A Review of Public Health Ethics in Disease Prevention Among Marginalized Communities and The One Health Framework

Abstract

Public health ethics provides a framework for ensuring disease prevention efforts are equitable and just. The One Health approach, which recognizes the interconnection between human, animal, and environmental health, has gained importance in managing emerging diseases. However, its ethical application in marginalized communities remains underexplored. Many of these communities—such as low-income groups, Indigenous populations, and racial minorities—face historical injustices, structural barriers, and inadequate access to preventive healthcare. Additionally, mistrust in public health institutions due to past ethical violations continues to hinder participation in disease prevention efforts. This literature review synthesizes key ethical concerns surrounding One Health in marginalized communities, categorizing them into five themes: (1) the ethical justifications for One Health, (2) barriers to access and policy gaps, (3) mistrust in public health, (4) inequities in preventive measures, and (5) ethical considerations for animal welfare. The discussion highlights policy failures, ethical gaps, and necessary reforms to ensure that One Health strategies are inclusive, transparent, and community-driven. The study concludes that achieving ethical One Health implementation requires policy changes, improved community engagement, and greater equity in resource distribution to prevent health disparities in marginalized communities.

Introduction

Public health ethics serves as a guiding framework for ensuring that policies and interventions promote health while respecting human rights, equity, and social justice (Gostin & Powers, 2006). Unlike clinical ethics, which focus on individual patient care, public health ethics address the well-being of populations, often requiring trade-offs between individual freedoms and collective health benefits (Childress et al., 2002; CDC, 2024). These ethical considerations become even more complex when applied to global health challenges such as zoonotic disease prevention, where human, animal, and environmental health are deeply interconnected through the One Health approach. The One Health Approach is a collaborative, multisectoral framework that recognizes the interdependence of human, animal, and environmental health in disease prevention (Lee & Brumme, 2013). Ensuring ethical implementation of One Health strategies requires trust, transparency, and active community engagement, particularly among populations historically marginalized by public health policies.

The One Health approach has emerged as a critical framework for managing zoonotic diseases, which account for approximately 60% of emerging infectious diseases globally including outbreaks like SARS, Ebola, and COVID-19 (Allen et al., 2017; Jones et al., 2008; Karesh et al., 2012). While this interdisciplinary strategy offers promising solutions for disease prevention, it also raises significant ethical concerns. Questions of fairness, trust, and accountability arise, particularly in marginalized communities, such as low-income populations, Indigenous groups, and African Americans, who have historically been subjected to unethical public health practices (Aliyu, 2021). For instance, the United States Public Health (USPH) Study of untreated syphilis in the Negro male denied African American men access to treatment, leaving a legacy of medical mistrust that persists today (Reverby, 2012). Such mistrust affects participation in health initiatives, including One Health programs, which require strong community engagement to be effective (Bailey et al., 2017). Beyond mistrust, ethical concerns arise over who benefits from One Health interventions and who bears the risks. For example, disease surveillance programs often rely on low-income, rural, or Indigenous communities for data collection but may fail to provide these populations with adequate health resources, protections, or decision-making power (Schmidt, 2020).

Prevention is also a central component of ethical public health practice and One Health interventions, as it seeks to reduce disease burden before it occurs. However, systemic inequities often result in marginalized communities facing disproportionate risks of infectious disease exposure while lacking access to preventive measures, such as vaccines, sanitation infrastructure, and veterinary services (Lee & Brumme, 2013). Ethical frameworks must account for these disparities to ensure that prevention efforts are both equitable and effective.

Ethical decision-making in public health is based on key principles such as respecting individual choices, doing good, avoiding harm, and ensuring fairness (Beauchamp & Childress, 2013). Beyond individual rights, public health ethics also consider the well-being of entire communities and the need for preventive measures (Kass, 2001). The COVID-19 pandemic made these ethical challenges more visible, especially when balancing personal freedoms with efforts to protect public health (Gostin et al., 2020). In emergencies, decisions often focus on protecting as many people as possible, which can raise concerns about individual fairness and global cooperation (Aliyu, 2021). In health crises, ethical values like responsibility, fairness, and public trust should guide decision-making (Annas, 2002). As new health threats emerge, transparency and accountability become even more important (WHO, 2021). To maintain trust and protect human dignity, health officials must carefully explain their decisions and ensure they are based on solid evidence (Gostin & Berkman, 2007).

This review aims to critically examine the ethical dimensions of public health and One Health in disease prevention, with a specific focus on marginalized communities. The study employs review of literature and thematic analysis, synthesizing historical case studies, contemporary policy discussions, and ethical frameworks to provide a comprehensive examination of One Health ethics in public health disease prevention.

