real life public health planning: where medicine meets the law
TRANSCRIPT
Real Life Public Health Real Life Public Health Planning: Where Medicine Planning: Where Medicine
Meets The LawMeets The Law
PresentersPresenters
Edward P. Richards, JD MPHEdward P. Richards, JD MPHProfessor, and DirectorProfessor, and DirectorProgram in Law, Science and Public HealthProgram in Law, Science and Public HealthLSU School of Law http://biotech.law.lsu.eduLSU School of Law http://biotech.law.lsu.edu
Katharine C. Rathbun, MD, MPHKatharine C. Rathbun, MD, MPHSpecialist in Public Health and Preventive Specialist in Public Health and Preventive MedicineMedicineOur Lady of the Lake Health Care SystemOur Lady of the Lake Health Care SystemBaton RougeBaton Rouge
Public HealthPublic Health
Disease ControlDisease ControlFood SanitationFood SanitationWater PurityWater PurityWaste DisposalWaste DisposalAnimal ControlAnimal ControlVector ControlVector ControlNuisance AbatementNuisance Abatement
Public MedicinePublic Medicine
Providing personal medical careProviding personal medical care
Often in Health DepartmentsOften in Health Departments
Very Limited in USAVery Limited in USA
15% of people have no health insurance 15% of people have no health insurance and thus limited access to medical careand thus limited access to medical care
Medical DisastersMedical Disasters
HurricanesHurricanesMeaslesMeaslesTuberculosisTuberculosisSARSSARSPandemic FluPandemic Flu
HurricanesHurricanes
Environmental Public HealthEnvironmental Public Health
food, water, waste, vectorsfood, water, waste, vectorsDisease ControlDisease Control
immunizationsimmunizationsNuisance AbatementNuisance Abatement
housing, weedshousing, weeds
MeaslesMeasles
Classic Disease ControlClassic Disease ControlNo indigenous casesNo indigenous cases ImmunizableImmunizableNo sub-clinical cases – rash and feverNo sub-clinical cases – rash and feverWell defined incubation periodWell defined incubation periodSelf-limited diseaseSelf-limited disease
TuberculosisTuberculosis
Disease Control with Legal ProcessDisease Control with Legal ProcessSlow growing bacteriaSlow growing bacteriaNot very contagiousNot very contagiousTreatableTreatableCare is government funded & providedCare is government funded & providedLegal process slows things downLegal process slows things downPeople do catch it during the processPeople do catch it during the process
SARSSARS
This is what we are planning forThis is what we are planning for Index case = source caseIndex case = source caseRings of contagionRings of contagion Isolate those who are sickIsolate those who are sickQuarantine those exposedQuarantine those exposedPublic health orders are issuedPublic health orders are issuedServices are providedServices are provided
SARS IssuesSARS Issues
Public Health ReportingPublic Health ReportingPublic Health PhysicianPublic Health Physician
Knowledge and experienceKnowledge and experienceCourageCourage
Medical FacilitiesMedical FacilitiesSocial SupportSocial SupportCompensationCompensation
Pandemic FluPandemic Flu
We have flu epidemics every winterWe have flu epidemics every winter 30 million cases (10% of population)30 million cases (10% of population) 30,000 excess deaths (.1% mortality)30,000 excess deaths (.1% mortality) The most likely candidate for a pandemicThe most likely candidate for a pandemic
Pandemic FluPandemic Flu 20% infection with 2.5% mortality20% infection with 2.5% mortality 1.5 million excess deaths1.5 million excess deaths 2.5 million other deaths2.5 million other deaths
How Flu PresentsHow Flu Presents
Sporadic cases during the summerSporadic cases during the summer Increase with school and cold weatherIncrease with school and cold weatherSentinel cases (retrospective)Sentinel cases (retrospective)The epidemic hitsThe epidemic hitsMultiple epidemics simultaneouslyMultiple epidemics simultaneously1-3 weeks to recognize a bad flu1-3 weeks to recognize a bad flu
Flu PreventionFlu Prevention
Individual disease control is pointlessIndividual disease control is pointlessMass immunizationMass immunizationSocial distancingSocial distancingMaintaining medical care systemMaintaining medical care systemMass care for flu victimsMass care for flu victimsMaintaining social support systemsMaintaining social support systems
Florida Pandemic Influenza Bench Florida Pandemic Influenza Bench GuideGuide
Is this proper as an Advisory Opinion?Is this proper as an Advisory Opinion?Based on incorrect medical assumptionsBased on incorrect medical assumptionsConflict of interestConflict of interestMisuse of authorityMisuse of authority
Out of state casesOut of state casesCommentatorsCommentatorsUnited States Supreme Court cases like United States Supreme Court cases like
Mathews v. EldridgeMathews v. EldridgeNot a problem solving documentNot a problem solving document
Florida Bench Guide as a Potemkin Florida Bench Guide as a Potemkin PlanPlan
Potemkin VillagePotemkin VillageAfter Grigori Aleksandrovich Potemkin, who After Grigori Aleksandrovich Potemkin, who
had elaborate fake villages constructed for had elaborate fake villages constructed for Catherine the Great's tours of the Ukraine and Catherine the Great's tours of the Ukraine and the Crimea. the Crimea.
