2005 Johnson & Johnson Lecture: Public Health Emergencies and Containment Strategies

good afternoon i was just commenting that i knew that we were about ready to get started when the calvary were brought in to handle the technology here so my name is bernal venable powell and as dean of the university of south carolina school of law it is my pleasure to welcome you to the annual johnson and johnson healthcare lecture series beginning in 1999 johnson and johnson began sponsoring this lecture series allowing the law school to bring in distinguished speakers on timely issues this year the school of law has become an active participant in this sponsorship over the years the law school community has been benefited greatly by the johnson and johnson lectureship's contribution to education and informed decision making this year is no exception we are pleased to have with us today mark rothstein a prominent scholar specializing in many different facets of the law including bioethics genetics in the law and public health law currently the herbert f bale chair of law and medicine and the director of the institute for bioethics health policy and law at the university of louisville professor rothstein teaches at both the university of louisville school of law and their school of medicine before going to the university of louisville professor rosting taught at the university of houston school of law where i might note i first had an opportunity to meet him the university of texas school of public health where he was an adjunct professor and at west virginia university where he taught in the school of law and was an adjunct professor of medicine and also at ohio northern university professor ross dean has also been a visiting professor at the university of pittsburgh and georgetown university in addition to a distinguished teaching career professor rothstein serves as serves on many boards and committees currently he is a member of the national committee on vital and health statistics for the department of health and human services and his and in the past has served as a member of a special emphasis panel for the public health practice program office at the center for disease control and prevention professor rothstein has traveled widely speaking in many of the institutions that regrettably have become all too familiar to us through daily news accounts the center for disease control and prevention columbia and texas university's schools of public health the national institute for health and the world conference on diabetes he has also spoken at some of the leading law schools in the nation chicago columbia georgetown and harvard whether the topic has been the regulation of tuberculosis legal protection for people with disabilities policy development on managed care and cancer or as he spoke to the faculty in colloquium this afternoon do any genetic testing laws work professor rosting has proven to be an informed and formidable advocate for policy making that is guided by an understanding of the interdisciplinary concerns of genetics ethics and public health indeed most recently professor rosting was involved in a report entitled quarantine and isolation lessons learned from soros with insights gained therefore through that effort and many others we are pleased to have him this afternoon to address sars and other public health emergencies containment issues and the law i know too that it is especially appropriate to have this topic this year as south carolina's department of health and environmental control is currently developing regulations for the recently enacted emergency health powers act as part of the south carolina homeland security act i ask you then to please join me now in warmly welcoming professor mark rothstein for remarks [Applause] appreciate it thank you good afternoon everyone thank you dean powell and it's a pleasure to be here to come back to south carolina after a number of years to see my relatives from south carolina and my friends from south carolina and spend some time with the faculty and i appreciate the invitation i appreciate the support from johnson johnson and today i'm going to be addressing the public health future of the world small topic for this afternoon and uh what we are going to do about it and the preparations that we need to make to prepare for the next great epidemic epidemics of infectious disease are as old as humanity i'm going to be talking a lot today about influenza and you may be interested to know that the word influenza although we misuse it on a routine basis to refer to a bad cold has its origins in the latin and so influenza really means under the influence of as if someone who developed such a terrible illness was under the influence of the deity and was not too long for this world unfortunately we have a tendency i think to to believe that our technology is so great today and our medical science is so wonderful that we need not worry about the traditional scourges of the past and unfortunately that's not the case in fact we may be worse off today than we've been at any time in the past for the following three reasons number one we live closer to animals especially in some parts of the world so in guangdong province in china where the sars epidemic began there are 85 million people and it just so happens that this province is right on the flight path of the migratory birds of asia and if you go to thailand or vietnam hundreds or even thousands of chickens and ducks and other birds live among the people and so living close to animals increases the risk that an influenza epidemic could appear the second reason why we may be in more dire straits is that we live closer together than in the past influenza is