5 Public Health Ethics, Law, and PolicybenkrutiStockThi.docx

5 Public Health Ethics, Law, and Policy
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Learning Outcomes
After reading this chapter, you should be able to
• Explain the relationship between ethics and public health
work.
• List the central assumptions of the Public Health Code of
Ethics.
• Summarize the importance of key public health cases.
• Illustrate how policies and laws are utilized in public health
efforts.
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resale or redistribution.
150
Section 5.1 The Role of Ethics in Public Health
The ethics, morals, laws, policies, and legislation involved in
public health can become very
confusing, even for those who work in the field. This chapter
provides a brief overview of each

of these elements, plus examples of their importance and
function in the public health realm.
In public health, it is important to understand and differentiate
between terms such as ethics
and morals, as they can be vastly different in practice. The
Public Health Leadership Society’s
principles of ethical practice are also key to understanding how
and why public health offi-
cials make policy recommendations.
Lastly, this chapter discusses the difference between policy and
law, focusing on how policy
shapes public health, including its responsibilities and its
outcomes. The role of policy briefs,
their purpose, and how they are written is explored, and
examples of existing policies that
became laws and how they have worked within the public health
realm are summarized.
5.1 The Role of Ethics in Public Health
Morals and ethics are very much alike in many respects, and the
terms are often used inter-
changeably; however, they are not the same concepts. Morals
are an individual’s principles of
right and wrong. They set the stage for acceptable behaviors and
beliefs. Morals are not uni-
versal, and they are highly individualized, often shaped by
upbringing and culture. A person
living in House A on Street A may believe that elbows on the
table during dinner is unaccept-
able (it is “wrong,” or immoral), while a person living in House
B on Street B may believe that
elbows on the table at meal time is fine (it is “right,” or moral).
Ethics are principles that govern a person’s behavior because
they are rules provided by an

external source, such as codes of conduct in a community
setting or a workplace. Ethics are
more universal and common to a set community. For example,
the community of residents on
Street B are Amish, and those on Street A are not
Amish. The community ethical code in the Amish
community (everyone on Street B) would state
that elbows on the table are unethical behaviors.
This is now considered a principle governed by an
external source (the Amish community). So, while
the person living in House B on Street B may have
a moral belief that elbows on the table are fine, the
community of Street B says it is unethical. This is
where ethics and morals can collide. In most situ-
ations, the ethics of the community outweigh the
morals of the individual.
In public health, morals and ethics collide fre-
quently in decision-making. Vaccinations against
certain diseases are good examples of this colli-
sion. For instance, the state of Pennsylvania might
represent the community and mandate vaccination. In this case,
Pennsylvania is the external
source that sets the code of conduct—the ethical standards for
those who live in the state. But
there may be many individuals in the state who personally
disagree with this code and refuse
vaccination. The individuals’ moral beliefs collide with the
overarching community’s code.
Ridofranz/iStock/Thinkstock
Personal and cultural beliefs about
allowing terminally ill or dying
patients to refuse treatment or request
physician-assisted suicide may conflict
with laws.

151
Who wins? Who is right? If the law intervenes, it will usually
be the community ethical stan-
dards that will be upheld; however, if there are no laws, the
individual’s morals may stand.
A national law states that all children must receive vaccinations
before attending school. In
this case, if an individual is opposed to vaccination yet has a
child who needs to attend school,
the individual must abide by the law in order to send the child
to school.
As noted in the vaccination example, laws do not always agree
with every single community’s
morals, but the laws are established to protect that society as a
whole. In many cases, laws
truly conflict with ethics and morals. For example, it is illegal
to kill another human being,
even in cases of physician-assisted suicide for dying, or
terminal, patients. However, some
cultures and individuals believe that it is ethical to allow a
person to die with dignity rather
than live in pain. Individually, people may believe that
physician-assisted suicide is also right.
In this case, ethics and morals are similar, but the law prohibits
the intended action.

Research and Clinical Ethics
The idea that ethics plays a role in public health is relatively
new. More widely understood are
the concepts of research ethics and clinical ethics. Research
ethics involves the protections
of human subjects who are taking part in a study. This usually
includes a plethora of disclo-
sures and permissions. Most people won’t encounter the concept
of research ethics unless
they are part of a research project.
Clinical ethics is more commonly understood because it is
encountered in doctor’s offices,
clinics, hospitals, and all health-related organizations and
facilities. Clinical ethics addresses
issues that arise within the patient care realm. Privacy and
confidentiality of the patient are
the most common ethical practices in the clinical setting, the
importance of which contrib-
uted to the law known as the Health Insurance Portability and
Accountability Act of 1996
(HIPAA). This law requires the protection and safeguarding of
all personal health information.
Ethically, it seems obvious that health information should be
private, and many offices had
already been keeping it private before the law was passed
because it was valued as important.
Making it law transformed this ethical practice into a legal
requirement.
Public health is quite different from clinical health, and,
therefore, the focus areas of ethics in
both arenas are different. Clinical ethics is related to the
treatment of disease and injury, while
public health ethics is important in the prevention of disease

and injury. Table 5.1 shows a
comparison of the two.
The terms principles and values appear frequently in this
chapter, and both play a key role in
the ethical practice of public health. However, whose principles
and values are being consid-
ered? While all people have values of some sort, public health
values are rooted in science and
community in an effort to prevent disease and injury, protect the
public from harm, and pro-
mote health and well-being (Barrett et al., 2016). Public health
professionals do not use their
morals when making decisions that will affect the public. Public
health values rest on two
ideas: that most health interventions rely upon the community’s
acceptance, cooperation,
and participation to be successful, and that public health must
gain a community’s trust to be
able to function effectively. These are the guiding values of
public health and the basis for all
actions that public health professionals perform at the local,
state, federal, and global levels.
152
Ethics and Public Health Decision-Making
In all public health activities, principles and values provide the
framework and justification

for decision-making. In essence, every aspect of public health
must adhere to an ethical frame-
work. The CDC (2017w) follows three core functions when
applying an ethical framework to
its activities:
1. Identify and clarify the ethical dilemma.
2. Analyze the dilemma in terms of alternative courses of
actions plus whatever result-
ing consequences may occur.
3. Resolve the dilemma through decision-making that
incorporates and balances the
guiding principles and values.
This framework comes with several key questions to help public
health professionals walk
through the process to determine the next steps.
Core Function 1: Identifying and Clarifying the Ethical
Dilemma
When examining a potential intervention in public health, the
first step is to provide the foun-
dation on which to base the decision. These questions are
usually discussed at length:
• What are the risks, harms, and/or concerns?
• What are the public health goals?
• What is the scope of legal authority? That is, what laws and
regulations may or may
not apply?
Table 5.1: Comparison between clinical and public health ethics

Clinical ethics Public health ethics
Medical interventions by clinical professionals Range of
interventions by various professionals
Individual benefit Social, community, or population benefit
Seeks to avoid harm based on the provider’s
fiduciary relation to the patient
Seeks to avoid harm based on collective action
Respect for individual patients Relational autonomy of
interdependent citizens
(community)
Professional duty for patients over provider Duty to community
over individual
Based on trustworthiness of physician and medical
profession
Based on law
Informed consent from individual Community consent through
consensus
Limited to treating patients equally and ensuring
universal access to health care
Concern with social justice regarding health and
achieving health equity
Source: Adapted from “Public Health Ethics: Global Cases,
Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C.
Saenz, R. G.

Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H.
Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G.
Bolan (Eds.),
Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 23),
2016, Geneva, Switzerland: Springer International Publishing,
Open Access.
153
• What are the moral norms of the community?
• Are there any similar cases that provide legal or ethical
guidance?
Consider the potential issues of requiring motorcyclists to wear
helmets. In this situation,
public health officials have to analyze the risks to, and concerns
of, the rider as well as those
who may be affected, such as the rider’s family, those who pay
for the medical services and
costs, and other people on the road. The ethical dilemma is
“What harm would come if hel-
mets were required for all motorcyclists?”
This function of the framework also examines community
norms. Is there a social concern
with motorcyclists not wearing helmets across the state? Is there
a strong advocacy call for
helmet use? What economic issues would result if helmets were
required? Obviously, there

is the cost of the helmet, but there is also the cost of medical
care in the event an accident
occurs. Some people in opposition to the helmet laws state that
it violates their personal
rights to make their own choices. Supporters of the laws claim
that those who get into acci-
dents and succumb to head trauma drain medical resources—
especially those who do not
have insurance. It is an injury that can be prevented just by
wearing a helmet.
States’ opinions on the helmet law vary based on the answers to
these questions. Some have
no laws or require only passengers under age 17 to wear a
helmet; others require everyone
on a motorcycle to wear one (Insurance Institute for Highway
Safety, 2018). The state of New
York requires the use of helmets and has since 1967 (Insurance
Institute for Highway Safety,
2018). Refer to A Closer Look for another example of a state
examining an ethical dilemma in
public health.
A Closer Look: Applying the Ethical Framework to Alaska
Smoking Laws
While Alaska has one of the most lenient
smoking laws in the United States, smoking is
prohibited in schools, childcare facilities, most
health care facilities, and elevators (American
Lung Association, 2016). However, the
state government has left the door open for
communities to take matters into their own
hands, which includes establishing stricter
regulations if they wish to do so.

While public health professionals view the
ban as a lifesaving measure, others see it as
an attack on personal rights. This is an ethical
dilemma that the state cautiously addressed
by leaving the main decisions in the hands of
each municipality. The state law takes into
consideration the rights of smokers by not
banning the practice under one law.
(continued)
Stefan Malloch/iStock/Thinkstock
Alaska has one of the most lenient
smoking laws in the United States.
Communities can apply stricter
regulations if they wish to but are not
required to do so.
154
Core Function 2: Analyzing the Dilemma
This function revolves around options. Three key points are
considered:
• What are the short- and long-term options given the responses
to the questions from
Core Function 1?
• What are the ethical concerns of each option?

