Moral frameworks for public health

Colonial Algeria, Social Medicine: Moral Imperatives in Fanon’s Physician Writing 
A key figure in postcolonial thought, psychiatrist Frantz Fanon wrote extensively about the effects of social determinants on the health of patients under his care. Theorising on the impacts of colonialism, war, economic marginalisation, and repressive state interventions in Algeria, he further denounced the actions and attitudes of his physician colleagues who collectively opposed social change. This paper argues that distinct moral imperatives pertaining to public health and social medicine can be discerned in Fanon’s literary treatment of patients. 

I provide a historical perspective on Fanon’s physician writing, examining the treatment of ethical questions in his books (The Wretched of the Earth, Toward the African Revolution, A Dying Colonialism) and articles. Close reading reveals that Fanon perceived duties and responsibilities towards patients, health institutions, and the whole of society. I identify moral stances and commitments that depart from the values promoted by the health system of colonial Algeria. 

Fanon articulated a moral vision for revolutionary social medicine. Empowering patients through culturally informed care, he reformed the hospital as a space for healing, community and solidarity. He broke ground recognising racism as a public health issue. Moreover, he advocated for political liberation to improve material conditions of care. Fanon’s texts, embedded in a larger transformative project, remain morally instructive for contemporary evaluations of writing about public health. 

Epidemics and ethics in Costa Rica 
A young Costa Rican republic witnessed two significant outbreaks of disease within the first 35 years of declaring independence. A smallpox outbreak in Cartago, and particularly the Cholera epidemic of 1856, claimed between 8% and 10% of the population (Botey, 2008).  During that time, Costa Rica did not have an ethical framework for managing such significant public health crises. One of the few philosophers of that era in Costa Rica was José Maria Castro Madriz, first president of Costa Rica, with a Ph.D. in Philosophy from Nicaragua at Leon University. Castro Madriz drew his inspiration from French philosophers like Jean Jacques Burlamaqui, and it could be suggested that his work created a moral framework for many of the significant public works of the era, including the establishment of The Hospital San Juan de Dios in 1845 and the post-cholera creation of a “Protomedicato” in 1858. 
  
By the 20th Century, new outbreaks challenged a now more established state in Costa Rica, including influenza in 1920 and smallpox in 1934. By this time, the commercial bonds with Europe were well established, and with the education of young wealthy men in Europe and the United States, public institutions could now confront these health crises with new ideas like Marxism. It is not clear how socialist ideas shaped the ethical decisions during these two pandemics, but the protection of the majority of people with vaccine mandates (1934) suggests there was a more social standpoint influencing decisions. As well as a vaccine mandate, policy makers limited access to public spaces and closed down most commerce as a measure to protect public health, but these measures were not easily accepted by many Costa Rican citizens, creating significant conflict between the state and the citizenry. The similarities of the ethical conflicts between the state and the citizens, bears a striking resemblance to the world’s most recent public health crisis: SARS-CoV-2.