Fluent Essays

This discussion board forum will focus on Chapter 6 of the textbook, Environmental and Occupational Public Health, Aspen Bakers TED talk, A Better Way to Discuss Abortion, and the Believed podcast, How He Got Caught.   How Larry Nassar Got Caught : Believed : NPR   Aspen Baker: A better way to talk about abortion | TED Talk 177© The Author(s) 2016 D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe, Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_6 Chapter 6 Environmental and Occupational Public Health Bruce Jennings 6.1 Environment and Workplace: Key Venues for Public Health Environmental health and occupational health and safety have long been established subfi elds of public health research , policy , and practice (Frumkin 2010 ). More so perhaps than areas such as infectious disease or health promotion , environmental and occupational health remind us that the health of a society is profoundly affected by its economic system and economic development . Today, the environmental health fi eld is largely concerned with a human-made (anthropogenic) environment brought about by urbanization, the extraction of natural resources, industrial manufacture, the physical separation of home and workplace, and the transportation systems needed to support this mode of economy and pattern of living. Economic development alters the natural environment and sometimes harms ecosystems in terms of the humanly useful services they provide, their diversity , and their resilience. We are coming to understand that all of this has signifi cant consequences for human health. Environmental health has been understood as a public health issue in relation to air quality, water quality, and exposure to environmental pollutants that are toxic, carcinogenic, or teratogenic or are chemically bioactive in other ways. The rise of fossil fuels as the energy base for economic production and transportation, the industrial-scale advances in mining and metallurgy, and the creation and widespread presence of synthetic chemical substances have contributed to environmental health risks throughout the past two centuries. Indeed, these changes have redefi ned the meaning of environmental health. For the most part, environmental health involves The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution . B. Jennings , MA (*) Center for Biomedical Ethics and Society , Vanderbilt University , Nashville , TN , USA e-mail: [email protected] mailto:[email protected] 178 the domain of chronic illness and disease, and it investigates factors that increase population risk and susceptibility to patterns of physical and mental illness in vari- ous forms. Epidemiological investigation is key to public health response to envi- ronmental health hazards. If the public health of entire populations is affected in the background by modern- ization and industrialization in the form of environmental hazards, the personal health of a large number of individuals—especially people who work in industrial settings or are otherwise exposed to workplace hazards —is also affected directly in often injuri- ous ways (Bayer 1988 ). Despite struggles to protect people in the workplace, the lit- erature on occupational health is replete with examples of work-related cancers and pulmonary disease. Moreover, issues of safety and health go hand in hand in the occupational arena. Occupational accidents and injuries are a substantial factor in the overall health profi le of society. Some occupational sectors remain particularly dan- gerous due to inherent features of the work environment, the necessary technology and equipment, or the absence of adequate policies and protections for workers. The recent emphasis in public health research and policy on personal injury and trauma may lead to renewed interest in occupational health as a public health issue. More effective public health policy in regard to environmental and occupational health is made diffi cult by the fact that they tend to have distinct regulatory struc- tures. Each is governed by different authorizing statutes and accumulated bodies of administrative rules and is overseen by different agencies of varying government levels (particularly in countries with federal systems). Nonetheless, occupational health and environmental health should be viewed in relation to each other, since both ultimately spring from a common root in the recent history of the impact of science and technology on society. Moreover, the public health responses to these two areas has varied with different understandings of the appropriate role of the state and public authority. This is to be expected, given that health matters overall, though biologically and biochemically connected, raise political , economic, and social issues. Major disparities in environmental and occupational risk, for example, stem from race and socioeconomic status (Shrader-Frechette 2005 ), and thus raise ethical questions about political and social rights, economic entitlements and wel- fare safety nets, and the just distribution of risk, wealth, and power . One additional feature of a contemporary perspective on environmental and occupational public health should be noted: Our paradigm for understanding the interrelationships of health, the natural environment, and the workplace environ- ment is broadenin g. Lang and Rayner ( 2012 ) distinguish among fi ve models for public health, each with its own historical origins and core ideas. These models are (1) the sanitary-environmental model; (2) the biomedical model, both individual and population focused; (3) the social-behavioral model; (4) the techno-economic model; and (5) the ecological model. The fi rst four models take an essentially human-centered approach. In these mod- els, the term “environment” is understood as a mere backdrop or aggregation of condi- tions and risk s for states of human health and illness. By contrast, model fi ve, the ecological model, understands the natural environment to be comprised of complex systems , not as an array of separate factors. The environment is the functional and