Real Life Public Health Planning: Where Medicine Meets The Law

Presenters Edward P. Richards, JD MPH Professor, and Director Program in Law, Science and Public Health LSU School of Law Edward P. Richards, JD MPH Professor, and Director Program in Law, Science and Public Health LSU School of Law Katharine C. Rathbun, MD, MPH Specialist in Public Health and Preventive Medicine Our Lady of the Lake Health Care System Baton Rouge Katharine C. Rathbun, MD, MPH Specialist in Public Health and Preventive Medicine Our Lady of the Lake Health Care System Baton Rouge

Pandemic Flu What is the Medicine?

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

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

Medical Disasters Hurricanes Hurricanes Measles Measles Tuberculosis Tuberculosis SARS SARS Pandemic Flu Pandemic Flu

Hurricanes Environmental Public Health Environmental Public Health food, water, waste, vectors Disease Control Disease Controlimmunizations Nuisance Abatement Nuisance Abatement housing, weeds

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

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

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

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

Pandemic Flu We have flu epidemics every winter We 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 pandemic The most likely candidate for a pandemic Pandemic Flu Pandemic Flu 20% infection with 2.5% mortality 20% infection with 2.5% mortality 1.5 million excess deaths 1.5 million excess deaths 2.5 million other deaths 2.5 million other deaths

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

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

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

Florida Bench Guide as a Potemkin Plan Potemkin Village Potemkin Village After Grigori Aleksandrovich Potemkin, who had elaborate fake villages constructed for Catherine the Great's tours of the Ukraine and the Crimea. After Grigori Aleksandrovich Potemkin, who had elaborate fake villages constructed for Catherine the Great's tours of the Ukraine and the Crimea. Potemkin Plans 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. 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.

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

The Planning Imperative For the feds, plans = action For the feds, plans = action Smallpox at the National Security Administrative Course Smallpox at the National Security Administrative Course Katrina and Hurricane Pam 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 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 State legislators do the same to their own state and local governments

Post-Katrina Plans The Lesson from Katrina The Lesson from Katrina We need more plans We need more plans Translation - The Feds want to better document how the next screw up is your fault 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 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 Why the feds think this is working

What is the Structural Problem? National is the wrong level for emergency response National is the wrong level for emergency response All state and local public health, police, and other first responders are already committed about 110% 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 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 Existing problems like crime and disease control do not go away during disasters

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

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? 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? Did anything prevent GA or the CDC from just having the Europeans pick him up? What was their excuse? What was their excuse? Not enough law Not enough law Remember, folks like Larry Gostin make their money selling more law to the CDC and the states Remember, folks like Larry Gostin make their money selling more law to the CDC and the states

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

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

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

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