Volume 12, Issue 2, Spring 2002

Public Health in the Age of Bioterrorism

The following is an edited transcript of a dialogue organized by the Communitarian Network on public health and bioterrorism. It was held at the National Press Club on October 26, 2001. The participants were Alan Kraut, professor of history at American University; Fitzhugh Mullan, a clinical professor of pediatrics and public health at The George Washington University; and Richard Riegelman, professor of epidemiology and biostatistics and the founding dean of The George Washington University School of Public Health and Health Services. Amitai Etzioni moderated the discussion.

Amitai Etzioni: Ladies and gentlemen, welcome to a communitarian dialogue on the ethical and legal issues raised by bioterrorism. Because one of the issues we are most concerned with as communitarians is the delicate and difficult balance between individual rights and the common good, we are concerned both with protecting our rights and with protecting the health of our people.

A place where many discussions on this issue start is with the scenario of a terrorist group infecting a large number of people with smallpox. Let's stipulate that smallpox is highly infectious, that it has a high fatality rate (30 percent), and that there is a period in which you have symptoms but you are not yet contagious. In most of the scenarios, you come to a situation where very quickly a very large number--hundreds of thousands, millions--of people are infected. And then the question is how to stop the plague. Some people call for an education campaign, some for quarantining. It's deciding from the range of voluntary to coercive means that we are so concerned with.

Personal Risk vs. the Common Good

AE: Before we even discuss the attack itself, let's talk about preventive vaccination campaigns. When we had various forms of vaccination in the past, for instance for protecting children from various diseases, we had an increasing number of parents who did what economists call "free riding": they basically assumed that if everyone else's child is vaccinated, they will not have to expose their child to whatever risk is entailed through vaccination; their child will still be protected. So, let's start with asking: How far are we willing to go in the prevention period to see that everybody takes the limited risk and participates? Because obviously, if more and more people bow out, the whole system is going to fall apart.

Alan Kraut: I think public shame went out with the Puritans. I don't think we're going to put people in stocks. But I think in the case of school boards and so on, there will be less tolerance on the part of those officials who are most directly involved. In other words, those who don't want to have the vaccination, parents who don't want to have their children vaccinated are going to be subjected to greatly increased public pressure, possibly social ostracism, possibly simply exclusion from the public discourse. What other measure can one adopt? In short, in crisis period, and we're talking about something that's really crisis management, the traditional level of individualism probably isn't going to be as tolerable as it was in a calmer period.

Fitzhugh Mullan: I would be for very strenuous laws and means to prosecute any campaign of vaccination. We do that essentially with children. There are many loopholes; states treat it a little bit differently. We use schools as the hammer, actually, because kids can't go to school if their vaccine card isn't up to date. There are exclusions for religious and other reasons. Now with this scenario, we're moving in a different time frame--and with the whole population, not just kids. But I would both write laws and enforce laws that were very exacting in terms of 100 percent vaccination, if that was what was the target of mass vaccination.

AK: I would, too. I think in the redefined kind of warfare that we're talking about, we can't avoid the notion that the civilians in the society are also subject to a discipline usually reserved to the military.

AE: As bin Laden keeps reminding us.

AK: As bin Laden keeps reminding us. And it's sad but it's true. In the case of those in uniform, their bodies belong to the United States Army or the United States Navy. Certain things can be done to them and they can be exposed to certain dangers to which we wouldn't ordinarily expose a civilian population. But I think in this redefined kind of world, and redefined kind of situation, where there is a palpable threat, I agree with Fitz. I think there's a very good argument to be made to compel people to comply with a vaccination in a way that we ordinarily wouldn't, given our culture, given our society, and given our mores.

Richard Riegelman: I think that the issue of vaccination revolves very much around what is the risk of the vaccination itself, as well as the risk of having an epidemic. But the risk of the old vaccine was considered to be quite high. The hope is that the new technologies for developing vaccines will actually reduce very substantially the risk; side effects are expected to be far less severe. But these new vaccines will be put into effect without any of the standard testing, so we are flying by the seat of our pants in terms of how safe these vaccines are going to be.

Where to Draw the Line?

AE: All right, so now we've had the attack and let's assume the terrorists used smallpox. So now we get the scenario, and instead of doing what some say is very harsh and very un-American--locking up many citizens and using at least nonviolent means to keep them there--we have the suggestion from D.A. Henderson [now the director of the Office of Public Health Preparedness in the Department of Health and Human Services] that we should encourage people to stay home. It would be a system of voluntary domestic quarantining.

