On Lawyer’s iPod

Ok, I’m about 6 months behind on Radiolab episodes. But on my morning run I listened to Patient Zero, a typically fascinating hour of exploration of tracing diseases back to their origins.

We got Typhoid Mary. And an in-depth look at where AIDS came from (patient zero, chimp zero, and monkey zero.)

Buried in there are some fascinating legal issues, which I hope we can discuss in depth in the future.

But just consider…

When can the government imprison an innocent, but contagious, person? Does it matter if she definitely knows she is infecting people but refuses to take precautions?

Can you go to jail for giving someone AIDS? If you do it on purpose?

Should the government be able to trace your phone records to try to piece together patterns about the spread of disease? (imagine agents showing up to ask questions at the home of someone who has just made a bunch of calls to a health provider…)

Definitely worth a listen!

Swine flu again. . .

So there’s been more talk in the news about the impact of swine flu on the upcoming flu season– i’ve heard wild estimates that the incidence of flu could be double what we see in a normal flu season, with mostly mild to moderate disease. I’ve also heard estimates that ICU’s may be at 100% capacity entirely with flu patients. (heard mostly via NPR).

1. Not so much with the surge capacity?  We should get on that. Lawyer knows about this kind of thing from her days as a disaster preparedness VISTA.

2. Paying ICU nurses overtime = great for Nurse, expensive for hospital/medicare/whatever is paying. . .

3. Flu vaccines are coming to a hospital employee health deartment near you, but is there enough? And, speaking of, we generally vaccinate the most vulnerable– very young, very old, or compromised– in a situation like this, healthcare providers should perhaps be among the ones chosen. Those ventilators can’t work themselves. . .

Don’t shoot yourself in the foot!

Lawyer:  Here is part three of my series on public health emergency law.

There are a number of measures written into various laws that allow government agencies more flexibility during public health emergencies. We have a lot of regulations surrounding health care, including privacy rules, procedures for various state-fudned health care programs, and regulations about the use of drugs and medical equipment, and when we need to act fast, these rules, which are important protections most of the time, can really get in the way of a quick and coordinated response. Here are a few interesting possibilities:

Emergency Use Authorizations: The Health and Human Services Secretary can ask the FDA commissioner to issue an authorization to use a drug or device that has not yet been approved if there is reason to believe that its risks are minimal and it will help with the health emergency. Likewise, they can authorize the use of an approved drug in a new population or for a new use. These have been used in the past, and there is one in place now allowing the use of flu drugs in children.

Certain laws relating to Medicare/Medicaid — specifally, some of the requirements of health care professionals (i.e. specific timetables for certain kinds of paperwork, requirement that the license be in the specific state where they are providiing services, etc.)

These kinds of built-in flexibilities are important to a functioning system! We wouldn’t want to operate this way all the time, but we also wouldn’t want to be bound by regulations that don’t make sense in a context that requires rapid action. The potential concern — that flexibility opens up the possibility for abuse — is mild in this context, and the alternative is far worse. (As I write this, Arizona has moved up in the list of states with the most cases, but the flu also continues to look mild, and the hot weather may slow its spread — here’s hoping!

(xposted on Ready or Not.)

Public Health Emergency Law

Lawyer: This morning I participated in a conference call with several lawers from FEMA and HHS. They gave a broad overview of federal law as it applies to public health emergencies. It was interesting to me, but then, I’m a nerd, so I’ve tried to distill a few broad ideas from it to share.

First, there are two ways an emergency can be declared. Either the president can declare an emergency or a major disaster, or the HHS Secretary can declare a public health emergency (which he has just done.) The main reason for these declarations is to gain access to additional funds, supplies, or powers that may help control the emergency or, in this case, the potential emergency. The legal issues surrounding pandemic response can be grouped into several categories.

1. Liability. A lot of the laws surrounding disasters and emergencies deal with protecting emergency workers from being sued, altering licenscing regulations so that workers can more easily respond without sacrificing quality of care, and protecting volunteers. Federal laws generally apply only to federal employees. State laws vary widely.

2. Many of the laws are designed to give government agencies and hospitals more flexibility in emergency situations. Some temporarily relax requiremetns surrunding medicare and medicaid, and there is a program that allows for the emergency use of drugs or other treatments that have shown themselves to be helpful but have not yet been approved by the FDA.

3. Some laws make provision for the availability of resources - -not money as much as medical personnel (HHS commissioned corps, for example) and the Strategic National Stockpile, a large collection of medications, medical devices, supplies, and equipment that would help the US to respond to a public health emergency. The public health emergency declaration isused early this week gives the federal government the authority to deploy these resourcesnot just domestically, but overseas, if there is evidence that such an action would protect our own national security.

