Public Health Controversies Research Articles

Fact‐value framework for adjudicating public health policy debates

AbstractThat policy should be evidence‐based has become a widely accepted dictum, especially in public health, where evidence‐based policy is strongly emphasized. Yet, most public health controversies arise because there is a conflict over values, which facts alone cannot resolve. Moreover, promoting population‐based health interventions requires the art of political actors to arouse public support. In discussing this tension in public health, studies often frame value conflicts as a barrier to rational decision‐making rather than viewing value considerations as an inherent part of democratic policymaking. We argue that by failing to engage value‐conflicts directly, public health professionals actually stymie evidence translation, which requires public and political buy‐in. We suggest a two‐by‐two framework that seeks to make value concerns more explicit in public health policymaking by breaking out policy controversies and alternatives along two dimensions—factual debates and value debates, creating four categories: uncontested alternatives, value debates, fact debates, and contested alternatives. We demonstrate that the policies that are most likely to be contested are those with a strong value conflict and where the evidence‐base is less solid. We also show that the framework is dynamic: fact and value conflicts are neither static nor inevitable. Rather, interested actors use both fact and value to try to push issues from contested to uncontested and vice‐versa. We conclude by demonstrating how the framework can help specify the role of both value and fact debates in public health policymaking through examples from U.S. public health policy controversies, including during the present COVID‐19 crisis.

The Reshaping of the E-Cigarette Retail Environment: Its Evolution and Public Health Concerns.

E-cigarette use represents a public health controversy in the US and globally. Despite the potential of e-cigarettes to support cigarette cessation, their use increases health risks and risk for addiction, particularly in young people. Various federal, state, and local laws have impacted tobacco retail in general and e-cigarettes in particular. In the US, 2019–2020 federal laws increased in the minimum legal sales age for tobacco to 21 and banned flavored cartridge-based e-cigarettes. Many states and localities were early adopters of Tobacco 21 and implemented more comprehensive flavor restrictions than the federal ban. Meanwhile, cannabis retail is increasingly being legalized in the US—while cannabis-based product regulation has notable gaps at the federal, state, and local levels. These regulatory complexities have impacted specialized retailers selling e-cigarettes, including “vape shops” that exclusively sell e-cigarettes, “smoke shops” that sell e-cigarettes and other tobacco (and potentially CBD/THC and other un- or under-regulated products), and online retail. This commentary outlines public health concerns related to: (1) youth access; (2) consumer exposure to a broader range of tobacco products and marketing in retail settings where they may seek products to aid in cigarette cessation (i.e., such broad product exposure could hinder cessation attempts); (3) consumer exposure to un-/under-regulated products (e.g., delta-8-THC, kratom); and (4) federal, state, and local regulations being undermined by consumer access to prohibited products online and via the mail. These concerns underscore the need for ongoing surveillance of how retailers and consumers respond to regulations.

Politicisation, depoliticisation, and repoliticisation of health care controversies: Vaccination and mental health care reform in the Czech Republic

This article analyses the politicisation of public health debates by focusing on vaccination and mental health care in the Czech Republic. The mainstream understanding of politicisation commonly refers to politics-as-sphere, linked with the political instrumentalisation of health care controversies as part of electoral campaigning and power struggles. In our analysis, we conceive politicisation more broadly, as politics-as-activity, which encompasses the role of civic engagement and the involvement of patients in these processes. We thus view politicisation as a process which encompasses a plurality of political actors and, in addition to politicians, includes patients, users, carers, citizens, and experts. Our analysis draws on extensive empirical evidence, consisting of observations, semi-structured interviews, and a review of available documents. The study took place in the Czech Republic from 2017 to 2019. We conclude that politicisation takes place alongside four dimensions: (1) contingency, (2) agency, (3) a plurality of opinions and approaches, and (4) visibility. We further argue that the contingent nature of biomedical controversies is articulated in three different, possibly interconnected layers. Thus, the politicisation of the two Czech analysed cases refers to (a) uncertainties and problematic aspects of biomedical objects of controversy; to (b) social rights, economic needs, and legal aspects as well as social representations of illness and vaccinations in the public debate; and to (c) the political processes which determine the previous two layers of politicisation, labelled as meta-politicisation. Last but not least, we stress the dynamic and non-linear nature of politicisation processes, the varieties of connections between the third sector and expertise, and the necessity to analyse the politicisation of public health controversies hand in hand with its connection to depoliticisation and repoliticisation.