• Are there other considerations that should be reviewed, such
as privacy, commit-
ments, or transparency?
One such public health dilemma received considerable attention
and review at this step of
the ethical framework: bicycle helmet usage. In the early 1970s,
the issue gained momen-
tum in Australia, where a significant number of bicyclists died
from head injuries. The Royal
Australian College of Surgeons actively campaigned to raise
awareness of head injuries and
their prevention through the use of helmets. Shortly after the
campaign went into effect, Aus-
tralia became the first country to require helmets for bicyclists,
in the early 1990s (Rachele,
A Closer Look: Applying the Ethical Framework to Alaska
Smoking Laws (continued)
The compromise was simple: If a community desires to allow
smoking, it must designate
specific locations and clearly mark them with signage. This is to
protect the health of those
who do not wish to inhale secondhand smoke, as the law states
that everyone has the right to
clean air. The signage is helpful, but some municipalities did
desire to go beyond the state’s
law. As a result, some major cities and smaller towns adopted
stronger policies based on
residents’ desires (see Core Function 1 of the ethical decision-
making framework):
• Sitka, November 18, 2005: Banned smoking in all enclosed
workplaces, including

restaurants but exempting bars
• Anchorage, July 1, 2007: Banned smoking in all workplaces,
bars, and restaurants
• Juneau, January 2, 2008: Banned smoking in bars and
restaurants (but not other
workplaces)
• Nome, September 20, 2011: Banned smoking in bars,
restaurants, outdoor stadiums,
vehicles when used for public transportation, and all enclosed
workplaces
Only 11 cities in the state of Alaska have adopted completely
smoke-free workplaces:
Anchorage, Bethel, Haines, Juneau, Klawock, Nome, Palmer,
Petersburg, Skagway, Unalaska,
and Valdez. Most of the cities and towns in Alaska abide by the
signage law imposed by the
state.
Sources: American Lung Association. (2016). SLATI state
information: Alaska. Retrieved from
http://www.lungusa2.org/slati
/statedetail.php?stateId=02
State of Alaska. (2017). Alaska smoking law. Retrieved from
http://dec.alaska.gov/eh/fss/Smoking_Home.html
http://www.lungusa2.org/slati/statedetail.php?stateId=02
http://www.lungusa2.org/slati/statedetail.php?stateId=02

155
Badland, & Rissel, 2017). New Zealand followed suit in 1994.
Deaths and head injuries from
bicycle riding began to drop due to helmet use, and the word
was spreading into other coun-
tries. In 1987, the United States began to adopt helmet laws at
the state level; however, there
was pushback from adults (Helmets.org, 2017). Most people
agree that protecting children
under age 18 is important. Therefore, laws that focused on
children and youth helmet use
were mostly welcomed.
Today in the United States, there are no federal laws
requiring bicycle helmet use by anyone riding a bicy-
cle. Twenty-two states require helmet use, typically
for children, and more than 200 localities (munici-
palities, cities, etc.) maintain local ordinances on
the issue (Helmets.org, 2017). For example, Kansas
does not have a statewide law requiring helmet use
while riding a bicycle, but the city of Lawrence, Kan-
sas, requires all children and youth under age 16 to
be helmeted (Helmets.org, 2017). There is no law
in any state that requires adults to wear a helmet
(Insurance Institute for Highway Safety, 2017b).
According to Nicaj et al. (2006), 97% of bicyclists
who died in an accident in New York City from 1996
to 2005 were not wearing a helmet.
Bicycle helmet use remains a significant ethical
dilemma for communities. When addressing the
questions in Core Function 2, the local municipali-
ties were given the authority to determine whether

a bicycle helmet law would invade their residents’
rights, privacy, and way of life. Public health lost the
battle to have an overarching law on helmet use, as
regulations more often focus on the protection of
children rather than the entire population of bicycle
riders. Advocacy groups are still working toward a
federal law requiring all bicyclists to don a helmet.
Core Function 3: Resolving and Justifying the Decision
Decisions in the public health realm are not random. They
require solid justification by taking
into consideration all aspects and opposition. Public health
officials ask five key questions
when justifying decisions (Table 5.2). One important aspect
related to the practice of public
health is to ensure that the values of the community do not clash
with the values of the public
health intervention. After all steps are reviewed and options
considered, the decision mak-
ers must be able to address the five factors and their associated
questions in full to adopt an
intervention, law, or policy.
LydiaGoolia/iStock/Thinkstock
There are no federal laws that require
helmet use for anyone riding a bicycle,
but about half of the states have laws
that require helmet use, typically
for children.
156

For example, not all states have adopted helmet laws for
motorcyclists because those five key
elements could not fully address all residents’ questions. The
biggest element fell under “least
infringement,” where people felt this law was a violation of
their values, rights, and principles.
The intervention was intended to increase safety, but it collided
with the values of motorcycle
riders themselves. As a result, only 19 states and the District of
Columbia have laws requiring
motorcyclists to wear helmets (Insurance Institute for Highway
Safety, 2017a). In addition, 28
states have modified laws, requiring only some motorcyclists to
wear helmets. Three states
have no law at all: Iowa, Illinois, and New Hampshire (Figure
5.1).
Table 5.2: Justification for public health decisions
Factor Key questions
Effectiveness Is the action going to be effective? Will it make a
difference in terms of the overall
goal(s)?
Proportionality Will the benefits outweigh the infringement on
the community’s individual values,
principles, and morals?
Necessity Is this intervention truly needed to achieve the
goal(s)?
Least infringement Will this intervention cause the least

disruption and upheaval of the community’s
values, principles, and morals?
Public justification Is there solid evidence to justify this
decision that most people will find acceptable?
Source: Adapted from “Public Health Ethics: Global Cases,
Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C.
Saenz, R. G.
Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H.
Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G.
Bolan (Eds.),
Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 29),
2016, Geneva, Switzerland: Springer International Publishing,
Open Access.
Figure 5.1: Motorcycle helmet laws by state
Most states have some type of law regarding motorcycle helmet
use. Only three states have no law
requiring the use of a helmet while riding a motorcycle: Iowa,
Illinois, and New Hampshire.
Source: Insurance Institute for Highway Safety, Arlington,
Virginia USA. http://www.iihs.org. Used with permission.
HI
TX
CA
NV
OR

WA
ID
MT
WY
UT
AK
AZ NM OK
KSCO
NE
SD
ND
WI
MN
IL
IA
MO
AR
LA
MS AL GA
FL

SC
NC
TN
KY
MI
IN OH
PA
NY
WVVA
MA
NH
RI
DE
NJ
CT
MD
DC
MEVT
Universal law Partial law No law

http://www.iihs.org
157
Section 5.2 The Public Health Code of Ethics
In 2015 alone, helmets saved the lives of 1,772 people. If every
motorcyclist had worn a hel-
met when riding, another 740 more could have been saved
(CDC, 2017o). Helmets reduce the
risk of death by 37% and the risk of head injury by 69% (CDC,
2017o). Furthermore, accord-
ing to the CDC (2017o), helmet use would save more than $1
billion.
However, it is important to note that people in a community are
far more committed to their
political views, ethical and religious values, and how a specific
law, policy, or action might affect
them personally than to scientific evidence or community
impact. That is why not all states
have enacted a full universal law making helmets a requirement
when riding a motorcycle.
This policy has been far more controversial than any other
traffic law on record. In 1967, the
federal government enacted a helmet law, which prompted the
establishment of motorcycle
rights groups (Homer & French, 2009). The federal helmet law
was revoked in 1976. Some of
these groups still encourage motorcyclists not to wear helmets
and argue that effective rider
training and education sessions, not legally required helmet use,
will result in fewer accidents
and fatalities (Homer & French, 2009). Public health

professionals continue to work through
the steps in communities and states separately, hoping for
improved results to eventually
enact a federal law requiring helmet use.
5.2 The Public Health Code of Ethics
Those in public health have an obligation to protect the health
of the public. This obligation
has a strong moral basis and involves a significant amount of
trust. This is why a code of ethics
is important. A code of ethics represents a professional’s
commitment to honor the public’s
trust and to avoid abusing power in a way that deprives a
population or community of posi-
tive outcomes. While public health practice has existed for
centuries (as noted in Chapter 1),
a universal code of ethics did not emerge until 2002.
Origins and Development
The code originated as a class project of the 2000 graduating
class from the Public Health Lead-
ership Institute (Thomas, Sage, Dillenberg, & Guillory, 2002).
The institute provides advanced
leadership training to those already in public health professions.
The 2000 graduating class
had members from various agencies, including the CDC;
American Public Health Association
(APHA); National Association of City and County Health
Officers (NACCHO); departments of
health in Connecticut, Ohio, Maine, Virginia, and Alabama; and
Center for Health Leadership
and Practice in Oakland, California (Thomas et al., 2002).
The code focuses on those who work in public health, including
public health departments,
schools of public health, and institutions with a public health

focus. It took 2 full years of devel-
opment to finalize the document, which included values and
belief statements, explanations,
and 12 specific ethical principles (see Table 5.3). The APHA
Executive Board formally adopted
the code on February 26, 2002. The APHA is a membership-
based organization focused on
improving the health of communities across the United States
and beyond. The group advo-
cates for and has influenced many public health policies
supported by scientific research and
brings together members from all fields of public health. Not
long after the APHA adopted the
158
code, further adoptions came from the CDC, NACCHO, the
Association of State and Territorial
Health Officials, the Association of Schools of Public Health,
and a plethora of other public
health organizations. Once the code is adopted, an organization
must then integrate the prin-
ciples into all of its policies, procedures, and actions.
Key Assumptions
The code of ethics is a document called Principles of the Ethical
Practice of Public Health. It is
widely used as the foundation for ethical practice in public
health. The preamble to the code

explains its purpose and audience:
The code is neither a new nor exhaustive system of health
ethics. Rather it
highlights the ethical principles that follow from the distinctive
characteristics
of public health. A key belief worth highlighting, and which
underlies several of
the Ethical Principles, is the interdependence of people. This
interdependence
is the essence of community. Public health not only seeks to
assure the health
of whole communities but also recognizes that the health of
individuals is tied
to their life in the community. (Public Health Leadership
Society, 2002, p. 4)
This code is intended for public health professionals and other
institutions that focus on pub-
lic health initiatives to provide the least harm for the greatest
good in all public health–related
actions. Those who adopt this code must also understand the
underlying values and beliefs
that the Leadership Society calls “key assumptions” for all
professionals. These assumptions
fall within three areas: health, community, and bases for action.
Health
The key assumption for this area is that every human being has
a right to health resources.
The code affirms the first notation under Article 25 of the
Universal Declaration of Human
Rights, which states that all people have a right to a standard of
living for positive health and
well-being:

