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Public health measures to control an epidemic often encounter resistance.

We list here challenges to the ethical practice of public health in the COVID-19 pandemic.

Concerns

  • Years of under-funding and losses in the public health workforce mean public health capacity is not as robust as it needs to be. The Nation’s Health
  • With a largely preventative goal, public health has been overlooked and underfunded. Washington Post
  • Public health department funding and employment has been steadily decreasing for years, leaving a workforce ill-equipped to handle this outbreak. Associated Press
  • As demand for tests continues to increase, experts fear another test shortage throughout the country. The Atlantic

Ethical principles challenged

  • Developing and maintaining health-care infrastructures for primary care is a ma­jor priority for pandemic preparedness, especially because such investments will be beneficial at all times and not only during a pandemic. WHO Ethics in Pandemic Flu
  • Public health officials have a responsibility to maximize preparedness in order to minimize the need to make allocation decisions later. CDC Ethics in Pandemic Flu 
  • Provide for the recruitment, retention, and career development of highly qualified public health practitioners in managerial roles. APHA Code of Ethics, 4.11.1.

Concerns

  • A CDC error in developing a COVID-19 diagnostic test resulted in blame, mistrust, and silencing of the agency. Washington Post
  • The US federal government blamed WHO for their flawed early response to COVID-19 and lost United States funding. Time Magazine
  • The federal government’s “state authority handoff” (delegating the COVID responses to the states) lessened federal level effectiveness and credibility. New York Times
  • The federal executive branch does not accept responsibility for errors and inadequacies, instead blaming scientists and the prevalence of pre-existing health conditions for high COVID-19 death tolls. CNN

Ethical principles challenged

  • The public should know who is responsible for making and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are inappropriate. WHO Ethics in an Outbreak 
  • Public health practitioners and organizations promote competence, honesty, and accuracy and ensure that their work is not unduly influenced by secondary interests. Public health decision makers need to be transparent and honest about disclosing conflicting interests and influences. APHA Code of Ethics, Section 2.

Concerns

  • Hospitals are now mandated to send data about COVID-19 hospitalizations to a federal database rather than the Centers for Disease Control and Prevention. National Public Radio
  • Due to the invisible nature of public health programs, the United States government has historically ignored and denied threats of new epidemics. The New Yorker
  • Placing the responsibility on individuals to decide for themselves what to do and turning public health measures into partisan issues have rendered public health efforts less effective. CNN
  • Scientists have become a target and conspiracy theories have brought negative attention to public health organizations. Politico
  • Federal executive branch contradictions of the CDC have left citizens unsure of what guidance and precautions to follow. The News & Observer
  • A lack of federal guidelines and rules for reopening businesses has resulted in businesses rather than public health professionals deciding on the measures they will take. Washington Post

Ethical principles challenged

  • Promote constructive communication among the public, nongovernmental entities, individuals, and groups that draft and enact public health legislation and individuals and groups within the government that develop and implement public health activities. APHA Code of Ethics, 4.12.1
  • Avoid conflicts of interest that could interfere with the willingness to acknowledge public health threats. APHA Code of Ethics 4.2.2
  • Public health laws should be established by government authorities authorized to enforce public health laws. APHA Code of Ethics, 4.6.1

Concerns

  • Without public access to CDC data, public health agencies will be hindered since they rely on the information to make projections and crucial decisions.  WRAL
  • A report written by the CDC entitled “Guidance for Implementing the Opening Up America Again Framework” was not published to the public. Associated Press News
  • A government whistleblower faced retaliation for opposing a White House directive allowing widespread access to hydroxychloroquine. Associated Press
  • Hospitals are threatening to fire healthcare workers who share information with the press about their working conditions during the pandemic. Bloomberg

Ethical principles challenged

  • Avoid conflicts of interest that could interfere with the willingness to acknowledge public health threats. APHA Code of Ethics 4.2.2
  • There is a commitment to transparency throughout the pandemic influenza planning and response process. CDC 
  • Transparency requires policymakers to ensure that their decision- making process is open and accessible to the public, through clear and frequent communication of information. WHO Ethics in Pandemic Flu 
  • Establish formal structures, such as ethics committees, to address and resolve ethical disagreements and challenges and to enhance organizational ethics and decision making. APHA Code of Ethics, 4.11.7.

Concerns

  • Public health workers are facing regular threats around the country, which is leading to burnout and resignation. CNN
  • Public health officials have become targets of threats and harassment. The New York Times
  • Security details have been assigned to state health leaders due to increased public scrutiny. Kaiser Health News
  • Public health officials are facing threats and intimidation in person and online. The Wall Street Journal
  • Business employees are facing assault and threats for enforcing masking rules. Washington Post

Ethical principles challenged

  • Provide legal protections for health care providers who, during a declared public health emergency, may be asked to perform services outside of their usual realm of responsibilities or to administer interventions which are not yet scientifically validated. CDC Ethics in Pandemic Flu
  • Maintain an organizational culture that promotes ethical integrity and equal dignity and respect in relationships among staff, with the outside community, and with the beneficiaries of the organization’s public health programs and services. APHA Code of Ethics 4.11.4
  • Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during an evolving health crisis. Trust is enhanced by upholding such process values as transparency. University of Toronto

Concerns

  • Elected officials and people in the community are pressuring public health officials to ease restrictions. CNBC
  • Attacks and threats towards public health officers impairs their ability to make recommendations solely on science and free from intimidation. Stat News
  • A public health official in Florida was pressured to adjust information on the public facing portal to align with the decision to start loosening restrictions. Washington Post
  • Fear that the FDA will come under pressure to approve a vaccine or treatment before it is fully vetted for safety and efficacy. The Washington Post
  • The governor of Georgia s suing the Atlanta mayor and city council to block the city from enforcing its masking mandate. Associated Press

Ethical principles challenged

Concerns

  • The politicization of the pandemic coupled with widespread anxiety and unpopular containment measures has led to a loss of public trust. The Washington Post
  • To many people, masks represent adherence to civic duty and a willingness to make individual sacrifices for the greater good of public health. To others, masks symbolize government overreach and a violation of personal liberty. Washington Post
  • Misinformation about contact tracing has some citizens believing that public health officials are invading their privacy in the name of contact tracing.  National Public Radio
  • The federal executive branch has undermined CDC recommendations, leading to public doubt of the recommendations. Washington Post
  • Individuals claim that mask requirements impair individual freedom. The Guardian

Ethical principles challenged

  • Balance perceived needs with expressed and expert-defined needs to improve community health. APHA Code of Ethics, 4.1.3
  • Be responsive to community perspectives on health challenges, opportunities, and priorities for action. APHA Code of Ethics, 4.4.5
  • Include appropriate publication of the public health law and educate the public on how to comply with both the letter and the spirit of the law. APHA Code Ethics, 4.6.5

Concerns

  • At least 27 state and local health leaders from 13 states have resigned, retired, or been fired since April 2020. Kaiser Health News
  • Concern for the long-term health impacts of losing so many public health professionals. The San Diego Union-Tribune
  • A West Virginia public health commissioner faced forced resignation due to blame and lack of confidence from the governor. Associated Press

Ethical principles challenged

  • Provide adequate institutional and professional support to enable competent public health workforce performance. APHA Code of Ethics, 4.8.4
  • Provide for the recruitment, retention, and career development of highly qualified public health practitioners in managerial roles. APHA Code of Ethics, 4.11.1