A Business Ethics Center Rethinks Its Role

This paper explores some of the reasons why we, as a business ethics center housed at a state university, are transitioning from being a largely neutral platform on business ethics topics to becoming an advocate for specific perspectives. Comprising the topics of interest are issues such as climate change, capitalism, and certain medical and public health controversies. Presented here are four main reasons behind this move: pluralistic arguments, moral “switching,” existential crises, and combating disinformation. Two examples regarding capitalism and vaccine mandates are used to demonstrate advocacy in practice.

Visualizing evidence-based disagreement over time: the landscape of a public health controversy 2002-2014.

Systematic reviews answer specific questions based on primary literature. However, systematic reviews on the same topic frequently disagree, yet there are no approaches for understanding why at a glance. Our goal is to provide a visual summary that could be useful to researchers, policy makers, and health care professionals in understanding why health controversies persist in the expert literature over time. We present a case study of a single controversy in public health, around the question: "Is reducing dietary salt beneficial at a population level?" We define and visualize three new constructs: the overall evidence base, which consists of the evidence summarized by systematic reviews (the inclusion network) and the unused evidence (isolated nodes). Our network visualization shows at a glance what evidence has been synthesized by each systematic review. Visualizing the temporal evolution of the network captures two key moments when new scientific opinions emerged, both associated with a turn to new sets of evidence that had little to no overlap with previously reviewed evidence. Limited overlap between the evidence reviewed was also found for systematic reviews published in the same year. Future work will focus on understanding the reasons for limited overlap and automating this methodology for medical literature databases.

Time for a makeover-cosmetics regulation in the United States.

Cosmetics and personal care products are ubiquitous. Consumer pressure arising from recent episodes of products found to be unsafe has led to new policy proposals to modernize cosmetics regulation in the United States. We reviewed contemporary cosmetics regulation and collected major past and current policy proposals relating to cosmetics regulation with a focus on public health controversies. Under a structure originally established in 1938 that places regulation of cosmetics under the Food and Drug Administration (FDA), cosmetics manufacturers in the United States are not required to register their products or forward consumer complaints to the FDA, leading to broad under-reporting of adverse events. The FDA has limited authority to mandate product recalls. The existing FDA database system that collects adverse events related to cosmetics has limited public health utility. Current proposals for new cosmetics regulations seek to establish better systems for data collection and mandatory manufacturer registrations funded by cosmetic manufacturers. Additional policy changes could include a premarket review process for cosmeceuticals (cosmetics that make drug-like claims) and more advanced real-world data safety monitoring tools. With continued consumer concern and several recent cosmetic-related public health controversies, the FDA should be given more resources and broader authority to protect consumer safety.

A football helmet prototype that reduces linear and rotational acceleration with the addition of an outer shell.

Amid the public health controversy surrounding American football, a helmet that can reduce linear and rotational acceleration has the potential to decrease forces transmitted to the brain. The authors hypothesized that a football helmet with an outer shell would reduce both linear and rotational acceleration. The authors' objectives were to 1) determine an optimal material for a shock-absorbing outer shell and 2) examine the ability of an outer shell to reduce linear and/or rotational acceleration. A laboratory-based investigation was undertaken using an extra-large Riddell Revolution football helmet. Two materials (Dow Corning Dilatant Compound and Sorbothane) were selected for their non-Newtonian properties (changes in viscosity with shear stress) to develop an outer shell. External pads were attached securely to the helmet at 3 locations: the front boss, the side, and the back. The helmet was impacted 5 times per location at 6 m/sec with pneumatic ram testing. Two-sample t-tests were used to evaluate linear/rotational acceleration differences between a helmet with and a helmet without the outer shell. Sorbothane was superior to the Dow Corning compound in force reduction and recovered from impact without permanent deformation. Of 5 different grades, 70-duro (a unit of hardness measured with a durometer) Sorbothane was found to have the greatest energy dissipation and stiffness, and it was chosen as the optimal outer-shell material. The helmet prototype with the outer shell reduced linear acceleration by 5.8% (from 75.4g to 71.1g; p < 0.001) and 10.8% (from 89.5g to 79.8g; p = 0.033) at the side and front boss locations, respectively, and reduced rotational acceleration by 49.8% (from 9312.8 rad/sec2 to 4671.7 rad/sed2; p < 0.001) at the front boss location. Sorbothane (70 duro) was chosen as the optimal outer-shell material. In the outer-shell prototype helmet, the results demonstrated a 5%-10% reduction in linear acceleration at the side and front boss locations, and a 50% reduction in rotational acceleration at the front boss location. Given the paucity of publicly reported helmet-design literature and the importance of rotational acceleration in head injuries, the substantial reduction seen in rotational acceleration with this outer-shell prototype holds the potential for future helmet-design improvements.

