The relationships among medicine, public health, ethics, and human rights are now evolving rapidly, in response to a series of events, experiences, and struggles. These include the shock of the worldwide epidemic of human immunodeficiency virus and AIDS, continuing work on diverse aspects of women's health, and challenges exemplified by the complex humanitarian emergencies of Somalia, Iraq, Bosnia, Rwanda, and now, Zaire.
From among the many impacts of these experiences, three seem particularly salient. First, human rights thinking and action have become much more closely allied to, and even integrated with, public health work. Second, the long-standing absence of an ethics of public health has been highlighted. Third, the human rights-related roles and responsibilities of physicians and other medical workers are receiving increased attention.
Public Health and Medicine
To explore the first of these issues--the connections between human rights and public health--it is essential to review several central elements of modern public health.
Medicine and public health are two complementary and interacting approaches for promoting and protecting health--defined by the World Health Organization (WHO) as a state of physical, mental, and social well-being. Yet medicine and public health can, and also must be differentiated, because in several important ways they are not the same. The fundamental difference involves the population emphasis of public health, which contrasts with the essentially individual focus of medical care. Public health identifies and measures threats to the health of populations, develops governmental policies in response to these concerns, and seeks to assure certain health and related services. In contrast, medical care focuses upon individuals--diagnosis, treatment, relief of suffering, and rehabilitation.
Several specific points follow from this essential difference. For example, different instruments are called for: while public health measures population health status through epidemiological, survey, and other statistically based methods, medicine examines biophysical and psychological status using a combination of techniques, including dialogue, physical examination, and laboratory study of the individual. Public health generally values most highly (or at least is supposed to) primary prevention, that is, preventing the adverse health event in the first place, such as helping to prevent the automobile accident or the lead poisoning from happening at all. In contrast, medicine generally responds to existing health conditions, in the context of either secondary or tertiary prevention. Secondary prevention involves avoiding or delaying the adverse impact of a health condition like hypertension or diabetes. Thus, while the hypertension or insulin deficiency exists, its effects, such as heart disease, kidney failure, or blindness, can be avoided or delayed. So-called tertiary prevention involves those efforts to help sustain maximal functional and psychological capacity despite the presence of both the disease, such as hypertension, and its outcomes, heart disease, stroke, or kidney failure.
Accordingly, the skills and expertise needed in public health include epidemiology, biostatistics, policy analysis, economics, sociology, and other behavioral sciences. In contrast, medical skills and expertise center on the exploration, analysis, and response to the biophysical status of individuals, based principally on an understanding of biology, biochemistry, immunology, pharmacology, pathology, pathophysiology, anatomy, and psychology.
Naturally, the settings in which public health and medicine operate also differ: governmental organizations, large-scale public programs, and various fore associated with developing and implementing public policy are inherently part of public health, while private medical offices, clinics, and medical care facilities of varying complexity and sophistication are the settings in which- medical care is generally provided. …