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  • Public health policies = slip slop slap, anti-smoking etc
  • Nuffield Intervention Ladder = a spectrum for categorising how coercive a public health intervention is
    • More ethically difficult when it becomes more coercive

Nuffield examples

  • Eliminate choice: quarantine (TB), elicit drugs, drink driving, fluoridated water, folate in bread, chest x-ray for entering Australia
  • Restricted choice: smoking, alcohol
  • Disincentives: tax for smoking
  • Incentives: vaccination (if you vaccinate your child, you get benefits), free flu shots
  • Changing default policy: e.g. screening programmes (should actually be further down the ladder)
  • Enable choice: needle exchange programme
  • Provide info: slip slop slap, measure up
  • Do nothing: cancer registry


  • Cost effective = $50k/QALY
  • Autopsies: if doctor asks, if coroner asks, or if patient's family asks (but always need patient's family's permission unless coroner thinks there suspicion).
    • If no evidence for cause of death, then there should be an autopsy
  • When to report to coroner: violent, unnatural, unknown, death > 6month seeing a doctor, death after procedure without big risk of death, reportable Dx death, psychiatric hospital
    • Hospital autopsies: only with next of kin permission
    • Autopsying everyone is very resource intensive
  • Newborn screening: not mandatory


Healthy food

  • Positives
    • Better health outcomes
    • Healthy environment
    • Prevent long term problems
    • Provide healthy options people want but unable to access (e.g. long line at Stock Market)
    • Good example
  • Negatives
    • Authority - free choice/decision
    • Punishing entire population?
  • Harmed: store owners, the poor

HIV

  • In Australia, HIV+ can't have sex with someone else without telling them and their consent. If they're going to do that, then you have to tell the PHU
    • If the doctor is given permission to tell their partner, then you have to tell the patient the time you're going to do it
  • Should there be such heavy punishments for transmitting HIV compared to other STIs?

Breast screening

  • Positive: reduced mortality by 20%
  • Harms: overdiagnosis (can't tell if it will progress - for every 1 death prevented, there are 3 cases of overdiagnosis occur)
    • Mammogram painful, radiation
    • False positive = psychological issues and distress, anxiety
    • Campaigns make people more issue
  • + more inclined to get tested with more information; reassurance
  • more anxiety, not appealing process, lots of info - difficulty for low health literacy (targets high SES)
  • not justifiable to give someone a mammogram if they're within 10 years of their life expectancy
  • 70% of cervical cancer is due to HPV
  • 80% anal cancer
  • 12-60% oropharyngeal cancer
  • 20% penile
  • 73% coverage of girls
  • 59% decrease in genital warts
  • expected: decrease in men