Ethical Issues in COVID-19 Communication to Mitigate the Pandemic: Dilemmas and Practical Implications

Communication plays a critical role in all stages of a pandemic. From the moment it is officially declared governments and public health organizations aim to inform the public about the risk from the disease and to encourage people to adopt mitigation practices. The purpose of this article is to call attention to the multiple types and the complexity of ethical challenges in COVID-19 communication. Different types of ethical issues in COVID-19 communication are presented in four main sections. The first deals with ethical issues in informing the public about the risk of the pandemic and dilemmas regarding communicating uncertainty, using threats and scare tactics, and framing the pandemic as a war. The second concerns unintended consequences that relate to increasing inequities, stigmatization, ageism, and delaying medical care. The third raises ethical issues in communicating about specific mitigation practices: contact tracing, wearing face masks, spatial (also referred to as social) distancing, and handwashing or sanitizing. The fourth concerns appealing to positive social values associated with solidarity and personal responsibility, and ethical challenges when using these appeals. The article concludes with a list of practical implications and the importance of identifying ethical concerns, which necessitate interdisciplinary knowledge, cross-disciplinary collaborations, public discourse and advocacy.

Ethical Challenges in Health Care Policy during COVID-19 Pandemic in Italy

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, Italy has proven to be one of the countries with the highest coronavirus-linked death rate. To reduce the impact of SARS-CoV-2 coronavirus, the Italian Government decision-makers issued a series of law decrees that imposed measures limiting social contacts, stopped non-essential production activities, and restructured public health care in order to privilege assistance to patients infected with SARS-CoV-2. Health care services were substantially limited including planned hospitalization and elective surgeries. These substantial measures were criticized due to their impact on individual rights including freedom and autonomy, but were justified by the awareness that hospitals would have been unable to cope with the surge of infected people who needed treatment for COVID-19. The imbalance between the need to guarantee ordinary care and to deal with the pandemic, in a context of limited health resources, raises ethical concerns as well as clinical management issues. The emergency scenario caused by the COVID-19 pandemic, especially in the lockdown phase, led the Government and health care decision-makers to prioritize community safety above the individuals' rights. This new community-centered approach to clinical care has created tension among the practitioners and exposed health workers to malpractice claims. Reducing the morbidity and mortality rates of the COVID-19 pandemic is the priority of every government, but the legitimate question remains whether the policy that supports this measure could be less harmful for the health care system.

Language barriers and epistemic injustice in healthcare settings

Contemporary realities of global population movement increasingly bring to the fore the challenge of quality and equitable health provision across language barriers. While this linguistic challenge is not unique to immigration contexts and is likewise shared by health systems responding to the needs of aboriginal peoples and other historical linguistic minorities, the expanding multilingual landscape of receiving societies renders this challenge even more critical, owing to limited or even non-existing familiarity of modern and often monolingual health systems with the particular needs of new linguistic minorities. The centrality of language to health beliefs, attitudes, practices, cultural scripts, and conceptual frameworks emphasizes its pivotal role in the healthcare process, and consequently in the adverse effects of treatment that is language-insensitive and unaware. Such an attitude on the part of medical authorities risks considerable epistemic injustice in the form of a (mis)judgement of patients' intelligence, credibility, and rationality based on the language that they speak and the manner in which they speak it, consequently impacting the quality and equity of care provided. This danger, I argue, may be effectively countered by fostering among the participants in the healthcare process a sense of epistemic humility through greater metalinguistic awareness. Outlining a range of operative steps that can be used to facilitate this. I argue that the reality of language barriers in the healthcare process, while not entirely eliminable, may nevertheless be successfully addressed, in order to mitigate the challenge of quality and equitable healthcare provision in multilingual societies.

