Bioterrorism, Public Health and the Law 
Law 801: Health Care Law Seminar
Professor Vernellia R. Randall

A Public Health Primer

 

Syllabus
Resources
Lesson Schedule
00: Intro to the Course
01: Intro to the Problem
02: Public Health System
03: Real Threat?
04: Public Health Law
05: Disease-Reporting
06: Quarantine
07: Model Act
08: Military Presence
09: Health Law Revisited

 

 
Dr. Marion Warwick
Journal of Homeland Security
July 2002

 

In an era when bioterrorism attacks are a possibility, it has become critical for those working in many fields to understand the public health system and our national defense in responding to a bioterrorism attack and to assess related weaknesses that endanger national security.

Fundamental to these weaknesses is the lack of a coherent vision and mission for public health—a vision capable of influencing public policy and strengthening national security. Years of underfunding have resulted in a public health system lacking in basic infrastructure and trained personnel. Although there are many exceptions, such as the Centers for Disease Control and Prevention (CDC), overall a pervasive rift exists between practitioners of medicine and of public health. Medicine and public health would each be stronger if they functioned together, and this collaboration should begin at the academic level for each discipline. A closer relationship among those working in medicine, public health, and public policy would set the stage for developing and articulating a clear mission for public health, thus protecting national security.

How Does Public Health Differ From Health Care?

To effectively plan for bioterrorism, one must understand the distinction between private medicine and public health. In private medicine, doctors and nurses see individual patients in hospitals and clinics operating independently from public health. Private medicine is sometimes referred to as a system, though it consists mostly of teaching hospitals and businesses with little formal interaction and no central control. Although limited patient care is also provided by some public health agencies, this is not the central mission of public health. In public health, people analyze trends, find health risks, and implement protective measures in the population as a whole, even if those measures are targeted to subpopulations.

However, effective communication between the fields of private medicine and public health is essential to both. Persons taking care of patients are sometimes in a position to see what measures are needed in the population to control disease. They need to have a mechanism for input into the public health system. When trends are suspected, confirmation and, if necessary, implementation of remedies proposed by those working in public health often depend on the assistance of those in private medicine. Therefore, those working in public health need to understand how the private medical system works. Mutual understanding between these fields will be essential for an effective and complementary process.

What Is the Role of Public Health?

The role of public health encompasses the full range of the medical field: any kind of illness that affects individuals can be studied by persons in public health to detect trends and take measures to decrease illness in populations. Its mission of “prevention rather than cure” is universally compelling, saving money and reducing human suffering. This mission now includes the need for early detection of a bioterrorism release and rapid mobilization for investigation and response.

Hepatitis A is an example of a disease that public health can take measures to prevent. Persons eating in a restaurant where a worker with early hepatitis A has not followed proper handwashing procedures are at risk for hepatitis A. One enthusiastic public health department worked to get a law passed in their county requiring all restaurant workers to be vaccinated against hepatitis A. [1] The surrounding counties soon followed suit. Wouldn’t you rather live in an area with a good public health department?

Prevention becomes even more important for serious diseases, those released as an act of war, or ones for which there is no cure. Considering the enormous amount of money we spend on taking care of illness in this country, it would make sense to spend more on preventing it.

The Current System for Public Health in America

Public Health: The Federal Level

A bioterrorism event in the United States would almost certainly require national coordination: for resources, for expertise, and to keep the rest of the country informed. The CDC is the federal agency for public health. The CDC originated in the 1940s as a military program to control malaria and has gradually grown to encompass a broad range of public health programs. [2] The CDC operates under the direction of the Department of Health and Human Services, which also oversees the National Institutes of Health, the Food and Drug Administration, and many other large federal organizations.

The Bioterrorism Preparedness and Response Program was created within the CDC two years ago. Since that time it has facilitated discussions, assisted state health departments in beginning bioterrorism programs, participated in planning exercises, and responded to potential threats. It coordinates between the many units at the CDC that contribute to bioterrorism planning but does not house disease programs. In the event of a bioterrorism attack, the Bioterrorism Preparedness and Response Program would assist with coordination, but disease programs would assist with outbreak investigation and control measures.

