A public health doctor’s critical analysis of the Kerala Public Health Act warns of ethical pitfalls

However, Dr Karpagam’s commentary points out significant concerns, particularly the Act’s apparent disregard for fundamental public health ethics.

“The Act recognises the importance of prevention and strengthening of social systems, but it falters in the public health ethics and human rights framework,” she states, highlighting the absence of considerations for autonomy, privacy, transparency, and accountability.

This oversight, according to Dr Karpagam, could lead to “a potential tool of abuse, particularly against already vulnerable communities”.

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Problem with ‘harm principle’ 

Dr Karpagam argues that the “harm principle” advocates for the freedom of individuals to act as they please, provided their actions do not harm others. When the government perceives a threat to public health from a disease, it might deem it necessary to limit the freedoms of individuals or groups.

In such scenarios, it’s crucial that principles such as minimal coercion, mutual support, fairness, respect, dignity, privacy, and the broader welfare of society are given due importance, particularly when dealing with individuals from marginalised groups, she argues.

Dr Karpagam emphasises the essential principles of public health, stating that the Act falls short in integrating these crucial guidelines.

She points out, “The ‘harm principle’ suggests that individuals should be free to act unless their actions harm others. However, the Act justifies restricting freedoms based on potential harm from disease, sidelining principles like minimal coercion and reciprocity, especially for marginalised groups.”

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Is ill health a crime?

One of the most contentious aspects of the KPHA is the broad powers granted to public health officers, including directives that can significantly impact individual freedoms.

Dr Karpagam argues, “Sections of the Act make ill-health appear like a crime, legitimising punitive action by state bodies without clarity on state responsibility and how broader ethical principles of public health will be upheld.”

This approach, she warns, risks criminalising individuals for their health status, undermining the ethical principle of treating ill health within a supportive, rather than punitive, framework.

The commentary draws from the lessons learnt about state overreach during the Covid pandemic, and the need for ethical caution in public health legislation. “The Covid pandemic in India itself offers ample learnings, which have been disregarded, on the need for caution against state overreach.”

On the principle of reciprocity, Dr Karpagam notes, “When individuals sacrifice their liberties for public health, such as through isolation, there’s an ethical obligation for the state and the society to support them in return. This support could be economic, psychological, or social, ensuring the burden of public health measures doesn’t disproportionately impact individuals.”

She believes that the Kerala Public Health Act overlooks this reciprocal relationship, potentially placing an undue burden on individuals, particularly those in vulnerable positions.

Dr Karpagam uses tuberculosis (TB) management as a case study to illustrate the Act’s limitations.

“TB’s interconnection with social determinants of health requires a multifaceted response, extending beyond biomedical solutions to address social and economic barriers. The Act’s narrow biomedical focus misses the opportunity for a more comprehensive, effective public health strategy,” she points out.

She emphasises the need for a broader perspective in public health legislation that accounts for the complex interplay of health with societal factors.

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Why target migrant workers?

Specific provisions within the KPHA, such as those targetting migrant workers for health checks, have raised additional ethical questions. Dr Karpagam questions the necessity and justification for such targeted interventions, stressing the importance of non-discrimination and transparency in public health measures.

“If migrant workers are indeed a group that requires a ‘special focus’ and differential treatment, the scientific reasons for this should have been clearly spelt out in the Act,” she argues.

She concludes with a plea for Kerala’s policymakers to prioritise ethical considerations deeply into public health strategies, especially in times of crisis.

As Kerala is often seen as a benchmark for public health in India, the stakes are high.

“Kerala’s policymakers actively foreground the principles of trust, transparency, and accountability, especially during an outbreak or pandemic,” Dr Karpagam urges, highlighting the importance of ethical governance for achieving genuine public health benefits.