spread by direct human contact from one person to another such as coughing and the closer we are to more people the more likely the virus is to spread and the third reason i say that is because of the global transportation system we don't have oceans to protect us anymore an epidemic that begins in any part of the world can be in the united states within hours for many of us our first rude awakening to the perils of infection and epidemics arose with the sars epidemic that began in the winter of 2002-2003 by the time sars was abated there were 774 deaths of the roughly 8 000 cases in 29 countries there were 73 cases of sars in the united states and no deaths there's one very good explanation for why there were no deaths in the united states and that is we were very lucky the woman who went from toronto to hong kong and became infected when she stayed at the miropol hotel she could have flown back to columbia south carolina or colombia columbia missouri or to columbus ohio or i'm out of columbus some other place just as well as flying back to toronto historical standards we were let off easy by sars with only 8 000 deaths and yet sars represents the kind of calamity and gives us an insight into how widespread the problem would be we are still feeling the effects of sars throughout asia and certainly throughout canada the current concern is over avian flu as of last week there had been 55 human cases of avian flu in vietnam and thailand with 42 deaths a staggering 76 percent mortality rate and the virus has been found in other animals as well including ducks cats and pigs and we need to be very concerned about pigs because pigs are the biological intermediaries between avian viruses and human viruses and so when pigs become infected we realize that there's an increased risk of infection of humans now the last step in having a an epidemic is the ability to transmit the disease from person to person and we thought we were okay with the avian flu virus until a report appeared in new england journal of medicine on january 27th which proves the transmission of the virus from one person to another actually this case involved a mother and aunt of an affected girl and they were in very close contact with her in the hospital and so it's not the normal kind of contact that we need to worry about but nevertheless this is the first documented instance of person-to-person contact of the avian influenza virus according to the world health organization this is possibly a source of the next major pandemic in the world sometimes we see the letters uh a h5n1 to describe the virus and for those of you of a scientific bent the a means that it's a type a influenza virus and the h and n refer to the different parts of the virus it's like a sort of a tinker toy that's put together with different proteins and therefore the the name reflects the the composition of the virus the who estimates that the next flu pandemic would affect 20 to 50 percent of the world's population that's an unbelievable number of billions of people resulting in conservatively the death of two to fifty million people as i mentioned earlier one of the risks is increased population density and transportation systems but it's the possibility that we could be overwhelmed by an epidemic before we even knew about it let's imagine we have a disease with a latency period of seven days people get on planes there well they get off the planes there still well they mix and mingle among the population and now suddenly we realize that they were infected how many thousands of people did they come in contact with and how many thousands of people did those people come in contact with and it may be very difficult to contain an epidemic at that point and even though these diseases often begin in the developing world this is not a problem of just the developing world quite the contrary cdc estimates estimates that a pandemic would lead to the infection of 28 percent of the u.s population with an extremely high mortality rate the mortality rate for sars is only about 10 and so far the avian flu has a mortality rate of about 75 percent there's some good news a little bit um we think that certain drugs there are two antivirals that would be effective against this type of type a influenza virus the bad news is that we only have enough drugs to treat 2.3 million people and that is obviously not going to be enough and we don't only have to treat the people in the united states if we're going to control an epidemic we have to uh help treat the people throughout the world who may be spreading that epidemic the problem of avian flu came up very strangely i would add in hhs secretary tommy thompson's resignation speech these resignation speeches usually don't include this kind of material but he chastised congress for not approving funds to address the threat of avian flu saying that it was one of if not the major public health threats to the country and i want to review for you some historical examples in the 20th century the worst case of influenza epidemic was the spanish flu epidemic that killed 20 to 50 million people worldwide including 675 000 americans actually the spanish flu is a misnomer because it the spanish flu most experts believe began in kansas of all places and it spread from birds to pigs to humans in kansas but in a mild form and then the soldiers who were in fort riley kansas became infected and went to europe in 1918 during the spring and summer uh during the sort of the final days of world war one once the influenza virus got to europe it mutated into a much more aggressive and serious strain and killed more troops on both sides than battle did it was not reported in the press of any of the combatant countries