Circulating Cholesterol Levels May Link to the Factors Influencing Parkinson's Risk.

A growing literature suggests that circulating cholesterol levels have been associated with Parkinson's disease (PD). In this study, we investigated a possible causal basis for the cholesterol-PD link. Fasting plasma cholesterol levels were obtained from 91 PD and 70 age- and gender-matched controls from an NINDS PD Biomarkers Program cohort at the Pennsylvania State University College of Medicine. Based on the literature, genetic polymorphisms in selected cholesterol management genes (APOE, LDLR, LRP1, and LRPAP1) were chosen as confounding variables because they may influence both cholesterol levels and PD risk. First, the marginal structure model was applied, where the associations of total- and LDL-cholesterol levels with genetic polymorphisms, statin usage, and smoking history were estimated using linear regression. Then, potential causal influences of total- and LDL-cholesterol on PD occurrence were investigated using a generalized propensity score approach in the second step. Both statins (p < 0.001) and LRP1 (p < 0.03) influenced total- and LDL-cholesterol levels. There also was a trend for APOE to affect total- and LDL-cholesterol (p = 0.08 for both), and for LRPAR1 to affect LDL-cholesterol (p = 0.05). Conversely, LDLR did not influence plasma cholesterol levels (p > 0.19). Based on propensity score methods, lower total- and LDL-cholesterol were significantly linked to PD (p < 0.001 and p = 0.04, respectively). The current study suggests that circulating total- and LDL-cholesterol levels potentially may be linked to the factor(s) influencing PD risk. Further studies to validate these results would impact our understanding of the role of cholesterol as a risk factor in PD, and its relationship to recent public health controversies.

Omega-3 polyunsaturated fatty acids: new evidence supports cardiovascular benefits

A notable public health controversy during the past decade has been whether omega-3 (n-3) polyunsaturated fatty acids (PUFA) are beneficial in either the prevention or treatment of cardiovascular disease (CVD), chiefly in coronary heart disease (CHD), in arrhythmias, particularly atrial fibrillation, and in relation to surgery. Both proponents and opponents have substantial evidence to support their views. Since CVD is the leading cause of death in the world, less toxic and dietary approaches have considerable appeal. As a result, even though about half of Americans eat less fish than is recommended, supplemental “fish oil” is used by 8.9% of the American population, with a market in excess of US$32 billion worldwide. Therefore, the question of whether the benefits of this investment are supported by science is relevant to cardiology societies and public health officials in formulating evidence-based policies—and to consumers in guiding their decisions.

Technological anxieties: telecom towers and public health controversies in urban India

Headaches, infertility and cancer are some of the health hazards most commonly associated with exposure to the electromagnetic fields (EMF) generated by mobile handsets and base transceiver stations. In contemporary India, home to the world’s second biggest market of mobile phone users, the impact of EMF on health has attracted a considerable degree of attention in recent years, leading to debates between citizen lobby groups, central and municipal authorities, telecommunication companies, medical practitioners and scientists. This essay discusses anti-tower activism in urban India and the government’s response to it, aiming to understand how online newspapers and magazines report on this topic and how concerned citizens use various media platforms to challenge government policies around telecom towers. It argues that interpreting anti-tower protests simply as the result of fear-mongering by the media or uninformed citizens overlooks the ways in which campaigners strategically employ discourses about health hazards, in particular the scientific uncertainty surrounding the impact of EMF on health, to protest against the haphazard proliferation of towers and to voice their discontent with the state’s failure to regulate and control the telecom industry.

“A man's mouth is his castle”: The midcentury fluoridation controversy and the visceral public

ABSTRACTThis essay forwards a theory of “visceral publics” through a case study of a bitter public health controversy in a small midcentury New England town. Proponents of fluoridation claimed that it yielded significant positive health outcomes, while opponents charged that the measure was politically suspect and physically dangerous. In this essay, I analyze the controversy as it took shape in letters to the editor and argue that the root of opposition to fluoridation was not in political ideology, as scholars have often claimed, but in a perceived threat to the body's boundaries, which created intense feelings. Although visceral publics are most clearly observable in controversies over the boundaries of the human body, the essay concludes by showing how the concept may be applied to controversies over the boundaries of the national body as well.

