Spectacular progress, both intellectual and material, has been achieved through the Enlightenment notion of the centrality of the individual and the supremacy of science and technology in advancing health and healthcare practices. The modern Western belief system and its frames for global thinking that have now become powerful worldwide are succinctly characterized by an individualistic, self-determining, and rights-bearing concept of being; an epistemological framework that centers on abstract thinking, objectivity in observation, logical reasoning processes, verifiable knowledge, and a positivist version of the scientific method; and moral and political values of autonomy supportive of individual rights. Scientific and technological progress and diverse socioeconomic systems contributed to fostering great “accelerations” in the scale of production, consumption, communication, and transportation that in particular since 1945 have improved the duration and quality of life for many people.

Introduction

To profess interest in global health is one of the latest trends in medicine, and many universities, especially in North America, are developing Departments or Centers of Global Health (McFarlane et al., 2008; Drain et al., 2009). The rapidly proliferating spectrum of new organizations, alliances and funds to address global health issues has generated a challenging new “global health landscape”(Global Health Watch 2 – People's Health Movement, Medact and the Global Equity Gauge Alliance, 2008). But it is neither entirely clear what is meant by “global health,” nor how this term is being used by a range of actors.

On the one hand we need to ask if it is: (a) a description of the medically measurable health status of all individuals globally (a medically defined state of affairs); (b) an assertion about (or aspiration to) the state of health of all throughout the world (an activist agenda); (c) about providing medical treatment to all globally who are suffering from medically defined diseases (an extended biomedical approach to health); (d) a description of how health services are, or should be, structured and governed worldwide (a governance of health issue); (e) about measures to improve health governance and reduce disparities in health and health care across the globe (a global social justice issue); or (f) reference to the quest to sustain a healthy planet (an environmental health concern).

Introduction

Although unpalatable to consider, we are at a watershed in the history of the control of tuberculosis (Fauci, 2007). The progressive increase of resistance of tuberculosis (TB) to pharmacotherapy has raised the possibility of a response to tuberculosis without medications, in essence returning us to the situation as it was in the 19th century or, as some have posited, the dawn of the post-antibiotic age (Raviglione, 2006). The combination of high rates of TB infection with high seropositivity rates for HIV in sub-Saharan Africa has raised the ante of global tuberculosis control.

It is instructive to note that from almost any perspective, tuberculosis is one of the most well-understood diseases in all of medicine. Understanding tuberculosis has been important historically, in constituting the very notion of causality in biology and medicine. Robert Koch explained the concept of infectious diseases and stated his famous postulates largely on the basis of the study of tuberculosis. Our concept of clinical causality is rooted in randomised clinical trials, of which one of the first and most influential was the UK Medical Research Council's streptomycin trial for the treatment of tuberculosis (MRC, 1948), From Hippocrates to the present day, much of our understanding of clinical medicine, bedside lore, and the signs, symptoms and phenomenology of disease arise from our collective experience of tuberculosis.

Knowledge of the disease is extensive in a multitude of dimensions (Verma et al, 2004). We know its genetic fingerprints and its mechanism of resistance at the molecular level. The social determinants of the disease, rooted in poverty, adverse living conditions, and social disadvantage, are not contested (Benatar, 2001). The social consequences of stigma and how these vary from culture to culture are also well characterised (Croft and Croft, 1998; Rajeswari et al, 1999; Khan et al, 2000).

Introduction

Eradicating communicable diseases has been a primary public health goal for centuries, and vaccination programmes comprise a significant part of that population health effort. To achieve community health, public health authorities are bestowed with policing powers whereby individual rights may be sacrificed for the greater good of the population (Mann et al, 1999; Gostin, 2004). However, healthcare providers and scholars are encouraging public health programmes to attain their community health goals through the least coercive and intrusive means possible (Gostin, 2004). The coercive strategies implemented by public health authorities in the past are discouraged today (Mann et al, 1999). Public health strategies that aim to balance individual and community rights and recognise that protecting human rights positively affects individual and population health are preferred (Mann et al, 1999). Despite a history of coercive strategies adopted by public health vaccination programmes, particularly in the US, vaccines have been deemed among the most successful public health interventions (Salmon and Siegel, 2001). However their success has been accompanied by controversy. Anti-vaccination movements have challenged state infringement of bodily integrity and individual rights since the nineteenth century and have been particularly vocal in countries mandating vaccination (Arnup, 1992; Colgrove, 2005; Blume, 2006; Salmon et al, 2006).