B. Jennings 179 relational context in which human health and behavior emerge, not just a set of back- ground conditions. The growing infl uence of the ecological model of public health is reorienting the study and regulation of both environmental health and occupational health, and this model has the potential to bring them into closer alignment. There are several reasons for this. First, research on the social determinants of health indicates that distinguishing the social from the natural aspects of an environ- ment’s health effects is not straightforward. Even in remote wilderness areas, the natural environment is shaped by human activity. Moreover, the social features of everyday life include not only psychological effects (happiness and well-being) but also physiological effects (cardiovascular, hormonal) on the internal biological environment of the human body. Second, the growing discussion around the health effects of global climate change contributes to this reorientation of environmental health by reminding us that ecosystems are holistic and complex networks of interrelationships and interde- pendencies. Therefore, hazards to human health take the form of both discrete threats and general factors that undermine the integrity or functioning of ecosys- tems upon which the health and functioning of all life ultimately depend. For exam- ple, a recent literature review on the public health effects of climate change summarizes the situation as follows: Impacts of climate change cause widespread harm to human health, with children often suf- fering the most. Food shortages, polluted air, contaminated or scarce supplies of water, an expanding area of vectors causing infectious diseases , and more intensely allergenic plants are among the harmful impacts. More extreme weather events cause physical and psycho- logical harm. World health experts have concluded with “very high confi dence” that climate change already contributes to the global burden of disease and premature death. IPCC [Intergovernmental Panel on Climate Change] projects the following trends, if global warm- ing continues to increase, where only trends assigned very high confi dence or high confi - dence are included: ( 1 ) increased malnutrition and consequent disorders, including those related to child growth and development, ( 2 ) increased death, disease and injuries from heat waves, fl oods, storms, fi res and droughts, ( 3 ) increased cardiorespiratory morbidity and mor- tality associated with ground-level ozone. While IPCC also projects fewer deaths from cold, this positive effect is far outweighed by the negative ones (Hansen et al. 2013 , 8). Third, the way the built environment is developed can affect not only greenhouse gas emissions but also lifestyle factors that impinge on human health–for example, land use and zoning patterns that lead to suburban housing sprawl and automobile dependency (Frumkin and McMichael 2008 ). Environmental health hazards can no longer be thought of simply as discrete entities (e.g., pathogens, toxic chemicals, carcinogenic substances) within an otherwise health- neutral fi eld (Kassel and Stephens 2011 ). Previously environmental health hazards (even air and water pollution) were viewed on rather narrow local or regional scales and in close proximity to effected human populations. Now we must view the health haz- ards emerging from systemic disruptions or dysfunctions as operating on far broader scales and far more remotely than previously suspected. Deforestation in tropical areas involves a chain of factors that ultimately affects the quality of life of people with asthma in Central Asia; changes in the salinity and temperature of the oceans will affect heat emergency events in Europe. A contaminated well is a localized health risk. 6 Environmental and Occupational Public Health 180 Conversely, environmental changes on the Himalayan plateau that alter the hydrology of a river spanning miles upon which hundreds of millions depend for fresh water, represents a different challenge for public health analysis and response. The problem is global and institutional , which is to say, fundamentally political and economic. The public health response needs to involve not only specifi c protections and rules or law s aimed at individual decisions and behaviors, such as toxic dumping in a particular site, or the point source pollution of a river, but also the institutional and systemic gover- nance that alters the structure of power and wealth, and the process by which decisions and policies are made. The perennial debate between an approach aimed at individual behavior and one aimed at structural change is endemic to both environmental health and occupational health and safety . Because both environmental and occupational public health raise public issues that involve public perception, a couple of the thorniest ethical problems concern the concept of acceptable risk and criteria for risk management and risk reduction . Environmental risks to the public’s health can be managed (or prevented) in multi- ple ways. The same can be said of workplace risks, especially when conditions put workers in contact with dangerous machinery or industrial processes; expose work- ers to harmful substances; and, in the case of health care profession als and biomedi- cal researchers , expose them to infectious diseases . The debate always concerns how risk management should be done and at what cost . 