in world war one because of the concern of both citizen morale and morale the armed forces but spain was neutral in world war one and and was greatly affected in fact the king of spain uh came down with the flu and so the press reports were all from spain so this became the spanish flu even though we cooked it up in kansas and then it was sent back to us when the troops returned home from world war one interestingly the um the major port at which the troops came back from world war one in the fall uh was boston so the troops landed in boston at the end of august and the beginning of september of 1918 and the public health authorities were i would say indifferent to the brewing epidemic and one of the reasons why people have conjectured that they were indifferent was the red sox were clinching the american league pennant and september 1st babe ruth pitched a three-hitter and against the philadelphia athletics to clinch the pennant for the the red sox and for baseball fans the the 1918 series was cut short because of the war and so the day after labor day the world series began between the red sox and the chicago cubs and uh so the next point was philadelphia and uh these boston sailors then were put on a ship even though they were infected they came to the port of philadelphia and this was the first place where the sailors mingled with the population and philadelphia within a period of two weeks became the most infected city in the united states based in part on contamination from liberty loan parades that were going on to raise money for the war and other things and from there it spread throughout the country and i may say a little more about philadelphia and the spanish flu so one of my bizarre interests uh in 1957 we had an asian flu epidemic that killed 70 000 americans there was another asian flu epidemic in 1968 and of course 2003 with sars when we extrapolate from sars to the possible pandemic you can see what might happen it was mentioned earlier that we did work for cdc on this issue and in 2003 my institute was asked to study what happened in the six jurisdictions around the world most affected by sars and that was canada china hong kong singapore thai taiwan and vietnam and to report back to cdc with recommendations of what we should do in the united states if such an epidemic was here and this is a this just the cover page of our report which is available on our institute website and i'm going to be sharing some of our recommendations with you i think it's clear that a pandemic of the kind i'm talking about would affect virtually every social institution we've been spared in our lifetime these kinds of scenes where people are checked for their temperature and for other signs and symptoms of disease everywhere they go where every institution is affected by disease this public notice i doubt you can read it but i will read it for you this was issued in 1918 and it says the mayor acting on october 16th of that year has ordered the following theaters and moving picture houses shall be closed and remain closed churches and chapels of all denominations shall be closed and remain closed on sundays all schools public or private including sunday school shall close and remain closed hospitals shall be closed of visitors no public shall be admitted to the courts except etc etc etc so you can see how many areas of life it affects and on the next slide you see some of the modern ways in which our society might be affected through public health agencies and government at all levels and the military and educational institutions and the legal system which i'm going to talk about later i want to focus on two areas in particular even though i could talk about 10 or 20 ways in which it might affect this i want to talk about health care and also the law the first thing that we need to think about is do we have facilities adequate to to cover such an epidemic this slide shows a picture of a hospital being constructed in beijing it was built in two weeks so today is march first and if i said there's going to be an epidemic here tomorrow or two weeks from now you've got two weeks to build a hospital everybody ready go what could we do in two weeks well we might get our certificate of need finished maybe the zoning permits possibly the environmental impact statement maybe we could get some sketches from an architect we're not going to have the whole thing done i guarantee you that this is not a model for the united states it may be a model for china it's not a model for the united states we need to think in advance about uh whether we have adequate facilities some of the countries that we studied and we also look to europe they have in place entire floors of hospitals that they cannot use unless there is an emergency declared by the president or the governor or something and they've got the beds they've got the supplies they've got everything they're trained as soon as the word comes down they flip on the lights and now they're in business we don't have that in the united states if there were an epidemic where would i go i'm a transient i don't have a home if i were quarantined south carolina where would i go where would the homeless people go and we're not prepared for that and we just don't build regular old hospitals uh we need isolation beds with negative pressure rooms rooms such as this or any room you've got um you know intake and outlet [Music] vents so that the air circulates you don't want that when there's an infectious disease you can't have the air from the patient going throughout the hospital so you have to have isolation beds and negative pressure rooms where the air is vented into a separate system we need supplies gloves gown masks etc