From self-interest to solidarity: One path towards delivering refugee health

The recent and ongoing refugee crisis in Europe highlights conflicting attitudes about the rights of migrants and refugees to health care in transition and destination countries. Some European and Scandinavian states, such as Germany and Sweden, have welcomed large numbers of migrants, while others, such as the U.K., have been significantly less open. In part, this is because of reluctance by certain national governments to incur what are seen as the high costs of delivering aid and care to migrants. In response to these assumptions, some theorists have argued that the appropriate way to view the health needs of migrants is not in terms of rights, but in terms of the interests of destination and transition countries-and have argued that providing care to migrants and refugees will generate benefits for their host countries. However, self-interest alone is less effective at motivating the provision of care for health deprivations that do not pose a threat to third parties, or to migrants and refugees in poor or distant countries. In this paper, I argue that while self-interest is unlikely in itself to motivate the provision of all necessary health care to all migrants and refugees, and may risk stigmatizing already vulnerable persons, it can provide the foundation upon which such motivations can be built. My goal is therefore to show how and why a more just approach to the provision of health care to migrants can and should be derived from narrower, self-interested commitments to preserving citizen health.

Discussing rights and wrongs: Three suggestions for moving forward with the migrant health rights debate

Claims for improving migrants' access to care often draw on universalistic ethical notions, such as the principle of equity as it is specified in human rights law and public health ethics. These claims contrast with political realities across most welfare states. In the underlying public discourses, the frontline arguments against greater inclusion have often focused on practical concerns, such as the costs of healthcare provision. Yet it has also been suggested that ultimately context-specific moral frameworks play a key role in demarcating legitimate right-holders from undeserving others. Hence, is this a conflict between ethical principles and practical concerns? Or between different ethical perspectives? And why would that question matter? We propose that awareness of the nature of the arguments involved and respect for different ethical views are critical for coherent and constructive debates. This paper looks at the ways in which ethical concepts are used to justify exclusionary policy decisions. In particular, it examines the rationales that inform health policies towards documented and undocumented labor migrants in two welfare states, Germany and Israel, through the qualitative analysis of policy documents and 71 in-depth interviews. The study points to the central role of particular concepts of health-related deservingness. These results lead to the proposition that the fundamental clash in the discussion on migrants' access to care is one, albeit not solely, between contrasting ethical perspectives. Drawing on process-oriented approaches to ethical decision-making, the paper concludes with three suggestions for moving forward with the migrant health rights debate.

Mind the Scales: Harnessing Spatial Big Data for Infectious Disease Surveillance and Inference

Spatial big data have the velocity, volume, and variety of big data sources and contain additional geographic information. Digital data sources, such as medical claims, mobile phone call data records, and geographically tagged tweets, have entered infectious diseases epidemiology as novel sources of data to complement traditional infectious disease surveillance. In this work, we provide examples of how spatial big data have been used thus far in epidemiological analyses and describe opportunities for these sources to improve disease-mitigation strategies and public health coordination. In addition, we consider the technical, practical, and ethical challenges with the use of spatial big data in infectious disease surveillance and inference. Finally, we discuss the implications of the rising use of spatial big data in epidemiology to health risk communication, and public health policy recommendations and coordination across scales.

Practical, ethical, and legal challenges underlying crisis standards of care

Public health emergencies implicate difficult decisions among medical and emergency first responders about how to allocate essential resources. While various actors have proffered approaches on how to make these tough choices, meaningful guidance on shifting standards of care in major emergencies remained lacking. In March 2012, the Institute of Medicine (IOM) released additional guidance to assist facilities and practitioners to address scarce resource allocation through the development of "crisis standards of care" in catastrophes. As discussed in the article, identifying and resolving of complex practical, ethical, and legal challenges underlying real-time implementation of these standards are indispensable to protecting the public's health.

Conflicts of quarantine the case of Jewish immigrants to the Jewish state

Shaar Haaliya--Israel's Ellis Island during the mass immigration of the 1950s--is a case study that challenges the historian's understanding of the concept of quarantine. It was isolated and fenced off for declared health purposes and was widely referred to as a quarantine, but archival and historiographical documentation suggest that Israeli public health policy did not define it as such. I track the discussion and conflict surrounding Shaar Haaliya's function and perception as a quarantine. This is a story that illuminates the way fear of disease converged with fear of immigration as well as the way defiance of public health institutions took shape in a unique framework of citizenship and during a unique wave of migration.

Resource allocation on the frontlines of public health preparedness and response: report of a summit on legal and ethical issues

OBJECTIVES

In the face of all-hazards preparedness challenges, local and state health department personnel have to date lacked a discrete set of legally and ethically informed public health principles to guide the distribution of scarce resources in crisis settings. To help address this gap, we convened a Summit of academic and practice experts to develop a set of principles for legally and ethically sound public health resource triage decision-making in emergencies.

