Public Health is a discipline rooted in helping people realize their most basic human rights of health. The goal has always been to keep people as healthy as possible, but through the years, we have failed many people in this endeavor, losing their trust. One way in which trust has been compromised is the use of paternalism which can be useful, but often fails to produce the desired result because of how and when it is implemented.
Historical breaches of trust, human rights, and ethics, between the population and government in relation to maternal care and occupational illness due to poor regulation and the misuse of paternalism, have damaged public health professionals’ ability to enact meaningful change for impacted groups; moving forward they must learn from past failures and work collaboratively with all concerned parties, avoiding a strictly top-down approach, in order to rebuild, maintain, and improve relationships so that mothers and workers can utilize their own rights.
Many have argued that government and public health organizations have no business acting to ensure that industry regulates occupational threats to health. The argument was that this paternalistic approach interferes with the market and its ability to take care of itself and that occupational accidents, illness, and even death, were unavoidable side effects of industry. There are certainly situations in which government oversight did not create the desired outcome, but there have been many times in history when industries did nothing to stop or acknowledge the danger they were placing their workers in.
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Take the Triangle Shirtwaist Factory Fire in 1911, where over a hundred women were killed because of the unsafe conditions the factory owners placed them in (Rosner 537). Additionally, countless workers contracted silicosis and lead poisoning through occupational exposures, leading to illness and often death (Rosner 538). Without intervention from public health groups, it is hard to say how many more would have died.
Over time, this failure to provide adequate oversight caused a shift in the beliefs of the people. The trust they had was damaged by many years of mistreatment, causing them to start seeking a more reliable way to ensure protection rather than continuing to accept the historical expectation of personal accountability (Markowitz and Rosner 12). Once they started lobbying for change, policy started being created to meet their needs.
Looking forward to the late 1970s, we saw that poorly implemented paternalism created the emergence of a new occupational failure. A lead plant, American Cyanamid, barred women from working at the factory due to the threat that exposure could have on possible offspring, forcing women into sterilization, prematurely ending their reproductive years to keep their jobs (Bayer 2018). This is an example where an unethical paternalistic approach led to a very poor outcome.
Introduction of government interventions like OSHA in 1971 acknowledged the growing public outrage over unsafe working conditions that punctuated the era, but lawsuits and unsafe conditions are still pervasive, showing that, while opinions shifted and regulations have been put in place, there is still an issue (Rosner 536). Action only occurred when tragedies and public outrage pushed the government into acting, demonstrating that the voices of the masses are integral to creating meaningful change. We see similar paradigms in other areas of public health, like in the continuing battle for maternal mortality prevention.
Women and their wellbeing have been at the bottom of the priority list in many arenas, notably when it comes to human rights and particularly regarding their rights to good and safe healthcare and the dangers of pregnancy. Historically, women have been forced to work long hours in physically demanding tasks, sometimes until the day they gave birth (Fett 27). Women held as slaves in the 19th century were often subjected to this type of treatment (Fett 27), causing them to have high risk to both mother and child. Things have improved overall since then, but many still contend with serious danger when facing motherhood.
Paternalism in the form of human rights enforcement, is an approach that is really missing regarding maternal health. We have moved past the time when maternal mortality was accepted as an inevitable and unavoidable consequence of procreation. We have learned that most causes are treatable, and most cases are avoidable, yet one woman dies every minute due to childbirth or related complications (Freedman 52).
So, we have the knowledge and the resources, yet women are still dying because women’s health remains a low priority in law, regulation, and resource allocation. The UN has crafted a clear list of human rights for all people, women’s and maternal health included, but nothing is being regulated, enacted, or enforced – except one of the most useful preventative measures, contraception.
One of the most essential failings of paternalistic intervention in maternal health is the blatant disregard for human and women’s rights in the regulation and criminalization of contraceptive options. Many countries, governing bodies, and even healthcare providers allow religious and personal ideologies to take priority over an individual’s right to make their own educated decisions about their health and their bodies (OHCHR).