Everyone has the right to a standard of living adequate for the
health and well-
being of himself and of his family, including food, clothing,
housing and medi-
cal care and necessary social services, and the right to security
in the event of
unemployment, sickness, disability, widowhood, old age or
other lack of liveli-
hood in circumstances beyond his control. (United Nations,
1948, article 25,
section 1)
Community
There are six assumptions under this value:
1. All humans are interdependent, meaning that we require
companionship, friendship,
family, and social interaction for survival. Positive
relationships, especially among
institutions, make up the basis for a healthy community. Under
this assumption, it is
noted that one person’s decision can affect other people.
159
2. Without the value of trust, a community
cannot be effective in any public work.
There must be trust between the pub-
lic and public health institutions, and

this includes truth telling, transparency,
accountability, reliability, and reciprocity.
3. People do not work in silos. To accomplish
positive outcomes in health, a community
must collaborate and work together as one
unit.
4. Humans interact with their environments;
therefore, a healthy environment makes
for a healthy community. In other words,
poorly designed communities or poor man-
agement of natural resources can generate
unhealthy populations.
5. People in a community must be able to speak out against or
for an action and feel
that their voices are heard. This assumption requires a process
for community mem-
bers to develop and evaluate policy and actions before they are
implemented.
6. Public health professionals cannot come into a community
and change whatever they
want if the community is not on board with said change. This is
where solid assess-
ment can ensure the community identifies its fundamental
needs. This assumption
works hand in hand with the third assumption of collaboration:
People must learn to
work together to promote a community’s health needs.
Bases for Action
This area comprises four specific assumptions: knowledge,
science, responsibility, and action.

1. Knowledge revolves around ensuring that people of a
community have the informa-
tion they need to make decisions about their community’s
health. This could involve
participation in policy-making or engaging community members
via promotion and
education campaigns.
2. Science becomes the basis for all decisions made in the
public health realm. Scien-
tific tools used include qualitative and quantitative
methodologies to assess and
evaluate a population’s needs. These activities become critical
evidence that is used
to develop interventions for health improvement.
3. Responsibility means that community members are given the
role of making deci-
sions based on science and knowledge. Failure of community
members to act in
any manner breaks this assumption and indicates an
unwillingness of a community
to move toward healthier outcomes. Without this assumption, it
is difficult for any
movement toward improvements to be effective.
4. Actions are often performed without full information simply
because it is unavailable
or unknown. The values and beliefs statements in the code note
that action is often
required in the absence of full information on a topic. It is
important to know that the
values and dignity of each person in a community are often the
driving force behind
actions, more so than science-based evidence and research.
Whichever is followed, a

community must do so with full consensus and collaboration.
dolgachov/iStock/Thinkstock
Humans have an interdependent
relationship with the environment.
Thus, the design of a community
and the management of its natural
resources affect the population.
160
Principles of Ethical Practice
Taking these value and belief assumptions into consideration,
these principles of practice are
followed by all public health professionals in the United States
(Table 5.3).
Table 5.3: Principles of the ethical practice of public health
1. Public health should address principally the fundamental
causes of disease and requirements
for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that
respects the rights of individuals
in the community.
3. Public health policies, programs, and priorities should be
developed and evaluated through

processes that ensure an opportunity for input from community
members.
4. Public health should advocate and work for the empowerment
of disenfranchised community
members, aiming to ensure that the basic resources and
conditions necessary for health are
accessible to all.
5. Public health should seek the information needed to
implement effective policies and programs
that protect and promote health.
6. Public health institutions should provide communities with
the information they have that is
needed for decisions on policies or programs and should obtain
the community’s consent for
their implementation.
7. Public health institutions should act in a timely manner on
the information they have within the
resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a
variety of approaches that anticipate
and respect diverse values, beliefs, and cultures in the
community.
9. Public health programs and policies should be implemented
in a manner that most enhances
the physical and social environment.
10. Public health institutions should protect the confidentiality
of information that can bring harm
to an individual or community if made public. Exceptions must
be justified on the basis of the

high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional
competence of their employees.
12. Public health institutions and their employees should engage
in collaborations and affiliations
in ways that build the public’s trust and the institution’s
effectiveness.
Source: From “Principles of the Ethical Practice of Public
Health” (version 2.2), by Public Health Leadership Society,
2002
(https://www.apha.org/-
/media/files/pdf/membergroups/ethics/ethics_brochure.ashx).
Every action performed by public health professionals must
occur under an ethical code. The
code should guide practitioners in how they tackle a health
problem. Section 5.3 includes
three cases that ended up in court and that highlight the
importance of having an ethical code.
https://www.apha.org/-
/media/files/pdf/membergroups/ethics/ethics_brochure.ashx
161
Section 5.3 Public Health Ethics Cases
5.3 Public Health Ethics Cases
For many public health lawsuits, the courts are asked to weigh

the rights of the individual
against the responsibilities and rights of a larger organization,
such as the federal or state
government. When does a person’s right to decide for himself or
herself trump a public health
concern, and vice versa? For example, in 1885, the Supreme
Court ruled that some actions
are essential for the health of the population even if they
restrain individual liberties (Barrett
et al., 2016). While courts are primarily concerned with the law,
legal debates often become
ethical debates as well. The following three cases illustrate how
having a public health code
of ethics can help clarify what decisions need to be made.
Case No. 1: Jacobson v. Massachusetts
Jacobson v. Massachusetts (1905) is considered the
most important public health case to support states’
rights when creating and enforcing laws that limit
individual autonomy in favor of protecting public
health (Barrett et al., 2016; Gostin, 2008).
In the early 1900s, the state of Massachusetts man-
dated vaccination against smallpox. Anyone who
did not receive the vaccination was fined $5. Cam-
bridge minister Henning Jacobson refused the vac-
cine and also refused to pay the fine. His first argu-
ment was that he had once received the vaccine as
a child in Sweden and experienced a long period of
suffering following the inoculation (Barrett et al.,
2016). His second argument stated that the law was hostile and
removed personal freedom
of choice for individuals. Both state and superior courts ruled
against Jacobson, stating that
there were no exemptions permitted and that medical history
had no bearing on his ability to

refuse the vaccine. However, one of the key findings from the
State Supreme Court was that
if people refused to be vaccinated, it was not within the power
of the public health realm to
force inoculation (Commonwealth v. Henning Jacobson, 1903).
This case eventually went to the U.S. Supreme Court, where it
was determined that anyone
with a health condition should not be subject to the vaccination,
as it would be considered
“cruel and inhuman in the last degree” (Barrett et al., 2016, p.
42). The court then found
Jacobson to be in perfect health, which required him to receive
the vaccination. The final rul-
ing was for Jacobson to either obtain the inoculation or pay the
fine. He eventually paid the $5
fine as outlined by the law (Barrett et al., 2016).
This case illustrates the potential conflict between a
community’s health and well-being and
personal rights and freedoms. When a personal right puts the
rest of the community at risk,
then that personal right is an infringement on the population’s
well-being. In this case, even
the U.S. Supreme Court felt the public’s health trumped
individual rights.
scyther5/iStock/Thinkstock
Do laws that require citizens to receive
certain vaccinations to promote overall
public health infringe upon personal
rights?

162
Case No. 2: New York City Soda Ban
On September 13, 2012, New York City became
the first city in the United States to ban the sale of
sugar-loaded beverages, such as sodas larger than
16 ounces, at restaurants, arenas, movie theaters,
and food carts (Park, 2012). If establishments
did not abide by the ruling, they were subject to a
$200 fine. While the concept was in support of the
nationwide anti-obesity campaign and was largely
supported by public health professionals, it was not
very popular with residents. Why? People felt that a
law limiting the amount of a product an individual
could purchase infringes on personal rights.
In 2012, more than half of New York City adults and almost
40% of elementary and middle
school children were overweight or obese (Park, 2012). Sugary
drinks make up 43% of the
added sugar in the average diet (Park, 2012). Most restaurants
and other venues serving such
drinks serve the products in 20-ounce glasses or larger. This
adds a significant number of
sugar/carbohydrate calories to an individual’s diet. Banning
supersized beverages was seen
as a means of reversing the city’s obesity trend and was
approved by the board of health by a
vote of 8–0 (Park, 2012).
At the time the law was presented for public comment, the
members of the New York City

