the bioterrorism band-aid: why we cannot manage bioterrorism with a broken public health system
TRANSCRIPT
The Bioterrorism Band-Aid:
Why We Cannot Manage Bioterrorism with a Broken Public Health System
Edward P. Richards Director, Program in Law, Science,
and Public Health Louisiana State University Law
Center [email protected] http://biotech.law.lsu.edu Google: Smallpox Law
Thesis Public Health is Driven by Fear
Bioterrorism Frightens Politicians Bioterrorism Gets Attention
Bioterrorism Preparedness Does Not Improve Public Health
The Smallpox Vaccination Plan for Health Care Providers Shows why Public Health Infrastructure and Trust Matters
We Have to Fix Public Health and Health Care to be Prepared for All Public Health Disease Threats
Why is Bioterrorism so Scary? Bombs and Armed Attacks
Open and Obvious Obvious Endpoints
Chemical and Bioterrorism Includes Nuclear Contamination Stealth Unknown reach Unknown Duration
Why Smallpox Bioterrorism?
Stable Aerosol Virus Relatively Easy to
Produce Infectious at Low Doses 10 to 12 day incubation
period High mortality rate (30%) No proven treatment
Victims as Vectors
Smallpox Spreads Primarily Through Person to Person Contact People are Infectious When They Start to
Develop Sores Stay Infectious Until They Recover or Die
Cases must be isolated until cured Contacts should be Vaccinated and
Quarantined for 2 weeks
The President's Smallpox Vaccination Campaign In mid-December, the White House
announced a campaign to vaccinate 500,000 health care workers over the next two months
Three months later, approximately 10,000 health care workers have been vaccinated and many hospitals have refused to participate
Why?
Smallpox Vaccine is Dangerous
Only dangerous vaccine in use Live Virus Vaccine (Vaccinia Virus) Must be Infected to be Immune
Complications of Vaccination
Local Lesion Can be Spread
on the Body and to Others
Progressive (Disseminated) Vaccina Deadly Like
Smallpox, but Less Contagious
Historic Probability of Injury
35 Years Ago 5.6M New and 8.6M Revaccinations a
Year 9 deaths, 12 encephalitis/30-40%
permanent Death or Severe Permanent Injury -
1/1,000,000 Injuries were to
Immunosuppressed Persons
How Have Medical Risks Changed?
Immunosuppression Was Rare in 1970 Immunosuppression is More Common
HIV, Cancer Chemotherapy, Arthritis Drugs, Organ Transplants
Because of HIV privacy policies, many HIV infected persons do not know it
Many Others Do Not Realize Their Medicines Make Them Immunosuppressed
How Have Legal Risks Changed?
Society has much less tolerance for risk
Society has lower respect for public health authorities
Tort law was a minor problem in 1970 Now you must have legal immunity or
it is too risky to use smallpox vaccine
Homeland Security Act Section 304 provides governmental
immunity to persons and institutions participating in the smallpox vaccination program
You must sue the Public Health Service under the Federal Tort Claims Act
Probably cannot win under discretionary immunity Even if it is dumb, you cannot sue for things
the government does on purpose Atom bomb cases
Problems with Sec. 304 Poorly Drafted
Probably does not apply to medical staff members
Some other ambiguities Cuts off compensation
Injured health care providers are limited to worker's compensation
Injured third parties such as family members and patients are out in the cold
Concerns of Health Care Providers
Health Departments do not have enough personnel
Hospitals are worried about paying worker's comp costs
Workers are worried about injuries and the limited payments by comp
Everyone is worried about risks to immunosuppressed patients and family members and how to pay for their care
Epidemiologic Issues Many hospitals believe the plan is
unsound so it does not justify taking any risks
No provisions for regionalizing care No provisions for triaging smallpox
cases away from hospitals No provisions for quarantine and
isolation
Isolation and Quarantine Do You Let Them Stay at Home
and Promise to Not Go Out? How do They Get Food? Medical Care?
Take Over A Hotel or Prison? No Good Respiratory Isolation If Someone Gets Sick, All Are At Risk Pest House
What if there is a Smallpox Outbreak? CDC Assumption - Hard to Spread
Limited Transmission Self-policed Quarantine At Home Vaccinate Contacts and Trace New Cases
Other Scientists - Easy to Spread Hard Quarantine for Cases and Contacts Mass Immunization
Which Way Do You Want to Bet? Is the CDC Being Politically Expedient?
Why Are We Unprepared for Smallpox? Public Health Believed the Virus Was
Safely Locked Away Stopping vaccinations was controversial No Work on Better Vaccines
Intelligence Agencies Knew Smallpox Out of the Box in 1992
Public Health Did Not Know this Until 1999
10 Years Could Have Solved the Vaccine Problem
Are We Doing Better with AIDS?
