University of Illinois at Rockford
Debra Anderson, BS, Director of Management Services, Winnebago County Health Department, Illinois
Karen Ayala, BASW, Director of Health Support Services, Winnebago County Health Dept, Illinois
Adapted from Leadership in Public Health 2002;6(1):49-57
In recent months the need for empowerment of local public health departments in the war against terrorism has been reinforced by U.S. President George W. Bush, Homeland Security Chief Tom Ridge, Health and Human Services Director Thomas Thompson and the Centers for Disease Control and Prevention. While there have been extensive references to the critical roles local public health departments (LPHDs) must play in the ongoing battle against bioterrorism, there are a number of legal and ethical issues that will need to be addressed to ensure LPHDs success as they fully define, develop and engage in these roles.
There has been an exponential increase in the amount of attention paid and resources provided for bioterrorism (BT) preparedness in the United States since 9/11 as well as acknowledgment of how public health is woefully currently unprepared to respond. However, the experience of one community has highlighted some areas of concern curiously absent from the scene. The first is a lack of recognition of the impact BT "non-events" including hoaxes, as yet undetermined events and fears of an impending local event following reported events outside a particular jurisdiction. These have proven to be far more numerous and thus more burdensome than BT "events" which are confirmed dissemination of bioagents or criminal credible threat designation. Even though fear and disruption of society has been recognized as the goal of (bio)terrorism, the focus of information/planning has been on the BT "event." The second area of concern is the reality of the unique LPHD role in managing the "non-event" and the expectations of their community results in a vast drain of LPHD resources beyond dealing with the expected BT "event" preparedness. This only exacerbates the already daunting under-resourced day-to-day agendas of LPHDs.
These two overlying concerns provide a backdrop to deal with three prominent ethical and legal dilemmas facing LPHDs in their roles in planning, preparation and response to BT that will be further explored. The dilemmas are grouped in three broad categories, namely:
On October 4, 2001, the first confirmed case of Bacillus anthracis (anthrax) in the United States since 1976 was reported. Between October 4 and November 2, the Center for Disease Control and Prevention (CDC) and state and local public health authorities reported 10 confirmed cases of inhalation anthrax and 12 confirmed or suspected cases of cutaneous anthrax in workers from the District of Columbia, Florida, New Jersey and New York. Epidemiological investigation indicated that the outbreak resulted from intentional delivery of anthrax spores through mailed letters or packages.
Local suspected incidents in WildBagel County (a bedroom county 85 miles west of Chillytown with a population of 278,418) began the week of October 9, 2001. More than 260 9-1-1 anthrax-related calls were received from concerned citizens by city and law enforcement between October 9 and December 30, 2001. The WildBagel County Health Department (WCHD) located in Stonetown, Illini became involved initially during the week of October 16. The health department had received a call from an anxious community member with pre-existing respiratory/medical symptoms. The person was referred by several local hospitals concerned that he/she and a family member had been exposed to anthrax powder from a letter received two weeks prior. The hospitals wanted to know if treatment was recommended. A second call came from a medical director of a local immediate-care facility requesting direction on how to deal with a hospital mask left in an exam room with suspicious writing and black powder on it. The mask had been thrown out by a staff member without notifying management. Multiple calls from local city and county police/Hazmat about how to get potential anthrax samples tested that the FBI did not deem credible were also received.
Hundreds of additional calls were received on law enforcement non-emergency lines. Local law enforcement reported that at the outset the FBI had stated that no cases would "ever" be deemed credible from the Stonetown area, and in fact no cases were considered credible by the FBI during the course of the local threats. Local law enforcement leaders became concerned about how to provide reassurance to local first responders and the public, particularly in the absence of specimen testing because state protocol required a credible threat status designation before laboratory testing would occur at the Illini Department of Public Health (IDPH) state lab. Medical professionals were concerned about how to decide whether to offer antibiotics to fearful patients and which antibiotics to offer. Employers and business owners were under pressure to provide a safe environment for employees and rule out suspected anthrax powders at work sites. WCHD was being informed by law enforcement about some "anthrax" cases but not others and differing protocols were being utilized by city and county responders for specimen collection, storage and destruction.