fortunately this is the one area where i think we're in good shape because cdc has already on the ground in atlanta pallets and and planes and loaded with supplies uh ready to take off on an hour's notice or maybe less if there's an epidemic but we also need facilities to evaluate individuals we don't want somebody showing up at the emergency department who's got a fever and coughing um waiting around coughing on all the other patients till they evaluate and decide what's wrong with this person so here is an example of an assessment clinic that was built on an ambulance doc to assess symptoms of sars and this is the outside of the building that you see here next to the hospital the inside looks something like this where um they have eight cubicles with metal frame pipes uh and thick plastic walls and each one was separately vented up through this ventilation system so that there would not be any sort of cross-contamination of the individuals even this type of facility might not be enough because as long as we're building it we need to build structures that would work in the case of terrorism that is biological term terrorism or radiological terrorism so we need decontamination areas when people have anthrax on them or they have radiation they need to be decontaminated and you need special collection pools for the water you don't just send them right down the sewers uh into the main water supply so it's a whole system that needs to be put in place we need a system to get patients to the hospital the number of ambulances that we have in any community are clearly insufficient these people are not going to call a taxi or drive themselves how are they going to get to the hospital and how are you going to coordinate between all the medical facilities in an area people who often don't even talk to each other in some parts of the country now they are in this thing together and they don't even know each other's names this is a picture of the sar one of the sars teams rushing to pick up a suspected patient in china we also have staffing issues sars was somewhat unique because it was a hospital-based virus and so the percentage of the sars cases among health care workers range from 19 in china to 57 in in vietnam the higher the number the better the virus was controlled in the hospital they got around to it late in china and so it was more dispersed in the community and only 19 of the cases were health care workers whereas vietnam they did a much better job of containing it in the hospital so 57 percent were there but in terms of staffing how do you replace the dead employees the sick employees as well as the ones who are in quarantine it represents a major hit to the staffing levels you also have to have more frequent shift rotation caused by personal protective equipment and fatigue docs can't and nurses can't work eight or ten hour shifts when they're wearing these suits um after two or four hours the the physical and emotional toll means that they just need to be replaced and so you need more employees per patient not less it seems to me that one of the only ways we could survive in terms of human resources is through cross-training we don't have nearly enough people trained in infection control so we have to rely i would think on other medical specialists who underwent some training on infectious disease control who could be drafted in an emergency or or properly volunteer an emergency to perform other functions this is a picture of a staff at new york general hospital being trained on the use of personal protective equipment during the sars epidemic another problem that from a bioethics perspective is very interesting is that in every jurisdiction that we studied significant numbers of health care workers refused to report to work to treat sars patients now there were several reasons for this one reason was that they didn't have adequate equipment or they didn't believe that they had adequate personal protective equipment so they were worried about getting sick themselves a second reason is that they were worried about getting infected and taking it home and infecting their children and families with it a third reason is indicated in this quote from a doctor in singapore the initial stages were painful for our staff because they faced a lot of fear and discrimination from the public we had many many cases of our nurses who if they were to leave in their uniforms would not be able to get a cab we had reports of schools or educational centers stopping children from our staff from going to school so you can see that there are a multitude of reasons why people would be reluctant to continue treating people with sars in taiwan there were 160 health care workers who resigned rather than work on sars wards and the governments in these countries came up with a mixture of carrots and sticks to try to keep adequate numbers of health care workers on the job in vietnam health care workers were given five times their regular salary in toronto it was doubled china went the stick route and fired at least six physicians and banned them from the practice of medicine for life question arises would things be better or worse in the united states in terms of work refusals by health care workers if we turn to the law there is no legal requirement that physicians provide treatment to any patient only legal provisions that prohibit discrimination on the basis of various statutorily prescribed criteria the laws if you're interested are title two of the civil rights act of 1964 which applies to public accommodations title vi of the civil rights act of 1964 which applies to recipients of federal financial assistance which would include medicare and medicaid dollars titled two and