As population health threats emerge and as new vaccines are developed to address them, the ethical implications of vaccination programmes (particularly of mandatory vaccines) will be of increasing concern to individuals of all ages, cultures and ethnicities. As public health departments prepare their vaccination programmes for the future, an approach that recognises the importance of protecting individual human rights, as delineated in both the Universal Declaration of Human Rights (UDHR) (United Nations, 1948) and the ‘Siracusa Principles’ (ECOSOC, 1984), is a necessary first step towards ensuring the health of the community.

The editors summarized the contributions written by colleagues in different parts of the world (Chapter 6) to illustrate the similarities, and occasional differences, in the management of depression in older people described in all the contributions. This appendix allows the reader to read the individual contributions.

Australia

Assessment

This 82-year-old woman is chronically disabled by pain and breathlessness and appears to have become socially disengaged. She has several symptoms of depression, including persistent low mood, loss of energy (which sounds to be out of proportion to her medical state), early morning waking, loss of interest in previously enjoyed activities, and persistent feelings that life is not worth living. The vignette does not provide information about her appetite and weight, concentration, any psychomotor changes, guilt feelings or confidence levels, but even so it is clear that, provided the symptoms have been present for two weeks (and this seems highly likely), she meets both DSM-IV diagnostic criteria for a major depressive episode and ICD-10 criteria for a depressive episode.

Australian health-care system

Within the Australian health-care system, in which specialists are accessible only after referral from a general practitioner (GP), this woman would normally be managed by her GP who in all likelihood will already be engaged in the management of her troublesome osteoarthritis and chronic obstructive pulmonary disease (COPD). She might well attend a respiratory outpatient clinic or rheumatology clinic in a public hospital, or (less likely as fewer than one-third of the elderly have private health insurance) be seeing a private medical specialist with expertise in one or both of these two areas.

What is public health ethics?

Public health has been described as the science and art of promoting and protecting health, preventing disease, prolonging life and improving quality of life through the organized efforts of society (Last, 2001). It achieves these goals using community interventions, disease control, and principles of epidemiology and biometry. Public health ethics is concerned with the ethical issues raised by such community and population-based approaches to health problems.

While the goals of public health and clinical medicine are to increase well-being, the latter uses individual action and intervention for the good of individual well-being, while the former uses a social approach to improving the good of communities.

As ethical reflection in healthcare evolves, the scope and range of issues of concern continues to grow. Early scholarship in ethics focused primarily on ethical issues arising from the care of individual patients in hospitals, such as end of life care, broad policy issues such as euthanasia and abortion, or the domain of research ethics. For the most part, the issues concerned analyzing ethical dilemmas arising from the extensive and well-described value conflicts that can arise between healthcare providers, patients, and families.

There is a transition occurring, with a new emphasis on issues emerging from intersection of the actions of healthcare providers, healthcare institutions, and broader social and community concerns. As well, there are new and emerging ethical issues arising at organizational levels. In terms of the level of reflection, the concerns are less with interactions between individuals as between individuals and collectives, and between collectives and collectives. Current efforts explicating the ethical challenges in planning for an influenza pandemic illustrate the interactions of ethical reflection at several levels of application and the complex set of values required for a coherent framework for analysis of these issues (Joint Centre for Bioethics Pandemic Influenza Working Group, 2005). For the most part, this level of ethical reflection has been neglected or underdeveloped in standard accounts of clinical ethics.

These issues fall, somewhat neatly, under the heading of health systems and institutions. The chapters in this section illustrate this transition.