The CDC is organized by disease programs, which preside over every aspect of prevention and control related to their disease(s). These disease programs are one of the CDC’s strengths. They monitor national rates of disease, perform laboratory testing, conduct research, promote measures for control, maintain hotlines for physicians and the public, assist state and local health departments with corresponding programs, and sometimes administer funding. They also provide the public health community, practicing physicians, and the general public with access to medical scientists who have depth of expertise on a single disease. This arrangement ensures that someone in the nation is focusing on each disease and that unique control measures necessary for a rare disease are not swept away by large bureaucratic processes.

Medical staff in the CDC’s disease programs are highly trained, often physicians with experience in research and publication. They are called upon to respond to outbreaks both here and abroad, and their research programs are international in scope. The CDC convenes panels and committees to prepare statements on clinical recommendations (how to treat patients) and formulates policy for public health programs, sometimes in conjunction with advisory boards. These programs have the best expertise in the world for the control of outbreaks.

Because measures for diagnosis, treatment, and control are specific to each disease, planning for bioterrorism response needs to occur in programs for each bioterrorism disease known to be a potential weapon. But funding for disease programs can vary according to the political strength of their constituencies. Programs for the bioterrorism diseases need to be established and be ready to advise decision makers in the event of a bioterrorism attack.

As the bioterrorism diseases are rare in actual practice, the programs for these at CDC are small or exist within programs that also handle other diseases. Communicable-disease programs tend to be organized by biologic classification: viruses, bacteria, etc. Some of the bioterrorism diseases are viruses, and others are bacteria, so their programs are scattered throughout different administrative sections: the program for plague is within the Vector-Borne Infectious Diseases program in Colorado, and the program for anthrax is in the Meningitis and Special Pathogens program in Atlanta.

Because the CDC has provided sound and current clinical recommendations helpful for practicing physicians, most physicians have heard of the CDC and respect its leadership. If physicians need assistance with particular diseases, they are likely to contact the CDC. During the anthrax events of 2001, the CDC’s website was overwhelmed with visits. This credibility will be important following a bioterrorism attack. Because physicians less often contact their local or state health agencies, they increase the workload on a massively overburdened federal agency and decrease the link that should exist between private and public medicine at the state and local levels.

Public Health: The State Level

If there were multiple bioterrorism releases in several states, the federal government could be spread thin in responding to all of them. States must also be able to respond to the full range of bioterrorism diseases. Because federal funding and technical assistance from the CDC flow to state and local health departments through the CDC’s programs, the CDC’s structure is reflected in the organization of state and local health departments nationwide.

State health departments receive direction and funding for communicable diseases almost exclusively from the CDC. Being smaller, state health departments frequently combine activities from several federal disease programs into smaller and more diverse programs. Most states have communicable-disease programs corresponding to four CDC programs, based on the flow of funding: tuberculosis, diseases preventable by vaccine, HIV/AIDS, and sexually transmitted diseases.

Generally, states have another program that handles any diseases that don’t fall into programs funded by the CDC. These communicable diseases without federally funded programs have included foodborne illnesses, respiratory diseases, influenza, and zoonotic diseases (in which animals play an important role in transmission), such as rabies. By default, most states have included the bioterrorism diseases in these programs. In recent years, the CDC has offered competitive funding for some of these diseases, and new funding for bioterrorism will address this situation. Programs for this collection of diseases exist in every state, handle most of the outbreaks, and have been the most pertinent to bioterrorism prevention.

Programs at the state level tend to have less highly trained staff than at the CDC and may have no physicians. State health departments lacking in medical capabilities may have difficulty gaining the respect of the physician community if they are unable to provide timely, accurate advice when physicians call or if they fail to show leadership in promoting measures that physicians see as important to the health of their patients.

Public Health: The Local Level

In some states, local health departments are field offices of the state health department, but in most states local health departments are separate agencies. The New York City health department is a local agency (now famous for its superb handling of West Nile virus) that is larger than the state health department. Large urban health departments are in many ways similar to state health departments.

