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
http://biotech.law.lsu.edu
 Katharine C. Rathbun, MD, MPH
Specialist in Public Health and Preventive
Medicine
Our Lady of the Lake Health Care System
Baton Rouge
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Pandemic Flu
What is the Medicine?
Public Health
Disease Control
 Food Sanitation
 Water Purity
 Waste Disposal
 Animal Control
 Vector Control
 Nuisance Abatement
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Public Medicine
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Providing personal medical care
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Often in Health Departments
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Very Limited in USA
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15% of people have no health insurance
and thus limited access to medical care
Medical Disasters
Hurricanes
 Measles
 Tuberculosis
 SARS
 Pandemic Flu
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Hurricanes
Environmental Public Health
food, water, waste, vectors
 Disease Control
immunizations
 Nuisance Abatement
housing, weeds
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Measles
Classic Disease Control
 No indigenous cases
 Immunizable
 No sub-clinical cases – rash and fever
 Well defined incubation period
 Self-limited disease
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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
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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
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SARS Issues
Public Health Reporting
 Public Health Physician
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Knowledge and experience
 Courage
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Medical Facilities
 Social Support
 Compensation
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Pandemic Flu
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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
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
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Flu Prevention
Individual disease control is pointless
 Mass immunization
 Social distancing
 Maintaining medical care system
 Mass care for flu victims
 Maintaining social support systems
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Florida Pandemic Influenza Bench
Guide
Is this proper as an Advisory Opinion?
 Based on incorrect medical assumptions
 Conflict of interest
 Misuse of authority
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Out of state cases
 Commentators
 United States Supreme Court cases like
Mathews v. Eldridge
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Not a problem solving document
Florida Bench Guide as a Potemkin
Plan
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Potemkin Village
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After Grigori Aleksandrovich Potemkin, who
had elaborate fake villages constructed for
Catherine the Great's tours of the Ukraine and
the Crimea.
Potemkin Plans
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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
 National security means federal command
and control
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The militarization of emergency response
 Federal national security laws can be used to
override state control
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The Planning Imperative
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For the feds, plans = action
Smallpox at the National Security
Administrative Course
 Katrina and Hurricane Pam
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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
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Post-Katrina Plans
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The Lesson from Katrina
We need more plans
 Translation - The Feds want to better
document how the next screw up is your fault
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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
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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%
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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
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How Did This Become a Legal
Problem?
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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
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Laws are cheap and easy to pass
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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?
 Did anything prevent GA or the CDC from
just having the Europeans pick him up?
 What was their excuse?
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Not enough law
 Remember, folks like Larry Gostin make their
money selling more law to the CDC and the
states
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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?
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Does the plan provide false assurances?
 If communities were given honest risk
information, would they make different
decisions?
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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
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Katrina Examples
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The core problem is living within the surge zone
and below sea level
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What has changed?
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If all the emergency prep had worked, not much
would have 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
Who Has A Duty to Speak up?
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Who does a public health lawyer really
represent?
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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?