METHODS

The invitation-only Summit, held in Washington, D.C., on June 29, 2006, assembled 20 experts from a combination of academic institutions and nonacademic leadership, policy, and practice settings. The Summit featured a tabletop exercise designed to highlight resource scarcity challenges in a public health infectious disease emergency. This exercise served as a springboard for Summit participants' subsequent identification of 10 public health emergency resource allocation principles through an iterative process.

RESULTS

The final product of the Summit was a set of 10 principles to guide allocation decisions involving scarce resources in public health emergencies. The principles are grouped into three categories: obligations to community; balancing personal autonomy and community well-being/benefit; and good preparedness practice.

CONCLUSIONS

The 10 Summit-derived principles represent an attempt to link law, ethics, and real-world public health emergency resource allocation practices, and can serve as a useful starting framework to guide further systematic approaches and future research on addressing public health resource scarcity in an all-hazards context.

[The Canadian plan to struggle against influenza epidemics: legal plea for a normative global approach]

The Canadian pandemic influenza plan for the health sector lies within a logic of precaution aiming at the effective prevention of human infections by the highly pathogenic influenza virus H5N1. Since the plan is designed as guidelines elaborated by the Canadian authorities to regulate behaviours should a pandemic occur, it possesses an eminent normative value. Yet, in spite of the attention being given by the experts to scientific and logistic measures, it seems clear that the Canadian plan has not undergone a thorough normative analysis, although it includes ethical considerations. The objective of this article is to show that a wider normative analysis should not be restricted to the elaboration of an ethical framework applicable to predetermined interventions. Such an analysis should also take into consideration how rational choices are made through the epistemological approach used by the experts.

Tangible evidence, trust and power: public perceptions of community environmental health studies

Communities with environmental health concerns in the USA frequently request studies from their local or state departments of public health. This paper presents findings from three focus groups conducted in communities north of Boston that have been the subject of two different environmental health studies. The focus groups were designed to elicit residents' perceptions of environmental health, and of the particular studies conducted in their communities. In all focus groups, participants had difficulty accepting the findings of health studies that contradicted their own experiences of environmental exposures and illness. Our results suggest that lay knowledge, informed in varying degrees by the experience of what we term "tangible evidence," creates a lens through which communities interpret a health study's findings. The differences in reliance on tangible evidence were related to participants' sense of trust in public officials, and the institutions responsible for conducting health studies. Participants from the wealthier, predominantly white communities discussed trust in study design and methodologies used. In contrast, participants from the lower-income, higher-minority communities assessed health studies with reference to their trust (or lack thereof) in study sponsors and public health institutions. Participants' experience of tangible evidence, trust or distrust in health agencies and research institutions, and a sense of relative community power, influence how they assess the findings of environmental health studies and may have implications for pubic health.

The disconnect between China's public health and public security responses to injection drug use, and the consequences for human rights

Stephen Koester discusses a research article by Elizabeth Cohen and Joseph Amon that illustrates how injection drug users are caught between China's conflicting policies and practices toward drug use and HIV prevention and care.

Integrating ethics, health policy and health systems in low- and middle-income countries: case studies from Malaysia and Pakistan

Scientific progress is a significant basis for change in public-health policy and practice, but the field also invests in value-laden concepts and responds daily to sociopolitical, cultural and evaluative concerns. The concepts that drive much of public-health practice are shaped by the collective and individual mores that define social systems. This paper seeks to describe the ethics processes in play when public-health mechanisms are established in low- and middle-income countries, by focusing on two cases where ethics played a crucial role in producing positive institutional change in public-health policy. First, we introduce an overview of the relationship between ethics and public health; second, we provide a conceptual framework for the ethical analysis of health system events, noting how this approach might enhance the power of existing frameworks; and third, we demonstrate the interplay of these frameworks through the analysis of a programme to enhance road safety in Malaysia and an initiative to establish a national ethics committee in Pakistan. We conclude that, while ethics are gradually being integrated into public-health policy decisions in many developing health systems, ethical analysis is often implicit and undervalued. This paper highlights the need to analyse public-health decision-making from an ethical perspective.

