What Ebola Teaches Us About Public Health In America
Editor s note: This post is part of a series stemming from theThird Annual Health Law Year in P/Reviewevent held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here .
2014 saw an epidemic of Ebola in Sierra Leone, Guinea, and Liberia, and an epidemic of fear in the US. Neither epidemic covered public health in glory. For Science. Ebola was the “breakdown of the year;” the Association of Schools and Programs of Public Health called it “the most important public health story” of the year; Politfact labeled it the political “lie of the year,” and Time magazine named “the Ebola fighters” its “Person of the Year.” All of these characterizations contain some truth.
Response to the epidemic in Africa relied heavily on volunteer organizations, especially Christian charity groups like Samaritan’s Purse and SIM (Serving In Mission), and medical NGOs, most notably Doctors Without Borders (MSF). It was MSF that called out the World Health Organization (WHO) for its failure to recognize the epidemic, and then its inability to respond to it. Their International Health Regulations, it turned out, were much more like guidelines than any form of law, and the WHO had no capacity to effectively respond to a new epidemic.
There is wide agreement among public health experts that the Ebola epidemic is a symptom of the wider problem of extreme poverty in Western Africa, and a symptom of porous infection control and weak patient safety practices in the US. In fact Americans showed almost no interest in the Ebola epidemic until September 30 when a visitor from Liberia was diagnosed with Ebola in Dallas, followed in mid-October by two of the nurses who treated him. The Dallas incident produced both massive news coverage and sustained fear.
The Danger of Framing Ebola as Terrorism
We compounded people’s fears of Ebola by identifying it as a possible terrorist threat and deciding that it should be managed as such. In this context, the threats of Ebola and ISIS were often paired, Ebola was described by the President (to the United Nations and Americans) as a “national security threat,” and proposals were seriously discussed to control it by adopting passport and visa controls and no fly lists, and the military was sent to Liberia to meet the challenge.
Even Paul Farmer, the leader of Partners in Health, adopted the terrorist metaphor, saying of Ebola in Western Africa: “This isn’t a natural disaster. This is the terrorism of poverty.” And the federal government’s most credible spokesperson, Anthony Facui of the National Institute of Health (NIH) said (in response to an admittedly bizarre question on whether terrorists will use Ebola as a bioweapon), “nature right now is the worst bioterrorist.” The President found it expedient to designate not a public health expert, but a lawyer, Ron Klain, to coordinate the US response to Ebola.
Following the national security metaphor, the new “Ebola Czar” reported to the president’s homeland security adviser (Lisa Monaco) on Ebola in the US, and to the president’s national security adviser (Susan Rice) on Ebola in Africa. Among Klain’s most urgent challenges was to improve and accelerate coordination between the Centers for Disease Control (CDC), the states, and individual hospitals.
Coordination also was a major challenge to NGOs, American and otherwise, working in Africa. Yet, with the appointment of an Ebola Czar, the CDC (like the WHO) was left to pursue a supporting role as technical adviser on homeland security. Tom Frieden, unhelpfully I think, later described the CDC mission in the Ebola epidemic in national security terms, “we will do everything in our power to protect Americans. That’s our top priority.”
This post-9/11 reframing of federal and state public health agencies as part of disaster preparedness, with an emphasis on counter-terrorism and the new metaphors we have deployed to describe public health has deformed our public health agencies and made them less able to prevent and respond to new infectious diseases. This is a tragedy for everyone.
That is not to say that using the military for public health purposes is never appropriate. Only that the CDC is not and should not be a military/terrorism preparedness agency the military has capabilities no other public or private entity has, and it is sometimes perfectly appropriate to use their assets for humanitarian purposes (e.g. the Tsunami, Haitian earthquake, Katrina).
Given the gravity of the Ebola epidemic and the inability of civilian organizations to respond effectively, it was perfectly acceptable and even commendable for the President to send troops to Liberia to, as they did in Haiti, repair and build runways, roads, and hospitals. But it should be a last resort, both because military tactics are not generally citizen-friendly, and because our military (unlike our physicians and nurses) are not uniformly welcomed as helpers in all parts of the world.
Taking a Public Health Approach
The 2014 Ebola response, however, does give us an opportunity to change directions. Public health must be based on science, not fear, and it should strive to work with populations (both in the US and globally) in an open and voluntary manner which fosters public trust. Without public trust, effective public health is impossible. And public health officials must trust the public as well. Americans, for example, have no interest in spreading diseases to others, or in avoiding medical treatment when they are sick. They will cooperate with any reasonable directions they are given by credible physicians, even government physicians, as long as they tell them the truth. They will even as we have seen in Ebola stay home in “voluntary quarantine” for 21 days, at least if they can have access to food and other supplies.
On the other hand, use of force, and even the threat of force, especially when seen as arbitrary, as it was in the case of quarantining nurse Kaci Hickox in a New Jersey hospital upon her return from treating Ebola patients in Sierra Leone, will likely be counterproductive. Lawyers helped get her home to Maine and negotiated voluntary self-monitoring there. The U.S. Constitution really does require adoption of the least restrictive alternative, even in the face of a national epidemic (which we imagined we were faced with).
In Geneva at WHO headquarters, there have been many meetings about what kind of research, including drug and vaccine research, can be done during the Ebola epidemic. The discussion has been mostly centered on identifying drugs and vaccines and developing a research design. Little discussion has been devoted to informed consent. This is unfortunate because even in the midst of an international pandemic, The International Covenant on Civil and Political Rights requires informed consent for medical research a requirement that no WHO group, no matter how distinguished and no matter how many times they meet in Geneva, can change on their own.
A WHO “Ethics Working Group” decided in October, for example, that “there is an ethical imperative to carry our research on potential therapeutic agents against EVD [Ebola virus disease].” (It’s always nice to find that ethical guidance require you to keep doing what you want to do, but this is seldom the case.) In Ebola, there is an ethical obligation to treat people who have the disease, and to try to halt its spread. When currently available therapeutic agents, including IV fluids, are not being universally used, it is hard to argue that ethics requires you to find new ones, without first using currently available treatments.
It is public health actions, including identifying and treating people with Ebola, and identifying and quarantining their contacts to determine if they have the disease, as well as public education and changing burial practices that will bring the epidemic under control. Of course finding an effective drug treatment or vaccine is highly desirable; but public health actions and medical treatment must always take precedence is an epidemic.
Ebola is fundamentally a public health problem, not a national security/terrorism problem, or a legal one. The disease will be defeated not by law or by imagining Ebola as a terrorist or even a bioterrorism weapon, but by treating it as an infectious agent made more threatening by poverty and lack of effective infection control measures. Diseases of poverty kill millions every year globally, and in the US, hospital-acquired infections kill 75,000 to 100,000 Americans annually. Ebola gives us an opportunity to adopt public health and social justice strategies to confront the root causes of these deaths.
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