Department of Health and Mental Hygiene and the New York
City Board of Health found
32,000 comments favored the ban while only 6,000 opposed it.
However, other consumer
polls revealed that there was more opposition than support, and
when the law was passed, it
set off a city-wide uproar that quickly spread across the
country.
Opponents of the law said it gave the government too much
control over what they personally
chose to eat or drink. Several groups petitioned the court to
revoke the law. These groups had
obtained more than a quarter million signatures from others who
also felt the law infringed
on their personal freedoms (Park, 2012).
A lawsuit was filed on October 12, 2012, in the New York
Supreme Court asking for a reversal
of the city’s law (N.Y. Statewide Coal. of Hispanic Chambers of
Commerce v. N.Y.C. Dep’t of Health
& Mental Hygiene, 2013). The petitioners did not dispute the
obesity problem but noted that
large drinks were not clearly connected to obesity. The coalition
also claimed that the city’s
health department “exceeded their authority and impermissibly
trespassed on legislative
jurisdiction” (N.Y. Statewide Coal. of Hispanic Chambers of
Commerce v. N.Y.C. Dep’t of Health
& Mental Hygiene, 2013, p. 10). In its decision, the court stated
that “even under the broadest
and most open ended of statutory mandates, an administrative
agency may not use its author-
ity as a license to correct whatever social evils it perceives” (p.
11). As a result of research,
legal precedent (previous laws), and a lack of evidence that

reducing the size of drinks sold
would actually reverse the obesity crisis, the court overturned
the law.
This is one instance in which a public health law did not have a
solid connection to a com-
munity’s health and well-being. The alleged greater good to
help the public was not clearly
defined and did far more damage to individual rights.
tongpatong/iStock/Thinkstock
Does a public health law that bans the
sale of large, sugary sodas in public
restaurants and businesses infringe
upon personal rights?
163
Case No. 3: Pelman v. McDonald’s
In the 2003 case Pelman v. McDonald’s, two teens
and their guardians filed a lawsuit against the fast
food chain claiming that McDonald’s food caused
obesity and increased the teens’ risk of other related
diseases such as heart disease and diabetes. In the
suit, the two girls claimed that the restaurant did not
disclose the ingredients of its foods and the effects
of eating such foods high in fat, salt, sugar, and cho-
lesterol. This was considered a landmark case in
the blame game of obesity. As thousands of people

struggle with weight, lifestyles, and the temptation
to eat unhealthy fast food, the nation watched this
case closely to see if the legal system could deter-
mine a root cause for the U.S. obesity epidemic.
The girls were Ashley Pelman and Jazlyn Bradley. At the time
of the suit, 14-year-old Ashley
Pelman was 4 feet, 10 inches tall and weighed 170 pounds, with
a BMI of 35.5. Jazlyn Brad-
ley, 17 years old, was 5 feet, 6 inches tall and weighed 270
pounds, with a BMI of 43.6 (Wald,
2003). The girls and their parents argued that McDonald’s
should be held accountable for
the girls’ obesity, heart disease, diabetes, high blood pressure,
and elevated cholesterol. At
the same time, several other cases were in the works. Caesar
Barber, 56 years old, was suing
McDonald’s, Wendy’s, Kentucky Fried Chicken, and Burger
King for causing his two heart
attacks and diabetes (Wald, 2003).
The U.S. District Court, Southern District of New York, heard
both sides of the argument in
2003 and ruled in favor of McDonald’s. The legal basis for the
case came when the teens
alleged negligence on behalf of McDonald’s, stating that the
restaurant distributed a prod-
uct “that is so dangerous that its danger is outside the
reasonable understanding of the con-
sumer” (Pelman v. McDonald’s, 2003, p. 19). The court found
this to be untrue, as the products
in question were fully approved by the FDA and abided by laws
such as food labeling and
general requirements for health claims for foods. Furthermore,
the plaintiffs had noted in
court that they primarily ate at McDonald’s but not wholly,

leaving room for questions about
the remainder of their diets.
In the final judgment, the court stated that this was not a case of
product liability, but one of
overconsumption of products whose ingredients are widely
known and available.
From an ethical standpoint, this case is intriguing because the
plaintiffs focused on blame
rather than personal responsibility. As issues crop up within the
realm of ethics and morals,
people tend to look outward rather than inward for a cause.
Some would say this case was
a waste of judicial resources when the individuals should have
been focusing on their own
health. Is this a trend in the United States? Are people now
looking for someone to blame for
their health issues instead of focusing on personal
responsibility?
KatarzynaBialasiewicz/iStock/Thinkstock
Are fast food restaurants accountable
for an individual’s weight issues, or is
the individual ultimately responsible
for his or her food choices?
164
Section 5.4 Policy and Law

5.4 Policy and Law
Although the terms policy and law are often used
interchangeably, the two are very different.
A policy is a strategy or commitment to some type of action
plan in the best interests of the
general population. It often outlines a course of action that
governmental bodies put together
to achieve some long-term goal. A law is an enforceable piece
of legislation that must happen
and must be followed; if it is not followed, consequences will
occur.
In public health, a policy typically includes laws, rules, and
regulations that achieve the over-
arching goal. However, the policy in itself is not an enforceable
law. A policy typically starts
with what is known as a policy brief. A brief is a summary of an
issue that is being reviewed,
the potential laws and action items that could tackle the
problem, and recommendations on
which would be the best approach (Food and Agricultural
Organization of the United Nations,
n.d.). Frankly, there is nothing brief about a policy brief.
There are two types of policy briefs: an advocacy brief and an
objective brief (Public Health
Law Center, 2015). The advocacy brief is a document that
shows one side of an issue, typi-
cally in favor of a particular course of action. The objective
brief provides both sides of an
issue, leaving the policy maker the opportunity to see all angles
and make up his or her mind
independently of the brief ’s author.
The policy brief provides lawmakers with an initial, complete
view of the potential laws and

actions that could address the overarching goal. If the policy
brief is accepted in whole, all
of the recommendations will eventually work their way into
legislation. In some cases, only
parts of a policy brief will be accepted and some of the
recommendations will become laws.
The next section explores how policies and laws work together
in the public health realm.
Policy to Law in Action
Public health professionals have developed numerous advocacy
and objective briefs in an
attempt to reduce the use of tobacco products. The overarching
goal in the public health realm
is to reduce the incidence of tobacco-related illnesses and
deaths. To achieve this goal, laws
must be in place to enforce healthy behaviors. As noted earlier,
sometimes the health of the
whole trumps the rights of the individual. When reviewing the
issue of tobacco control and/
or elimination, public health professionals focus their attention
on research that supports
their view (advocacy policy) or that brings to light various
alternatives (objective policy).
While a policy brief would be written in paragraph form as a
document, Figure 5.2 is a hypo-
thetical outline, including examples of what might be included
in a policy brief.
165

A goal, a goal statement, and actions that would help reach that
goal are required elements
of an effective policy brief that could eventually become law. In
fact, the hope is that those
actions would become supportive of the overall goal. A policy
brief is only a suggested list of
items. As each item becomes law, it is an enforceable set of
rules.
In reality, some, but not all, of these suggested policy actions
have become laws. Prohibiting
or eliminating tobacco manufacturing in the United States
would have created an economic
upheaval. The last four bullet points in the policy actions
section of Figure 5.2 did become law.
Figure 5.2: Policy brief outline
A policy brief is anything but brief, so this figure offers a
condensed view. It shows the goals of a
proposed policy, a policy statement, and actions—some of the
key elements involved in developing a
policy brief—for a tobacco example.
• Reduce tobacco deaths and illness
• Eliminate the use of tobacco products
• Enact tobacco controls that reduce or eliminate
the prevalence and incidence of tobacco
(smoking, chewing, etc.)

• Prohibit or limit the production of tobacco products in the
U.S.
• Pass smoke-free ordinances for public spaces
• Restrict tobacco advertising
• Limit the age for tobacco product purchases
• Set minimum pricing for cigarettes and other tobacco products
Goal
Policy brief goal statement
Policy actions
166
The removal of all tobacco manufacturers has been pondered
numerous times in history. Bear-
man, Neckerman, and Wright (2011) discovered that there
would be a significant economic
collapse if the tobacco industry were required to cease
operating. While smoking reduction
would certainly save lives, the billions of dollars in economic
revenue would significantly
hurt the United States. Furthermore, tobacco manufacturers

donate a significant amount of
money to public health and community development programs.
For example, between 1997
and 2005, $143 billion was donated to charity from tobacco
companies; 42% of that went into
public and community funds. That money would no longer be
available if the tobacco indus-
try collapsed (Bearman et al., 2011).
Refer to Spotlight on Public Health Figures for information
about a notable public health advo-
cate from the 1800s, Sir Edwin Chadwick. His work helped to
improve laws associated with
living conditions among the poor in England.
Spotlight on Public Health Figures:
Sir Edwin Chadwick (1800–1890)
Who is Sir Edwin Chadwick?
Sir Edwin Chadwick was born in Manchester, England, in
1800. As a young boy, he was encouraged by his father to
read, especially radical authors such as Thomas Paine. As
a result of his father’s urging and interest in radical ideals,
Chadwick decided to study law. He was not wealthy, so
he funded his college education by writing for various
publications on the topics of social change and the need
for political reform. Chadwick spent his entire life focused
on reforming the national laws regarding the poor.
What was the political climate at the time?
The 1800s ushered in the Victorian era in Britain. Under
Queen Victoria’s rule, Britain became the largest empire
in the world and a mecca of financial security, and many
people felt it a privilege to be ruled by such a great
leader. Britain’s empire at the height of the Victorian age
extended to about one fifth of the world’s population.

