Policy as a Public Health Tool
Sharon McDonnell MD MPH
Dartmouth Medical School MPH Program
ECS 154
Goals
1. In ECS 154 we will learn about and practice specific
areas of policy relating to the Attorneys General
Office and their campaign to address pharmaceutical
financing, health and consumer protection
2. In this podcast I summarize policy approaches to
public health problems
3. Provide examples to illustrate the ideas and
approaches
Policy Interventions for Health

In US constitution there is no specific right or law about health

Federal Government engagement in health was originally
through regulation of interstate commerce

Local and States were involved through “protection” and police
powers

Successive re-defining of the unacceptable with changes in role
of law, government, and methods

Case in point: Protection and the significant changes in the role
of the FDA reflecting cross-culture forces
Health and the Law
Health and the law intersect on many levels –Health
care policy is shaped through a combination of
methods at the local, state and federal level.
Many agencies in Government at National, State and
local level
Governmental roles mandated by policy or regulation:
Protection, detection and response to Public Health

Major Roles:
 Define health status of population
 Prevent and protect - Road safety, car design
 Disease and health threat investigation
 Disease detection, case finding, contact tracing
 Provide or assure for treatment and case management
(e.g., quarantine, Chemoprophylaxis,
 Monitor, evaluate (access, outreach)

Surveillance, monitoring, and evaluation
Public Health Intervention Wheel
Policy
Public Health Intervention Wheel
Policy Areas

Goal setting (Healthy people, performance standards)

Recommendations and Guidelines (associated with funding or
standards)

Legislation- Laws, regulations, and rules (Media exposure, age
limits)

Litigation (lead, air quality, tobacco)

Enforcement (product recall, fines, seat belts, BAC, lead
levels)
How does policy work?


Tension between “freedom” and “protection”
Most policy limits choice or freedoms (social contract)


Is it acceptable that government or lawmakers are involved in
the issue? Some say “no, never”
 Does culture change precede policy change or does policy
change reflect cultural change?
 Other mechanisms: Psychological forces exerted on people
that want to be law abiding, not fined, embarrassed, or lose
rights to drive. Among states that enacted laws defining DUI
based on a BAC of 0.08% there as been a 7% median
decrease of in fatal alcohol-related MVA crashes.
When is a policy response the “right” thing


Must wear helmet
Folate fortification (19% decrease in neural tube defects and
100% decrease in pellagra)

The legal system helps define the roles and responsibilities of
different players in the health care system or about health
issues.

For example, state and federal laws have been used to set the
minimum standards that affect the provision of health care, the
scope of health coverage, public program policy, consumer
protections, as well as the regulation of pharmaceuticals and
medical devices.

The judicial system also oversees and enforces malpractice
compensation that help protect patients and doctors as well as
policies that affect patient privacy and patient rights.
Does a law make sense?
Since 1980, the courts have analyzed regulations affecting
advertising for commercial products or professional services
under the four-part test set forth by the U.S. Supreme Court in
Central Hudson Gas & Electric Corp. v. Public Service
Commission of New York. The "Central Hudson" test asks:
(1) whether the issue concerns lawful activity and is not
misleading;
(2) whether the asserted government interest is substantial; and,
if so,
(3) whether the regulation directly advances the governmental
interest asserted; and
(4) whether it is not more extensive than is necessary to serve
that interest.



Government bears the burden of identifying a substantial
interest and justifying the challenged restriction:
“The government is not required to employ the least restrictive
means conceivable, but it must demonstrate narrow tailoring of
the challenged regulation to the asserted interest — a fit that is
not necessarily perfect but reasonable; that represents not
necessarily the single best disposition but one whose scope is
in proportion to the interest served.”
The four parts of the Central Hudson test are not entirely
discrete. All are important and, to a certain extent, interrelated
More guidance on laws and rules


Can you see what you are trying to control?
“Making an example”-- demonstrating the importance of
law and that people can get caught

Evidence for the “risk”

Passive vs active

Effort involved to reach end (floridation of water vs flouride
tablets or changing the RR crossing or education)
Targeting

How laws happen… culture change or changing culture?

First….. Targeted laws towards a specific population that may
be at increased risk or vulnerable or to whom we feel protective
 Age or condition (e.g., child safety seat laws or pregnancy)
 Behavior or risk (“drug abusers” or persons with HIV/AIDs)
 As a means to enjoy a “good” ie Educational requirements
(e.g., vaccination requirements for child care and school
attendance)

Second…..Broad-based policies Community-wide interventions
(e.g., water fluoridation, smoking bans and laws)
Mello NEJM 354;24 www.nejm.org june 15, 2006
Mensah Prev Chronic Dis 2004 Jan [date cited]. URL: http://www.cdc.gov/pcd/issues/2004/jan/03_0033.htm
This exploration of the frontier of laws to fight obesity
illustrates the dynamic nature of the relationship between
public health law and the broader cultural and public health
environment.
There are many historical examples of the law driving social
change; however, progressive laws are unlikely to be
implemented until the dominant cultural mores are sufficiently
favorable