Real Life Public Health Planning: Where Medicine Meets The Law

1. Real Life Public Health Planning: Where Medicine Meets The Law

2. Presenters • Edward P. Richards, JD MPHProfessor, and DirectorProgram in Law, Science and Public HealthLSU School of Law http://biotech.law.lsu.edu • Katharine C. Rathbun, MD, MPHSpecialist in Public Health and Preventive MedicineOur Lady of the Lake Health Care SystemBaton Rouge

3. Pandemic Flu What is the Medicine?

4. Public Health • Disease Control • Food Sanitation • Water Purity • Waste Disposal • Animal Control • Vector Control • Nuisance Abatement

5. Public Medicine • Providing personal medical care • Often in Health Departments • Very Limited in USA • 15% of people have no health insurance and thus limited access to medical care

6. Medical Disasters • Hurricanes • Measles • Tuberculosis • SARS • Pandemic Flu

7. Hurricanes • Environmental Public Health food, water, waste, vectors • Disease Control immunizations • Nuisance Abatement housing, weeds

8. Measles • Classic Disease Control • No indigenous cases • Immunizable • No sub-clinical cases – rash and fever • Well defined incubation period • Self-limited disease

9. Tuberculosis • Disease Control with Legal Process • Slow growing bacteria • Not very contagious • Treatable • Care is government funded & provided • Legal process slows things down • People do catch it during the process

10. SARS • This is what we are planning for • Index case = source case • Rings of contagion • Isolate those who are sick • Quarantine those exposed • Public health orders are issued • Services are provided

11. SARS Issues • Public Health Reporting • Public Health Physician • Knowledge and experience • Courage • Medical Facilities • Social Support • Compensation

12. Pandemic Flu • We have flu epidemics every winter • 30 million cases (10% of population) • 30,000 excess deaths (.1% mortality) • The most likely candidate for a pandemic • Pandemic Flu • 20% infection with 2.5% mortality • 1.5 million excess deaths • 2.5 million other deaths

13. How Flu Presents • Sporadic cases during the summer • Increase with school and cold weather • Sentinel cases (retrospective) • The epidemic hits • Multiple epidemics simultaneously • 1-3 weeks to recognize a bad flu

14. Flu Prevention • Individual disease control is pointless • Mass immunization • Social distancing • Maintaining medical care system • Mass care for flu victims • Maintaining social support systems

15. Florida Pandemic Influenza Bench Guide • Is this proper as an Advisory Opinion? • Based on incorrect medical assumptions • Conflict of interest • Misuse of authority • Out of state cases • Commentators • United States Supreme Court cases like Mathews v. Eldridge • Not a problem solving document

16. Florida Bench Guide as a Potemkin Plan • Potemkin Village • After Grigori Aleksandrovich Potemkin, who had elaborate fake villages constructed for Catherine the Great's tours of the Ukraine and the Crimea. • Potemkin Plans • Elaborate plans for public health emergency preparedness that cannot be carried out because of lack of staff, resources, political will, competence, or any combination of the above.

17. The Post 9/11 Emergency Planning World • Emergency preparedness becomes a national security issue • National security means federal command and control • The militarization of emergency response • Federal national security laws can be used to override state control

18. The Planning Imperative • For the feds, plans = action • Smallpox at the National Security Administrative Course • Katrina and Hurricane Pam • Federal push down requiring elaborate plans on every crisis de jure, with federal programmatic funding depending on the right answers in the plan • State legislators do the same to their own state and local governments

19. Post-Katrina Plans • The Lesson from Katrina • We need more plans • Translation - The Feds want to better document how the next screw up is your fault • The plans have to address all the federal target issues and have to say that the state and localities are prepared to carry out the functions • Why the feds think this is working

20. What is the Structural Problem? • National is the wrong level for emergency response • All state and local public health, police, and other first responders are already committed about 110% • There have been net cuts in most programs as emergency response has been added • Existing problems like crime and disease control do not go away during disasters

21. How Did This Become a Legal Problem? • HHS and CDC believe that the problem with emergency preparedness is that we do not have enough laws • Model State Emergency Health Powers Act • The CDC/RWJ Model Law Movement • Laws are cheap and easy to pass • Fixing budgets, staffing levels, and competence for state and local departments is way too expensive and troublesome

22. The Xdr-TB Example • Does anyone here really think that the GA guys could not have grabbed that TB carrier if they had really wanted to? • Did anything prevent GA or the CDC from just having the Europeans pick him up? • What was their excuse? • Not enough law • Remember, folks like Larry Gostin make their money selling more law to the CDC and the states

23. Why Should You Care About Potemkin Plans? • Could you do a plan that works instead of the Potemkin Plan? • What is the effect on risk communication to the at risk communities? • Does the plan provide false assurances? • If communities were given honest risk information, would they make different decisions?

24. Pan Flu Examples • Address the real issues like food, water, realistic rationing decisions, etc. • Prepare and respond properly to the yearly pandemic • Deal with universal access to health care • Admit that we are choosing cheap over safe because we do not want to fund government

25. Katrina Examples • The core problem is living within the surge zone and below sea level • If all the emergency prep had worked, not much would have changed • What has changed? • We have lots more plans • Efforts to continue to subsidize the insurance cost • They do not change anything about the risk • They convince people that it is OK to go back and do the same thing

26. Who Has A Duty to Speak up? • Who does a public health lawyer really represent? • The director? • The agency? • The public? • As we deprofessionalize public health agencies, who else can speak up? • What is the long term impact on agencies and policy when political considerations outweigh public good?