Communicable-disease staff in urban areas are well situated to engage the physicians in their community through attending meetings of infectious-disease physicians. Teaching hospitals, often located in urban areas, usually have periodic meetings at which specialists in infectious diseases discuss recent interesting cases in their practice. The participation of persons with a public health perspective in these meetings could foster the exchange of information beneficial to both disciplines. This relationship would be particularly useful in a bioterrorism event, as most physicians follow the lead of infectious disease specialists in treating their patients. However, if non–federally funded programs for communicable disease have no physicians on their staff, or no persons capable of following and contributing to such discussions, this important link is not made.

At the other end of the spectrum are numerous rural departments with only a handful of staff. In many rural health departments, non–federally funded programs for communicable diseases are handled by one person, who may also have responsibility for other programs. There can be a high turnover rate for staff in rural non–federally funded programs for communicable disease, which have little funding and cover the largest number of diseases. As staff in smaller rural health departments tend to be minimally trained in communicable diseases that do not have federally funded programs, including the management of outbreaks, they may depend on state health department staff expertise when they detect outbreaks. One small foodborne outbreak can take two staff members several days to investigate—a large proportion of staff for some non–federally funded state programs for communicable diseases.

Public Health and Private Medicine: Surveillance for Diseases

Surveillance for diseases is necessary to detect the presence of outbreaks and may provide the first indication that a bioterrorism attack has occurred. Under the current system, public health agencies receive reports of diseases from doctors and other health professionals who see patients. Although doctors are legally responsible for sending reports of specific infectious diseases to their local health agency, penalties for failing to do so are not enforced. Doctors must remember which diseases need to be reported and keep track of a myriad number of forms, which can vary among the reportable diseases. Not surprisingly, only a small percentage of diseases reported come from physicians. The largest percentage comes from infection-control nurses in hospitals and laboratories that have been able to make reporting a part of their routine.

The current disease surveillance system demonstrates the need for closer collaboration between the fields of medicine and public health. A system that depends on mailing paper forms after a diagnosis has been made is not capable of detecting an outbreak in time to intervene effectively. Given that confidentiality could be preserved, an ideal system would collect specific data from computerized medical records flowing electronically to databases at local, state, and federal levels of government and setting off alarms if rates exceeded preset thresholds. However, since most medical records are neither standardized nor electronic, and many health departments did not have computers until recently, such a system is a ways in the future.

Outbreak Response

Each level of government is responsible for identifying unusual trends and outbreaks within its jurisdiction. When a local health agency identifies an outbreak beyond the capability of its staff or expertise, it may request help from the state, which may in turn call upon the CDC. At both the state level and the CDC, requests for assistance with outbreaks are handled by the appropriate disease program, which may respond with medical information and epidemiological advice, laboratory assistance, or personnel. Outbreak investigations have several components:

bulletFinding the cause of the outbreak and stopping it, such as by taking a food product off the market or decontaminating a building from anthrax (finding the cause may involve many interviews and some statistical analysis)
bulletIf it is not possible to contain the cause, preventing transmission may still be possible with measures specific to each disease, such as vaccination, spraying for mosquitoes, or recommending handwashing
bulletProtecting people who may have been exposed, such as by providing antibiotics to people in a building where anthrax has been found
bulletTaking care of the ill by notifying doctors (and sometimes the public) to facilitate proper diagnosis and treatment
Many outbreaks result in the publication of new findings related to the transmission or control of disease.

How Could the Public Health System Be Improved?

Areas for Improvement: The Federal Level

CDC lacks the authority necessary for its charge.

In this country we are fortunate to have an agency with the expertise and capabilities of the CDC. State and local health officials normally receive assistance and advice from the CDC on all aspects of communicable disease control, including outbreaks. Practicing physicians see excerpts from the CDC’s magazine (the Morbidity and Mortality Weekly Report) each week in the Journal of the American Medical Association and may contact experts at the CDC for advice on patient care. The CDC also has an international reputation, as a consequence of providing assistance to other countries experiencing outbreaks (such as Hong Kong during the influenza crisis and India during the pneumonic plague outbreak).

But the CDC lacks authority and scope to address many of the charges that fall under its mission, because other agencies often oversee parts of issues that affect the health of the public. To adequately prepare for a biological attack, a mechanism needs to be provided for adjudicating between federal agencies when matters pertaining to human health affect issues regulated by other federal programs.