Excluding the poor from accessing biomedical literature: a rights violation that impedes global health

Most biomedical journals charge readers a hefty access toll to read the full text version of a published research article. These tolls bring enormous profits to the traditional corporate publishing industry, but they make it impossible for most people worldwide--particularly in low and middle income countries--to access the biomedical literature. Traditional publishers also insist on owning the copyright on these articles, making it illegal for readers to freely distribute and photocopy papers, translate them, or create derivative educational works. This article argues that excluding the poor from accessing and freely using the biomedical research literature is harming global public health. Health care workers, for example, are prevented from accessing the information they need to practice effective medicine, while policymakers are prevented from accessing the essential knowledge they require to build better health care systems. The author proposes that the biomedical literature should be considered a global public good, basing his arguments upon longstanding and recent international declarations that enshrine access to scientific and medical knowledge as a human right. He presents an emerging alternative publishing model, called open access, and argues that this model is a more socially responsive and equitable approach to knowledge dissemination.

Building public health law capacity at the local level

Local health officials are called upon every day to implement the programs, enforce the regulations, and take the actions that protect the health of the citizens in their districts. These responsibilities and duties are created and regulated by a complex interplay of federal, state, and local law. Not only is an understanding of these laws necessary to carry out public health activities on a daily basis, but many public health scholars and practitioners also believe that the law can be used as a tool to take proactive steps to improve public health. Unfortunately, many local public health officials do not have access to the legal assistance they need to address the various legal questions that confront them. This deficit makes it harder for them to meet their day-to-day responsibilities and makes it much more difficult for them to use the law proactively as a method to improve public health in their communities. In addition, many of the attorneys who provide legal support to public health departments do not have the time or resources to develop a thorough and up-to-date understanding of public health law. This paper examines the experience of a number of local health offices in obtaining legal advice and of attorneys who provide legal advice and assistance to local health departments and assesses different models for organizing and financing the provision of legal services to local public health officials.

Litigation as a strategy to hold governments accountable for implementing the right to health

This article offers a framework for exploring litigation as a strategy to advance the right to health by holding governments accountable to human rights norms. Since the 1990s, cases in which people go to court to claim their right to health have increased dramatically in resource-poor countries. With issues ranging from access to health services and medication, to discriminatory labor practices, to public health, to the basic determinants of health (such as food, water, shelter, and a healthy environment), these cases potentially have huge financial and social implications. Little is known, however, about the success of such attempts to hold governments accountable for their obligations with respect to the right to health--or about who benefits. Is litigation primarily used by marginalized persons to gain fair access to medical services, or is it more often a means by which those patients with more financial resources or creativity in seeking assistance pursue access to treatment that is not otherwise provided due to expense? To what extent does litigation affect health policy and service delivery? What little is known about these cases is fragmented and anecdotal The theoretical framework outlined here facilitates the systematic comparative and interdisciplinary studies needed to advance knowledge in this field, taking account of the entire litigation and implementation process.

Challenging orthodoxies: the road ahead for health and human rights

Two decades of work delivering health care in poor communities provide a standpoint from which to challenge conventional doctrines in human rights and public health. These orthodoxies include the priority often assigned to civil and political rights over economic and social rights and a narrow concept of cost-effectiveness in public health policy. An analysis based on economic and social rights underscores, for example, that effectively treating infectious diseases in poor communities requires ensuring that people receive adequate food The challenge of maternal mortality in low-income settings similarly shows the need for an approach to rights that is simultaneously comprehensive and pragmatic. In many settings, paying community health workers for their efforts on behalf of their neighbors can also be seen as a critical strategy to realize right. Across contexts, the yield on the expanded and pragmatic view of health and human rights adumbrated here may be considerable. In forthcoming issues, Health and Human Rights will continue to investigate the conceptual, but above all the practical aspects of such issues, seeking to shift the health and rights agenda in a way that may make sense to the world's poor and marginalized, the chief victims of contemporary human rights violations.

