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

Pandemic FluPandemic Flu

What is the Medicine?What is the Medicine?

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?