Between October 9 and December 30, 2001, WCHD was involved directly in 29 different suspected anthrax cases/reports from law enforcement. Responders in providing medical case management for more than 100 suspected victims, arranging for laboratory services and transportation of specimens, etc. In addition, WCHD's Epidemiologist, Director of Disease Control and Administration responded to several hundred phone calls from medical professionals, media, concerned citizens and law enforcement officials. The calls began tapering off in early December. No samples tested positive for B. anthracis from WildBagel County nor were there any confirmed cases of anthrax of any kind.
Although WCHD had received a $12,500 Bioterrorism Preparedness Planning grant from IDPH early in September 2001 and planning through the Stonetown Health Council's Infectious Disease Committee was in the initial stages, little was known about how to effectively respond to what was about to happen- specifically, the high levels of anxiety from the public, coupled with the lack of credible threats which would warrant additional resources- resulting in higher demands with no additional dollars for local public health departments.
I. Fairness and Equity in Distribution of Scarce Resources
The prioritization of resources is a concept very familiar to public health practitioners at every level. What is less familiar is the actual practice of prioritizing resources across multiple stakeholders in emergency conditions and the magnitude of health resources that must be managed concurrently in a rapidly changing environment.
The resource distribution dilemmas facing local public health professionals in the war on BT are complex and multi-faceted. They include prioritization of existing public health resources and recommendations for distribution of additional resources with the goal of ensuring accessibility of necessary resources equitably to all citizens through processes that enable input from the community. The graph below outlines the variety of scarce resources that will need to be prioritized; describes how one LPHD prioritization process has begun and suggests policy recommendations for resource distribution issues not yet resolved:
|
Distribution of Scarce Resources |
Local Decisions Made |
Recommended Policy |
|
Financial Resources (What important public health issues do LPHDs not spend money on while taking on additional expenses of BT?) |
LPHD direct expenses: - local stockpile of broad spectrum antibiotics for first 24 - 48 hours - various communications for clinicians (mass mailings, conference, faxes, e-mail) - field testing and sample storage equipment to assist in field detection/ screening of bioagents in lieu of a credible threat status by FBI - courier and culture testing for BT samples by area lab LPHD indirect expenses: - staff time - ten different LPHD staff involved up to 50% over past seven months - equipment used (vehicles, pagers, copiers, etc) |
Increased local financial support ongoing from tax levy specifically for local BT preparedness Regional LPHD pooling of finances for regional BT planning/response needs (i.e. ongoing field testing expenses, surveillance/ communication systems) State/federal financial assistance to ensure flow of federal BT dollars to LPHD for needs such as developing/ maintaining syndromic surveillance and 24/7 communications systems. General - small but dramatic shift of overall funding priorities beginning at federal level to increase public health funding by 100% (from 1 to 2% of current health care funding levels ). |
|
Staffing Resources (What important public health issues do LPHDs not spend staff time on to handle BT demands?) |
BT Planning - determined a priority for all top level management staff - assigned leadership roles in community BT planning process through local Health Council. Consultation - staff Epidemiologist, Directors of Disease Control and EH, and Administration on-call 24/7 for consultation/information. Medical Case Management provided for 29 law enforcement local anthrax threat cases. Screening - provided staff 24/7 to respond to HazMat request for field testing of potential bioagents. Collaboration - initiated and provide leadership for BT planning group and ongoing First Responder group including ER Response planners. |
Epidemiology and health planning/ communication staff - state to allocate BT funding for larger LPHDs to employ. Increased LPHD staffing resources required for both BT "events" and "non-events" - state and federal recognition through increased funding for BT training for staff and other local PH professionals, and for additional staff. General - further easing of categorical funding approach which restricts LPHDs from shifting priorities including staffing to best meet the immediate needs of their communities.. |
|
Medical Resources/ Equipment & Supplies (What role do LPHDs play in deciding how local resources will be distributed?) |
Prophylaxis - initially LPHD Administrative team determined local First Responders a priority for receipt of prophylaxis in BT event and developed preliminary distribution plan; also developed initial plan to receive/distribute NPS (National Pharmaceutical Stockpile) to community. BT Planning - strongly involving medical professionals/clinicians in BT planning group (input on distribution priority decisions, determine existing medical resources/ supplies, etc). Training/Communication - to community medical/PH professionals - providing notification, setting for relevant BT satellite trainings; local conference for clinicians; supplying updated diagnosis and treatment protocols/info resources for bioagents. |
Ensure community input to determine local distribution of medical supplies (equipment and medication) prior to BT event through the local BT planning group including law enforcement, ER responders, hospital and medical staff. General -promote balanced messages regarding caution in overuse of antibiotics during BT planning (especially during Anon-event@) to ensure availability and viability when needed.. |
II. The Right to Restrict Individuals for the Common Good
Determining when the authority to promote and protect health of the public supercedes civil liberties of individual citizens has served as the basis of public health law. However, our communities have evolved dramatically since the days of "quarantine" signs posed on the door of individuals suffering from communicable diseases, or the infamous tuberculosis asylums. Many public health laws/ordinances have not kept pace or have been promulgated inconsistently in overlapping jurisdictions.