A human rights approach to quality of life and health: applications to public health programming

Approaching health as a basic human right has a profound impact on the way we treat it politically. Viewing health as a public good--with both individual and collective dimensions--shapes the nature of health policies. The concept of a right to health can be used to formulate policies, organize systems and services, and develop actions that promote better health outcomes. Building on experiences in Latin America, this article discusses lessons learned for achieving policies and health systems that contribute to building democracy into a system that guarantees sodcial justice. Drawing on work in Latin American Social Medicine, it specifically proposes new ways of thinking about social fragility (instead of risks) and developing inter-sectoral programming to improve care, as well as to reduce inequalities among population groups. The article argues that a right-based approach can be a concrete tool for restructuring both public policies and action.

Health systems and the right to the highest attainable standard of health

The right to the highest attainable standard of health should be the cornerstone of any consideration of health and human rights. The content of this fundamental human right is now sufficiently well understood to be applied in an operational, systematic, and sustained manner. At the heart of the right to the highest attainable standard of health lies an effective and integrated health system, encompassing medical care and the underlying determinants of health, which is responsive to national and local priorities and accessible to all. Yet in many countries, health systems are failing and collapsing, giving rise to an extremely grave human rights problem. This article outlines the general approach of the right to the highest attainable standard of health toward the strengthening of health systems. It identifies some of the key right-to-health features of a health system, such as transparency, participation, equity and equality, a comprehensive national health plan, a minimum "basket" of health-related services and facilities, disaggregated data, monitoring and accountability, and so on. This general approach has to be consistently and systematically applied across the "building blocks" that together constitute a functioning health system. By way of illustration, the article applies this approach to one of these "building blocks:" leadership, governance, and stewardship. There are numerous health movements and approaches, including health equity, primary health care, social determinants, and so on. All are very important. But it is misconceived to regard human rights as yet another approach with the same status as the others. Like ethics, the right to the highest attainable standard of health is not optional--and, like ethics, it recurs throughout all other approaches. The right to the highest attainable standard of health is the only perspective that is both underpinned by universally recognized moral values and reinforced by legal obligations.

What is a human-rights based approach to health and does it matter?

A human rights approach to health is critical to address growing global health inequalities. Three aspects of the nature of health as a right are relevant to shaping a human rights approach to health: (1) the indivisibility of civil and political rights, and socio-economic rights; (2) active agency by those vulnerable to human rights violations; and (3) the powerful normative role of human rights in establishing accountabiliy for protections and freedoms. Health professionals' practice, tpically governed by ethical codes, may benefit from human rights guidelines, particularly in situations of dual loyalty where clients' or communities' human rights are threatened Moreover, institutional accountability for protecting human rights is essential to avoid shifting responsibility solely onto the health professional Human rights approaches can include holding states and other parties accountable, developing policies and programs consistent with human rights, and facilitating redress for victims of violations of the right to health. However, underlying all models is the need to enable active social mobilization, without which legal approaches to rights lack sustainability and power. Evidence from South and Southern Africa has shown that different conceptions of what is meant by human rights impact substantially on state willingness and abiliy to meet constitutional obligations with regard to the right to health. New approaches to health polity development, which draw on the agency of vulnerable groups, link local struggles with their global context, and explicitly incorporate rights frameworks into public health planning are needed. Models that move away from individualizing conflict over rights between health professionals as disempowered duty bearers and patients as frustrated rights holders, toward more mutual approaches to shared rights objectives may be possible and are being actively pursued through the development of a learning network to realize the right to health in South Africa.

"Nationals" and "expatriates": challenges of fulfilling "sans frontières" ("without borders") ideals in international humanitarian action

The international humanitarian organization, Médecins Sans Frontières (MSF), is strongly committed to principles of universalism, egalitarianism, and equity, in both its internal and external relations. Nevertheless, the organization distinguishes between so-called "national" staff members (those who are indigenous to the countries where MSF projects are located), and "expatriate" staff (those who are involved in projects outside their countries of residence), in certain ways that it has self-critically termed "discriminatory", "colonialist", and even "racist". It has resolved to remedy such practices. Through a first-hand case study of MSF activities in Russia, this article demonstrates that the dynamics of the "nationals"/ "expatriates" divide is a more complex phenomenon than MSF's self-accusatory diagnosis implies; that a fuller recognition and utilization of nationals' local knowledge would mitigate some of the conditions of inequality and inequity that they experience; but that it would not necessarily be desirable to expunge all differences between the two groups of staff Furthermore, because they are intrinsic to the structure and conditions of international humanitarian action, some of these differences could not easily be elminated by MSF, or by any other organization engaged in this kind of action.

