Bioterrorism and Public Health
The prospect of a bioterrorist attack and the actual attacks in Florida, the District of Columbia, New York, New Jersey, and Connecticut have changed public health in the United States. Since the founding of the country, public health has been considered primarily the business of the states.
The reason is that when the former colonies delegated powers to the federal government in the U.S. Constitution, they retained the authority to protect the public’s health and safety, usually referred to as the state’s “police powers.”7,8
The federal government may, nonetheless, affect public health and safety through its constitutional authority to spend money, regulate interstate and foreign commerce, and provide for national defense. The Congress established the Public Health Service and the Centers for Disease Control and Prevention (CDC) with federal money and used its authority under the commerce clause of the Constitution to establish the Food and Drug Administration (FDA).
The creation of these federal agencies, however, did not alter the states’ responsibility for public health; the anthrax attacks did.
Bioterrorism — the deliberate release of a harmful biologic agent to intimidate civilians and their government — constitutes a threat to public health that differs from any other public health threat that our country has faced. An act of bioterrorism is both a state and a federal crime, and it can also be an act of war.9 Because of our highly developed transportation system, communicable diseases can be spread widely in a short period of time.
All these factors make it reasonable to view bioterrorism as an inherently federal matter under both the national-defense and commerce clauses of the Constitution.
Thus, the Federal Bureau of Investigation (FBI) and the CDC took the lead in investigating all the anthrax mail attacks. Moreover, had the attacks originated outside the country, the U.S. military and the Central Intelligence Agency would have been called on to respond.
Building a Modern Public Health System
In the immediate aftermath of the September 11 attacks and the subsequent anthrax attacks through the U.S. mail, hospitals, cities, states, and federal officials began developing or revisiting protocols to deal with possible biologic attacks in the future. The federal response has so far emphasized the stockpiling of drugs and vaccines that could be used to respond to an attack, especially one involving smallpox.10
Other proposals have included improving the public health infrastructure of the country (especially the ability to monitor diagnoses made in emergency departments and pharmacy sales of relevant drugs) and training emergency medical personnel to recognize and treat the diseases most likely to be caused by a bioterrorist attack (such as anthrax, smallpox, and plague).11
Major efforts are also under way to improve coordination and communication among local, state, and federal officials who are responsible for responding to emergencies and to delineate more clearly the lines of authority involving “homeland security.”
All these measures are reasonable and responsible steps our government should take.
Properly worried that many state public health laws are outdated and perhaps inadequate to permit state officials to contain an epidemic caused by a bioterrorist attack, the CDC has advised all states to review the adequacy of their laws, with special attention to provisions for quarantining people in the event of a smallpox attack.12 In addition, the CDC released a proposed model act for the states, the Model State Emergency Health Powers Act, on October 23, 2001.12,13
The act was constructed by the Center for Law and the Public’s Health at Georgetown University and Johns Hopkins University and was pieced together from a variety of existing state laws.
The Original Model State Emergency Health Powers Act
The original model act permits the governor to declare a “state of public health emergency,” and this declaration, in turn, gives state public health officials the authority to take over all health care facilities in the state, order physicians to act in certain ways, and order citizens to submit to examinations and treatment, with those who refuse to do so subject to quarantine or criminal punishment.
The model act specifies that public health officials and those working under their authority are immune from liability for their actions, including actions that cause permanent injury or death; the only exceptions are in cases of gross negligence and willful misconduct.
A public health emergency (the condition that requires the governor to declare a state of public health emergency) is defined as “an occurrence or imminent threat of an illness or health condition, caused by bioterrorism, epidemic or pandemic disease, or [a] novel and highly fatal infectious agent or biological toxin, that poses a substantial risk of a significant number of human fatalities or incidents of permanent or long-term disability.”13
The declaration of a state of public health emergency permits the governor to suspend state regulations, change the functions of state agencies, and mobilize the militia. Under the model act, all public health personnel will be issued special identification badges, to be worn “in plain view,” that “shall indicate the authority of the bearer to exercise public health functions and emergency powers. . . .”13
Public health personnel may “compel a health care facility to provide services or the use of its facility if such services or use are reasonable and necessary for emergency response . . . [including] transferring the management and supervision of the health care facility to the public health authority.”
According to the act’s provisions, public health personnel have exceptionally broad powers, and failure of physicians and citizens to follow their orders is a crime. Section 502 of the act, which covers mandatory medical examinations and testing, states:
Any person refusing to submit to the medical examination and/or testing is liable for a misdemeanor. If the public health authority is uncertain whether a person who refuses to undergo medical examination and/or testing may have been exposed to an infectious disease or otherwise poses a danger to public health, the public health authority may subject the individual to isolation or quarantine. . . . Any [health care provider] refusing to perform a medical examination or test as authorized herein shall be liable for a misdemeanor. . . . An order of the public health authority given to effectuate the purposes of this subsection shall be immediately enforceable by any peace officer.13
Section 504, on vaccination and treatment, states, “Individuals refusing to be vaccinated or treated shall be liable for a misdemeanor. If, by reason of refusal of vaccination or treatment, the person poses a danger to the public health, he or she may be subject to isolation or quarantine. . . . An order of the public health authority given to effectuate the purposes of this Section shall be immediately enforceable by any peace officer.”13
The Need for New State Laws on Bioterrorism
Of course, state public health, police, fire, and emergency planners should be clear about their authority, and to the extent that it encourages states to review their emergency laws, the model act is constructive.