The problem of improving disease surveillance for bioterrorism demonstrates the need for collaboration with other federal agencies. Biological weapon agents can be used to attack animals, plants, and inanimate objects in addition to humans. It follows that surveillance for biological attacks should occur for all these entities and should ultimately integrate this information. But public health agencies do not currently integrate their data with that of agencies tracking rates of disease in plants or animals. If the authority to coordinate information applicable to medical surveillance were designated within a single agency, data systems to house this information and mechanisms to monitor it would still need to be established. Much needs to be learned about the interaction of disease among humans, animals, plants, the environment, climate, and other factors. [3]

Another example of this lack of authority is the relatively small CDC program dedicated to diarrheal diseases, which are mostly food- or waterborne. Whether animal or vegetable, sources of food go through many steps to reach the table, not all of them overseen by the CDC. Improving food safety must include participation from the Department of Agriculture, the Environmental Protection Agency, the Food and Drug Administration, private industries, and other entities that play a role in overseeing parts of the food industry. However, each entity brings different priorities and perspectives, and the measures to protect food have a cost. Lacking an easy way to resolve differences, issues tend to remain unresolved. Much interagency work will be required to close gaps in keeping our food supply safe.

The CDC’s internal structure could benefit from integration.

Because the CDC’s programs focus on a single disease or several disease, they have a tendency to work more closely with their counterparts at state and local levels of government than with other staff at the CDC. As a result, there is an effective vertical integration of disease expertise across all levels of government but a less effective horizontal integration across disease programs. This structure (sometimes informally termed “stovepiping”) promotes academic excellence and effective intervention strategies and benefits physicians and the public when they call for information. However, it is also important that mechanisms be in place to integrate functions between programs. This is where the CDC’s internal structure could be improved.

The weaknesses of the stovepiping structure could be mitigated by creating an additional administrative structure of units designed to address disease transmission. This would follow the CDC’s approach of an organizational structure that reflects scientific principles, because it would recognize disease transmission as process that could benefit from both scientific study and practical application. These units would allow participation from all programs with diseases that share the same method of transmission. Some diseases being transmitted through more than one route could maintain their research focus under viruses or bacteria yet benefit from work done to prevent transmission through various means. Current disease programs would maintain the strengths of their present focus but also pool resources to address complex national problems (such as diseases transmitted by food).

The CDC has combined some disease programs in organizational units based on transmission. There is a Vector-Borne Infectious Diseases division for diseases transmitted by vectors (such as insects and rodents). Recently the Sexually Transmitted Diseases program added HIV/AIDS to its list of diseases. The Bioterrorism Preparedness and Response Program is an example of a program formed specifically to address a method of transmission, the intentional spread of weaponized biological agents. The intent of a bioterrorism attack and its political implications require preparation for many other issues. A more comprehensive approach for the CDC would add organizational structures specifically addressing all the important methods of disease transmission.

Similar units addressing intervention methods could also be established as needed. The National Immunization Program is an example of a unit housing the programs for diseases preventable by vaccine. Another potential health intervention that needs study and public discussion is quarantine. If we faced a large outbreak of a contagious disease, such as smallpox, how helpful would it be to close airports or quarantine cities to prevent the transmission of disease, and what effects would the quarantine have on the economy? Understanding the complex issues around quarantine will require the participation of many parties external to the CDC to bring together necessary expertise in economics, government, law, and policy.

Units organized around disease transmission or interventions may require broad powers in order to undertake major prevention efforts. If this approach were adopted, care would have to be taken so that the scientific and medical emphasis that makes individual disease programs so successful is not lost in achieving the broad authority to effect interagency cooperation.

Areas for Improvement: The State and Local Levels

There is a widespread lack of trained professionals with health care experience at the state and local levels.