But Chadwick did not see Britain as the world’s greatest
nation due to its significant number of public health
concerns. Cities were growing and becoming far more
crowded and unsanitary. Cholera was a major issue
during this time. Typhoid was another concern, and
major cities in England experienced typhoid epidemics in
1837 and 1838. At the time, public health and sanitation
were not keeping up with the cities’ growth spurts,
and living conditions (especially among the poor) were
directly causing poor health outcomes.
(continued)
Renfields_Garden/iStock/Thinkstock
Sir Edwin Chadwick lived in
Victorian England, when cities
were crowded and conditions were
often unsanitary. Sir Chadwick
supported reforms and measures
that improved living conditions
among the poor.
167
Public Health Laws
All public health laws start as policies. Some are in depth and
controversial, like the law of
Prohibition, which was eventually revoked, and others are
rather easily adopted, such as

those regarding child safety seats. Public health laws focus on
protecting the population as a
whole or reducing injury, illness, and death. The following are a
handful of the thousands of
public health laws that have been keeping people in the United
States safe for decades.
Prohibition
In the 1920s, alcohol use and abuse was brought to the forefront
of the country’s public
health concerns. While the concept was well intended—reduce
drinking and eliminate issues
Sir Edwin Chadwick (1800–1890) (continued)
What was his contribution to public health?
Chadwick was one of the most influential public health activists
of the 1800s. He was most
passionate about political and social reform, which led him to
investigate living conditions
and poor sanitation. He pushed for social reforms and measures
to improve ventilation,
draining, and cleanliness of living conditions in order to build a
happier community.
Although he was a firm believer in miasma theory (which
suggests all infectious diseases are
spread through the air), he still focused his efforts on improving
the living conditions of the
poor to improve the overall health of England. Although Dr.
John Snow proved that miasma
theory was incorrect, Chadwick still focused on the link
between poor living conditions and
life expectancy.
What motivated him?

As a lawyer, Chadwick believed he had significant power to
effect change at the political
and social levels. He leveraged this power to push through
social improvements in England
during the 1800s. He focused his attention on changing the Poor
Law, which was a Victorian-
era law that called for all parishes (local church communities)
to take care of the poor by
providing food, clothing, money, and housing. In those times, it
was well known that the
housing provided was subpar and contributed to poor health
outcomes. Chadwick’s activism
directly contributed to the development and passage of the 1834
Poor Law Amendment Act,
which improved conditions in workhouses and provided food
and clothing to all who resided
in such housing.
Sources: Bloy, M. (2002). The 1601 Elizabethan Poor Law.
Retrieved from
http://www.victorianweb.org/history/poorlaw/elizpl.html
Evans, E. (2011). Overview: Victorian Britain, 1837-1901.
Retrieved from
http://www.bbc.co.uk/history/british/victorians/overview
_victorians_01.shtml
National Archives Education Service. (n.d.). 1834 Poor Law.
Retrieved from http://www.nationalarchives.gov.uk/documents
/education/poor-law.pdf
Science Museum. (n.d.). Edwin Chadwick (1800-90). Retrieved
from
http://broughttolife.sciencemuseum.org.uk/broughttolife/people
/edwinchadwick
Trueman, C. N. (2015). Edwin Chadwick. Retrieved from
https://www.historylearningsite.co.uk/a-history-of-
medicine/edwin-chadwick/

http://www.victorianweb.org/history/poorlaw/elizpl.html
http://www.bbc.co.uk/history/british/victorians/overview_victor
ians_01.shtml
http://www.bbc.co.uk/history/british/victorians/overview_victor
ians_01.shtml
http://www.nationalarchives.gov.uk/documents/education/poor-
law.pdf
http://www.nationalarchives.gov.uk/documents/education/poor-
law.pdf
http://broughttolife.sciencemuseum.org.uk/broughttolife/people/
edwinchadwick
http://broughttolife.sciencemuseum.org.uk/broughttolife/people/
edwinchadwick
https://www.historylearningsite.co.uk/a-history-of-
medicine/edwin-chadwick/
168
connected to alcoholism—it violated individual rights far more
than expected. The outcry and
underground operation of alcohol distillation and sales that
followed were extensive.
Prohibition was clearly outlined in the 18th Amendment to the
U.S. Constitution. It originally
had a time limit for ratification, which was later removed. The
remainder of the law contained
the following:
Section 1. After one year from the ratification of this article the

manufacture,
sale, or transportation of intoxicating liquors within, the
importation thereof
into, or the exportation thereof from the United States and all
territory subject
to the jurisdiction thereof for beverage purposes is hereby
prohibited.
Section 2. The Congress and the several States shall have
concurrent power to
enforce this article by appropriate legislation.
Section 3. This article shall be inoperative unless it shall have
been ratified as
an amendment to the Constitution by the legislatures of the
several States, as
provided in the Constitution, within seven years from the date
of the submis-
sion hereof to the States by the Congress. (State University of
New York, 2018)
Leaders of the prohibition movement felt that a solid
educational campaign would lead to a
sober nation. It did work, as alcohol consumption dropped by
30% after the law went into
effect (Ohio State University, 2018). What wasn’t considered
was the ethical nature of such a
law. How ethical was it to prohibit the consumption of a
product? This was an ethical dilemma
that involved both individuals and alcohol producers, who were
not included in the decision
to create the prohibition law.
Of interest, the 18th Amendment did allow for alcohol use when
prescribed by a doctor, and
it could be used for religious purposes and scientific reasons.

To expand on the concepts
included in the 18th Amendment, the Volstead Act was written
(Hanson, 2018). The 25 pages
of the Volstead Act outlined what was legal and what was
illegal. (Refer to A Closer Look for
more about the dos and don’ts in the Volstead Act.)
Prohibition lasted from 1920 to 1933, at which time repeal laws
began. The 21st Amendment
to the Constitution ended Prohibition on December 5, 1933. It is
the only amendment in U.S.
history that has ever been repealed.
169
Speed Limits
Speed limits originally provided information on road hazards
rather than driver protection.
For example, slower speed limits indicated to the driver that the
road was winding or perhaps
bumpy (Edwardson, 2002). As time passed and the safety of
drivers and passengers became
critical, the focus on speed limits was aligned more with
personal safety—a public health
concern.
The first type of speed limit began in the colony of New
Amsterdam (now known as New York
City). In 1652, a decree was issued stating that “no wagons,

carts or sleighs shall be run, rode
or driven at a gallop” or people would incur a fine equivalent to
about $150 in today’s money
(History Channel, 2018, para. 2). When the motorized vehicle
hit the roads, there was no such
thing as a “gallop” for these types of transportation, thus
leading to the advent of speed limit
legislation.
A Closer Look: The Volstead Act: An Explanation of
Prohibition
The Volstead Act was written to clarify the 18th Amendment. It
focused on what a person
could and could not do in relation to alcohol consumption and
purchase. Here are a few of
the dos and don’ts outlined in the Volstead Act:
Legal:
• Drinking alcohol in your home or at a friend’s home
• Buying alcohol with a medical prescription (one pint every 10
days)
• Obtaining a permit to move alcohol if changing residences
• Obtaining a permit to manufacture, sell, or transport alcohol if
used for sacramental
or non-beverage use
Illegal:
• Carrying a hip flask
• Giving alcohol as a gift
• Taking or drinking alcohol in public places such as restaurants
and hotels
• Buying or selling homemade alcohol

• Shipping alcohol to anyone for beverage use
Source: Adapted from “Prohibition Laws and Repeal Laws in
the U.S.” [web post], by D. J. Hanson, 2018, in Alcohol
Problems and
Solution
s (https://www.alcoholproblemsandsolutions.org/volstead-act-
national-prohibition-act-of-1919/). Copyright 1997–2015
by D. J. Hanson, State University of New York.
https://www.alcoholproblemsandsolutions.org/volstead-act-
national-prohibition-act-of-1919/
170
Connecticut was the first state to pass a speed limit law, in
1901. All motor vehicles were

required to drive a maximum speed of 12 mph in all cities, and
15 mph on other roads. Two
years later, New York City adopted the world’s first
comprehensive traffic code. William
Phelps Eno, known as the father of traffic safety, developed the
code and later also traffic
plans for New York City, London, and Paris. He was also
credited with inventing stop signs,
one-way streets, taxi stands, traffic circles, and pedestrian
safety islands—all in the name of
public health safety (Eno Center for Transportation, n.d.-a).
Refer to Spotlight on Public Health
Figures for more about Eno’s contributions to public health.
William Phelps Eno (1858–1945)
Who is William Phelps Eno?
Eno, known as the father of traffic safety, was a
pioneer of traffic control and regulation. Born
on June 3, 1858, in New York City, Eno was
raised in a wealthy family of businessmen and
politicians. He graduated from Yale University,
started his career in the family’s real estate
business, and later followed his interests into

public transportation.
What was the political climate at the
time?
At the time, Eno was focused on transportation,
the United States had established itself as a
world power, the entire continent had been
settled, and the war with the American Indians
seemed to be over. American society was
focused on industrial capacity, especially in the production of
steel, as well as the newly
invented gas-powered engine car. Telephones were widely used,
and access to electricity was
spreading across the country. The United States triumphed in
the Spanish-American War
of 1898. President William McKinley was assassinated in
1901—at which time Theodore
Roosevelt assumed the office.
Eno was the first person to create transportation safety rules. He
called them “rules of the
road.” Adopted by New York City in 1909, these rules
constituted the world’s first city traffic
plan. Eno popularized stop signs, pedestrian safety islands, and

other safety features that are
still used today for traffic control.
(continued)
ClassicStock.com/SuperStock
William Phelps Eno created some of
the earliest traffic rules and features,
such as stop signs and pedestrian
islands, to enhance transportation
safety.
171
Safety and speed limit laws were slowly adopted across the
United States. Only 28 states had
such laws by 1930 (American Safety Council, 2014). In 1974,
President Richard Nixon signed

a national law requiring a maximum speed limit of 55 mph
(American Safety Council, 2014).
By this point, public health was driving the move to limit
automotive speed. The 1970s oil and
gas shortage also spurred conservation measures to reduce the
consumption of gas and oil.
Both efforts had the public health benefit of successfully
reducing traffic fatalities from 4.28
million in 1972 to 2.73 million in 1983 (American Safety
Council, 2014). In 1987, speed limits
were increased nationally to 65 mph, and later, the National
Highway System Designation Act
of 1995 repealed the national speed limit, allowing states to
control their own speeds. This is
why some states allow 70 mph maximum speeds when others
still limit the speed to 55 mph.
There is an ongoing debate about freedom versus regulation in
terms of speed limits. Since
the 1995 act, which allowed traffic speeds to be determined at
the state level, the num-
bers of fatalities on highways that allow a maximum speed
above 65 mph have gradually
increased, as shown in Figure 5.3. Public health safety
professionals are still tackling the

issue of speeding—more than 300 years after it was first
addressed in the U.S. colonies.
William Phelps Eno (1858–1945) (continued)
What motivated him?
When he was 9, he and his mother were caught in a traffic jam
of horses and carriages in
New York City. The jam was created by a lack of order at an
intersection—no one knew who
had the right of way. That specific event remained with Eno for
years. He felt that increased
traffic resulted in increased confusion. He took it upon himself
to develop a traffic plan,
which was the beginning of what is now known as the rules of
the road. Eno never learned
how to drive, but he was issued an honorary driver’s license.
Sources: Blazeski, G. (2016, November 16). The man who
invented stop signs, one-way streets, never passed his driving
test. The Vintage
News. Retrieved from
https://www.thevintagenews.com/2016/11/16/the-man-who-
invented-stop-signs-one-way-streets-never

