of anti-intellectualism, I believe (and hope!).  This is rather because of my engagement with the overwhelming evidence that access to health care services is simply not a prime determinant of health and its distribution in human populations.  In a seminal 2007 essay in Health Affairs, Paula Lantz, Richard Lichtenstein, and the good Dr. Pollack himself note that “Lack of access to health care is not the fundamental cause of health vulnerability or social disparities in health” (p. 1256).*  The authors go on to warn of the limits of medicalizing health policy, and suggest that if we want to use laws and policies to improve overall population health and compress health inequities, we need to go way beyond simply expanding access to basic health care services.

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Fatness, Health, & Uncertainty

By Daniel Goldberg

Reading Nir’s thought-provoking post below sparked a couple of thoughts in my mind regarding fatness, ethics, and population health.  The first is what I take to be the professional obligation to engage seriously with the epidemiologic uncertainty regarding the connections between fatness and health.  With notable exceptions — see the Rudd Center, for example — most of the work in bioethics and law that discusses obesity problems does so by averring (1) that obesity is an enormous problem for public health; and then (2) proceeding to discuss a particular intervention intended to ameliorate it.  But I generally perceive all too much haste with the first step. Read More