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Rethinking Public HealthRethinking Public Health
Edward P. Richards, J.D., Edward P. Richards, J.D., M.P.H.M.P.H.
Professor of LawProfessor of Law
Executive DirectorExecutive Director
Center for Public Health LawCenter for Public Health Law
University of Missouri Kansas University of Missouri Kansas CityCity
http://plague.law.umkc.edu/http://plague.law.umkc.edu/cphl cphl
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What Motivates ModernWhat Motivates ModernPublic Health?Public Health?
Social JusticeSocial Justice• Health People 2010Health People 2010
Integrated Delivery SystemIntegrated Delivery System• NIH Future of Public Health StudyNIH Future of Public Health Study
““Our Patients”Our Patients”• Unnamed State Health DirectorUnnamed State Health Director
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APHAAPHA
Vision: Healthy People in Healthy Vision: Healthy People in Healthy CommunitiesCommunities
Mission: Promote Physical and Mission: Promote Physical and Mental Health and Prevent Mental Health and Prevent Disease, Injury, and DisabilityDisease, Injury, and Disability
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Public HealthPublic Health
Prevents epidemics and the spread of Prevents epidemics and the spread of diseasedisease
Protects against environmental hazardsProtects against environmental hazards Prevents injuriesPrevents injuries Promotes and encourages healthy behaviorsPromotes and encourages healthy behaviors Responds to disasters and assists Responds to disasters and assists
communities in recoverycommunities in recovery Assures the quality and accessibility of Assures the quality and accessibility of
health serviceshealth services
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Essential Public Health Essential Public Health Services 1-5Services 1-5
• Monitor health status to identify community Monitor health status to identify community health problemshealth problems
• Diagnose and investigate health problems Diagnose and investigate health problems and health hazards in the communityand health hazards in the community
• Inform, educate, and empower people about Inform, educate, and empower people about health issueshealth issues
• Mobilize community partnerships to identify Mobilize community partnerships to identify and solve health problemsand solve health problems
• Develop policies and plans that support Develop policies and plans that support individual and community health effortsindividual and community health efforts
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Essential Public Health Essential Public Health Services 6 - 10Services 6 - 10
• Enforce laws and regulations that protect Enforce laws and regulations that protect health and ensure safetyhealth and ensure safety
• Link people to needed personal health services Link people to needed personal health services and assure the provision of health care whenand assure the provision of health care whenotherwise unavailableotherwise unavailable
• Assure a competent public health and personal Assure a competent public health and personal health care workforcehealth care workforce
• Evaluate effectiveness, accessibility, and Evaluate effectiveness, accessibility, and quality of personal and population-based healthquality of personal and population-based healthservicesservices
• Research for new insights and innovative Research for new insights and innovative solutions to health problemssolutions to health problems
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The Big Umbrella ProblemThe Big Umbrella Problem
Different Skills SetsDifferent Skills Sets Different Finance ModelsDifferent Finance Models Different Professional ParadigmsDifferent Professional Paradigms Different and Conflicting Legal Different and Conflicting Legal
AuthorityAuthority Different Political BaseDifferent Political Base
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Conflicting Legal AuthorityConflicting Legal Authority
Parens PatriaParens Patria Police PowersPolice Powers Criminal LawCriminal Law Individual Liberties LawIndividual Liberties Law
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Parens PatriaeParens Patriae
"Parens patriae," literally "parent of "Parens patriae," literally "parent of the country,”... It is the principle the country,”... It is the principle that the state must care for those that the state must care for those who cannot take care of themselves, who cannot take care of themselves, such as minors who lack proper care such as minors who lack proper care and custody from their parents.and custody from their parents.• Blacks Law DictionaryBlacks Law Dictionary
The King as FatherThe King as Father The Country as FamilyThe Country as Family
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Modern Parens Patriae Modern Parens Patriae PowersPowers
Child WelfareChild Welfare Indigent CareIndigent Care Wellness ProgramsWellness Programs Mental Health CareMental Health Care
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Why do Lawyers and Law Why do Lawyers and Law Professors Like Parens Professors Like Parens Patriae?Patriae?
