John Schumann, MD Assistant Professor of Medicine MacLean Center for Clinical Medical Ethics Human Rights Program Univer

1. Epidemics: When Public Health and Human Rights CollideEpidemics Then & NowUniversity of Chicago’s Summer Institute for EducatorsJune 29, 2006 John Schumann, MD Assistant Professor of Medicine MacLean Center for Clinical Medical Ethics Human Rights Program University of Chicago

3. Objectives • Define Epidemics • Explore concepts of Human Rights; Health & HR • Discuss the inherent collisions • Abrogating an individual’s rights • Case examples • Rights (priorities) to scarce resources • What is the public’s right to information during an outbreak? • Vaccinations or medications • Links to literature

4. Influenza pandemic, 1919 WPA Poster, 1930s Avian flu, 2007(?)

5. Epidemics • In epidemiology, an epidemic (from Greekepi- upon + demos people) is a disease that appears as new cases in a given human population, during a given period, at a rate that substantially exceeds what is "expected", based on recent experience (the number of new cases in the population during a specified period of time is called the "incidence rate"). • Defining an epidemic can be subjective, depending in part on what is "expected". An epidemic may be restricted to one locale (an outbreak), more general (an "epidemic") or even global (pandemic). Because it is based on what is "expected" or thought normal, a few cases of a very rare disease like rabies may be classified as an "epidemic", while many cases of a common disease (like the common cold) would not.

6. Epidemics • Common diseases that occur at a constant but relatively high rate in the population are said to be "endemic". An example of an endemic disease is malaria in some parts of Africa (for example, Liberia) in which a large portion of the population is expected to get malaria at some point in their lifetimes. • Famous examples of epidemics include the bubonic plague epidemic of MedievalEurope known as the "Black Death", the Great Influenza Pandemic concurring with the end of World War I, and the current AIDS epidemic, which some also consider to be of pandemic proportions.

7. Epidemics Non-biological usage: • The term is often used in a non-biological sense to refer to widespread and growing societal problems, for example, in discussions of mental illness or drug addiction. -from Wikipedia

8. Biomedical Epidemics -Some examples from this week: • Contagion • Mesopotamia • Small pox • Diptheria • Pertussis • Tetanus • Cholera • Polio • Black Death Ceratophyllus faciatus

9. Social/Political Epidemics • Torture • Human rights • Nuclear weapons • Gun violence • Domestic violence • Accident prevention • Capital punishment • Female genital mutilation • Education (lack of access or equal opportunity)

11. Public Health Prevents Epidemics • Elvis Presley gets vaccinated for Polio (1956)

12. Human Rights • Universal declaration of human rights (1948)

13. Human Rights • Universal Declaration of Human Rights (UDHR) • Article I • All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. • Article 2 • Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

14. UDHR (1948) • Article 3 • Everyone has the right to life, liberty and security of person. • Article 4 • No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms. • Article 5 • No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.

15. UDHR (1948) • Article 9 • No one shall be subjected to arbitrary arrest, detention or exile. • Article 13 • (1) Everyone has the right to freedom of movement and residence within the borders of each State. • (2) Everyone has the right to leave any country, including his own, and to return to his country

16. UDHR (1948) • Article 25 • (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. • (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

17. Is it ever OK to limit human rights?

18. Is it ever OK to limit human rights?

19. Torture

20. Lancet 2004; 364: 725-29

21. The article became a book—published June 27, 2006

22. Siracusa Principles (1985 update to the 1966 ICCPR) • The restriction is provided for and carried out in accordance with the law. • The restriction is in the interest of a legitimate objective of general interest. • The restriction is strictly necessary in a democratic society to achieve the objective. • There are no less intrusive and restrictive means available to reach the same goal. • The restriction is not imposed arbitrarily, i.e., in an unreasonable or otherwise discriminatory manner.

23. Why Protect Public Health using a Human Rights Framework? • Now more than ever • Darfur, AIDS, Avian Flu, Tsunami, Katrina • Disparities at home • Curricula? • Engagement

24. Doctor-Global Level Issues • Disparity of resource allocation • Industrialized economies vs. “rest” • Disparity in health outcomes • TB/AIDS • Malaria • Maternal/child health • Preventable diseases • Nutrition

25. Severe Acute Respiratory Syndrome (SARS)

26. Quarantine • Quarantine refers to the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious. Quarantine of exposed persons is a public health strategy, like isolation, that is intended to stop the spread of infectious disease. Quarantine is medically very effective in protecting the public from disease. • States generally have authority to declare and enforce quarantine within their borders. This authority varies widely from state to state, depending on state laws. The Centers for Disease Control and Prevention (CDC), through its Division of Global Migration and Quarantine, also is empowered to detain, medically examine, or conditionally release persons suspected of carrying certain communicable diseases. This authority derives from section 361 of the Public Health Service Act (42 U.S.C. 264), as amended.

27. Severe Acute Respiratory Syndrome (SARS)

28. Siracusa Principles (1985 update to the 1966 ICCPR) • The restriction is provided for and carried out in accordance with the law. • The restriction is in the interest of a legitimate objective of general interest. • The restriction is strictly necessary in a democratic society to achieve the objective. • There are no less intrusive and restrictive means available to reach the same goal. • The restriction is not imposed arbitrarily, i.e., in an unreasonable or otherwise discriminatory manner.

29. What is the public’s right to information?

33. World Health Organization • Promoter of Health and Human Rights • Handles outbreaks and sets policy regarding global health problems

34. www.phrusa.org

35. Health Care Justice

36. The Special Role of the Physician • Healer/Comforter • Intermediary • Interpreter • Advocate • Oath-taker • Seeker of Excellence (outstanding care, quality improvement, scientific advancement) • Societal Respect • High-Mindedness

37. The Special Role of the Physician • Societal responsibility • Ethical imperative • No other profession like it—so much trust with personal and private information • Seek social justice, global health

39. Ken Fox, MD, Pritzker Class of 1989 Pediatrician, Erie Family Health Center, Chicago Medical Director, Reach out and Read Soros Physician Advocacy Fellow

40. Ken Fox, MD, Pritzker Class of 1989 Epidemic: Literacy

42. Allen Keller, MD Internist, Bellevue Hospital, New York Member, Physicians for Human Rights (PHR) Founder, NYU Program for Survivors of Torture

43. Allen Keller, MD Epidemic: Torture

45. Paul Farmer, MD, PhD Infectious Disease, BWH, Boston Founder, Partners in Health Global Reduction in death from AIDS/TB in the world’s poorest nations

46. Paul Farmer, MD, PhD Epidemic: HIV/AIDS, TB, Poverty, Global Apathy

47. Links to Literature • Albert Camus (1913-1960) • ‘The Plague’ (1946)

48. Links to Literature • Randy Shilts (1951-1994) • Chronicler of the disease that killed him • FDA approval of protease inhibitors in 1995-96

49. Links to Literature

50. Links to Literature • Jose Saramago receives the 1998 Nobel Prize in Literature