6.2 Population Benefi ts , Individual Rights, and Ethically Acceptable Risk The four intriguing cases in this chapter provide examples of policy , decision mak- ing, and public health practice under specifi c circumstances. Looming in the back- ground of each case are fundamental questions about power, equality, and social justice . The cases indicate the need for a more systemic understanding of environ- mental and occupational health factors, from the small-scale ecosystem of poten- tially contagious organisms within the human body to the large-scale natural ecosystem’s reaction to the effects of mining technology and operations. Here are the main themes and issues that the cases in this chapter pose for envi- ronmental and occupational health, especially from the perspective of an ecological model of public health ethics: • How should a society democratically set priorities and manage its economic sec- tors to ensure productivity in the global economy and at the same time protect its limited natural resources, its core values, and cultural diversity of regional and ethnic ways of life? Snyder and colleagues address this theme in their case on mining and health equity . • How should vulnerable populations , such as hospitalized patients, be protected from serious infection, and to what extent should those measures impinge on individual rights and careers of health profession als who are subject to screening and possible exclusion from clinical practice? This theme is addressed by Rump B. Jennings 181 and colleagues in their case involving the exclusion of physicians who test posi- tive for Methicillin-resistant Staphylococcus aureus (MRSA) from performing patient related interventions. • How should nongovernmental organizations (NGOs) working on development projects in resource poor and underserved areas allocate limited resources effec- tively and equitably? What responsibility does the NGO have when its programs inadvertently pose health risks to the community that also may threaten its future capacity to provide services? This theme is addressed in Hayward’s case about well construction in areas without access to safe drinking water. Hayward com- pares the health risk s and benefi ts to the cost of different construction methods. • What are the ethical responsibilities of organizations whose staff and volunteers do public health work in areas lacking public safety and security resources? What balance should be struck between outreach to those who need services and the personal health and safety of the organization’s employees? This case, also by Hayward, describes how Peace Corps volunteers use motorcycles to reach otherwise inaccessible areas, which increases their risk of traffi c accidents. As mentioned previously, the forces of economic, scientifi c, and technological development brought environmental health and occupational health and safety issues to the forefront of contemporary public health. Indeed, public health as we know it today is an outgrowth of the industrial revolution, which has brought about both great advances and signifi cant disparities of wealth and power . Worldwide, public health operates amid highly urbanized social systems stratifi ed by class, race, and ethnicity. In its quest for optimal health outcomes on a population basis, public health is ethically constrained by individual rights and liberties that may confl ict with that goal, just as it is politically constrained by powerful vested interests. Nonetheless, social inequality is an obstacle against which public health pushes. For the most part, certainly in the post- World War II era, the direction of public health has been toward greater access to the resources and conditions necessary for widespread health and well-being, greater social and economic equality, and fairness for the most vulnerable and marginalized. Operating within that trend, decision making about environmental and occupa- tional health draws primarily on two ethical concepts of public health: One is a utili- tarian ethic of population well-being, and the other is an ethic of human right s , dignity, and justice . Utilitarianism defi nes the ethical rightness of human acts toward maximizing aggregate net social benefi t (happiness, utility, preference satisfaction). Not surpris- ingly, utilitarianism is a signifi cant aspect of public health ethics. Its orientation toward aggregative outcomes befi ts its concern for population s rather than individ- ual health—weighing and balancing options rather than delimiting intrinsic value or ethical absolutes. Rights- and justice-based ethics focus on intrinsic rightness or wrongness of spe- cifi c acts and general actions— not on the consequences of those acts. Actions embody fundamental values such as respect , dignity, equality, autonomy , and inclusiveness and therefore have intrinsic rightness. This ethical orientation appeals to cultures with a heritage of humanitarian concern and to political and legal systems that are simulta- neously democratically egalitarian and protective of individual liberty . 6 Environmental and Occupational Public Health 182 Utilitarian ethics and rights-based ethics may confl ict when situations pit aggre- gate net population benefi ts (i.e., health and welfare) against equity and fairness perspectives that reject discrimination and are unwilling to violate the rights of one, or a few, to achieve well-being among many. Such dilemmas and trade-offs often arise in public health practice. For example, one confl ict involving individual rights arises in the case from Rump and colleagues. In this case, a precautionary policy of exclusion provides safety for hospitalized patients who have contact with a medical student who is a carrier of MRSA. But at the same time, the exclusion policy burdens the medical student who faces personal and profession al risk to her livelihood. An individual’s rights may be violated when health status becomes the basis for discriminatory treatment or for the loss of liberty or opportunity. A physician or other health care professional with a condition that poses undue risk to patients illustrates the confl ict between individual rights or freedom and protection of patients health collectively, or indeed, protection of patient health individually. To resolve such confl ict, one must strike a balance among competing values, informed by factual (biomedical) knowledge. No individual has the right to intentionally harm an innocent person, and no physician has a right to deliberately harm a patient. These confl icts typically arise when facts are uncertain and knowledge is imperfect or probabilistic. Thus, the question turns not on absolute right and wrong, but on reasonably acceptable risk . Is a policy that provides