Ethical and Legal Considerations in Mitigating Pandemic Disease Workshop Summary (2007) / Chapter Skim
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1 Learning from Pandemics Past
1 Learning from Pandemics Past
Pages 31-60
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From page 31... ...
Reflecting on key outbreaks of emerging infectious disease over the past three decades, Heymann examines what these episodes reveal about the roles and responsibilities of health workers in a pandemic, the consequences of infectious disease to global trade, the challenge of providing equitable access to healthcare resources, and the balance of individual rights versus public welfare. He describes how increasing recognition of the threat posed by emerging infectious diseases led to greater international cooperation in reporting and responding to disease outbreaks, as illustrated during the first outbreak of severe acute respiratory syndrome (SARS)
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From page 32... ...
Beyond these advantages, Henderson attributed the success of the smallpox eradication campaign -- the first and only successful attempt to eliminate a human infectious disease from the planet -- to its judicious use of available resources in host countries, its broad goals that could be achieved in multiple ways, and its support of a wide range of clinical, epidemiological, and operational research. Henderson also explored the ethical implications of the smallpox campaign's central strategy, the vaccination of 80 percent of the world's population -- which, he reported, proved a far more viable means of disease control than either quarantine or isolation.
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From page 33... ...
In this brief summary, four key ethical issues related to emerging and reemerging infectious diseases are highlighted: the roles and responsibilities of health workers; the consequences of infectious disease to commerce among nations; the challenge of providing equitable access to health-care resources; and the balancing of individual rights versus public welfare. These four issues were very important, for example, during the first outbreak of severe acute respiratory syndrome (SARS)
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From page 34... ...
In 1978, for example, a medical photographer at a research institution in Birmingham, England, became infected with the smallpox virus and, before dying, transmitted it to her parents. Health workers were also disproportionately affected in the 1957 H2N2 influenza pandemic, in which 52 percent of unvaccinated health workers in New York City and 32 percent of unvaccinated health workers in Chicago became infected themselves.
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From page 35... ...
probably smallpox or measles bubonic plague nature of epidemic unknown FIGURE 1-1 The spread of epidemics. SOURCE: Heymann (2006)
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From page 36... ...
. 1-2 TABLE 1-1 From Quarantine to International Health Regulations: A Framework for Global Health Surveillance and Response 1374 Venice Quarantine for Plague 1851 Paris First International Sanitary Conference 1947 Geneva WHO Epidemiological Information Service 1951 Geneva International Sanitary Regulations 1969 Geneva International Health Regulations SOURCE: Heymann (2006)
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From page 37... ...
The revision addresses a long-standing problem: that countries often do not report the presence of infectious diseases within their borders because they fear the economic consequences of doing so. Trade sanctions resulting from infectious disease are often more severe than necessary, as happened, for example, following the discovery that people had contracted variant Creutzfeldt-Jakob disease by eating beef from cattle in the United Kingdom (UK)
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From page 38... ...
Passengers with fevers are taken aside, examined and, at times, prevented from traveling. These are only two of the many instances in which individual rights have been sacrificed in the interest of protecting the public from infectious diseases.
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From page 39... ...
On February 14, the Chinese government reported that 305 such cases had occurred, including five that resulted in death, but it described the outbreak as "under control." WHO remained very concerned, however, in part because the 1957 and 1969 influenza pandemics are thought to have originated in southern China and partly because the outbreak had included a large number of health workers, which suggested a possible amplification of transmission in the hospital setting. The WHO network of influenza laboratories, which looks for novel influenza viruses that might have pandemic potential, was notified of this outbreak, as were the WHO offices in countries throughout the world.
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From page 40... ...
There, during a single day, he was somehow able to transmit the virus to other hotel guests who afterwards traveled to Canada, Singapore, and Vietnam, and to one who later entered a hospital in Hong Kong. That index case and secondary cases resulted in the infection of 219 health workers.
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From page 41... ...
Based on this information, WHO issued its first global alert on March 12: a moderate announcement informing governments, ministries of health, and journalists that a new and highly virulent atypical pneumonia of unknown cause was occurring in Vietnam and Hong Kong. By March 14, WHO had received reports from Canada and Singapore of persons fitting the case definition of the new atypical pneumonia.
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From page 42... ...
Airline travel to affected areas all but halted, resulting in more than $30 billion in losses in Asia, according to estimates by the Asian Development Bank estimates. Revision of the International Health Regulations Within four months of beginning containment activities, and without the use of novel drugs or vaccines, all chains of human-to-human transmission were broken, the SARS virus was driven out of its new human host, and the outbreak was declared over.
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From page 43... ...
That framework can accommodate all emerging infectious diseases of international concern, including pandemic influenza. Possible outbreaks are detected using information from networks, as well as from individual countries, and, in a significant break with the past, reports other than official government notifications can be used by WHO to alert the world to an event of international concern.
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. In what follows I will link some of the lessons learned from pandemics past to the quandaries that policymakers are grappling with today in response to a potential influenza pandemic and other microbial threats.