AK: Well, I haven't seen the full proposal, but it sounds rather unrealistic that people are going to accept voluntarily that kind of a societal lockdown, that families won't try to see extended members of the family and friends, and so on. It really doesn't sound like a very practical way to do it.

FM: My sense is, not having talked to him [Henderson] about it, that there may be ways to abate or buffer the epidemic, short of a formal, physical quarantine of hundreds of thousands of people. This is something that you walk back to after you examine the alternative, that is the full formal lockdown of hundreds of thousands of people. I have not engaged in that war game entirely, but people are doing that. And to the extent that I have visited that scenario, it's a hard one to envision. I think it's not one we should duck, and at least in its broad outlines it makes more epidemiologic sense. But when you talk about quarantining Washington, D.C. or Topeka, Kansas the implications are far beyond anything we've ever experienced. And I would like personally to see that walked through as to how that would work.

AE: Henderson's argument is, first of all, as far as extended family is concerned, I think he would say once we explain to people that if you go to visit your grandmother, you're killing her, they may want to refrain from visiting her for 17 days. And what concerned me initially when I heard that is if I am infected and stay home, I'm going to infect my family who are healthy at that moment, and surely I will not want to do that. I'd rather go voluntarily to the place of quarantining. But it was explained to me that Henderson would suggest that you immediately vaccinate the other members of the families and you have this two-day window in which you can do that. I think there's a little more reality to it than there seems at first--other than that there's one catch, which in my judgement is not surmountable. This plan assumes a very high compliance rate. It assumes that not only will all people who have the symptoms then voluntarily stay home, be sure that nobody visits them, and have no member of the family go out--which is a hell of an assumption, as we know from compliance in practically any other medical intervention--but, worse, it assumes that a very high percentage of the people will recognize the symptoms correctly, including in our less-educated population.

AK: Using history as an example, if we take a look at the polio epidemic in 1916, and we take a look at how families reacted that were quarantined, that had a child quarantined, how neighboring families attempted to send their children out of town and to evade quarantine signs that were hung in apartment buildings in Philadelphia and in New York, there's not a really good record on Americans complying. This individual ethic, which is such an important part of the American consciousness, of the American ethos, really works against expecting that kind of compliance. The reporting and the compliance will not be readily forthcoming.

AE: So now we discovered that after we tried voluntary quarantining for one week, the cost in human life was immense. We are now in a new city and we have an early warning system that tells us daily about new infections. And we are now examining this harsh option of quarantining. Now, we do not need in this case to quarantine the whole family, because we want to quarantine only those people who have early indications of the illness and we catch them, we assume, before the contagious stage. We don't want to quarantine the whole city, we just want to ask people who have the symptoms to join us at the most luxurious beach resort we can find, around which we are going to throw a ten-foot wall, reinforced by guards with nonviolent means of stopping people who want to leave.

FM: I don't think that's a likely scenario. I want to step back. I think we're misreading a little bit the public health management of scenario one, the initial scenario where amidst a population of hundreds of thousands, a number of thousand have been exposed--you just aren't quite sure who, or you're sure who's exposed but not to what extent. If we're talking smallpox and we're talking current vaccine supplies, the ring notion was that you vaccinate everybody who was in contact or is likely to be in contact with an infected person, and that basically provides protection, containment, exhaustion, or the extinction of that particular mini-epidemic. The problem with multiple individuals in a city is you can't ring them very easily. They are in a hundred thousand different places amid a population of a million. Then you talk about mass vaccination and that is plausible. You can mass vaccinate everybody in that city very rapidly. It would be better if our public health structure was in better shape to do it, but depending upon the circumstance, that's quite plausible.

With smallpox the problem is when you run out of vaccine and you've still got cases in two or three other cities. Then you are in a situation where you now have lost your defense, your vaccine, and then quarantine becomes your only way to limit it. Then you come to the question, now perhaps robbed of any immunologic defense, as in vaccine, how do you contain the epidemic? And that gets to be a very difficult scenario in terms of people wanting to flee the area in particular, and the necessity to keep them there until either the epidemic runs its course or, with what vaccine you have available, you have contained it as well as you can. I think the big problem there is you're going to have people who are not sick, don't think they've been exposed, or maybe even think they've been exposed but don't want to stick around to find out, who are anxious to get out--out of the area, out of the country--and that's when I think you'll have enormous problems containing people.

AE: Let's hold it just for one second because I want to clarify the scenario. First of all, I don't know that everybody knows that we don't have endless vaccines ready. And there are some questions about how effective those vaccines we do have are, because they've been sitting there since the 1970s. Is that a fair question?

FM: Yes.

AE: And how long will it take us to make another hundred million? Over twelve months?