three of the americans with disabilities act which apply to public entities and public accommodations but other than that there is no law that says a physician has to treat any particular patient and they get to choose which patients they want to see well what about the ethical obligations of physicians to treat infected patients in an epidemic we reviewed the ethical codes and statements of the 29 major medical specialty colleges and societies and only one addressed this issue the uh aside from the issue of hiv infection which is a special uh case and those came about in the mid to late 1980s the internists have the only position and they said physicians and healthcare entities have an obligation to treat all patients regardless of disease state to deny care to any class of patients is unethical well what about the ama in 1847 the ama promulgated its first code of ethics and had a wonderful statement that was incorporated from the british code of ethics it said physician its physician's province to enlighten the public in regard to quarantine regulations in regard to measures for the prevention of epidemic and contagious diseases and when pestilence prevails is physicians duty to face the danger even at the jeopardy of their own lives what a wonderful statement that is that probably explains why in 1977 the ama repealed it and today the ama's declaration of professional responsibility merely contains a vague statement that physicians should use their knowledge and skills quote though doing so may put us at risk there was actually a proposal last year at the ama to reinstate the 1847 principle that was defeated well i don't want to be overly harsh on physicians i don't think that the ama is to blame if uh docs don't want to treat people in epidemics i think we're all to blame for it over the last uh 10 or certainly 20 years we've done everything in our power to destroy the physician-patient relationship in the united states we've adopted a system of managed care that means that every time the third party payer of your health care thinks they can get a better deal with a different system of hospitals and doctors you have to go see different doctors and so many people don't even know who their doctor is and many physicians see patients once or twice and of uh for you know 10 minutes of several hundred that they see we have a system of hospital-based acute care now where anybody who's sick enough they are immediately sent to the hospital and some physicians don't even have treating or admitting privileges at hospitals all the care is rendered by full-time hospitalists if you have a patient who's sick enough they'll take care of them in the hospital or if you have a patient who's sick after hours that you go to urgent care or some other method of treating you so is it reasonable to expect that physicians who have now become increasingly isolated from their patients would in fact risk their lives on a routine basis for people who might be strangers i would say yes but i think that we have to be realistic about what we can expect people to do let me go back to 1918 and tell you a personal story in 1918 when the boston sailors arrived in philadelphia there was a barber at the philadelphia naval guard who gave a haircut to one of the boston sailors and became infected he was the index case of spanish flu in philadelphia he was also the next door neighbor of my maternal grandmother who became infected as well as did virtually everyone in the neighborhood and i'm told that the lone doctor in the area was literally dragged off the street by every person as he was making his rounds and he came to one house after another after another he became infected and died of the spanish flu yet he continued treating patients as long as he could and keep in mind that in 1918 we had nothing to offer patients there was no medication it was all palliation and kind words why did he risk his life and ultimately lose his life to treat these people it had to be because he was more than just their nominal doctor he was their friend he was their neighbor he lived down the street he taught he he cared for generations of the same families how could he not render care we don't have that anymore and i think we need to uh in some ways try to restore not the same sort of horse and buggy mentality of practicing medicine but not move to the high tech level and expect that we're going to have the same relationships we had with physicians many years ago after the anthrax scare researchers at the ama did a survey of 526 physicians to see their willingness to treat in the setting of potential bioterrorism but it has great bearing here as well the second question would you be willing to put yourself at risk of contracting a deadly illness to save others lives 40 said yes and that's in the abstract doesn't cost you anything to say yes right um now it might be that in in a real emergency people would suddenly develop an uh bravery uh it's also possible that people would suddenly weigh the risks and benefits and head for the hills our culture needs to be considered as well would our individuals be as compliant as the people were in asia and in canada i don't think so uh polls of individuals uh asking whether they would obey quarantine 25 percent of americans say no that's not much of a quarantine when 25 of the people break quarantine and let me just distinguish for the non-healthcare people the difference between isolation and quarantine isolation is people who are already sick and they are separated and treated separately until they're they are over the period of uh infectivity quarantine is for people who are well who are asymptomatic and they are kept apart under the theory that they may be