-passed-his-driving-test/
Eno Center for Transportation. (n.d.). William Phelps Eno.
Retrieved from https://www.enotrans.org/about-eno/mission-
history/
Library of Congress. (n.d.). America at the turn of the century:
A look at the historical context. Retrieved from
https://www.loc.gov
/collections/early-films-of-new-york-1898-to-1906/articles-and-
essays/america-at-the-turn-of-the-century-a-look-at-the
-historical-context/
invented-stop-signs-one-way-streets-never-passed-his-driving-
test/
invented-stop-signs-one-way-streets-never-passed-his-driving-
test/
https://www.enotrans.org/about-eno/mission-history/
https://www.loc.gov/collections/early-films-of-new-york-1898-
to-1906/articles-and-essays/america-at-the-turn-of-the-century-
a-look-at-the-historical-context/

172
School Vaccination
Before 1922, children did not have to be vaccinated to attend
school. As noted in Chapter 3,
communicable diseases were common until vaccines were
invented to prevent them. Vac-
cines have created herd immunity, which protects the public
from these diseases. Schools
contain hundreds and sometimes thousands of people gathered
in one place. This is a breed-
ing ground for communicable diseases, and without vaccines,
illnesses would spread easily
and quickly.
All 50 states require vaccinations for children to attend either

public or private school. There
are some exceptions based on religious and medical reasons.
But if herd immunity is achieved,
then population protection holds despite these exceptions.
However, in cases where there is
not herd immunity, a disease outbreak can occur. An example of
this is the 2014 measles out-
break in California that affected hundreds of children (Barraza,
Schmit, & Hoss, 2017). The
cause? There were too many exceptions to the vaccination rule.
Since then, stricter rules on
exemptions have been exacted across nearly every state.
Figure 5.3: Speeding-related fatalities by speed limit, 1983–
2002
Since the National Highway System Designation Act of 1995,
which allowed traffic speeds to be
determined at the state level, the numbers of fatalities on
highways that allow a maximum speed above
65 mph have gradually increased. It may be important to revisit
the law and create a standard across the
United States.
Source: Adapted from “Analysis of Speeding-Related Fatal

Motor Vehicle Traffic Crashes,” by Department of
Transportation, 2005
(https://safety.f hwa.dot.gov/speedmgt/data_facts/).
Year
50 mph and below 55 mph 60–65 mph Above 65 mph
N
u
m
b
e
r
o
f
fa
ta
li
ti

e
s
1980 1985 1990 1995 2000 2005
10,000
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000

0
https://safety.fhwa.dot.gov/speedmgt/data_facts/
173
The impact of vaccinations is astounding and considered one of
the biggest accomplish-
ments of public health. But the law played an important role in
this triumph. It is important to
remember that once vaccines became available, they were not
legally required. To eradicate
various diseases, public health professionals petitioned
lawmakers with policy briefs, which
outlined the various actions that would lead to their stated goal.
One of those key actions was
the requirement of vaccinations. Thus began an era of reduced
infectious diseases and the

eradication of many others. Table 5.4 shows the decline from
the 20th century to the year
2000 (the start of the 21st century).
Table 5.4: Comparing historical and current morbidity of
vaccine-preventable
diseases of children in the United States
Disease
Annual morbidity
Percentage
decreaseDuring the 20th century* 2000
Smallpox 48,164 0 100
Diphtheria 175,885 4 99.99
Measles 503,282 81 99.98
Mumps 152,209 323 99.80
Pertussis 147,271 6,755 95.40

Polio (paralytic) 16,316 0 100
Rubella 47,745 152 99.70
Influenza type B 20,000 167 99.10
*Typical average during the 3 years before vaccine licensure.
Source: Adapted from “Vaccine Mandates: The Public Health
Imperative and Individual Rights,” by K. M. Malone and A. R.
Hinman,
in R. A. Goodman, R. E. Hoffman, W. Lopez, G. W. Matthews,
M. Rothstein, and K. Foster (Eds.), Law in Public Health
Practice (2007,
pp. 338–360). Oxford, England: Oxford University Press.
Seat Belts
Title 49 of the United States Code, Chapter 301, Motor Vehicle
Safety Standard, required the
installation of seat belts in all vehicles with the exception of
buses (U.S. Code, Title 49 – Trans-
portation, 2009). That law went into effect on January 1, 1968;
however, the requirement to
use seat belts did not occur until the mid-1980s, almost 20 years
later.

The National Highway Traffic Safety Administration (2000)
reported the effects of the law on
fatalities and found some astounding results, as shown in Table
5.5. Since the inception of the
seat belt law, the nation has seen a tremendous reduction in
motor vehicle accident deaths.
This is yet another way the law is intertwined with public
health.
174
Vehicle Emissions
Clean air responsibilities also fall into the public health realm.
Poor air quality has caused
various respiratory diseases such as asthma and lung cancer. It
has also been connected to
cardiovascular diseases, adverse pregnancy outcomes such as

preterm birth or death, and a
lower quality of life (National Institutes of Health, 2017a).
When motor vehicles were invented, no one truly thought about
the consequences of air pol-
lution. After World War II, economic growth, rapid
suburbanization, and an extensive trans-
portation boom led to a significant increase in air pollution. It
wasn’t until the Clean Air Act of
1970 that public health officials began focusing on regulating
pollution from cars, trucks, and
other forms of transportation (EPA, 2017).
The Clean Air Act was a success because it not only set the bar
for strict regulations on car
emissions, but also laid the foundation for policies and laws to
guide future standards for
cleaner air. As a direct result of the 1970 act, new passenger
vehicles were 98%–99% cleaner,
in terms of tailpipe emissions, than their 1960s counterparts.
Fuels have also become cleaner
because of the elimination of lead and sulfur levels. Cities have
seen significant air quality
improvements despite an increase in population and vehicle
miles traveled daily. This also

has led to more pollution-reducing laws and policies across
various industries that release
pollution into the air. See Figure 5.4 to compare emissions from
1980 to 2015.
Table 5.5: Fatalities of belted and unbelted drivers and
passengers, 1977–1985
Driver died, front
passenger survived
Driver survived, front
passenger survived Both died
Both unbelted 11,186 11,469 5,317
Driver unbelted, passenger belted 300 152 74
Driver belted, passenger unbelted 186 487 102
Both belted 497 653 242
Note: n = 30,665 vehicles
Source: Adapted from Fatality Reduction by Safety Belts for

Front-Seat Occupants of Cars and Light Trucks (Report No. 809
199),
by National Highway Traffic Safety Administration, 2000,
Washington, DC: U.S. Department of Transportation.
175
National School Lunch Program
In 1946, providing nutritionally balanced, low-cost or free
lunches to children K–12 in both
public and private schools every day became a requirement
(U.S. Department of Agriculture
[USDA], 2017a). The lunch program started as an effort to help
feed children who lived in
poverty. In fact, the effort of school lunches (and now
breakfasts) began following the 1904
publication of a book by Robert Hunter called Poverty (USDA,
2017b). This book, which exam-

ined widespread hunger among children, had a strong influence
on the U.S. decision to work
within the school systems to bring nutritional lunches to
poverty-stricken students (USDA,
2017b).
Figure 5.4: Comparison of growth areas and emissions, 1980–
2015
The choices we make can affect air pollution. For example,
emissions increase as more vehicles are on
the roads or the population increases. Emissions also increase
along with the gross domestic product.
This is a significant problem that is currently being reviewed at
local, state, and federal levels (but clean
air policies have also contributed to air quality improvements).
Source: Adapted from “History of Reducing Air Pollution From
Transportation in the United States (U.S.),” by Environmental
Protection
Agency, 2017 (https://www.epa.gov/air-pollution-
transportation/accomplishments-and-success-air-pollution-
transportation).
Vehicle miles traveled

Gross domestic product Population
Aggregate emissions
(six common pollutants)
CO2 emissions
Energy consumption
P
e
rc
e
n
t
g
ro
w
th
Year

1980 1985 1990 1995 2000 2005 2010 2015
153%
106%
41%
25%
18%
-65%
160%
140%
120%
100%
80%

60%
40%
20%
0%
-20%
-40%
-60%
-80%
https://www.epa.gov/air-pollution-
transportation/accomplishments-and-success-air-pollution-
transportation
176