a blanket exclusion of health workers who are MRSA posi- tive appropriate? Or is this policy overly inclusive and cautious? Moreover, how do we ethically factor in the costs or harms done by exclusion of risk? Perhaps a gifted physician who poses a low risk of infecting patients may greatly benefi t them. If so, then considerations of nondiscrimination for the individual (physician) and aggre- gate net benefi t for the population (patients) could coincide. Hayward presents a mirror image in her case on threats to personal safety . This case involves transportation safety in the developing world, a signifi cant public health problem to everyone living and working there. Under discussion is a policy that pro- hibits staff and volunteers from using dangerous forms of travel, such as motorcycles, even when alternative means of accessing remote areas do not exist. This would affect many fi eld staff and volunteer health workers who strive to maximize client services by minimizing transportation time, even at the risk of a traffi c accident. The rights- based question in this case has to do with individual freedom of choice versus pater- nalistic protection by institutional authorities, again within the context of ethically acceptable risk . The utilitarian question may be framed as a cost–benefi t comparison of population harm done by the death or injury of health workers (to themselves, their families, and their clients) and the harm done by suboptimal service delivery (slower, but safer modes of transportation). A far-reaching consequence may be the loss of public health and economic development programs that benefi t the community. Risk and harm appear in yet another guise in Hayward’s case on safe water stan- dards and well construction in rural Africa . An ethical dilemma arises because a less expensive drilling technique (shallow rather than deep-drilled wells) can produce more water for more people; however, the risk of contamination and harm to users will increase. How can decision makers resolve the trade-off between water quan- tity and quality to benefi t the aggregate net population ’s health and welfare? In this B. Jennings 183 instance, an organizational and programmatic risk is also involved. The dilemma decision makers face has broad implications for future public health initiatives in the region. If too few wells with a high per unit cost are produced, the community might perceive that the needs of many are not being considered. Similarly, they might perceive their health and safety are being neglected if the wells are inexpen- sive. Decision makers should strive to preserve community trust if they are to gain cooperation in future public health initiatives . These three cases illustrate how almost every conceivable approach to risk man- agement can pose one or more ethical problems. Risk management interventions may protect some while shifting the exposure and burden of risk to others, raising serious questions of distributional equity or fairness . Or, interventions to mitigate risk and protection efforts may supplant or inhibit other programs or public health activities since intervention is expensive and may lay claim to scarce resources . Moreover, the concept of risk is seemingly impossible to defi ne in value-neutral terms and is inherently controversial. Even more ethically charged are the questions of what level or degree of risk is socially acceptable, who should decide, and how exposure to risk should be distributed across the affected population. Routine public health practice in environmental and occupational risk management involves inter- ventions and policies designed to prevent harm to individuals and to lower health risks within the population . Interventions include various forms of public health surveillance —screening and testing—of different groups, with the attendant untow- ard effect of discrimination or social stigma. Policies may involve regulations with substantial fi nancial consequences in the form of job loss in regulated industries and hence higher unemployment rates in the overall economy or higher production costs and hence higher prices for consumers . The question of ethically justifi able public health paternalism versus individual autonomy arises when individuals want to continue engaging in activities that put themselves, third parties, or the general public at risk. Among the diffi cult issues raised about situational ethics are ( 1 ) identifying the genuine interests and agendas of public health authorities who follow seemingly paternalistic programs to reduce risks and harms ; ( 2 ) identifying when individuals knowingly (and willingly) expose themselves to environmental or occupational risks, given the context of inequalities of power and wealth involved and the lack of employment or residential options available to these individuals and their families; ( 3 ) determining a reasonable level of acceptable risk in the face of scientifi c uncertainty; and ( 4 ) gauging how a policy to reduce public health risk will affect public perception and trust . 6.3 Systems and Power: The Ethical Importance of Ecological and Social Context We generally know that human health is undermined when the diversity , services, and functioning of ecosystems are compromised. We also know that various eco- nomic activities that extract raw materials, manufacture commodities, and provide jobs often secure these benefi ts at the expense of the environment. On a local or 6 Environmental and Occupational Public Health 184 regional scale, the health burdens are often felt by people in the immediate area, whereas the benefi ts and wealth often accrue to people far removed from the local environmental disturbances and health risks. When viewed as a manifestation of eco- nomic systems , environmental health and occupational health are inseparable from questions of global health justice, and these are very diffi cult theoretical and practical questions indeed. Moreover, these dimensions of the ethics of environmental public health are evolving. Today, given what is known about climate change , we