harboring some infection that just hasn't manifested itself the term quarantine comes from the italian quaranta which means 40 and ships were kept out of the harbor in venice for 40 days to make sure that they were not plague infected there are also financial issues who wants to be the sars hospital or the flu hospital doing a treating patients and being the flu hospital it could be and is likely to be tantamount to filing for bankruptcy because you've got no revenue coming in and you've got unbelievable expenses for an indefinite period of time under our mixed health care system our private public system we don't have the ability to designate you're going to be the you're going to be the infection hospital the way they were able to do in taiwan or singapore and if government is going to subsidize hospitals so they can stay afloat what government is it your city is it your state is it the federal government and if it's a huge pandemic where a million people are infected maybe we can't even do that at all and what about the effect on other health services this is a long quote that you'll pardon me for reading from a doctor in toronto during the sars epidemic despite all our efforts many hospitals became infected at alarming rates making non-sars care too risky elective surgery including that for newly diagnosed cancers was postponed as operating rooms and outpatient clinics shut down across the city elderly non-soros patients who simply happened to be in the hospital at the time of the outbreak became trapped for weeks after their recovery as transfers between hospitals and nursing homes were halted as medical and nursing staff fell ill with sars vital patient care services collapsed a hospital cannot run safely without its intensive care unit it wasn't long before our emergency department the busiest in the city was forced to close down placing a terrible strain on other facilities and our community we were devastated this is a if you've ever been to toronto a wonderful vibrant modern city with excellent healthcare facilities and this is what happened well some of you may be asking what about the legal issues bring on the law well the law plays an important role in public health especially in public health emergencies the statutory authority is section 361-b of the public health service act which designates cdc as the lead federal agency and controlling communicable diseases and subjects individuals to quarantine in isolation to prevent introduction in foreign and interstate commerce that's the constitutional authority of cdc public health as i'll talk later is a local and state health function primarily so cdc's job is to keep people who are infected out of the united states and to assist with the control in interstate commerce now you'll note that they're only a designated list of um diseases on the under the statute cholera diphtheria etc it took an executive order 13295 signed by president bush to add sars to the list because sars of course was a a new condition the states are going to be required to take the lead on public health public health is a state function under the state's police power and each one of our states approaches the subject differently we have public health models in some states where that rely heavily on county or local health departments others are much more centralized where the state health department exercises greater authority and there are numerous legal challenges that arise from this federalism system of public health coordinating public health services across various levels of government and government agencies i live in louisville which is across the ohio river from indiana i can guarantee you that if we have an epidemic in louisville they will have an epidemic in indiana viruses do not respect geographical borders even when they are separated by water the folks on our side of the river rarely talk to the folks on the other side of the river and it's time that we do so we also need to be vigilant in protecting civil liberties to the greatest extent possible public health is a balance of collective and individual rights and we have to be careful that we don't go overboard in our zeal to control an infectious disease that we infringe on the rights of individuals unnecessarily thermal scanning was introduced in canada to try to to measure the temperature of individuals coming into the country and they scanned 2.4 million passengers at only two airports in toronto and vancouver it turned out that zero had sars but suppose that it proved to be effective in scanning individuals who had a fever how could we ever get rid of it there would be people who would say now that we've proven the benefits of the technology we should scan everybody um indefinitely so that i'm sure everyone in this room has gotten a cold or some sort of uh health problem from flying on airplanes the air recirculates uh once uh every 24 hours and um i know that if there's no little kid who wants to kick the seat to put behind me they put somebody who's coughing and sneezing behind me and so that um wouldn't that be a great idea well here's what it looks like and i'm this is the only picture i could found find of of a thermal scanner well that's even worse up there than it is here okay imagine these are people walking through security and this is a guard here and a thermal scanner is sort of like a a radar detector and it's taking their temperature which is shows up on here and on the screen and people who have a fever are just told you can't come in quarantine and isolation may play an important role in epidemics but state laws dealing with quarantine and isolation were originally enacted for tuberculosis and cholera and conditions in the early part