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When public health goes wrong : the history and ethics of public health errors Bavli, Itai


This dissertation comprises three papers examining the historical, ethical, and social aspects of public health errors. My first paper explores how US health authorities responded to the discovery of the late health effects of radiation treatment. Based on the examination of multiple primary and secondary sources of evidence; archival research conducted at the National Archive in Washington, DC; and research conducted through media web-archives, I show how efforts by Michael Reese hospital in Chicago to locate and examine former patients (and the media attention these efforts attracted) led to a nationwide campaign by the National Cancer Institute (NCI) to warn those who underwent radiation treatment during childhood. My second paper investigates the ethics of evidence and post-market surveillance of pharmaceuticals in Canada. Drawing on philosophical discussions of inductive risk, the paper examines what evidence should have been sufficient for Health Canada (HC) to revise the misleading information that appeared in the product monograph for OxyContin. Given the stakes involved, I argue that a less strict standard of evidence would have been appropriate, yet HC in fact took the opposite course, insisting on a higher standard of evidence than it normally requires. The time it took for Health Canada to revise the monograph may have contributed to the prescription opioid epidemic in Canada. This paper also contributes to existing philosophical work by demonstrating that inductive risks in the post-approval stage are important and linked to pre-approval inductive risks. My third paper provides a new concept of public health errors—defined as acts of commission or omission, culpable or not, by public health officials, whose consequences for population health were clearly worse than those of an alternative that could have been chosen instead. This conception better corresponds to the task of public health, compared to policy failure literature, where achievement of political objectives is often used to measure success, and has practical and theoretical advantages. It also serves as a valuable analytical lens for understanding general mechanisms leading to public health errors, with utility for scholars who study policy errors as well as for public health actors interested in preventing them.

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