Legal clauses have been drafted and adopted, recently, for exemptions to a variety of widely-effective public health strategies, (e.g. immunizations, ability to refuse medical treatment) as the inherent tension between individuals rights and the governments duty to provide safety and security to populations collide. In addition, our society has become increasingly mobile and considers that mobility an important application of their civil liberties. Another complicating factor is that many local public health officials are unaware of the extent of their authority in a public health emergency or how to exercise it. Utilizing the matrix introduced above, we explore these issues
| Common Good and Individual Rights
|
Local Decisions Made |
Recommended Policy |
| Quarantine contagious individuals/Isolate infected individuals (What happens if individuals refuse to follow PH mandates?) |
Local/state ordinances effecting LPHD authority to mandate quarantining/isolation need to be reviewed. Local BT Plan will utilize CDC's recommendations as a guide for local treatment/prevention decisions during BT Event; will include local/state public health legal powers to mandate quarantining/ isolation. |
Update local ordinances to ensure they meet emerging BT needs. Educate local law enforcement/first responders and the community as to CDC recommendations/rationale and PH legal authority to impose. Adoption of Model Public Health ER Health Powers Act (Center for Law and the Public) at state level to provide consistency in legal basis across multiple local/state jurisdictions. |
|
Travel /Gathering Restrictions (What happens if individuals refuse to follow PH travel restrictions?) |
Reviewed Lessons Learned in TOPOFF/Dark Winter BT table top exercises as to need for more effective means to communicate/administer travel restrictions across multiple jurisdictions and need for voluntary public cooperation. Local BT Plan will include travel restriction recommendations for varying bioagent scenarios. |
Provide public information/education increase confidence in local BT Plan - and voluntary compliance during appropriate BT events. Adoption of Model State ER Health Powers Act to ensure legal and court challenges across jurisdictions do not interfere with effective disease containment strategies during BT event; to ensure legal and court challenges across jurisdictions do not interfere with effective disease containment strategies during BT Event.
|
| Mandatory Prophylaxis/Tx (What happens if individuals refuse prophylaxis/ treatment and endanger health of community?) |
Updated prophylaxis/treatment protocols were reviewed through medical literature/ CDC for various bioagents and disseminated to local medical community. |
Local isolation protocols will be included as part of local BT Response Plan for individuals who refuse prophylaxis and/or treatment. Adoption of Model State ER Health Powers Act to ensure legal authority to mandate prophylaxis/treatment or adherence to isolation protocols; to ensure legal authority to mandate prophylaxis/treatment or adherence to isolation protocols. |
further:
III. Balancing Authority and Priorities of Local Agencies across Multiple Disciplines and differing Jurisdictions (Local, State, Federal)
One of the major difficulties in determining an effective response to bioterrorism is the complexity of coordinating not only the large numbers but also diversity of groups/disciplines involved in the response from legal, medical, emergency, human service, public, including the various layers of their counterparts such as local (townships, cities, counties), state and federal levels. Labor intensive ongoing collaboration/communication is needed as priorities may be unclear, differ or conflict and communication between security, law enforcement and public health must be facilitated. There is a need for a common, flexible leadership structure that deals with the unique aspects of BT incident - unknown source/growing health effected population/sustained health emergency response/with security and criminal implications. Recommendations from TOPOFF and Dark Winter BT Response table exercises highlighted the need to clarify who is in charge during a BT event since legal authority and responsibility may not be determined, may be determined but not known, or may be misunderstood or disagreed with.
