The Public Health Balance

Improving the health of the public versus personal autonomy

Christian Sandrock, MD, MPH, Yolo County Public Health Officer
July 14, 2011

Public health-based interventions and policies are aimed at protecting and improving the public’s health and wellness. However, these interventions can often come at the cost of individual autonomy and freedom. In obvious cases, such as a new deadly infectious disease outbreak, interventions and laws aim to halt the spread of disease (e.g. quarantine and isolation) and are usually well accepted and supported by the public. However, most interventions and policies are less dramatic, and while they are designed to reduce mortality and improve health, their greatest benefit is most noticed on a narrower segment of the public. In these broad interventions, a conflict with autonomy and personal liberty may arise as a policy partially improves one person while greatly improving the health of another. A number of recent policies and interventions in California and Yolo County – required pertussis vaccination and smoking bans – have highlighted the difficulty of this balance between individual liberty and autonomy, and the public’s health and wellness.

Public health evaluates the entire population and thus decisions are made with the larger population’s risks and benefits taken into account. However, when a physician examines a patient in the office, this larger risk-benefit can be difficult to translate directly to the patient at the bedside. Recent legislation requiring pertussis (whooping cough) vaccination for middle and high school children has taken effect, with documentation required after July 1, 2011 to start school. In 2010, California had the largest outbreak of pertussis in 50 years, with 9,120 cases, 804 hospitalizations and 10 deaths. A closer look reveals that a majority of the hospitalizations were infants under the age of 6 months (76%) and 90% of the deaths were under 2 months of age. Most of the hospitalizations and deaths were among the Latino community. Thus, when a 15-year-old non-Latino is evaluated for vaccination, the risk of pertussis-related morbidity and mortality is much different than that of a 15-year-old migrant worker from Mexico. While vaccination will reduce the risk of both 15-year-olds from getting pertussis, it will more importantly protect those at highest risk in the community, i.e. infants under the age of 6 months, particularly those from the Latino community. Both the 15-year-old, along with the high risk infants, will benefit from vaccination, albeit with unequal risk-benefit ratios.

This fine balance between public health policy and programs, and individual autonomy, is only successful with ongoing research and data. Incorporating up-to-date scientific research along with epidemiologic data from the general population and the highest risk groups will yield policies that will be implemented only when needed. If a risk-benefit ratio changes or a high-risk group is no longer at risk, the policy must be altered to maximally preserve and respect autonomy. The recent increase in pertussis cases, along with data supporting waning adult immunity and increased rates among infants, fully supported the pertussis policy.

Translating public health data, policy and interventions to the individual patient at the bedside is difficult. Much is lost in translation, and often patient autonomy will override the larger benefit to the population. Therefore, medical providers and public health officials must work closely together to relay the impacts of these individual decisions, from declined vaccinations to smoking, on the larger public.