It wasn’t until more than four decades after the publication of
Poverty that policy makers
stepped in to make school lunch programs a requirement. About
7.1 million children partici-
pated in the program in its first year (USDA, 2017a). Since
then, the program has blossomed,
bringing much-needed food to children across the country.
Figure 5.5 shows how participa-
tion levels have risen since 1970.
Figure 5.5: National participation levels of school lunch
programs
About 7.1 million children participated in the National School
Lunch Program in its first year. Since
then, the program has blossomed, bringing much-needed food to
children across the country. This graph
shows participation rates over time.
Source: Adapted from “National School Lunch Program,” by
U.S. Department of Agriculture, 2017 (https://fns-
prod.azureedge.net/sites

/default/files/cn/NSLPFactSheet.pdf ).
Year
P
a
rt
ic
ip
a
ti
o
n
i
n
m
il
li
o

n
s
35
30
25
20
15
10
5
0
1960 1970 1980 1990 2000 2010 2020
22.4
26.6

21.1
27.3
31.8
30.4
Without the law, school lunch programs might not have ever
become a school requirement.
Poverty has been associated with poor health outcomes and,
therefore, has been a topic of
public health for decades. Laws that implement programs such
as this one have helped to
eliminate some of that burden.
https://fns-
prod.azureedge.net/sites/default/files/cn/NSLPFactSheet.pdf
https://fns-
prod.azureedge.net/sites/default/files/cn/NSLPFactSheet.pdf
177

The law now includes a nutrition standard for those meals
served at school, which was
approved in January 2012 (USDA, 2012). Under this rule,
schools are required to:
• Offer fruits and vegetables as two separate
meal components;
• Offer fruit daily at breakfast and lunch;
• Offer vegetables daily at lunch, includ-
ing specific vegetable subgroups weekly
(dark green, orange, legumes, and other
as defined in the 2005 Dietary Guidelines)
and a limited quantity of starchy vegetables
throughout the week;
• Offer whole grains: half of the grains would
be whole grain-rich upon implementation
of the rule and all grains would be whole-
grain rich two years post implementation;

• Offer a daily meat/meat alternate at
breakfast;
• Offer fluid milk that is fat-free (unflavored
and flavored) and low-fat (unflavored only);
• Offer meals that meet specific calorie ranges for each
age/grade group;
• Reduce the sodium content of meals gradually over a 10-year
period through two
intermediate sodium targets at two and four years post
implementation;
• Prepare meals using food products or ingredients that contain
zero grams of trans
fat per serving;
• Require students to select a fruit or a vegetable as part of the
reimbursable meal;
• Use a single food-based menu planning approach; and
• Use narrower age/grade groups for menu planning. (USDA,
2012, p. 4088)
The rule also requires state agencies to:

• Conduct a nutritional review of school lunches and breakfasts
as part of the adminis-
trative review process;
• Determine compliance with the meal patterns and dietary
specifications based on a
review of menu and production records for a two-week period;
and
• Review school lunches and breakfasts every 3 years,
consistent with the HHFKA
[Healthy Hunger-Free Kids Act]. (USDA, 2012, pp. 4088–4089)
There are numerous laws and regulations for school food
programs, but these are the larger
ones that affect all lunch and breakfast programs now served in
K–12 schools around the
United States.
JGI/Jamie Grill/Blend Images/SuperStock
School lunch programs can help ensure
that all children, especially those
who live in poverty, have access to
nutritious foods on school days.

178
Summary & Resources
Summary & Resources
Chapter Summary
Ethics and the law work in conjunction with public health. In
fact, some would say that public
health couldn’t exist without the law. This chapter covered a
fraction of public health law and
policy concerns; there are thousands more instances where the
law has stepped in to help the
public health realm.
Ethics are the principles that govern a person’s behavior; they
are rules provided by an exter-
nal source, such as codes of conduct in a workplace. Morals are
an individual’s principles
of right and wrong. They inform standards of behaviors or

beliefs concerning acceptable
behavior for individuals. The code of ethics for public health
practitioners provides details on
how public health utilizes all of these concepts in its decision-
making process. The Principles
for the Practice of Public Health Ethics, developed by the
Public Health Leadership Society, is
the foundational document used by nearly all public health
professionals and public health–
focused organizations. Most decisions are not cut and dried and
require a significant amount
of critical thought in application to the ethical practice of public
health. The code provides a
blueprint for reviewing all issues before decisions are made.
Ethics and the law can clash considerably, and the courts have
faced numerous cases where
personal rights and public protections needed to be considered.
The Jacobson v. Massachu-
setts case illustrated the tension between personal freedom and
public health protections
in compulsory vaccinations. The New York State soda ban,
which was repealed before it was
enacted, exemplified personal choice versus governmental
interference. Personal responsi-

bility in nutrition was highlighted in Pelman v. McDonald’s, in
which two teens claimed the fast
food chain made them fat. Public health’s role is to intercede
when the population’s health is
at risk. Sometimes, that conflicts with a person’s morals or a
community’s ethics. But public
health works to improve population well-being by following
community-based, rather than
individual, ethics.
Policy and law are also key elements in the administration of
public health. A policy is a docu-
ment that outlines what an organization or government agency
is planning to do for the popu-
lation. It is not a law, but it can become a law if it is approved
by Congress and signed by the
president. Laws, such as wearing a seat belt while driving a car,
help protect the population.
Policies provide the background to support such laws. For
instance, a community may have a
policy to provide fresh fruit to all local stores but may not be
able to fully act on it depending
on a number of variables (transportation, the agricultural
industry, cost, etc.). One example
of the transformation from policy to law is limits on tobacco

use. To reduce smoking, a policy
might be to dismantle the tobacco industry. Because of the
surrounding ethical issues, this
type of policy is unlikely to become a law. However, some
tobacco policies—such as no smok-
ing in public places—have become law in many states. There
are many policies that have
become law in the public health realm, including speed limits,
limits on vehicle emissions, and
the National School Lunch Program.
179
Summary & Resources
Critical Thinking and Review Questions
1. What is the difference between morals and ethics?
2. What role does ethics play in public health?
3. What does the Public Health Code of Ethics mean for public

health? For the general
population?
4. Consider the Principles of the Ethical Practice of Public
Health, developed by the
Public Health Leadership Society. Explain at least two of the
principles and why you
believe they were included in this document.
5. In reviewing the Jacobson v. Massachusetts case, why do you
think that Jacobson
believed his personal rights were violated?
6. If we are given personal freedoms as per the U.S.
Constitution, why do some laws
seemingly remove that freedom by requiring us to behave in a
specific way (no
smoking in public places, wearing a helmet while riding a
motorcycle)?
7. What is the difference between a policy, a policy brief, and a
law?
8. Explain one example of how the law is used in public health.
9. Consider one area of need in your community. How could a

law or policy help to
address that issue?
10. Consider William Phelps Eno’s work in traffic control. Do
you think it has been effec-
tive? How could it be improved?
Additional Resources
Case laws of interest
https://biotech.law.lsu.edu/cases/food/index.htm
Review court cases that focus on food safety and ethics.
The CDC ethics cases and curriculum
https://www.cdc.gov/od/science/integrity/phethics/resources.ht
m
The Centers for Disease Control and Prevention provides open
access to public health ethics
cases and curriculum.
United Nations Universal Declaration of Human Rights

http://www.un.org/en/universal-declaration-human-rights/
This is the Universal Declaration of Human Rights as outlined
and approved by the United
Nations. It is an ethical statement of what countries in the
United Nations have agreed upon
in regard to human rights.
https://biotech.law.lsu.edu/cases/food/index.htm
https://www.cdc.gov/od/science/integrity/phethics/resources.ht
m
http://www.un.org/en/universal-declaration-human-rights/
180
Summary & Resources
Key Terms
advocacy brief A policy document that
shows one side of an issue, typically in favor
of a particular course of action.

clinical ethics Ethics addressing issues that
arise within the patient care realm.
ethics The principles that govern a person’s
behavior, as provided by an external source
such as codes of conduct in a workplace or a
community.
law An enforceable piece of legislation that
must happen and must be followed; if it is
not followed, consequences will occur.
morals An individual’s principles of right
and wrong.
objective brief A policy document that pro-
vides both sides of an issue, leaving the pol-
icy maker the opportunity to see all angles
and make up his or her mind independently.
policy A strategy or a commitment to some
type of action plan that will tackle an issue
and could potentially become law.
policy brief A concise summary of an issue

that is being reviewed that includes several
recommendations that may become indi-
vidual policies.
research ethics Ethics involving the pro-
tections of human subjects who are taking
part in a study.
8 Advocacy and Resource Allocation
xxcheng/iStock/Thinkstock
Learning Outcomes
After reading this chapter, you should be able to
• Differentiate between advocacy and lobbying.

• Explain the use of data and media for public health initiatives.
• Examine the importance of resources in public health
advocacy.
266
Section 8.1 Effecting Change in Public Health
This chapter highlights the importance of public health
advocacy and resource allocation.
In fact, public health professionals use advocacy far more often
than lobbying. It is rare for
public health professionals, particularly those working for
health departments, to lobby at all.
While lobbying and advocacy are closely related, lobbyists are
paid professionals and advo-
cates are not. This chapter will discuss the key differences
between lobbying and advocacy
and examine the purpose behind public health’s use of one

versus the other. Public health
data is used for both advocacy and media attention. While this
chapter focuses more on advo-
cacy work, it is important to recognize that advocates can
receive evidence from data that
supports their side of an argument or their point to enact a
policy. This chapter will explain
some of those uses, in addition to examining resource allocation
and its importance to the
public health realm.
8.1 Effecting Change in Public Health
The terms advocacy and lobbying are often used
interchangeably, but they are distinctly dif-
ferent. Advocacy seeks to affect society—to change a belief or
behavior, or convince individu-
als to act or not act on an issue. Lobbying is typically an act by
special interest groups or
industries to attempt to convince Congress to enact legislation
on a particular topic. In public
health, it is rare to find a lobbyist. While individuals in the role
are important to effecting
change in legislation, public health finds itself more aligned
with initiatives to create change
in population behaviors, regardless of whether the initiative is a

law or a recommendation. In
this regard, advocacy work is the key, and one of the most
important elements, for successful
public health endeavors that reach large populations.
The Role of Research
Research into health issues can often translate into advocating
for improvements in the pub-
lic’s health, from developing healthy eating habits to
eliminating behaviors that can lead to
poor health. For example, it wasn’t until piles of research
finally uncovered the link between
smoking and cancer that public health professionals advocated
for tobacco control (see A
Closer Look). When the law was proposed, lobbyists would
have likely come from tobacco
companies to oppose it because it would affect sales. In this
case, advocacy was focused on
simply changing the public’s behavior through regulation of any
sort, while lobbying focused
on specifically stopping the passage of the particular act.