The catalytic synergy of health and human rights: the People's Health Movement and the right to health and health care campaign

The Peoples Health Movement (PHM) is a global network at the intersection of many health and human rights organizations that has articulated and attempted to put into practice a human rights-based approach to improving health, organizing particularly in the area of economic, social, and cultural rights. PHM's approach to human rights and its Right to Health and Health Care Campaign (RTHHCC), the focus of this article, are responses influenced by several concerns: the failure to implement the primary health care strategy defined in the Alma Ata declaration, the discipline of social medicine, and the application of human rights methods to local health problems and to organiZational practice. Through PHM, a global network of activists is renewing the concept of citizenship and creating new forms of direct democratic social organization.

Will we take suffering seriously? Reflections on what applying a human rights framework to health means and why we should care

Since this journal was first published, rights-based approaches to health have prolferated in the health and development communities. At the same time, human rights advocacy organizations, courts, and UN actors have increasingly been engaged in applying rights norms in health contexts. Together with others in this issue, this article is a call not to lose sight of the radical potential of using a human rightsparadigm to promote health--even as we go about the pragmatic work of translating rights frameworks into practice in our research, advocacy, litigation strategies, program planning, and service delivery. Drawing together points made in other pieces in this issue, the article describes certain conceptual and practical implications of a transformative engagement between health and human rights. It argues that an appropriate starting point is to take suffering seriously; in so doing, approaches in both health and rights will necessarily shift. A human rights approach challenges biological individualism in both clinical medicine and public health, and builds on work in social epidemiology by providing frameworks for accountability. At the same time, using rights to advance the health of marginalized peoples around the world requires critiquing and expanding limited approaches to human rights, in theory and practice.

Beyond compassion: the central role of accountability in applying a human rights framework to health

Accountability is a central feature of any rights-based approach to health because it converts passive beneficiaries into claims-holders and identifies states and other actors as duty-bearers that can be held responsible for their discharge of legal, and not merely moral, obligations. This article reviews what we mean by accountability, how courts and other mechanisms are being engaged to promote accountability, and what we should understand as the central obligations of states and other actors if we are concerned with obligations of progressive realization relating to health and development goals. The first part of the article sets out a number of mutually-reinforcing dimensions of accountability, examines different duty-bearers, and discusses mechanisms for enforcement, with a focus on courts. The second part of the article explores how we might define the obligations of progressive realization for which we seek accountability. I argue that there are three aspects of accountability with which a human rights approach to health as a social policy and development issue should be concerned: (1) what the state is doing; (2) how much effort the state is expending; and (3) how the state is going about the process. Although the focus is on national obligations, I argue that donor states and other actors have parallel obligations.

Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures

Public health emergencies may result in mass casualties and a surge in demand for hospital-based care. Healthcare standards may need to be altered to respond to an imbalance between demands for care and resources. Clinical decisions that involve triage and scarce resource allocation may present unique ethical challenges. To address these challenges, the authors detailed tenets and procedures to guide triage and scarce resource allocation during public health emergencies. The authors propose health care organizations deploy a Triage and Scarce Resource Allocation Team to over-see and guide ethically challenging clinical decision-making during a crisis period. The authors' goal is to help healthcare organizations and clinicians balance public health responsibilities and their duty to individual patients during emergencies in as equitable and humane a manner as possible.

Avoiding the danger that stop smoking services may exacerbate health inequalities: building equity into performance assessment

Background

The UK is the only developed country to have established a nation-wide stop smoking treatment service. Apart from addressing tobacco dependence, which is the leading preventable cause of ill health and premature death, smoking cessation has been identified by the UK department of health as a service priority for reducing gaps in health between disadvantaged groups and the country as a whole. However smoking cessation tends to be more successful among affluent than disadvantaged groups. This means that for stop smoking services there is a trade-off to be had in terms of maximising the number of quitters and reducing socioeconomic inequalities in smoking prevalence. Current performance targets for the national stop smoking services in the UK are set only in terms of numbers of quitters, which does not encourage the adoption of strategies to reduce socioeconomic inequalities in smoking prevalence.