There is a need for many more physicians, nurses, and trained epidemiologists at all levels of public health. [4] For nearly two decades, funding shortages and hiring freezes for communicable-disease programs have left local and state public health departments with skeletal crews and haphazard ability to detect outbreaks. [5]

Finding persons with the necessary skills can be difficult. Schools of medicine and nursing teach little about public health. More students of public health specialize in law or management (which offer the possibility of lucrative jobs in the private sector) than specialize in epidemiology (which requires science and statistics). Even students specializing in epidemiology may graduate without training in infectious disease epidemiology or outbreak investigation.

The CDC has a two-year training program called the Epidemic Intelligence Service, which trains doctors and veterinarians in the techniques of investigating outbreaks. State health departments may request these trainees to assist them with specific outbreak investigations under the guidance of disease program staff at the CDC. The Epidemic Intelligence Service program was established 50 years ago in anticipation of biowarfare attacks and has been helping ever since with routine outbreak control. The program has about 150 officers, although some of them may be involved with projects overseas.

But few state and local health departments have been able to hire these persons at the salaries that graduates of these training programs would expect. [6] Hiring a majority of employees with minimal training can work in a static system, but works less well when a field is changing rapidly. Agencies in which a majority of persons have minimal training tend to continue doing business the way they were taught, neither seeing the need to change internally as the external world develops nor resisting external pressures when they should to preserve the public health. In these agencies, poorly paid administrative staff may end up advising nurses and doctors on critical public health issues, resulting in low public health credibility. A trained public health staff nationwide would greatly improve public health response capabilities for the detection of all health problems as well as bioterrorism preparation.

What sort of training is appropriate for those working in public health at the state and local levels?

The backgrounds of public health staff with undergraduate or graduate training reveal the kaleidoscope of skills needed in this field. Nurses, veterinarians, statisticians, pharmacists, microbiologists, doctors, and those trained in public policy or public health all work side by side. Those in the field of public health should possess
bulletMedical knowledge of how diseases are transmitted, diagnosed, treated, and prevented
bulletAn understanding of how the private medical system functions
bulletAn understanding of how to create and interpret databases (using epidemiology and statistics) to identify abnormal trends, either in the population as a whole or among subgroups of the population
bulletExpertise and authority to investigate causes of an outbreak and to intervene (such as identifying the West Nile virus and spraying for mosquitoes)
bulletEffective channels for disease alerts to the public
bulletEffective notification channels to those seeing patients in private medicine
bulletAn understanding of how the political system functions
bulletContinual engagement in refining programs, public policy, laws, regulations, and infrastructure (such as public drinking water)
bulletOngoing monitoring and application of research findings in both medicine and public health
bulletAbility to integrate bioterrorism response with other disciplines, such as the incident command system with public safety and collaborative outbreak investigations with law enforcement
Whatever sort of training the applicants bring to jobs in public health at the state and local levels, depending on the previous level of funding of individual agencies and the expertise of existing staff, employees with training may encounter some resistance from those with less training. Those now working in some state and local public health programs have been filling roles for years without the benefit of formal training, and they do not necessarily look with enthusiasm on the arrival of new trained staff. They sometimes tend to avoid hiring such new staff or to marginalize their roles after they are hired. Unfortunately, degrees do not necessarily confer common sense. There are many trained persons who seem unable to apply their training successfully and many persons without training who through intelligence and application have acquired skills to function effectively in their positions.

Nevertheless, everyone could benefit from training. Resistance could be countered by providing mechanisms for existing staff to become certified, offering opportunities to augment their experience with continuing education. Perhaps a way could be found to channel lessons learned from their experience into public health curricula. Clarifying the proficiencies needed for various positions may help to restructure both public health agencies and public health training.

Existing capabilities at schools of medicine, nursing, and public health could be a part of the solution. Funding opportunities could be written for academic institutions and state and local public health agencies to encourage cooperation on projects. Public health training would become more practical and government agencies would have educational expertise available to them. An ongoing relationship with academic communities could also help public health staff become informed on new skills necessary to address the threat of bioterrorism.

The Gap Between Private and Public Medicine

Physicians are a familiar sight in CDC disease programs, but not in state and local health departments, where the director or state epidemiologist may be the only physician. Unfortunately, what openings there are have sometimes attracted doctors who find the 40-hour work week better than their long hours and call schedule in clinical medicine or who have failed to function well in a clinical setting. These physicians have sometimes enjoyed high-level positions but have been unable or unmotivated to work toward bringing public health up to date with developments in the medical field. They have added to the negative impression many public health staff have of physicians.