267
A Closer Look: The Family Smoking Prevention and Tobacco
Control Act
The Family Smoking Prevention and Tobacco Control Act is
considered the most
comprehensive federal initiative against smoking since 1971,
when radio and TV advertising
for tobacco products was banned (Manz, 2009). What drove the
act into existence was
research that showed the following staggering statistics in 2009:
• 21% of American adults smoke cigarettes
• 23% of high school students smoke cigarettes
• 438,000 deaths each year can be attributed to smoking
Where did those statistics come from? Public health research!
As research continued to
show smoking caused poor health issues, including death, so did
advocacy efforts to make

a rapid and positive change. Advocates from numerous
agencies, including the American
Public Health Association, American Cancer Association, and
American Lung Association,
campaigned for stronger controls on tobacco. In a collective
effort, these advocates wrote
letters and attended meetings and official briefings in front of
legislators across the nation.
While that may appear similar to lobbying, the advocacy
methods used did not necessarily
support any legislation. Lobbying efforts, on the other hand,
would have specifically asked
Congress to pass that particular law. And it is likely that some
lobbying efforts were done in
that regard. The advocacy efforts were simply for stronger
policies on tobacco control. The
end result was this act.
Another driving force behind the law was the “endless series of
multimillion-dollar lawsuits
filed by individuals against major tobacco companies” (Manz,
2009, p. 2). Furthermore,
Medicaid, health insurance for low-income individuals in the
United States, was footing the
bill of more than $360 billion for more than 25 years

of treating illnesses from tobacco use (Manz, 2009).
Considering that Medicaid is paid by the tax dollars of
all Americans, it was a significant chunk of money for
U.S. residents to pay—whether they smoked or not.
Thanks to the advocacy work of public health
professionals as well as nonprofit organizations
vested in smoking cessation (such as the American
Lung Association), there is now regulation on the
manufacturing, distribution, and marketing of tobacco
products. The act does the following:
• Restricts tobacco marketing and sales to youth
• Bans sales to minors
• Bans vending machine sales
• Bans free giveaways of sample cigarettes
for promotional purposes
• Bans tobacco-brand sponsorships of
sporting, entertainment, or cultural events
• Requires smokeless tobacco product labels
that contain four key warnings:
• Can cause mouth cancer

• Can cause gum disease and tooth loss
• Is not a safe alternative to cigarettes
• Is addictive
(continued)
Stock Connection/SuperStock
One of the requirements of the
Family Smoking Prevention
and Tobacco Control Act is
that manufacturers provide
information about the
ingredients in tobacco products.
268
Who Advocates?
Who advocates for public health? That question could be

answered by two simple words:
nearly everyone. However, there are specific individuals and
groups that advocate for specific
elements of public health. At the individual level, the most
common acts of advocacy come in
the form of protests and letters. One example is pride parades,
which celebrate the commu-
nity of the LGBTQ population and are a statement of equal
rights for this group—especially
health. Pride parades are annual events across the globe that
bring awareness to the inequali-
ties and disadvantages experienced by LGBTQ persons.
According to Guinness World Records,
the 2006 Gay Pride Parade in São Paulo, Brazil, was the largest
pride parade ever held, with
an estimated 2.5 million participants (Ukrop News 24, 2016).
Whether intentional or not,
the efforts of these individuals coming together comprise an
advocacy effort. See Spotlight on
Public Health Figures for an example of an advocate who sought
to improve the quality of life
for African-American communities.
A Closer Look: The Family Smoking Prevention and Tobacco
Control Act (continued)

• Ensures “modified risk” claims are supported by scientific
evidence (companies
cannot state their product is “light,” “mild,” or “low” without
filing a modified risk
tobacco product application)
• Requires disclosures of ingredients in tobacco products
• Preserves state, local, and tribal authority, meaning that these
entities are the
authorities over their specific jurisdictions
Sources: Manz, W. H. (2009). Congress and the tobacco
industry: A legislative history of the Family Smoking
Prevention and Tobacco
Control Act of 2009. Retrieved from
https://www.wshein.com/media/brochures/69124.pdf
?d=20171021
U.S. Food and Drug Administration. (2018). Family Smoking
Prevention and Tobacco Control Act – An overview. Retrieved
from
https://www.fda.gov/TobaccoProducts/Labeling/RulesRegulatio
nsGuidance/ucm246129.htm

W. E. B. Du Bois (1868–1963)
Who is W. E. B. Du Bois?
William Edward Burghardt Du Bois was born in 1868. He was
the first African American to
earn a doctorate degree from Harvard University. Although his
skin color was considered
“black,” he was mixed race and was able to attend schools with
Whites during a time when
most schools were segregated. It wasn’t until long after his
education that he discovered
most Blacks across the nation were treated quite differently.
This unfair difference compelled
him to study the issue of equality and advocate for equal rights.
He died at age 95 in 1963.
(continued)
https://www.wshein.com/media/brochures/69124.pdf?d=201710
21
https://www.fda.gov/TobaccoProducts/Labeling/RulesRegulatio

nsGuidance/ucm246129.htm
269
W. E. B. Du Bois (1868–1963) (continued)
What was the political climate at the time?
The Jim Crow laws, a racial caste system that separated
people by color, pervaded the southern states during
Du Bois’s time. Although Lincoln had long ago freed
the slaves, Black people had very few rights, including
basic human rights. They were considered second-class
citizens. The Jim Crow laws legitimized racism against
Blacks, under a very rigid series of anti-Black laws
primarily found in the southern and southern border
states. The political realm supported them through
pro-segregation speeches. Blacks who violated the Jim
Crow laws were subject to personal violence, typically
in the form of lynching. Lynchings were often public, the
murders of Black people were not considered vicious
crimes, and the criminal justice system favored Whites

regardless of the situation.
Once he learned about the Jim Crow laws and the
poor treatment of Blacks, Du Bois began to serve as
an advocate for civil rights. He founded the Niagara
Movement, which was an African-American protest group of
scholars who focused on
advancing the rights of Blacks. He was also one of the founders
of the National Association
for the Advancement of Colored People (NAACP) and served as
its director for several
decades. Furthermore, he wrote a significant number of works
detailing the inequities of
Blacks in a world where slavery was illegal. Among his most
influential works on Black
health was The Philadelphia Negro: A Social Study, published
in 1899. Du Bois devoted all of
his efforts to gaining equal rights for Black people—which
improved the overall health of the
population (especially in the South, where large populations of
Blacks resided).
What motivated him?
Brought up in a predominantly White neighborhood, he had

never encountered racism until
he moved to Nashville, Tennessee, in 1885 to attend Fisk
University. It was there that he first
learned about the Jim Crow laws. Once he learned of this
discrimination, he felt motivated to
do something about it. This prompted his activism for equal
rights for Black people.
Sources: Biography.com. (n.d.-c). W. E. B. Du Bois biography.
Retrieved from https://www.biography.com/people/web-du-
bois-9279924
Ferris State University. (n.d.). What was Jim Crow. Retrieved
from https://ferris.edu/jimcrow/what.htm
National Association for the Advancement of Colored People.
(2018). NAACP history: W. E. B. Du Bois. Retrieved from
https://www
.naacp.org/oldest-and-boldest/naacp-history-w-e-b-dubois/
Underwood Photo Archives/SuperStock
W. E. B. Du Bois was an advocate
for basic civil and human rights
for Black communities in the
United States.
At the group or organizational level, there are specific groups of

people who advocate under
a single name for a cause. In public health, a good example is
the American Public Health
Association, which actually writes letters, visits politicians, and
focuses on activities that lead
toward improved health outcomes. The APHA has advocated for
cities to become smoke-free
through its speaker network as well as formal letter-writing
campaigns. Most organizations
https://www.biography.com/people/web-du-bois-9279924
https://ferris.edu/jimcrow/what.htm
270
that advocate for public health are nonprofit organizations with
a charitable purpose. Chari-
table groups are not supposed to engage in paid lobbying;
therefore, they focus on advocacy.

At the committee level, there are groups that focus only on
advocacy and, in some cases, lob-
bying efforts for a cause. For public health, these are often
political action committees (PACs)
that work toward defeating candidates with opposing views. For
instance, a PAC was devel-
oped to represent gun and firearms issues through the National
Rifle Association. PACs often
lobby rather than advocate, as they are focused on the passage
or elimination of legislation.
Governmental agencies are typically barred from advocacy or
lobbying work. These are
the organizations that enact the policies and legislation that
others lobby/advocate for or
against. However, in terms of taking a stance, governmental
public health organizations can
use media outlets for educational purposes. Consider the CDC’s
focus on prevention. Through
its National Prevention Information Network, the CDC can
“advocate” for healthier behaviors
to improve population well-being. Activities include education
on immunization, smoking,
and HIV/AIDS awareness (CDC, n.d.-d).

5 Public Health Ethics, Law, and PolicybenkrutiStockThi.docx

5 Public Health Ethics, Law, and PolicybenkrutiStockThi.docx

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