Discussion

This paper proposes an assessment framework, which allows the two dimensions of overall reduction in smoking prevalence and reductions of inequalities in smoking prevalence to be assessed together. The framework is used to assess the performance over time of a stop smoking service in Derwentside, a former Primary Care Trust in the North East of England, both in terms of meeting targets for the overall number of quitters and in terms of reducing socioeconomic inequalities in smoking prevalence.

The example demonstrates how the proposed assessment framework can be applied in practice given existing records kept by stop smoking services in England and the available information on smoking prevalence at small area level. For Derwentside it is shown that although service expansion was successful in increasing the overall number of quitters, the service continued to exacerbate inequality in smoking prevalence between deprived and affluent wards.

Summary

The Secretary of State for Health in the UK has warned about the dangers of health promotion services and messages being taken up more readily by the better-off, thus exacerbating health inequalities. Because smokers from affluent backgrounds are more successful at quitting than those living in deprived circumstances, it is important to build an equity element into the monitoring of individual stop smoking services. Otherwise the danger highlighted by the Secretary of State for Health will go undetected and unaddressed.

Ethical challenges in planning for an influenza pandemic

Pandemics have devastated humankind throughout history and the threat they pose is just as great now, at the beginning of the 21st century. Managing a public health emergency of the scale and complexity of a pandemic, and with the potential societal ramifications, poses enormous challenges. Public health planners must grapple with the intersection of competing values and priorities. This article provides a preliminary discussion of some of these ethical issues, specifically the necessary limitations on individual liberty posed by quarantine, the unavoidable need to prioritise health care resources, and the complexities associated with the obligations of health care professionals.

Ethical challenges related to elder care. High level decision-makers' experiences

BACKGROUND

Few empirical studies have been found that explore ethical challenges among persons in high public positions that are responsible for elder care. The aim of this paper was to illuminate the meaning of being in ethically difficult situations related to elder care as experienced by high level decision-makers.

METHODS

A phenomenological-hermeneutic method was used to analyse the eighteen interviews conducted with political and civil servant high level decision-makers at the municipality and county council level from two counties in Sweden. The participants worked at a planning and control as well as executive level and had both budget and quality of elder care responsibilities.

RESULTS

Both ethical dilemmas and the meaning of being in ethically difficult situations related to elder care were revealed. No differences were seen between the politicians and the civil servants. The ethical dilemmas mostly concerned dealings with extensive care needs and working with a limited budget. The dilemmas were associated with a lack of good care and a lack of agreement concerning care such as vulnerable patients in inappropriate care settings, weaknesses in medical support, dissimilar focuses between the caring systems, justness in the distribution of care and deficient information. Being in ethically difficult situations was challenging. Associated with them were experiences of being exposed, having to be strategic and living with feelings such as aloneness and loneliness, uncertainty, lack of confirmation, the risk of being threatened or becoming a scapegoat and difficult decision avoidance.

CONCLUSION

Our paper provides further insight into the ethical dilemmas and ethical challenges met by high level decision-makers', which is important since the overall responsibility for elder care that is also ethically defensible rests with them. They have power and their decisions affect many stakeholders in elder care. Our results can be used to stimulate discussions between high level decision-makers and health care professionals concerning ways of dealing with ethical issues and the necessity of structures that facilitate dealing with them. Even if the high level decision-makers have learned to live with the ethical challenges that confronted them, it was obvious that they were not free from feelings of uncertainty, frustration and loneliness. Vulnerability was revealed regarding themselves and others. Their feelings of failure indicated that they felt something was at stake for the older adults in elder care and for themselves as well, in that there was the risk that important needs would go unmet.

Trust influences response to public health messages during a bioterrorist event

This study builds on recent work describing African Americans' low trust in public health regarding terrorism preparedness by identifying the specific components of trust (fiduciary responsibility, honesty, competency, consistency, faith) that may influence community response to a bioterrorist attack. We used qualitative analysis of data from 75 African American adults living in Los Angeles County who participated in focus group discussions. Groups were stratified by socioeconomic status (SES; up to vs. above 200% of federal poverty guidelines) and age (18-39 years old vs. 40-65 years old). Discussions elicited reactions to information presented in escalating stages of a bioterrorism scenario. The scenario mimicked the events and public health decisions that might occur under such a scenario. Honesty and consistency of information from public health officials were the components most frequently identified as determining trust or distrust. Patterns of trust varied according to the scenario stage; honesty was most important upon initially hearing of a public health crisis, whereas fiduciary responsibility and consistency were important upon confirmation of a smallpox outbreak and the ensuing public health response. Findings can help public health officials design communications that address distrust and enhance trust during a bioterrorist event.