Set up by the Bathhouses in the 1970s Huge Hepatitis B Epidemic Really got AIDS Started
What have we Learned? Bathhouses are Open Again AIDS is on the Increase We do even know how many are infected
Other Emerging Infectious Diseases
Lyme Disease West Nile Dengue Resurgence of Tuberculosis 5,000 people a year die of food
borne illness
Why is Fear Necessary for Public Health?
Effective Prevention Depends on Fear Fear Justifies Personal and Tax Costs Fear Justifies Personal Risk
Fear Must Cut Across Classes The Middle and Upper Classes do not
Fear AIDS - We do Little to Prevent it TB Scared Wealth New Yorkers - TB
Control Increases
Primal Fear of Epidemics Breaks Down Family and Community
Structures Fear of the Infected No Backup When Caregivers are Ill Synchronous Infection Wiped out the
Indigenous Peoples in the Americas Disrupts Society
Scholars argue plague ended the feudal system
Critical to conquest of the Americas
Public Health is a Fundamental Government Function
Epidemics Threaten Public Order Right of Societal Self-Defense Justifies Draconian Actions Under
National and International Law From Quarantining Philadelphia to
Putting Alaskan Sex Offenders on the Internet
Epidemics in the US
Colonial Cities Were Wracked by Yellow Fever, Malaria, Cholera, and Typhoid
Periodic Smallpox, Lots of Tuberculosis Individuals, Cities, and Even States
were Quarantined Life Expectancy in Boston in 1840 was
25
Public Health in the Constitution
Original Intent is Clear Police Power Went to the States Federal Government Retained
Control over Interstate Commerce and National Security
State Public Health Most Public Health is done by state,
county, and local government Sanitation Communicable Disease Control Environmental Health
Broad Powers Seizure of Property Personal Restrictions Information Collection
Federal Public Health
First Acts of Congress Public Health Hospitals Quarantine Stations National Security Powers
Much Later FDA, Agriculture Department, HHS,
CDC Interstate Commerce Powers
Could the Feds Require Smallpox Vaccination?
Are There Federal Police Powers? Could the Invasion Clause of the
Constitution Support Mass Smallpox Vaccinations as a Protection Against Terrorist Invasion?
Current Method Threaten State Funding Political Intimidation Health Departments are Afraid to Resist
Public Health Revolution Sanitation Movement – Mid 1800s
Clean Drinking Water Waste Disposal
Disease Control Vaccinations TB Control Epidemiology: Investigation and
Intervention
Triumph of Public Health
High Point - 1960s TB is Controlled Vaccinations for Major Communicable
Diseases Life Expectancy More than Doubled in
100 Years 1968 - Surgeon General Says Public
Health is Solved, on to Chronic Diseases
Destruction of Public Health Medicare, Medicaid, Private Health
Insurance Make Medical Care Much More Financially Rewarding Medical Care is a Much More Expensive and
Cannibalizes Public Health Money Health Departments Fill with Medical Care
People Research is Dominated by Drugs for
Chronic Illness We Even Rationalize Away the Fear of
AIDS by Treating it as a Personal Choice
The Political Consensus Breaks Down
Without Fear, the Public Will not Pay for Prevention Politicians want Health Directors who Do not
Make Trouble about Public Health When Budgets are Cut, Public Health is First Hard to Hire and Retain Trained Staff
Schools of Public Health Lose Their Focus Privacy Trumps Public Good
Parallel Problems in Health Care Reduced Hospital Beds
Empty hospital beds costs money Managed care and DRGs have shorted hospital
stays, reducing the need for beds Reduced Emergency Room Capacity
EMTALA has forced many hospitals to close their ERs
Most remaining city ERs are over capacity If you cannot handle routine traffic, how
can you handle a large number of causalities?
Why Bioterrorism Money Does Not Help Post 911 Congress has Appropriated
Billions for Terrorism and Bioterrorism Most is Law Enforcement and Fire
Departments, Some Public Health Equipment Training
No Personnel No Long Term Commitments Mandates Cost More than the Funding
Doing the Numbers Health and Public Health Care are
Expensive when They Work Well They Are Much More Expensive When
They Work Poorly Only the Government Can Capture the
Savings Private Insurers and Employers have too
much turn over and too short a time horizon
States Cannot Do the Job
State Budgets are too Variable Local Politicians are too Short-
Sighted Insurance and Health Care Are
National Business and Need Federal Regulation
The Feds Already Control a Large Part of the Budget
Public Health as National Defense
The White House Recognizes that Public Health is Part of National Defense
National Defense is a Federal Function Demands Stable Federal Money Demands National Coordination Cannot Be Done By Telling the States to
Manage Bioterrorism on Short-Term Money
End of Presentation