Rethinking Public Health
Edward P. Richards, J.D., M.P.H.
Professor of Law
Executive Director
Center for Public Health Law
University of Missouri Kansas City
http://plague.law.umkc.edu/cphl
What Motivates Modern
Public Health?
 Social Justice
• Health People 2010
 Integrated Delivery System
• NIH Future of Public Health Study
 “Our Patients”
• Unnamed State Health Director
2
APHA
 Vision: Healthy People in Healthy
Communities
 Mission: Promote Physical and Mental
Health and Prevent Disease, Injury, and
Disability
3
Public Health
Prevents epidemics and the spread of disease
 Protects against environmental hazards
 Prevents injuries
 Promotes and encourages healthy behaviors
 Responds to disasters and assists communities
in recovery
 Assures the quality and accessibility of health
services

4
Essential Public Health Services
1-5
• Monitor health status to identify community health
problems
• Diagnose and investigate health problems and health
hazards in the community
• Inform, educate, and empower people about health
issues
• Mobilize community partnerships to identify and solve
health problems
• Develop policies and plans that support individual and
community health efforts
5
Essential Public Health Services
6 - 10
• Enforce laws and regulations that protect health and
ensure safety
• Link people to needed personal health services and
assure the provision of health care when
otherwise unavailable
• Assure a competent public health and personal health
care workforce
• Evaluate effectiveness, accessibility, and quality of
personal and population-based health
services
• Research for new insights and innovative solutions to
health problems
6
The Big Umbrella Problem
 Different Skills Sets
 Different Finance Models
 Different Professional Paradigms
 Different and Conflicting Legal Authority
 Different Political Base
7
Conflicting Legal Authority
 Parens Patria
 Police Powers
 Criminal Law
 Individual Liberties Law
8
Parens Patriae
 "Parens patriae," literally "parent of the
country,”... It is the principle that the state
must care for those who cannot take care
of themselves, such as minors who lack
proper care and custody from their parents.
• Blacks Law Dictionary
 The King as Father
 The Country as Family
9
Modern Parens Patriae Powers
 Child Welfare
 Indigent Care
 Wellness Programs
 Mental Health Care
10
Why do Lawyers and Law
Professors Like Parens Patriae?
 Helping the Downtrodden
 Empowering the Individual
 Distrust of the State
 Lots of Money in Suing for Individuals
 Not Much Money in Representing the State
 No Money or Private Practice in Public
Health Law
11
Police Power
 Right of Societal Self-Defense
 Right of the State to Protect Itself
 Right of the State to Protect Its Citizens
12
History
 From English Common Law
 Core of Colonial Government
 Key Power Reserved to the States
 The Key Public Health Law Doctrine until the
1980s
 Still the Doctrine Used by the Courts
13
Police Power v. Parens Patriae
 The state has a legitimate interest under its
parens patriae powers in providing care to
its citizens who are unable because of
emotional disorders to care for
themselves; the state also has authority
under its police power to protect the
community from the dangerous tendencies
of some who are mentally ill.
• Addington v. Texas, 441 U.S. 418 (1979)
14
Philosophical Differences
 Parens Patriae
• The Individual Is First
• Society is just the Sum of the Individuals
 Police Power
• Ecological Model
• Society is a Complex Organism
15
Practical Differences

Parens Patriae
•
•
•
•

Driven by Individual Medical Needs
Individual Lives Trump Statistical Lives
Protect Yourself From Disease
Informed Opt-Out Allowed
Police Power
• Driven by Community Protection
• Stresses Statistical Lives
• Protect Others From Disease
16
Criminal Law
 Subset of Police Powers
 Moral/Religious Overlay
 Prospective Deterrence
 Core Difference
• Allows Retrospective Punishment
• Special Constitutional Protections
17
Individual Liberties Law
 Bill of Rights Based
• Limited Balancing of Individual vs Societal
Rights
 Examples
• Privacy Law
• Tort Law
• Informed Consent and other Medical Law
Doctrines
18
The Physician-Patient
Relationship
 Trust is Fundamental
 Fiduciary Obligations
• Informed Consent
• Informed Refusal
• HMOs
 Patient’s Interests are Primary
• Drug Testing Pregnant Women
• Involuntary Commitment
19
Administrative Conflicts
 Personal Medical Services
•
•
•
•
Very Expensive
The Demand for Services is without Limit
The Providers are Expensive
The Emotional Pull is High
 Contrast with Public Health
 Resource Capture
20
Medical Police Problem
 Public Health Issues
• Reporting, Contact Tracing, Warning
• Coercive Actions
• Vital Statistics
 Criminal Law Issues
• Child Abuse
• Drug Use
 “Not On Our Patients” Problem
21
Skills Set Problem
 Why School of Public Health Do Not Work
• Too Many Different Skills to Train in One
Educational System
• Academic and Grant Pressures Devalue Core
Public Health
• Limits Admissions Requirements
 MPH Tells You Almost Nothing About Public
Health Knowledge
22
Community Support Problems
 Core Public Health
• Food, Water, Nuisance, Communicable Disease
Control
 Indigent Care
 Drug Addicts and the Mentally Ill
 Not Just Different, but Conflicting
23
War in the Big Tent
 Health Directors who Do Not Believe in
Public Health
• Confusing Patient Interests with Public
Interests
 Individual Liberties Law is not Public Health
Law
 Undermines Agency Authority
 Increases Agency Costs
24
Disaggregate Public Health
Services
 Personal Medical Services
 Core Public Health
• Food and Water Sanitation
• Infectious Disease Control
• Vermin, Animal Control, and other Nuisance
 Wellness
 Injury Prevention
25
Rethink Schools of Public Health
 Require Core Public Health Training in the
MPH
 Concentrate on the Special Skills of Public
Health
• Do Not Duplicate University Departments
• Privilege the Workers
 Do not Try to Save the World
• Bring Public Health to Medicine
26
Focus on Community
 Ecological Model
 Community as More than the Sum of
Individuals
 Duties, as well as Rights
 Use Fear Constructively
27
Emerging Infectious Diseases
 Demand Surveillance
 Case Finding
 Swift Action in the Face of Uncertainty
 Protect Individuals Against their Will
 Must Sometimes Sacrifice Individual
Rights to Societal Protection
 Same Issues in Bioterrorism
28
EID Control Depends on the
Police Power
How do We Restore the Police Power
to Public Health?