|
Balancing Priorities |
Local Decisions Made |
Recommended Policy
|
|
Non-Event vs Event (Hoaxes or Fear of Event vs Confirmed Bioagent) |
Non-Event Decisions - to utilize local resources to alleviate community fear without A credible evidence and without resources from state/federal sources - realization that locals "on their own" prior to confirmation of BT event Event Decisions - need to speed up local BT planning process while preparing for possible event before completion of plan - LPHD on their own in first 24-48 hrs minimally, need BT plan to address |
Communication section of local BT plan will include dealing extensively with "non-events" and "events" since communication plays such a strong role in mitigation of fear. Public Role - advocate active public involvement in BT planning, "event" and "non-event" to help mitigate fear. General - all local BT Plan sections must include management of "non-events" as well as "events" as to potential health consequences. |
|
Who is in charge? (ER Management; Fire Fighters; Law Enforcement; Public Health; Medical Professionals?) |
Collaboration - Provided leadership in collaboration efforts with First Responders, law enforcement and medical community to determine appropriate local response. Local BT Planning - Received IDPH BT Planning grant and initiated local multi-disciplinary BT planning group. Non-Event Leadership - took ownership of expertise in case management, and the lead in communication with law enforcement, ER response and medical providers and effected public during anthrax scares |
Collaboration - develop BT Response Plan that provides responsive leadership structure for changing health needs/multiple jurisdictions and disciplines. BT Event Leadership - Public Health has responsibility to provide leadership by assuming role of Incident Commander when appropriate in BT event. General - Develop modified Unified Command guidelines and require utilization for LPHD/state and federal agencies in BT event. |
|
Local/State vs Federal (Physical Health of Public vs Criminal/National Security) |
Criminal - Utilized CDC Interim Recommended Notification Procedures for Local and State PHD Leaders in the Event of a Bioterrorist Incident (notified or recommended citizen notification of local police, FBI and IDPH). Health - Initially followed State Protocols based on Criminal Evidence for lab testing of local samples; then cultivated own local testing resources to rule out anthrax. |
Criminal, Defense, Medical and Public Health sectors - advocate for stronger collaboration to determine best practices to respond effectively to BT. General - recommend new authority and forums for communication between security, law enforcement, medical and public health providers (authority through Model State ER PH Powers Act). |
Although local public health is widely touted as critical in protecting communities from BT, the necessary increase in local resources and authority to make it possible must also be widely supported. Those resources include providing a legal basis for consistent PH emergency powers across multiple jurisdictions; ensuring the flow of federal BT dollars to the local level; ensuring that "non-event" resources are part of the local support package.
Much is being planned for regarding BT "events", but little to no guidance is being offered for the management of non-events which have already devoured a plethora of local resources. Although fear has been recognized as the goal of terrorism, more resources need to be developed and allocated to alleviate the fear that surrounds "non-events" as well as "events". "Non-events" need to receive attention including protocols, financial and personnel resources since they represent the highest potential health resource burden in our ongoing battle against BT.
LPHDs must be held accountable to the communities they serve in developing and implementing BT Plans and policies that will provide maximum prevention and protection from BT agents. They must also be held accountable for ensuring input from the community and for the judicious use of additional resources allocated. Those who answer to the call for additional resources to the local level to respond to BT must realize that these resources will also enhance the ability of LPHDs to combat many other chronic communicable diseases unrelated to BT. The time to act is now, the place to act is at the community level, the haunting question remains - will the necessary resources be available?
Antrax Aftermath case study last revised April 21, 2004 (epowell)