The role of the public health official in communicating public health information

The prevailing views on the role of public health professionals refer to professionals in the academic world, without taking into account the fact that many public health professionals are government employees. For example, the American Public Health Association states that public health professionals play an active role in communicating public health information to nonscientific audiences, such as the general population or the mass media. We propose that public health officials have an important responsibility to promote the practice of public health. However, they must do so within the bureaucracy. Any actions that public health officials wish to take as advocates of particular public health activities should be carried out independent of their role as government officials.

Lessons learned from the Children's Environmental Exposure Research Study

We examined 5 different ethical concerns about the Children's Environmental Exposure Research Study and make some recommendations for future studies of exposure to hazardous environmental agents in the home. Researchers should seek community consultation and participation; make participants aware of all the risks associated with the research, including hazards discovered in the home and uncertainties about the risks of agents under investigation; and take steps to ensure that their studies will not have unfair representation of the poor or people of color. Researchers should also avoid even the appearance of a financial conflict of interest in studies that are likely to be controversial and make it clear to all parties that studies will not intentionally expose subjects to hazardous environmental agents.

Ethics in public health research: masters of marketing: bringing private sector skills to public health partnerships

Skill in marketing is a scarce resource in public health, especially in developing countries. The Global Public-Private Partnership for Handwashing with Soap set out to tap the consumer marketing skills of industry for national handwashing programs. Lessons learned from commercial marketers included how to (1) understand consumer motivation, (2) employ 1 single unifying idea, (3) plan for effective reach, and (4) ensure effectiveness before national launch. After the first marketing program, 71% of Ghanaian mothers knew the television ad and the reported rates of handwashing with soap increased. Conditions for the expansion of such partnerships include a wider appreciation of what consumer marketing is, what it can do for public health, and the potential benefits to industry. Although there are practical and philosophical difficulties, there are many opportunities for such partnerships.

Dental ethics in a larger context: one point of view

Since the end of World War II, the practice of dentistry has been largely transformed from a "calling" into a cog in the ever-expanding "Healthcare Industry". In the process, the distinction between professional ethics and the ethics of commerce has been attenuated and, to a large extent, lost. Today's dentist is faced with an inherent conflict between the pledge of the health professional to hold the patient's interests primary (and above all, to do no harm), and the self-protective commercial principle of caveat emptor. Pressures towards commercialism come from the government and the insurance industry, the increasingly unfavorable ratio between professional fees and the cost of production, and the high cost of dental education. Viewed simplistically, much of dentistry today has an outward form resembling commodity production. Recognizing the substantial forces tending to attenuate ethical standards in our profession may aid us in resisting their encroachments.

Can human rights discourse improve the health of Indigenous Australians?

OBJECTIVE

Recognition of the poor health outcomes of Indigenous Australians has led to an interest in using human rights discourse as a framework for arguing that the Australian Government has an international obligation to improve Indigenous health.

METHOD

This paper explores two potential directions for human rights discourse in this context. The first is the development and elaboration of an asserted 'human right to health'. The second focuses on developing an understanding of the interactions between health and human rights, particularly the underlying social determinants of health, and thereby creating an advocacy framework that could be used to promote the inclusion of human rights considerations into the policy-making agenda.

RESULTS

This paper argues that despite the symbolic force of human rights discourse, its capacity to improve the health of Indigenous Australians through international law is limited. This is so irrespective of whether recourse is made to a legal or moral imperative.

CONCLUSION AND IMPLICATIONS

The 'human right to health' is limited primarily by several barriers to its implementation, some of which are perpetuated by the current Australian Government itself. Although the potential advocacy capacity of human rights discourse is similarly limited by the hostility of the Government towards the notion of incorporating human rights considerations into its public policy decision making, it does provide a sustainable intellectual framework in which to consider the social and structural determinants of health and maintain these issues on the political agenda.