Real Life Public Health Planning: Where Medicine Meets The Law

Presenters

 Edward P. Richards, JD MPH Professor, and Director Program in Law, Science and Public Health LSU School of Law http://biotech.law.lsu.edu

 Katharine C. Rathbun, MD, MPH Specialist in Public Health and Preventive Medicine Our Lady of the Lake Health Care System Baton Rouge

Pandemic Flu

What is the Medicine?

Public Health

 Disease Control  Food Sanitation  Water Purity  Waste Disposal  Animal Control  Vector Control  Nuisance Abatement

Public Medicine

 Providing personal medical care  Often in Health Departments  Very Limited in USA  15% of people have no health insurance and thus limited access to medical care

Medical Disasters

 Hurricanes  Measles  Tuberculosis  SARS  Pandemic Flu

Hurricanes

 Environmental Public Health food, water, waste, vectors  Disease Control immunizations  Nuisance Abatement housing, weeds

Measles

 Classic Disease Control  No indigenous cases  Immunizable  No sub-clinical cases – rash and fever  Well defined incubation period  Self-limited disease

Tuberculosis

 Disease Control with Legal Process  Slow growing bacteria  Not very contagious  Treatable  Care is government funded & provided  Legal process slows things down  People do catch it during the process

SARS

 This is what we are planning for  Index case = source case  Rings of contagion  Isolate those who are sick  Quarantine those exposed  Public health orders are issued  Services are provided

SARS Issues

 Public Health Reporting  Public Health Physician  Knowledge and experience  Courage  Medical Facilities  Social Support  Compensation

Pandemic Flu

 We have flu epidemics every winter  30 million cases (10% of population)  30,000 excess deaths (.1% mortality)  The most likely candidate for a pandemic  Pandemic Flu  20% infection with 2.5% mortality  1.5 million excess deaths  2.5 million other deaths

How Flu Presents

 Sporadic cases during the summer  Increase with school and cold weather  Sentinel cases (retrospective)  The epidemic hits  Multiple epidemics simultaneously  1-3 weeks to recognize a bad flu

Flu Prevention

 Individual disease control is pointless  Mass immunization  Social distancing  Maintaining medical care system  Mass care for flu victims  Maintaining social support systems

Florida Pandemic Influenza Bench Guide

 Is this proper as an Advisory Opinion?

 Based on incorrect medical assumptions  Conflict of interest  Misuse of authority  Out of state cases  Commentators  United States Supreme Court cases like Mathews v. Eldridge  Not a problem solving document

Florida Bench Guide as a Potemkin Plan

 Potemkin Village  After Grigori Aleksandrovich Potemkin, who had elaborate fake villages constructed for Catherine the Great's tours of the Ukraine and the Crimea.  Potemkin Plans  Elaborate plans for public health emergency preparedness that cannot be carried out because of lack of staff, resources, political will, competence, or any combination of the above.

The Post 9/11 Emergency Planning World

 Emergency preparedness becomes a national security issue  National security means federal command and control  The militarization of emergency response  Federal national security laws can be used to override state control

The Planning Imperative

 For the feds, plans = action  Smallpox at the National Security Administrative Course  Katrina and Hurricane Pam  Federal push down requiring elaborate plans on every crisis de jure, with federal programmatic funding depending on the right answers in the plan  State legislators do the same to their own state and local governments

Post-Katrina Plans

 The Lesson from Katrina  We need more plans  Translation - The Feds want to better document how the next screw up is your fault  The plans have to address all the federal target issues and have to say that the state and localities are prepared to carry out the functions  Why the feds think this is working

What is the Structural Problem?

 National is the wrong level for emergency response  All state and local public health, police, and other first responders are already committed about 110%  There have been net cuts in most programs as emergency response has been added  Existing problems like crime and disease control do not go away during disasters

How Did This Become a Legal Problem?

 HHS and CDC believe that the problem with emergency preparedness is that we do not have enough laws  Model State Emergency Health Powers Act  The CDC/RWJ Model Law Movement  Laws are cheap and easy to pass  Fixing budgets, staffing levels, and competence for state and local departments is way too expensive and troublesome

The Xdr-TB Example

 Does anyone here really think that the GA guys could not have grabbed that TB carrier if they had really wanted to?

 Did anything prevent GA or the CDC from just having the Europeans pick him up?

 What was their excuse?

 Not enough law  Remember, folks like Larry Gostin make their money selling more law to the CDC and the states

Why Should You Care About Potemkin Plans?

 Could you do a plan that works instead of the Potemkin Plan?

 What is the effect on risk communication to the at risk communities?

 Does the plan provide false assurances?

 If communities were given honest risk information, would they make different decisions?

Pan Flu Examples

 Address the real issues like food, water, realistic rationing decisions, etc.

 Prepare and respond properly to the yearly pandemic  Deal with universal access to health care  Admit that we are choosing cheap over safe because we do not want to fund government

Katrina Examples

 The core problem is living within the surge zone and below sea level  If all the emergency prep had worked, not much would have changed  What has changed?

 We have lots more plans  Efforts to continue to subsidize the insurance cost  They do not change anything about the risk  They convince people that it is OK to go back and do the same thing

Who Has A Duty to Speak up?

 Who does a public health lawyer really represent?

 The director?

 The agency?

 The public?

 As we deprofessionalize public health agencies, who else can speak up?

 What is the long term impact on agencies and policy when political considerations outweigh public good?