can rea- sonably say that economic activity virtually anywhere can be environmentally dam- aging—from oil drilling in the Artic to land clearing in tropical rain forests—and that such damage affects the health and well-being of people everywhere, not just of those in the local or regional areas where the environmental damage takes place. If environmental public health cannot be divorced from economics, neither can it be understood apart from conditions of governance at international, national, and local levels. International policies and interventions, including the Millennium Development Goals and climate change response defi ned by international protocols beginning with the Kyoto treaty, are forms of global governance in which environ- mental public health and public health ethics play indispensable roles. Questions are no less complex for public health and for ethics at the national level. In the developing world, particularly countries still experiencing widespread poverty and lacking fundamental infrastructure and services, economic growth remains a priority and benefi t. Nonetheless, there is a trade-off between short-term economic gains and long-term national (and global) interest in health, economic sustainability, and environmental conservation. For example, ecosystems like rain- forests perform a vital function in absorbing atmospheric CO 2 . This global function can be undermined by economically driven decisions about land use and other com- mercial activities that lead to deforestation. Climate change is only one, albeit dra- matic, illustration. The collective carbon footprint of developing countries is growing, often placing the preservation of their ecosystems, biodiversity, and fresh water at risk. Putting the economic growth of developing nations on a more sustainable path is not only critical to global control of greenhouse gas emissions, it is also key to each nation’s economic future and to global public health . Economic development is no longer simply an issue for each national government to acknowledge in its internal affairs and domestic policy . In our global market, external forces impinge on options and resources of individual countries, even wealthy and powerful ones. Yet in the absence of international governance, it is the government of each country that remains ethically responsible for the health and welfare of its citizens and should legislate and regulate its social and economic affairs accordingly. In a democracy, public participation , debate, and consensus in view- point and among plural groups are valued and essential components of governance. The case from Snyder and colleagues provides an opportunity to examine the global and systemic dimensions of environmental public health ethics and governance. In Mongolia ’s economy, which is heavily dependent on the mining industry and mining operations, the trade-off between economic growth and environmental protection is acute. The country clearly needs investment and job opportunities to combat poverty. But issues of social justice , including health equity , are made complex by the stratifi ca- tion of wealth and income and by the uneven development of different regions and B. Jennings 185 sectors of the society. Mining operations can threaten a complex and fragile ecosystem and adversely affect health (e.g., toxic waste, air and water pollution). Mining opera- tions can also create social dislocations (work migration ) and change patterns in land use, especially in areas with a long cultural and economic tradition of pastoralism. The case by Hayward questions whether to drill expensive deep wells or less expensive shallow water wells in sub-Saharan Africa . Part of the health risk posed by the shallow wells requires a change in cultural behavior by preventing livestock from contaminating the wells and by controlling surface run-off. Thus, any success- ful public health effort cannot be assessed apart from the capacity of the local soci- ety to manage and behave toward both its natural and constructed environment in prudent and sustainable ways. Similarly, but on a larger scale, Mongolia ’s regula- tion of economic growth and its mining industry raise questions of cultural rights and cultural capacity as well as questions of social equity … All posts should be written in your own words and be referenced and cited with at least one scholarly peer-reviewed journal article to support your position. That means even if you are replying to another person’s posts, your post still needs to be original, and referenced, and cited with a scholarly peer-reviewed journal article. The reason that PRJA citations and references are a requirement is that it elevates the discussion. The citation also allows readers to understand exactly what portion of the post is paraphrased from the reference. No direct quotes are allowed - paraphrasing is expected. The source in which you are required to reference and cite in your discussion posts needs to come from a peer-reviewed journal article. A book (textbook or otherwise) is not appropriate. Your post and reference need to be original - not something that another student has posted and or used. You must include an APA or AMA formatted citation and reference in your post. Discussion participants may include the instructor or students. The post must pertain to the discussion board issue in which it is being posted. 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Finally, click Submit. Peer-reviewed articles (PRJA) are a subset of scholarly articles. They are special because they are published in academic journals that explicitly state that submitted manuscripts will undergo peer-review. In academic publishing, the goal of peer review is to assess the quality of articles submitted for publication in a scholarly journal. Before an article is deemed appropriate to be published in a peer-reviewed journal, it must undergo the following process: · The author of the article must submit it to the journal editor who forwards the article to experts in the field. 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