Potemkin PlansPotemkin PlansElaborate plans for public health emergency Elaborate plans for public health emergency
preparedness that cannot be carried out preparedness that cannot be carried out because of lack of staff, resources, political because of lack of staff, resources, political will, competence, or any combination of the will, competence, or any combination of the above.above.
The Post 9/11 Emergency The Post 9/11 Emergency Planning WorldPlanning World
Emergency preparedness becomes a Emergency preparedness becomes a national security issuenational security issue
National security means federal command National security means federal command and controland controlThe militarization of emergency responseThe militarization of emergency responseFederal national security laws can be used to Federal national security laws can be used to
override state controloverride state control
The Planning ImperativeThe Planning Imperative
For the feds, plans = actionFor the feds, plans = actionSmallpox at the National Security Administrative Smallpox at the National Security Administrative
CourseCourseKatrina and Hurricane PamKatrina and Hurricane Pam
Federal push down requiring elaborate plans Federal push down requiring elaborate plans on every crisis de jure, with federal on every crisis de jure, with federal programmatic funding depending on the right programmatic funding depending on the right answers in the plananswers in the plan
State legislators do the same to their own state State legislators do the same to their own state and local governmentsand local governments
Post-Katrina PlansPost-Katrina Plans
The Lesson from KatrinaThe Lesson from KatrinaWe need more plansWe need more plansTranslation - The Feds want to better Translation - The Feds want to better
document how the next screw up is your faultdocument how the next screw up is your faultThe plans have to address all the federal The plans have to address all the federal
target issues and have to say that the target issues and have to say that the state and localities are prepared to carry state and localities are prepared to carry out the functionsout the functions
Why the feds think this is workingWhy the feds think this is working
What is the Structural Problem?What is the Structural Problem?
National is the wrong level for emergency National is the wrong level for emergency responseresponse
All state and local public health, police, All state and local public health, police, and other first responders are already and other first responders are already committed about 110%committed about 110%There have been net cuts in most programs There have been net cuts in most programs
as emergency response has been addedas emergency response has been addedExisting problems like crime and disease Existing problems like crime and disease
control do not go away during disasterscontrol do not go away during disasters
How Did This Become a Legal How Did This Become a Legal Problem?Problem?
HHS and CDC believe that the problem HHS and CDC believe that the problem with emergency preparedness is that we with emergency preparedness is that we do not have enough lawsdo not have enough lawsModel State Emergency Health Powers ActModel State Emergency Health Powers ActThe CDC/RWJ Model Law MovementThe CDC/RWJ Model Law Movement
Laws are cheap and easy to passLaws are cheap and easy to passFixing budgets, staffing levels, and Fixing budgets, staffing levels, and
competence for state and local departments is competence for state and local departments is way too expensive and troublesomeway too expensive and troublesome
The Xdr-TB ExampleThe Xdr-TB Example
Does anyone here really think that the GA Does anyone here really think that the GA guys could not have grabbed that TB guys could not have grabbed that TB carrier if they had really wanted to?carrier if they had really wanted to?
Did anything prevent GA or the CDC from Did anything prevent GA or the CDC from just having the Europeans pick him up?just having the Europeans pick him up?
What was their excuse?What was their excuse?Not enough lawNot enough lawRemember, folks like Larry Gostin make their Remember, folks like Larry Gostin make their
money selling more law to the CDC and the money selling more law to the CDC and the statesstates
Why Should You Care About Why Should You Care About Potemkin Plans?Potemkin Plans?
Could you do a plan that works instead of Could you do a plan that works instead of the Potemkin Plan?the Potemkin Plan?
What is the effect on risk communication What is the effect on risk communication to the at risk communities?to the at risk communities?Does the plan provide false assurances?Does the plan provide false assurances? If communities were given honest risk If communities were given honest risk
information, would they make different information, would they make different decisions?decisions?
Pan Flu ExamplesPan Flu Examples
Address the real issues like food, water, Address the real issues like food, water, realistic rationing decisions, etc.realistic rationing decisions, etc.
Prepare and respond properly to the Prepare and respond properly to the yearly pandemicyearly pandemic
Deal with universal access to health careDeal with universal access to health careAdmit that we are choosing cheap over Admit that we are choosing cheap over
safe because we do not want to fund safe because we do not want to fund governmentgovernment
Katrina ExamplesKatrina Examples
The core problem is living within the surge zone The core problem is living within the surge zone and below sea level and below sea level If all the emergency prep had worked, not much If all the emergency prep had worked, not much
would have changedwould have changed
What has changed?What has changed? We have lots more plansWe have lots more plans Efforts to continue to subsidize the insurance costEfforts to continue to subsidize the insurance cost They do not change anything about the riskThey do not change anything about the risk
They convince people that it is OK to go back They convince people that it is OK to go back and do the same thingand do the same thing
Who Has A Duty to Speak up?Who Has A Duty to Speak up?
Who does a public health lawyer really Who does a public health lawyer really represent?represent? The director?The director? The agency?The agency? The public?The public?
As we deprofessionalize public health agencies, As we deprofessionalize public health agencies, who else can speak up?who else can speak up?
What is the long term impact on agencies and What is the long term impact on agencies and policy when political considerations outweigh policy when political considerations outweigh public good?public good?