AK: I think the plan calls for delivery within months. And I think that the key is that this strategy avoids some of these harsh decisions we have been discussing because it prepares us, if there is an outbreak, to quickly implement this kind of a strategy.

AE: You see, I salute and celebrate your tender hearts, in that you keep saying, "That's hard; I don't want to go there." But it's my job to take you there. So, let's go back to Fitz's scenario. We expend our vaccines and we now have some outbreaks in the city and we have zero left in the vault. And I am still not quite clear why we have to quarantine people who have no sign of illness. We are in the phase where they are not yet contagious, but they have the severe flu-warning symptoms. Why do we have to take anybody else but these people and invite them to our beach?

FM: Those people are clearly sick. What you have, however, is a 12- to 17-day latent period, during which time people who may be infected show no symptoms.

AE: But during this period they are not contagious. So say that person who has been exposed and has no symptoms runs from Chicago to Philadelphia. And now if she shows symptoms in Philadelphia, she'll be invited from there to go to the beach. So why do we want to stop people who have no symptoms? Why is it not enough to quarantine those who have symptoms in the pre-contagious stage?

FM: As a hypothetical matter I think that makes reasonable sense. The question of when symptoms are identified and who reports them and whether there is forthcomingness on the part of individuals, that becomes, I think, very difficult. I mean, hypothetically, if you had a point where they go from being non-infectious to being infectious or non-symptomatic to being symptomatic infectious, you'd need to move them to the Etzioni Hilton at that point, that would be convenient. Theoretically, that would make sense. I think practically, that would be very difficult.

AK: Essentially, it's an issue of reporting.

Drastic Times, Drastic Measures

AE: Let's move to the ultimate now. When our vaccine ring no longer exists, we'll have to throw walls around cities so we do not have to go into sorting and reporting. Should we let the plague get out of control in order not to do that?

AK: My answer would be no. You can't let the plague get out of control. At that point, the broader public health of the society, the country, the very survival of the society is at stake, and there is a good argument to be made for imposing laws and using force if necessary. The strictest quarantine possible must be imposed.

AE: You are not agreeing?

FM: I quickly confess to running out of tactical and ethical insight. I mean this is medieval. I mean that was the notion during those times, and our terminology recently slipped to plague rather than smallpox. This was the way plague was handled. People were confined to this town or that area. The vector plague was not understood then, but people knew they were going to die--and large numbers of people as well--because they were being forced to stay where it was until it effectively burned itself out. And whole towns in some cases in the 14th century expired that way. Trying to do that with Chicago today tests the limits of anything I can conceive of.

RR: I think coercion, in the communitarian terminology, is most effective at the beginning. If uniformly and quickly implemented, it can be implemented on the smallest possible scale. So, get in there and get in there quick and use coercion, but use it quickly and modestly.

AE: Now let's change direction a little and let's talk about the agencies and the players who could participate and what difference it makes. Who does the early warning? Who does the education? Who does the quarantining? And one place maybe to start is to say that maybe this is the time to make Americans less individualistic.

AK: Well that's easy to say, hard to do. You can change all kinds of things about the situation and the society, but changing the fundamental values of Americans--values with which they've been educated and raised and taught because of a democratic heritage--that's hard to do. Their individualism is the bedrock of their national character. Re-education sounds far and away like the most humane and proper way to do it. But how could you do something like that when we have difficulty with Americans accepting that there might be limits on who could get a kidney dialysis and accepting that kind of a triage situation? How much more difficult would it be in an atmosphere of panic to get people to accept the sacrifice of their freedom of choice voluntarily?

FM: I would disagree with that. Understanding Alan's premises, I would concur on his historical interpretation. We talk about the closing of the frontier, which was an important historical concept, speaking of the Western frontier. But the notion that we were an island nation and we were essentially protected, naturally quarantined from malevolent forces in the world--I think September 11, etc., etc. is going to bring that notion of frontier to a close for many of us who thought otherwise. It seems to me that an important adaptive feature of America in the future is going to have to be a sense of being part of the globe and being part of a community that has to defend itself. But this has to be more of a collective enterprise. The specter of biological disaster is like the Blitz in World War II in London. Nationwide, we're going to have to pull together. I don't think we can be the same country after this.

AE: I just want to take one second and switch my hat from just provoking and prodding to being a communitarian witness. First of all, the good news is, and I think I'm correct and certainly not alone, in reading American history, there has always been a tension between the Lockean notion of rights and individualism and the kind of communitarian, civic republican virtues and civility commitments. The very fact that the preamble talks about how we came together to form a more perfect union seems to be speaking to the other half of that struggle. But to go back to what happened after 9/11, that may change one more time. But at the moment, a lot of public opinion polls show a really dramatic shift in the willingness to care for each other, from blood donations to volunteering, and to trust our institutions and such. Now I'm not willing to predict how long it's going to last, but I don't want to leave it that we have no communitarian bone in our body.