Risk perception, psychological heuristics and the water fluoridation controversy

Increasingly, support for water fluoridation has come under attack. We seek an explanation, focusing on the case of Waterloo, Ontario, where a 2010 referendum overturned its water fluoridation program. In particular, we test whether individuals perceive the risks of water fluoridation based not on 'hard' scientific evidence but on heuristics and cultural norms. A sample of 376 residents in Waterloo were surveyed in June 2012 using random digit dialing. We use factor analysis, OLS regression, as well as t-tests to evaluate a survey experiment to test the credibility hypothesis. Perceptions of fluoride as a risk are lower among those who perceive fluoride's benefits (B = .473, p &lt; 0.001) and those whose cultural view is 'egalitarian' (B = .156, p &lt; 0.05). The experiment shows a lower level of perception of fluoride's benefits among respondents who are told that water fluoridation is opposed by a national advocacy group (Group A) compared to those who are told that the government and the World Health Organization support fluoridation (Group B) (t = 1.6547, p &lt; 0.05), as well as compared to the control group (t = 1.8913, p &lt; 0.05). There is no difference between Group B and the control, possibly because people's already general support for fluoridation is less prone to change when told that other public organizations also support fluoridation. Public health officials should take into account cultural norms and perceptions when individuals in a community appear to rise up against water fluoridation, with implications for other public health controversies.

The prevention and eradication of smallpox: a commentary on Sloane (1755) 'An account of inoculation'.

Sir Hans Sloane's account of inoculation as a means to protect against smallpox followed several earlier articles published in Philosophical Transactions on this procedure. Inoculation (also called ‘variolation’) involved the introduction of small amounts of infectious material from smallpox vesicles into the skin of healthy subjects, with the goal of inducing mild symptoms that would result in protection against the more severe naturally acquired disease. It began to be practised in England in 1721 thanks to the efforts of Lady Mary Wortley Montagu who influenced Sloane to promote its use, including the inoculation of the royal family's children. When Edward Jenner's inoculation with the cow pox (‘vaccination’) followed 75 years later as a safer yet equally effective procedure, the scene was set for the eventual control of smallpox epidemics culminating in the worldwide eradication of smallpox in 1977, officially proclaimed by WHO in 1980. Here, we discuss the significance of variolation and vaccination with respect to scientific, public health and ethical controversies concerning these ‘weapons of mass protection’. This commentary was written to celebrate the 350th anniversary of the journal Philosophical Transactions of the Royal Society.

Taking Facts Seriously: Judicial Intervention in Public Health Controversies

Taking Facts Seriously: Judicial Intervention in Public Health Controversies

Why persons choose to opt out of an exception from informed consent cardiac arrest trial

BackgroundWe sought to characterize persons who requested to opt out of an exception from informed consent (EFIC) cardiac arrest trial and their reasons for opting out. MethodsAt one site of a multi-site, out-of-hospital, cardiac arrest EFIC trial (September 2007 – June 2009), persons who did not want to participate in the study could request an opt-out “NO STUDY” bracelet to prevent trial enrollment. We surveyed all persons who requested a bracelet by phone interview, web or mail. Opt-out bracelets were advertised in all public communication about the study, including community consultation and public disclosure efforts. Survey questions included demographics, Likert scale items about attitudes toward the trial and research in general, plus open-ended questions. We used descriptive statistics for standardized questions and qualitative analysis to identify common themes from open-ended questions. ResultsSixty bracelets were requested by 50 individuals. Surveys were completed by 46 persons (92% response rate). Seventy percent of respondents agreed emergency research is important, but 87% objected to any research without consent. In the qualitative analysis, 5 overlapping themes emerged: questioning the ethics of EFIC research; concerns about how the study would impact end-of-life preferences; subjective emotions including sarcasm, anger, and allusions to past unethical research; negative reference to unrelated public health controversies; and objections to the study protocol based on misinformation. ConclusionsA primary reason for opting out from this EFIC trial was opposition to all research without informed consent, despite stated support for emergency research. Understanding the demographics and beliefs of persons opting out may aid researchers planning EFIC studies and help provide clarity in future EFIC-related community education efforts.