Helping the DowntroddenHelping the Downtrodden Empowering the IndividualEmpowering the Individual Distrust of the StateDistrust of the State Lots of Money in Suing for IndividualsLots of Money in Suing for Individuals Not Much Money in Representing the Not Much Money in Representing the
StateState No Money or Private Practice in Public No Money or Private Practice in Public
Health LawHealth Law
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Police PowerPolice Power
Right of Societal Self-DefenseRight of Societal Self-Defense Right of the State to Protect ItselfRight of the State to Protect Itself Right of the State to Protect Its Right of the State to Protect Its
CitizensCitizens
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HistoryHistory
From English Common LawFrom English Common Law Core of Colonial GovernmentCore of Colonial Government Key Power Reserved to the StatesKey Power Reserved to the States The Key Public Health Law The Key Public Health Law
Doctrine until the 1980sDoctrine until the 1980s Still the Doctrine Used by the Still the Doctrine Used by the
CourtsCourts
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Police Power v. Parens Police Power v. Parens PatriaePatriae
The state has a legitimate interest The state has a legitimate interest under its parens patriae powers in under its parens patriae powers in providing care to its citizens who are providing care to its citizens who are unable because of emotional disorders unable because of emotional disorders to care for themselves; the state also to care for themselves; the state also has authority under its police power to has authority under its police power to protect the community from the protect the community from the dangerous tendencies of some who dangerous tendencies of some who are mentally ill.are mentally ill.• Addington v. Texas, 441 U.S. 418 (1979)Addington v. Texas, 441 U.S. 418 (1979)
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Philosophical DifferencesPhilosophical Differences
Parens PatriaeParens Patriae• The Individual Is FirstThe Individual Is First• Society is just the Sum of the Society is just the Sum of the
IndividualsIndividuals Police PowerPolice Power
• Ecological ModelEcological Model• Society is a Complex OrganismSociety is a Complex Organism
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Practical DifferencesPractical Differences
Parens PatriaeParens 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
Police PowerPolice Power• Driven by Community ProtectionDriven by Community Protection• Stresses Statistical LivesStresses Statistical Lives• Protect Others From DiseaseProtect Others From Disease
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Criminal LawCriminal Law
Subset of Police PowersSubset of Police Powers Moral/Religious OverlayMoral/Religious Overlay Prospective DeterrenceProspective Deterrence Core DifferenceCore Difference
• Allows Retrospective PunishmentAllows Retrospective Punishment• Special Constitutional ProtectionsSpecial Constitutional Protections
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Individual Liberties LawIndividual Liberties Law
Bill of Rights BasedBill of Rights Based• Limited Balancing of Individual vs Limited Balancing of Individual vs
Societal RightsSocietal Rights ExamplesExamples
• Privacy LawPrivacy Law• Tort LawTort Law• Informed Consent and other Medical Informed Consent and other Medical
Law DoctrinesLaw Doctrines
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The Physician-Patient The Physician-Patient RelationshipRelationship
Trust is FundamentalTrust is Fundamental Fiduciary ObligationsFiduciary Obligations
• Informed ConsentInformed Consent• Informed RefusalInformed Refusal• HMOsHMOs
Patient’s Interests are PrimaryPatient’s Interests are Primary• Drug Testing Pregnant WomenDrug Testing Pregnant Women• Involuntary CommitmentInvoluntary Commitment
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Administrative ConflictsAdministrative Conflicts
Personal Medical ServicesPersonal Medical Services• Very ExpensiveVery Expensive• The Demand for Services is without The Demand for Services is without
LimitLimit• The Providers are ExpensiveThe Providers are Expensive• The Emotional Pull is HighThe Emotional Pull is High
Contrast with Public HealthContrast with Public Health Resource CaptureResource Capture
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Medical Police ProblemMedical Police Problem
Public Health IssuesPublic Health Issues• Reporting, Contact Tracing, WarningReporting, Contact Tracing, Warning• Coercive ActionsCoercive Actions• Vital StatisticsVital Statistics
Criminal Law IssuesCriminal Law Issues• Child AbuseChild Abuse• Drug UseDrug Use
““Not On Our Patients” ProblemNot On Our Patients” Problem
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Skills Set ProblemSkills Set Problem
Why School of Public Health Do Not Why School of Public Health Do Not WorkWork• Too Many Different Skills to Train in One Too Many Different Skills to Train in One
Educational SystemEducational System• Academic and Grant Pressures Devalue Academic and Grant Pressures Devalue
Core Public HealthCore Public Health• Limits Admissions RequirementsLimits Admissions Requirements
MPH Tells You Almost Nothing About MPH Tells You Almost Nothing About Public Health KnowledgePublic Health Knowledge
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Community Support Community Support ProblemsProblems
Core Public HealthCore Public Health• Food, Water, Nuisance, Food, Water, Nuisance,
Communicable Disease ControlCommunicable Disease Control Indigent CareIndigent Care Drug Addicts and the Mentally IllDrug Addicts and the Mentally Ill Not Just Different, but ConflictingNot Just Different, but Conflicting
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War in the Big TentWar in the Big Tent
Health Directors who Do Not Health Directors who Do Not Believe in Public HealthBelieve in Public Health• Confusing Patient Interests with Confusing Patient Interests with
Public InterestsPublic Interests Individual Liberties Law is not Individual Liberties Law is not
Public Health LawPublic Health Law Undermines Agency AuthorityUndermines Agency Authority Increases Agency CostsIncreases Agency Costs
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Disaggregate Public Disaggregate Public Health ServicesHealth Services
Personal Medical ServicesPersonal Medical Services Core Public HealthCore Public Health
• Food and Water SanitationFood and Water Sanitation• Infectious Disease ControlInfectious Disease Control• Vermin, Animal Control, and other Vermin, Animal Control, and other
NuisanceNuisance WellnessWellness Injury PreventionInjury Prevention
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Rethink Schools of Public Rethink Schools of Public HealthHealth
Require Core Public Health Training Require Core Public Health Training in the MPHin the MPH
Concentrate on the Special Skills of Concentrate on the Special Skills of Public HealthPublic Health• Do Not Duplicate University Do Not Duplicate University
DepartmentsDepartments• Privilege the WorkersPrivilege the Workers
Do not Try to Save the WorldDo not Try to Save the World• Bring Public Health to MedicineBring Public Health to Medicine
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Focus on CommunityFocus on Community
Ecological ModelEcological Model Community as More than the Sum Community as More than the Sum
of Individualsof Individuals Duties, as well as RightsDuties, as well as Rights Use Fear ConstructivelyUse Fear Constructively
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Emerging Infectious Emerging Infectious DiseasesDiseases
Demand SurveillanceDemand Surveillance Case FindingCase Finding Swift Action in the Face of Swift Action in the Face of
UncertaintyUncertainty Protect Individuals Against their WillProtect Individuals Against their Will Must Sometimes Sacrifice Individual Must Sometimes Sacrifice Individual
Rights to Societal ProtectionRights to Societal Protection Same Issues in BioterrorismSame Issues in Bioterrorism
EID Control Depends on EID Control Depends on the Police Powerthe Police Power
How do We Restore the Police How do We Restore the Police Power to Public Health?Power to Public Health?