This overt paternalistic subjugation is ultimately flawed and unethical, the goal being to control rather than protect, with most of the decisions being made by men, who will never be directly impacted by the decisions that are made. The government needs to shed the bias with which is regulates contraceptive use and create human rights-based laws. We need to place the power into the hands of women and men who have the goal of finding ethical ways to enforce human rights requirements so that women can exert their rights upon their own health. As stated in Freedman’s article,
“health is profoundly driven by the social and cultural contexts in which it exists… from the most intimate spaces of daily life to the macroeconomic policies of international financial institutions… we need ways to speak and think and act on our shared (and our differing) understandings about what human well-being is and how to achieve it” (53).
People who are invested and impacted by these decisions need to be at the table when the plans are being made. Having a single voice will never be sufficient to find a solution for everyone. Maternal mortality is influenced by “large scale economic and social forces” and we can’t allow the “complexity of our analysis to detract from the clarity and directness of our strategy. We need to see the big picture, but to do focused actions” (Freedman 52).
We can achieve this feat if we take a blended approach of both a top-down (look at the big picture from above) and a bottom-up (analyze the larger problem within smaller group contexts) to discover through community involvement what is needed for each group to have better outcomes. There is already proof that this works. During the Women’s Health Movement in 1969, normal women banded together with their stories of poor treatment by white male doctors, creating an educational campaign which led to the book Our Body, Our Selves (Keefe et al 59).
This group of women caused a huge ripple effect that helped inform and empower an entire generation of women to take control of their health, inspiring them to ask questions and eventually leading to work with “elected officials and federal agencies to promote the women’s health agenda” (Keefe et al 60). This approach served to empower women as well as demonstrated that taking a bottom-up approach is sometimes the only way important change will occur. We need to harness this knowledge and use it to help people going forward.
Many will argue that this approach is idealistic and unattainable, that the coordination required to tackle these complex situations will require too much time and effort. However, other methods have failed overall and if we want to make progress, we will need to do the hard work required for a community-involved solution. There are many challenges to taking this stance, as our ability to handle the complexity of working with large economic and social forces is stunted by human rights organizations’ lack of development and focus in the area (Freedman 58).
It will require a lot of dedication to get us up to speed on the inner workings of so many different systems and political agendas. However, it is too important a task to forgo simply because it is difficult to achieve. According to the Alma Ata Declaration on Primary Healthcare in 1978 – “all people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare” (Freedman 58).
We must ensure that this fundamental human right is being upheld. Another challenge is that paternalism can have a lot of unintended consequences, even when it is used with good intentions, because the intervention is not nuanced and does not target the correct concerns or solutions. In order to minimize these faults, we must direct the right questions to the right people, not just those in charge.
Through history, women and workers have been poorly represented and given little if any priority in the world of ethics and human rights. It is time to learn from the mistakes of the past and find a way to better implement paternalistic methods where and when appropriate. We have seen that these groups are not afforded the rights they are owed and are in a great deal of danger because of it. If public health professionals want to solve these problems, they will need to start incorporating those impacted into the conversations so that their interests will be represented and reflected in the interventions we create and enact. We have the power to change, but we must decide that it is worth the effort.
Works Cited
- Bayer, Ron. Session 6: Justice, the Duty to Protect, and the Duty to Provide: Securing Occupational Safety and Addressing the Inequalities in U.S. Healthcare. Lecture presented at Foundations of Public Health: Ethics Module in Columbia University Mailman School of Public Health, New York. (2018).
- Fett, Sharla M. Working Cures: Healing, Health, and Power on Southern Slave Plantations. Chapel Hill: University of North Carolina Press, 2002. Pages 15-35. Print.
- Freedman, LP. “Using human rights in maternal mortality programs: From analysis to strategy.” International Journal of Gynecology and Obstetrics 75 (2001): Pages 51-60.
- Keefe, Robert H., Sandra D. Lane, and Heidi J. Swarts. ‘From the bottom up: tracing the impact of four health-based social movements on health and social policies.’ Journal of health & social policy 21.3 (2006): 55-69.
- OHCHR (Office of the High Commissioner for Human Rights). “Contraception and Family Planning: Fact Sheet.” United Nations (2015).
- Markowitz, Gerald, and David Rosner. Deceit and Denial: The deadly politics of industrial pollution. Vol. 6. Univ of California Press, 2013.
- Rosner, David. ‘When does a worker’s death become murder?.’ American Journal of Public Health 90.4 (2000): 535 -540.