Lyme disease: a quintessential connection between ecosystems and human Health

The topic of emerging infectious diseases, including novel pathogens as well as those that have reemerged or spread into new geographic areas, is a subject of growing interest in the fields of disease ecology and public health. Many of these emerging diseases have strong ecological underpinnings because of their dependence upon arthropod vectors for transmission and zoonotic hosts as reservoirs. As a result, disease emergence is often affected by human-caused changes in climate and habitat that alter the ecologies of vector and host species, and the field of landscape ecology has the potential to make a significant contribution in the quest for new approaches to understanding and preventing these diseases. Lyme disease is a tick-borne disease that is caused by the spirochete Borrelia burgdorferi, vectored by the black-legged tick Ixodes scapularis, and dependent upon a variety of zoonotic reservoir hosts. It is arguably the most important vector-borne disease in North America and has emerged conspicuously over the past several decades. In the United States, cases have increased from less than 1,000 per year in the early 1980s to more than 30,000 confirmed and probable cases in 2010. In his book entitled Lyme Disease, the Ecology of a Complex System, Richard Ostfeld provides an ecologist’s perspective on the phenomenon of Lyme disease. This book delivers a unique scientific narrative that highlights several ongoing scientific controversies about Lyme disease ecology and is grounded in the author’s own extensive research on this topic. The book starts with a brief introduction to the history of Lyme disease and the public health controversies that surround this insidious ailment. The next several chapters are then devoted to exploring and deconstructing several prevailing hypotheses about the ecological determinants of Lyme disease risk. These include the role of the white-tailed deer as a keystone host necessary for maintaining high tick densities, the importance of the white-footed mouse as the primary reservoir host species involved in Borrelia burgdorferi transmission, and the influences of weather and microhabitats on tick populations. Although there is some evidence to support each of these hypotheses, Ostfeld highlights the many contradictory results in the scientific literature which suggest that a more sophisticated framework is necessary for understanding the complex ecology of Lyme disease. In the second half of the book, Ostfeld focuses on the presentation and synthesis of the results from his own research group emphasizing the importance of biodiversity and ecosystem function for understanding the ecology of complex zoonoses such as Lyme disease. Two key themes in this section of the book are the cascading effects of mast years through ecological food webs and how the biology and behavior of M. C. Wimberly (&) Geographic Information Science Center of Excellence, South Dakota State University, Brookings, SD 57007, USA e-mail: michael.wimberly@sdstate.edu

Influenza influencing democracy

The vaccine against the pandemic or so-called swine flu caused scientific, political, and public health controversy all over the world. In Croatia, the whole case told us a lot about the state of the health care system, scientific community, and level of democracy.

Public health controversies: Common characteristics

Public health controversies: Common characteristics

Vaccines: past mistakes, future opportunities

There have been numerous controversies regarding vaccines in the past. The recent scare regarding the safety of cervical cancer vaccine is a small reminder of the trials it had to face in the court of public judgement. The authors explore two such vaccine controversies to identify missed opportunities and lessons that could be learnt. a) The diphtheria-pertusis-tetanus vaccine was routinely used in public health with an established safety record. In 1974, a case series from Hospital for Sick Children at Great Ormond street, described 36 children who suffered severe neurological complications following their DTP immunisation. The negative publicity resulted in a sharp decline in vaccine uptake from 77% to 33%.There was uncertainty among the public and practitioners with regards to its safety until the National Childhood Encephalopathy Study was published 7 years later. b) The measles-mumps-rubella (MMR) vaccine was introduced in the U.K in 1988.It suffered a major setback following the study by Wakefield <i>et al</i> in 1998 suggesting an association between MMR and autism. There were several publications in the press in the following years, which conveyed ambiguous messages with no clear scientific consensus on MMR safety. MMR vaccine uptake dropped to 84% resulting in a mumps epidemic in 2005. Currently, measles is declared to be endemic in the U.K. The delay in robust defence of MMR vaccine until the Cochrane review in 2005, contributed to undermining confidence in MMR safety. <h3>Conclusion</h3> Significant delay has occurred in the past in responding to such public health controversies, resulting in increased morbidity and mortality. In the future, strategies have to be developed within the department of health, through existing agencies like the National Institute for Health and Clinical Excellence, to promote early response and prompt development of scientific consensus to guide health professionals and public in adopting evidence-based practice.

NEVER-ENDING CONTROVERSY

ASK ANY DENTIST whether fluoridated water helps prevent tooth decay, and in all likelihood they will reply that the difference between those who drink it and those who don’t is like night and day. Comparative studies have shown that, on average, the incidence of tooth decay among children in fluoridated communities is 15–50% less than it is in nonfluoridated communities. Yet after more than 60 years since the first intentional fluoridation of a public drinking water supply in Grand Rapids, Mich., the benefits and risks of fluoridation continue to be debated. No other public health controversy has been so long-running and so divided, with each side refusing to listen to the other, R. Allan Freeze and Jay H. Lehr note in their book “The Fluoride Wars: How a Modest Public Health Measure Became America’s Longest-Running Political Melodrama.” Advocates of fluoridation say it prevents dental cavities with no health risks. Those opposed question the benefits of ...