Methods

This study employs a literature review and thematic analysis to explore the intersection of public health ethics, disease prevention, and the One Health framework among marginalized communities. The methodology is structured as follows:

Literature Search and Selection Criteria

A structured search was conducted using PubMed, Google Scholar, Web of Science, and Scopus to identify peer-reviewed articles, policy documents, and relevant reports published between 2010 and 2024. The search terms included public health ethics, disease prevention, marginalized communities, One Health, and structural health inequities. The inclusion criteria were:

1. Articles published in English.

2. Studies that explicitly addressed public health ethics and disease prevention in marginalized communities.

3. Research incorporating One Health principles in public health interventions.

4. Peer-reviewed journal articles, government and institutional reports, and authoritative policy briefs.

Exclusion criteria included:

1. Studies focused exclusively on high-income settings without discussions of marginalized populations.

2. Articles that were lacking ethical analysis or policy implications.

3. Systematic reviews, meta-analyses, and opinion pieces.

4. Studies without a clear discussion of public health ethics or One Health principles.

5. Research which focused solely on individual patient care ethics rather than population-level ethics.

6. Non-peer-reviewed sources or editorials without empirical evidence.

Thematic Analysis

A qualitative thematic synthesis approach was applied to identify key themes in the selected literature. Using a structured data extraction matrix, key information from each study was categorized based on the following themes:

1. Ethical Justifications for One Health: The moral and practical basis for applying One Health in marginalized communities.

2. Barriers to Access and Policy Gaps: Structural inequities affecting disease prevention efforts.

3. Mistrust in Public Health: The role of historical injustices in shaping public perceptions.

4. Inequity in Access to Preventive Measures: Disparities in availability and affordability of health services.

5. Ethical Considerations for Animal Welfare: The impact of disease control measures on communities dependent on animals.

Historical Contextualization

This study also incorporates historical case analyses to contextualize contemporary ethical challenges in public health. The selection of historical cases, such as the Tuskegee Syphilis Study and historical disparities in vaccine access, was based on their relevance to disease prevention and ethical failures in marginalized communities.

Synthesis of Results

A narrative synthesis was conducted to:

1. Examine ethical issues in disease prevention among marginalized communities.

2. Identify and categorize common ethical themes in the application of One Health approaches.

3. Analyze ethical challenges in public health decision-making, with a focus on disparities in healthcare access, trust in public health institutions, and policy gaps.

Results

A review of the selected literature reveals that while public health ethics and the One Health approach are widely recognized as essential to disease prevention, relatively few studies explicitly examine their intersection in marginalized communities. This gap highlights the need for ethical frameworks that address structural inequities while ensuring One Health interventions are both inclusive and sustainable. The findings are categorized into five key themes:

Ethical Justifications for One Health in Marginalized Communities

The One Health approach integrates human, animal, and environmental health to address disease risks and is widely regarded as an ethical necessity in global health (Lee & Brumme, 2013). By linking public health ethics with interdisciplinary collaboration, One Health aligns with the principles of justice and beneficence, ensuring that disease prevention efforts are fair and effective (Lee & Brumme, 2013).

However, despite its theoretical strengths, real-world implementation often fails to meet ethical standards, particularly in marginalized communities. One Health interventions frequently lack inclusive decision-making and do not fully engage local populations, leading to unequal health outcomes and distrust in public health efforts (Bailey et al., 2017). Research highlights that community participation in One Health initiatives improves both public trust and health outcomes (Aliyu, 2021). Successful examples include disease surveillance programs in Indigenous communities and collaborative efforts in low-income regions to improve access to preventive care (WHO, 2021). These findings reinforce the ethical necessity of community-driven strategies in One Health implementation.

Structural Barriers and Policy Gaps in Disease Prevention

Systemic inequities in healthcare access, economic disparity, and legal frameworks limit the effectiveness of One Health interventions, particularly in low-income, rural, and Indigenous populations (Gostin & Powers, 2006). Research shows that these communities often remain disproportionately exposed to diseases due to environmental degradation, occupational risks, and inadequate healthcare infrastructure (Gochfeld & Burger, 2011).

Although global health initiatives advocate for equity-based approaches, in practice, funding and implementation often fall short. Policymakers frequently focus on short-term disease surveillance programs rather than investing in long-term, community-based healthcare infrastructure (WHO, 2021). Without sustained support and policy reforms, marginalized communities will continue to face disproportionate health burdens. To address these challenges, governments and global health organizations must prioritize inclusive policies, ensure adequate funding, and actively involve local communities in decision-making to create sustainable, equitable disease prevention strategies.

Mistrust in Public Health and Its Impact on One Health Adoption

Historical injustices in public health, including medical exploitation, coercive research practices, and unethical disease control measures, have created deep-rooted mistrust in marginalized communities (Reverby, 2012). Past violations, such as the USPH Study of untreated syphilis in the Negro male, have eroded trust in public health institutions, impacting participation in disease prevention programs, including One Health (Bailey et al., 2017).

Mistrust is particularly pronounced when One Health initiatives fail to include community voices in decision-making. Research on Indigenous-led disease prevention programs in North America shows that trust can be rebuilt through transparency, culturally appropriate communication, and participatory engagement (WHO, 2021). Ethical One Health interventions must prioritize community autonomy, ensure informed consent, and integrate local knowledge into health strategies (Kass, 2001).