AK: We do have a communitarian bone in our body during wartime and crisis situations, but one has to observe that those tend to be fairly short-term situations and they've always been somewhat limited before. And there have been violations of that communitarian spirit, whether we're talking about draft dodging or we're talking about buying oneself out of the service during the Civil War. In the aftermath of September 11 there is a lot of display of heartfelt communitarian spirit and spirit of cooperation and self-sacrifice, but I'm wondering in a sustained kind of conflict how long that lasts on a broad level. And faced with the kind of scenarios that we've been talking about, to what extent do people revert?

RR: Not only that, I think that the individualism has been expressed in institutional individualism, where everybody is competing and nobody's cooperating. And that's private-public; that's state, federal, and local; that's public health, hospitals, and physicians. If there's going to be a community, it's not just the individual behavior, it's institutional behavior that I think we need to focus on.

A Better Future?

AE: It's time now to let our imaginations really roam free. Can we use the threat of bioterrorism and the need to deal with it to build a better society and one in which there'll be more attention paid to public health?

AK: I would say yes. I would say that every war that the United States has ever fought has had indirect dividends in terms of what we've done medically, what we've done organizationally, creating new relationships between different parts of the government, different relationships between federal and state governments. And this current crisis is no exception. I think we're going to see out of this terrible situation, this national crisis, a set of new relationships. Some of it may have to do with different funding for the CDC, different balance of funding between different branches of the Public Health Service. A lot of it, I suspect, will have to do with the coordination between federal, state, and local. I think the kinds of chaos that we've been seeing, that we've been witnessing on almost a daily basis over who has jurisdiction over what and who ought to go to the microphone and who ought to be communicating with the White House--that's a lesson from a lack of preparedness and a lack of sound organizational practice. It probably will be corrected out of what we're seeing.

RR: I think we're going to see things that we knew we should have done for years now be done. This morning's news says that influenza has to be prevented now because it looks like anthrax. We're going to have the best immunization against influenza that we've ever had, and that's just hopefully the beginning. We're going to be applying our technology to put vaccines on the map. AIDS vaccines were never at the top of anybody's financing stream until recently, and the technology has to be applied, we have to use the most modern technology. We have had no surveillance system that comprehensibly looks for disease. We're going to have that now because we need it and hopefully it will have all kinds of spinoff effects that will improve our ability to monitor, detect, and rapidly react to new problems.

FM: I think Alan's point is a very good one, that crisis makes for opportunity. And both realigning what you have and creating new things will come out of this crisis as it's come out of others. So, I don't feel fatalistic about that. There are two specific things that occur to me. One is that as we consider massive new funding in this area, there is an instinct to buy vaccines and to stockpile immediate antibioterror implements--drugs, vaccines, etc. And that is as it should be. But if we don't invest at the same time in the infrastructure, the personnel, the communications capabilities, we will have lost that opportunity. So, to take this from the theoretical to the real, the design of the legislation and the funding of the legislation that we'll see coming forth very quickly here needs to take that into account. And there is an agenda ready to be funded. This is not a field that has gone unexamined. And the second thing is that I would hope that young people in the health sciences--in medicine and nursing, in public health, etc.-- think about their careers and weather the challenges, the tribulations, and the excitement of working in the public domain as doctors, nurses, and public health professionals more focused on and trained in these kinds of community-wide, population-wide, collectivist and communitarian issues. I hope many more will elect those kinds of careers.

AE: Well this is extremely helpful. So I'm taking away from this that we better prevent, and better be prepared before we are hit, and that we are much better off to the extent that we can rely on education. But we have no illusions that that will suffice, and we would, beyond that, if push comes to shove, rely on having vaccinations ready so that we can surround those who are ill with vaccination to prevent its spread. And we would resort to other voluntary means, which include putting pressures on those people who are not willing to line up and be vaccinated because they are individualistic or free riders or fearful. But we also realize that we may have to engage in full-blown quarantining. And, finally and maybe most importantly, out of these terrible tragedies some good may arise if we use this challenge to reinstitutionalize this--temporary, I grant--very community-minded spirit.

I also take one more thing away from this: that we can have a reasoned dialogue without hardball. Without interrupting each other or attacking each other, we had what I thought was an excellent, productive conversation. Dr. Kraut, Dr. Riegelman, Dr. Mullan--thank you very, very much for participating in this communitarian dialogue.

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