However, even if doctors bring excellent clinical skills and motivation, they need many other talents to function effectively at the state and local levels. Unlike doctors at the CDC, doctors at the state and local levels do not have the luxury of focusing chiefly on the medical and epidemiological aspects of a single disease or group of diseases. To function in more diverse programs, they also need skills in administration, an understanding of the agencies and levels of government that make up the public health system, and an appreciation of how these interact with the political system. These training objectives should be addressed at the academic level specifically for physicians entering public health, because they are often asked to fill high-level positions in the field.

But at the academic level, there has been a divergence between the fields of private and public medicine. Schools of public health have few physicians on their faculties, and medical school curricula have tended to include little about public health. Few physicians are trained as epidemiologists. Coordination needs to begin between the academic communities of medicine and public health.

The same is true for the field of nursing. Health departments often hire nurses at a lower salary than they would have to pay physicians, then ask them to autonomously perform physician-like functions, such as providing medical advice to their programs and to physicians who call. Some nurses have been able to fill these roles well with only occasional assistance from physicians. Their level of contribution should be fairly acknowledged and compensated. Other nurses are less able to fill these functions, but they may report to administrators who are unable to assess their competence. Standardized skills or certification might help with this problem.

Physicians and nurses working in clinical medicine contribute little to public health in the current system, but their broader participation could be a major part of making public health more innovative and relevant. Few people can be as passionate about public health as physicians and nurses who encounter the suffering of individual patients every day in their clinical practices.

Physicians are accustomed to following the medical literature and incorporating developments into the care of their patients; these skills are needed to bring the same advances into state and local public health programs. Yet there are few openings for physicians in public health outside the CDC. Physicians who choose to work in public health and want to keep up their clinical skills must pay high malpractice insurance fees normally paid by employers of full-time physicians. Complex problems in the medical care system are another reason physicians are not more involved in public health, but those are beyond the scope of this article.

They do raise an interesting question, though: Why has the voice of public health not been heard over the past several decades, defending the causes of nurses, doctors, hospitals, and others struggling in the current medical system? The chasm between the two disciplines has become so great that neither one sees in the other the seeds of potential solutions to problems within their own discipline.

The mission of public health is broad, including politically charged issues such as tobacco, needle-sharing, HIV/AIDS, and sex education. This broad scope increases the opportunities for political opposition. The average tenure of a state health director is two years. [7] Public health must choose its agenda carefully during each political season, and the medical voice often goes unheeded among those planning agendas for public health. Yet a medically motivated mission visibly filling an important role would make public health more attractive and politically viable at all levels of government. In an era when public health must forge new relationships to defend against the threat of bioterrorism, strong and visionary leadership is becoming increasingly essential.

Conclusions

Public health is a field increasingly being appreciated as having a critical role in national security. Problems at the federal level include weakness in authority and internal organization. These weaknesses differ from those at the state and local levels, where a lack of trained staff and local political constraints predominate. Throughout, an enormous gap between private and public medicine has prevented these disciplines from mutual assistance.

Public health needs to articulate a clear and compelling vision to its partners: the public, the legislature, academia, and private medicine. A dynamic public health system, with the vision to identify problems, see solutions, and convince national leaders to implement them, would be respected and would attract funding and talented people at all levels.

 
 
Related Pages:
Home ] Up ] History of Public Health pp 56-72 ] [ A Public Health Primer ] Pathogens, Behavior, and Social Norms: The Subject of Public Health ] The Uses of Fear in Public Health ] Local Public Health Agencies and Bioterrorism ] Challenges Confronting Public Health Agencies ]
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Home ] Syllabus ] Introduction to the Course ] Introduction to the Problem ] Public Health System ] Is Bioterrorism a Real Threat? ] Public Health Law and Bioterrorism ] Disease Reporting and Police Powers ] Quarantine and Police Powers ] Model State Public Health Law ] Military Presence and Public Health ] Public Health Law - Revisited ]
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 11/30/2002

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