On the other hand, many of the provisions of this act, especially those giving public health officials authority over physicians and hospitals, as well as authority to enforce a quarantine in the absence of meaningful standards, seem to be based on the assumption that neither physicians nor citizens are likely to cooperate with public health officials in the event of a bioterrorist attack. This assumption, in turn, seems to be based on the results of theoretical planning exercises involving simulated bioterrorist attacks, including the Top Officials 2000 (Top Off) and Dark Winter exercises.12
Top Off was an exercise that simulated a bioterrorist attack on Denver that involved the use of aerosolized Yersinia pestis, the bacteria that causes plague.14 Dark Winter simulated a smallpox attack on Oklahoma City.15 Using these simulated cases as a basis for legislation is unreasonable, given the extremely high level of voluntary cooperation on the part of the public, physicians, and hospitals after both the September 11 terrorist attacks and the subsequent anthrax attacks.
In my opinion, the model act poses several problems. First, proposed laws should respond to real problems. It is not at all clear what problem the model act is intended to solve, and this makes it extremely difficult to evaluate.
Second, the authority to respond to a bioterrorist attack or a new epidemic that the model act provides is much too broad, since it applies not just to real emergencies such as a smallpox attack but also to nonemergency conditions as diverse as annual influenza epidemics and the AIDS epidemic.16,17
Third, although it may make sense to put public health officials in charge of responding to a smallpox attack, it may not make sense to put them in charge of responding to every type of bioterrorist event. In the event of a bioterrorist attack, the state public health department has a major role in limiting the public’s exposure to the agent. However, the tasks of identifying affected persons, reporting them, treating them, and taking preventive actions will be performed by physicians, nurses, emergency medical personnel, and hospitals.
The primary role of public health authorities will usually be, as it was in the wake of the anthrax attacks, to provide guidance to the public and other government officials in identifying and dealing with the disease and to provide laboratory facilities where exposure can be evaluated and diagnoses definitively established.5,6,18
Fourth, there is no evidence from either the September 11 attacks or the anthrax attacks that physicians, nurses, or members of the public are reluctant to cooperate in the response to a bioterrorist attack or are reluctant to take drugs or vaccines recommended by public health or medical officials. In fact, medical personnel in the affected areas volunteered their time and expertise to help victims of the September 11 attacks, and the public lined up to be tested for anthrax and stockpiled ciprofloxacin.19
The public demand for testing and treatment was so great that the CDC had to issue recommendations against both.
Of course, anthrax, unlike smallpox, is not spread from person to person. The situation might have been different if smallpox had been used as a biologic weapon or if thousands or tens of thousands of people had been infected with anthrax. Nonetheless, there is no empirical evidence that draconian provisions for quarantine, such as those outlined in the model act, are necessary or desirable.
Persons with smallpox, for example, are most infectious only after fever and a rash have developed,12 and then they are usually so sick that they are likely to accept whatever care is available. Moreover, according to Barbera et al., the “long incubation period (10–17 days) almost ensures that some persons who are infected in the [smallpox] attack will have traveled great distances from the site of the exposure before the disease is recognized or quarantine could be implemented.”14
The key to an effective public health response is identifying and helping those who have been exposed. Even with a sufficient supply of smallpox vaccine, a quarantine enforced by the police would probably not be effective in controlling an outbreak of smallpox.12,14,20 This is a major reason for the current recommendation that smallpox vaccine be made available to the public on a voluntary basis.21
Finally, even if it is concluded that a quarantine law may be useful to respond to a bioterrorist attack (e.g., as a means of ensuring that the few unwilling Americans, if any, would be treated, vaccinated, or quarantined), it should be a federal law, not a state law. The reason is that bioterrorism is a matter of national security, not just of state police powers.
The existing federal quarantine law is based on the commerce clause of the Constitution (with special provisions for cholera, plague, smallpox, typhus, and yellow fever), and Congress could examine and update it to deal with bioterrorism.22,23 The governors of the states involved in the anthrax attacks all realized that bioterrorism is fundamentally a federal issue and quickly called for action from both the FBI and the CDC to deal with the attacks.
Read the rest here: nejm.org
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sir_isO
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Oh look, they’re trying to explain the damage of their policies, methodologies, practices and substances.
Because as a zombiedronerobosheepclone, you haven’t figured out that EVERYTHING they peddle is UTTER BULLSHIT for the PRS cycle.
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sir_isO
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So you’re going to have fuckloads of sick and dying people in the northern hemisphere (assuming the vaccine uptake and such is actually high), along with the damage of their policies and such, the increased environmental toxins, EMF and whatever…
Of course, they will try and use that to sell other shit while not addressing any of those causative issues. Oh, and it’s going to be really cold.
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sir_isO
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It’s so bad, that like an hour ago I had to tell my brother he’s not my brother.
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Aussie Viking
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Iso,
Your foul language and derogatory comments are not worthy of this site. Your verbal presence has prevented me from recommending the otherwise splendid, Principia Scientific to my friends.
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A Reasonable Man
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Sir_#% So we find the limits to free speech. Just turn him off.
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thumb sucking device
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thumb sucking device
Bioterrorism, Public Health, and Civil Liberties | Principia Scientific Intl.
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sofahouse.com.ar
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sofahouse.com.ar
Bioterrorism, Public Health, and Civil Liberties | Principia Scientific Intl.
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