of the 20th century and in many states they have not been updated although there is a project underway in many states and i think south carolina as well to update to the public health codes and i must add that lawyers and judges receive virtually no public health law training at only a handful of law schools in the united states is a course in public health law routinely or regularly taught and the enrollment may be five or ten students that is not enough to prepare the legal system for the many challenges dealing with public health law and judges receive no training whatsoever going on to the bench as i mentioned before we are at the university of louisville one of two cdc funded public health law centers in the united states and we have been preparing a series of judicial bench books on public health law for the judiciary our first state bench book dealing with indiana law will be released in two weeks one for kentucky will come out this summer and we've already started work on arizona and we are collaborating with other states that are interested illinois michigan etc and clearly these kinds of efforts as well as judicial education are essential we also need to educate law enforcement personnel about what their responsibilities are they may have to serve quarantine orders uh i once was a little bit taken aback by the answer that i got to the question of what would you do to restrain someone who was violating quarantine and without much thought they said oh we shoot him and i suggest that that may not be appropriate in all instances and if it's not what are we going to tell the law enforcement personnel that would be appropriate to do so here are some recommendations that we have in our report i think we need to think very closely about memorandum of understanding on federal and state jurisdiction for quarantine and isolation there is an overlap of jurisdiction and interstate commerce matters if somebody from south carolina wants to go to north carolina cdc as well as both states would have jurisdiction we need law enforcement training and serving and enforcing quarantine orders something that we're also working on we need procedures for ex-party hearings for quarantine orders i don't know too many judges that want the actual person in the courtroom coughing and sneezing on them that you're considering granting an order to so you need some electronic method for conducting the hearings which aren't available in all jurisdictions we need legislation prohibiting discrimination and employment against individuals in quarantine in every jurisdiction that we studied they enacted these kinds of laws because quarantined people are healthy there is nothing wrong with them they may be living from paycheck to paycheck or from day to day and they will leave quarantine if they're going to be fired from their job for being out of work there is no single law in the united states at the federal level or in any state that makes it unlawful to fire someone for missing work because they were in quarantine and there's also no law in the united states that provides for income replacement for individuals in quarantine in every jurisdiction that we study to keep people at home they were paid either by their employer or by the government some amount that represented enough for them to live on without doing that they'll break quarantine interestingly in canada they studied the the two worst offending groups of people who broke quarantine they were teenagers and health care workers in asia they were people who were the poorest and needed to sell newspapers or to to work on the street in some capacity in order to survive we also need legislation protecting individuals and quarantine against evictions and repossessions for missed payments we need to sort of hold these people harmless economically so that they don't have any incentives to leave work or to leave home sorry we need procedures for the emergency review of appeals and quarantine cases in some jurisdictions here's how you get a quarantine order the county health director shows up in the trial court and seeks an order before the judge and if the judge turns down the request for whatever reason doesn't like the lawyers has bad day misunderstands the facts then they there's an appeal taken to the court of appeals which is docketed on the expedited docket and heard in seven days okay what happens in seven days forget the appeal there's no there's no point to quarantining this person the whole state's infected so we need to make sure that the emergency appeal process is uh up to speed we also need a tremendous amount of logistics planning if we have as was the case in taiwan 150 000 people in quarantine who's going to supply them with their food their medicine to make sure that when the phones don't work they're repaired or to repair the heating and there are special problems with sub-populations of individuals just to pick one suppose we have some heroin addicts who we put in the quarantine and we just tell them listen we'd like you to stay home and not leave under any circumstances for the next two weeks i don't think that's a very effective way of quarantining such individuals i can only imagine the political debate that might ensue whether we deliver heroin to the homes of addicts so that they stay in quarantine and you can sort of picture your own uh uh elected official uh of of your choice and uh see where they might come down on that uh mentally ill individuals people who are homeless people who are mentally people who have uh special needs and can't walk or feed themselves how are we going to take care of these people these are very difficult problems indeed and we have not faced them i think friendly well i