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From page 45... ...
Policy makers, on the other hand, may find it more compelling that the record allows them to have the chance to observe how large numbers of people respond when a pandemic appears but vaccines and antivirals are neither effective nor widely available. History suggests that when faced with such a crisis, many Americans -- and more formally, American communities -- will adopt, in some form or another, what they perceive to be effective social-distancing measures and other nonpharmaceutical interventions (NPI)
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From page 46... ...
ETHICAL AND LEGAL CONSIDERATIONS IN MITIGATING PANDEMIC DISEASE Rosenberg characterizes the unfolding of an epidemic as a dramaturgic event, usually in four acts, with a distinct but somewhat predictable narrative plot line: During the first act, "progressive revelation," members of a community begin to acknowledge an increasing number of cases and/or deaths resulting from the spread of a particular contagious disease. Camus's The Plague demonstrates this pattern with one of the most memorably disgusting opening scenes in all of literature: When leaving his surgery on the morning of April 16, Dr.
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From page 47... ...
Plague of the Middle Ages; smallpox in the seventeenth and eighteenth centuries; the cholera pandemics of the nineteenth century (in 1832, 1845, 1866, and 1892) ; the influenza pandemics of 1880, 1918, 1957, and 1968; childhood infectious disease epidemics of the early twentieth century, including diphtheria, polio, and scarlet fever; small pox epidemics of the nineteenth and twentieth centuries; and also contemporary crises involving HIV/AIDS, tuberculosis, SARS, and other newly emerging infectious diseases (Markel, 1999, 2000, 2001, 2004; Stern and Markel, 2004; Markel and Stern, 1999, 2002)
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From page 48... ...
Still, old ideas about contagion are often slow to die and, like fevers of unknown origin, have the power to recrudesce; as a result, many people today have ideas about the cause and spread of particular infectious diseases that are markedly different than the principles we teach in the medical school classroom (Duffy, 1992)
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From page 49... ...
By the close of the 19th century, journeys from Europe or Asia to North America required a travel time of 7 to 21 days, which gave most infectious diseases ample incubation periods and facilitated their recognition by health officers at the point of debarkation. It is quite different today, when the main mode of international travel, commercial jet planes, allow people to travel anywhere in the world in less than a day.
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From page 50... ...
. At other times concealment efforts have been motivated by nationalistic bias, pride, or politics, as was the case with South Africa and HIV in the 1990s, China during the first months of the SARS epidemic of 2003, and, over the past few years, Indonesia and avian influenza (IOM, 2004, 2005)
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From page 51... ...
.4 At many -- but certainly not all -- points of time, poor people have been disproportionately affected by epidemics and pandemics. Public-health policies that place blame on victims or, worse, on perceived victims can have many negative consequences, including the misdiagnosis of the healthy and isolating or quarantining them with unhealthy people; social unrest, legal entanglements, 4 For a broader look at the history of quarantine, infectious diseases and public health, particularly as they pertain to influenza, see: Mullet CF.
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From page 52... ...
For example, during the 1918 pandemic it was very common for local business owners to oppose nonpharmaceutical interventions that seriously affected their economic health. School and business closings, restrictions on travel, and even the use of face masks often proved to be quite contentious issues.
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From page 53... ...
The Power and Limits of Historical Inquiry To investigate how historical inquiry can inform the planning of pandemic mitigation strategies, one must first be aware of the limits of this approach. Let us begin by describing the historian's laboratory: the archives.
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From page 54... ...
Other features of the modern world that need to be considered when studying the historical record of the 1918 pandemic in order to inform contemporary policymaking include the speed and mode of travel, particularly the development of high-volume commercial aviation; immediate access to information via the Internet and personal computers; a baseline understanding among the general educated population that the etiological agents of infectious diseases are microbial; and advances in medical technology and therapeutics which have vastly changed the options available for dealing with a pandemic. Another important aspect of American society circa 1918 that was markedly different from the present is how daily commercial transactions are carried out.
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From page 55... ...
Naval base at Yerba Buena Island, one mile from the busy port of San Francisco, and the mining town of Gunnison, Colorado not only escaped the pandemic, they also had carried out a particularly extensive menu of restrictive public health measures (i.e., nonpharmaceutical interventions)
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From page 56... ...
communities, 1918–1920 pandemic. Emerging Infectious Diseases 12(12)
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From page 57... ...
. We do not promise any oracular commandments for pandemic preparedness, but we are confident that our fine-grained, rigorous, and scholarly historical epidemiological analysis of these American cities will significantly inform those who are considering the application, utility, policies, and design of nonpharmaceutical interventions today.
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. Emerging Infectious Diseases: Past Is Prologue.
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2004. International efforts to control infectious diseases, 1851 to the present.
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From page 60... ...
Later, the First World Health Assembly is held in Geneva with delegations from 53 Governments that by then were Members. 1951 Text of new International Sanitary Regulations adopted by the Fourth World Health Assembly, replacing the previous International Sanitary Conventions.
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