4. Perhaps the most fascinating legal questions concern safety vs. civil liberties. In particular, this applies to quarantine laws, which are actually in the process of being rewritten for a world in which people don’t generally travel by ship. The new laws, which are due to be passed mid-June (we’ll see) include a procedure for appeals to take care of the 5th ammendment concerns that often acompany quarantine and isolation ideas.

Lots of issues to explore here. Unless breaking news demands my blogging attention, I might take the next few entries to look at each of these areas in more detail. Stay tuned!

xposted http://vcdc.wordpress.com

Perspectives on Swine Flu

This article form the BBC has some really interesting perspectives from a variety of folks living in the affected area.

It’s alarming — but it’s also interesting and gives this public health emergency a much more human face.

I (lawyer) will be listening to a CDC-sponsored conference call tomorrow on Federal Public Health Emergency Law — watch for an update tomorrow with more info!

Swine Flu: Nurse’s take.

Ok, I wrote this post before I saw Lawyer’s post, so sorry if there’s repitition!

So there’s an outbreak of swine flu in Mexico, which has killed some 68 so far– it’s in the news, and as a health care worker in Arizona, we’ve gotten some information about it at work, too, as there have been cases in the American southwest. Now there are 8 reported cases in NYC, too. This disease, unlike other strains, appears to spread human to human. The Mexican government has cancelled public events and closed schools to try to contain it, but President Calderon is seeking additional powers to inspect peoples’ homes and quarantine people. (see http://www.nytimes.com/2009/04/26/world/americas/26mexico.html?_r=1&hp) .


There is special concern over this virus because it’s killing otherwise healthy young adults, unlike other types of flu which usually strike the very  young and very old. The CDC and the WHO are worried, obviouly– but how to strike a balance between being prepared and inciting panic? Within the U.S., containment isn’t a viable strategy because there are cases spread out with no link found. So, is Mexico on the right track? Does quarantine  work? Is it warranted? When are a person’s individual rights superceded by public health needs?  Remember the guy who flew on an airplane while knowingly actively infected with TB? We all pretty much decided that wasn’t ok, right? Let’s find that boundary.

I think we’d better straighten out our plans BEFORE there’s a pandemic. At least from first-hand experience, hospitals are getting ready! Staff are being educated and supplies and drugs inventoried.

One of the best things we can do at this stage is educate people: flu is a respiratory virus, it’s transmitted by droplets. Cover your mouth and nose when you sneeze, WASH YOUR HANDS, and stay home if you’re sick.

Check out the CDC’s swine flu podcast for more information: http://www2a.cdc.gov/podcasts/player.asp?f=11226

Thoughts on Swine Flu from lawyer, wearing her disaster preparedness hat

Seen the stories recently about the swine flu that’s killed up to 61 people in Mexico? And has also been found in California and Texas? Especially scary because its victims are not the very old and very young, who are typical flu victims — it’s killing young, healthy adults. The article linked above gives details.

Mexico City has closed schools and museums to work on containing it, and though we don’t have a serious outbreak here, it remains possible. It raises some really tough questions. One topic is non-pharmaceutical interventions (NPI) — the most common of which are social distancing measures. (Maybe we’ll talk about drugs and vaccines and who should get them in another post.)

At what point does it become necessary or wise to close schools? Museums and movie theaters? Workplaces? My take is that closing museums and movie theaters and the like can help prevent the spread of disease and kind of sucks, but doesn’t create any huge social problems. Closing schools leaves many families up a creek — but is one of the most effective ways to prevent the spread of illness among  children. I’m in favor of it — and also in favor of requiring employers to allow employees to take leave if a school closure is enacted. It’s still a tough situation for a lot of people, but better a tough situation than dying of swine flu. And that’s really the bottom line here.

What about imposing requirements that people wear masks in public? What about curfews and quarantines?  It’s tricky — we don’t want to make overly restrictive laws (and even if we do, people may not obey them) but we do want to keep the public safe, and there will always be those who act irresponsibly. Even with the force of law, there’s not a lot that can be done to keep a few irresponsible people from spreading infection and posing a great risk to public health. When greatly restrictive laws have been imposed to combat previous outbreaks, governments have been unable to enforce them. Distribute masks with instructions on how to use them and why it’s important. Give people the tools to protect themselves. Success through education, not force.

Recently, we discussed what health care workers should be required to do in a public health emergency.  This discussion could become a lot less abstract in the coming months. If you work in healthcare, check into your institution’s policies.

Containment doesn’t seem to be an option here — it isn’t confined to a small geographical area — but in other pandemic situations, that’s another tough choice we’d face.

Here is my hope: that if US city and state governments end up facing this choice, they are as transparent as possible. Communicate clearly with the citizens. Let us know what’s going on. Make recommendations. Give us options. Help us understand why you’re asking us to do certain things rather than just telling us we have to.

Stay tuned for more thoughts as the situation unfolds!