recognize um that this has not been the cheerios talk uh my students always complain that i am sort of the darth vader of professors um and so i have a picture of my dog sunny on new year's eve a few years ago to remind me to end on a happier note so here's my here's my happier information for you perhaps you read in the newspaper in on december 27th that scientists said that there was a 1 in 37 chance that a 400 meter wide asteroid would crash into the earth on april 13th of 2029 and it was the first time that an asteroid was ranked four on the torino scale which goes from zero to ten for potentially threatening space rocks that's my good news no actually the good news came two days later on december 29th nasa scientists re-evaluated the data and they said there's no chance of an earth impact and they further said that no subsequent earth encounters in the 21st century are of any concern so there you have it uh the most cheery news i could give you to end my talk thank you so if if anyone has a uh a question other than is that the best you could do for good news um i'd be happy to answer it it was um in most places 12 days they used depending on the country a variety of facilities they put them in hotels they put them in vacation villas uh depending how lucky you were where you were quarantined one of the interesting um things that uh caught my eye as a dog person is that some people refused to go because they didn't want to leave their pets behind so they had to make provisions to have their pets fed so their pets were in quarantine at home while they were in quarantine uh somewhere else and and so they used military installations and all sorts of places but we'd need to come up with some comparable scheme here yeah yes in in china they quarantined entire villages uh it's called in the public health literature cordons soniter and there was one village in china that was quarantined for a month you couldn't get in or out martial law well of course you can um use the military under certain emergency situations so in the countries that we studied many of them did rely on the military to patrol the streets and do things like that i think in the united states it would using the military for a situation like this other than the national guard should be an absolute last resort because i think it would contribute to the panic that um we're we're so um unused to the military performing civilian functions at home that i think people would would panic over this and so one of our recommendations to cdc was to make sure that the appropriate institution of government took care of the problem to the extent possible so who does it is very important in terms of manuals and procedures part of it depends on what the disease is and so how we're going to respond cdc has done a variety of exercises across the country with public health officials and there is now a sort of training program going on for uh this kind of emergency i have to tell you um that i i have some concerns about the direction that we're going in frankly i think too much of our public health preparedness is being uh infused with anti-terrorism responsiveness and they're separate i mean there may well be a terrorist incident that causes a public health crisis but public health is not the same thing as homeland security and a lot of our public health response now in our public health planning is really being taken over by the the homeland security folks and uh we have different agendas in in many respects some of the things that work in terms of national security i don't think will work in public health and and and uh that's a great concern of mine public health has traditionally been underfunded everywhere including the united states and so people are anxious to get the dollars to upgrade their systems and what have you but i think the price is too high if it comes with changing the model of public health that works to a model of public health slash homeland security that's my personal view and i've seen that in in lots of areas so i think we have time for one last question uh all right three last questions it was it was uh dead heat and three-way dead heat on these questions just yes in the event of any sort of pandemic there's going to be considerable disagreement on the appropriate response another characteristic difference between this country and all those other countries including canada is i think that's a wonderful question in fact it's it's one of the specific recommendations we had so many that i couldn't share them with you um having one credible spokesperson telling the public about the latest scientific developments and illegals was essential in the countries that had sort of these multiple people and i can imagine you know your point about cable news you know all sars all the time uh it would be maybe counterproductive and so um one credible spokesperson in a routine basis actually in singapore they had a 24-hour tsar station that was run by the public health people but but uh public communication uh is essential and and let's face it we're we're creating a a generation of of scientifically marginally literate people and um i don't know how you suddenly bring them up to speed on these things okay there were two we'll go that way which is yes impossible to get anything passed i'm having a hard time imagining there being a federal legislative response without there being a large emf um and so i'm just wondering if that's i don't think you're cynical enough if you need some additional cynical uh uh cynicism uh uh you know um just send me an email i can supply it uh any 24 hours a day yes um model act and statute don't deal with some of the issues absolutely absolutely thank you very much you