Equity in Access to Preventive Measures

Prevention is a core principle of public health ethics, yet marginalized communities continue to face barriers to essential preventive measures such as vaccinations, sanitation infrastructure, and veterinary services (Karesh et al., 2012). One Health interventions must address inequities in disease prevention access, ensuring that resources are equitably distributed across all populations (Lee & Brumme, 2013).

For example, mobile veterinary clinics in rural African communities have successfully delivered preventive healthcare for both humans and animals, demonstrating integrative, equity-focused One Health strategies (Allen et al., 2017). However, barriers such as cost, geographic inaccessibility, and exclusion from health policy planning continue to restrict access to these interventions. Ethical One Health policies must explicitly prioritize the most vulnerable communities to achieve true health equity.

Ethical Considerations for Animal Welfare in One Health

One Health also raises ethical concerns about animal welfare, particularly in marginalized communities where livestock and companion animals play critical economic and cultural roles. Disease control measures, such as mass culling during zoonotic outbreaks, must be carefully evaluated for their ethical, social, and economic consequences (Lainé & Morand, 2020).

Ethical alternatives, such as vaccination programs and biosecurity training for smallholder farmers, offer more sustainable and humane approaches to disease prevention (Moiane, 2024). Ensuring that One Health strategies do not disproportionately burden vulnerable populations is critical for maintaining long-term trust and participation.

Discussion

The review shows that One Health has ethical benefits, but its implementation in marginalized communities is uneven. Many One Health programs fail to consider the needs of vulnerable populations, making them ineffective and unfair. A major challenge is policy gaps and barriers to healthcare access. Studies show that governments and health organizations need to invest more in local, community-driven solutions (WHO, 2021). Without this, marginalized groups will continue to face higher risks of disease without proper prevention measures. The fragmented nature of One Health governance also contributes to these disparities, as policymakers fail to integrate human, animal, and environmental health strategies in ways that benefit disadvantaged populations (Morgan et al., 2022). Addressing health disparities goes beyond improving healthcare services—it also means tackling the deeper causes of socioeconomic inequality (Bradley, 2021). To make One Health more ethical and effective, policies should focus on removing these obstacles and ensuring long-term support for vulnerable communities.

Public mistrust remains a significant ethical barrier to One Health implementation. Many marginalized communities have faced medical exploitation, unethical research, and lack of transparency in public health initiatives (Reverby, 2012). This history of mistreatment creates skepticism toward government-led health programs, leading to lower participation rates in disease prevention efforts. This was evident during the COVID-19 pandemic, where medical mistrust, particularly among African Americans, significantly impacted vaccine acceptance and healthcare engagement (Bogart et al., 2021; Momplaisir et al., 2021). Research highlights that trust can be rebuilt through transparency, cultural sensitivity, and genuine community involvement (Bailey et al., 2017). Programs that engage local leaders, incorporate Indigenous knowledge, and allow affected communities to participate in decision-making are more likely to be accepted and effective (WHO, 2021). Without these trust-building efforts, One Health interventions may be rejected, regardless of their scientific validity.

One Health programs must also address inequality in access to preventive care. Research suggests that mobile clinics, subsidized vaccines, and targeted outreach programs can help bridge the gap (Allen et al., 2017). However, these solutions require long-term policy support and financial investment to be sustainable. Ensuring equitable distribution of One Health benefits is crucial; otherwise, marginalized communities will continue to experience higher disease burdens despite ongoing global health efforts (Karesh et al., 2012).

One Health interventions should be guided by ethical principles that consider the close connection between human, animal, and environmental health. Spike and Spike (2024) suggest that ecological ethics can benefit from biomedical ethics, emphasizing the importance of minimizing harm and respecting all living beings. Similarly, Lainé and Morand (2020) call for a more inclusive approach to One Health that acknowledges the interdependence of humans, animals, and ecosystems while ensuring both health and ethical responsibility.

Finally, animal welfare should not be overlooked, particularly in communities that depend on livestock for economic and cultural survival. Disease control measures, such as mass culling without compensation during zoonotic outbreaks, have raised ethical concerns and often harm vulnerable communities by eliminating critical sources of income and nutrition. Ethical alternatives, where possible, offer more humane and effective approaches to disease prevention (Moiane, 2024). One Health strategies that do not disproportionately burden marginalized populations will help establish long-term trust and participation in these interventions.

Conclusion

To make One Health ethically sound and effective for all populations, policymakers, researchers, and global health organizations must take deliberate steps toward addressing these challenges. Specifically, future One Health efforts should focus on: i) policy reforms that explicitly prioritize marginalized communities in global health strategies, ii) investment in long-term, community-driven health programs rather than short-term, donor-driven projects, iii) stronger ethical oversight and accountability mechanisms to prevent public health exploitation, iv) transparent communication and trust-building strategies to improve public participation, v) equitable distribution of preventive care resources, including mobile clinics and affordable vaccines and vi) sustainable, ethical disease control measures that protect both human and animal welfare. By prioritizing justice, transparency, and equity, One Health can become a powerful and ethical tool for reducing health disparities and ensuring fair disease prevention for all communities.