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Problem Group Three

Starting points:
  - Teach as a "real time" evolving event, and add to the fact pattern as events unfold.
- Risk?definitions of risk
- Benefit?definitions of benefit
- Creating an appropriate response
- Distinction between preventive and responsive public health
- In connection with bioterrorism, pick a biological agent that might be used, or pick a few agents and compare responses: How do you respond with a known versus an unknown agent? How would responses differ?
         
Scenario #1
         
Fact Pattern: Aircraft inbound from South East Asia with very ill passenger-plane lands in SFO and the passenger dies. A few days later, another plane comes in from a similar part of the work (ex. Jakarta), and there is a passenger with a similar symptom. Suspected bioterrorist activity, but at this point the disease is unknown. Local agencies start trying to control incoming flights.
  - What are the responses?
- What would change if the pathogen were known (i.e. smallpox) versus unknown?
Local health officer notified-depending on timing, other people on the flight start getting sick, but have already left the airport. Then people start showing up at the local hospital. Some are sick and some die. Other people on the flight are completely unaffected.
         
Local Response:
  - What happens first?
- Get list of passengers from the flight.
- Do public notices trying to notify all those who may have been at the airport terminal. R Set up a hotline.
- Teaching concept: process of contact tracing C what are the legal implications?
         
Quarantine:
  - Federal quarantine regulations v. state quarantine regulations
- What degree of force can be used to quarantine?
- What laws have to come into play when hospitals quarantine people?
         
Vaccination:
  - What are forced or compulsory vaccinations?
- People can get penalized and/or quarantined for not getting vaccinations, but competent adults are not physically forced to get vaccinations.
- Smallpox vaccination at this time is wholly voluntary. What would happen if it was made mandatory?
         
Discussion point: Compare public health approach v. legal approach

Public health often outcome oriented. It looks for health as a value. Means to get to that point may be less important. Compare to the legal approach ? it's all about the means.
         
Variation: Religious objections from victim's family
  - Deceased airline passenger's autopsy and coroner's investigation. Family is notified and it turns out that the family has religious objection to autopsy
- Ex: Model Act? no religious exemption to forced vaccination or autopsy
         
Variation: Local and state tensions
  - Is there a tension between local and state in terms of who will be in charge?
- Ex: CA - State Emergencies Act (potential for a local emergency to be declared)
- Ex: 1905 bubonic plague outbreak in SF where Chinatown was quarantined-Create a more modern twist to relate to bioterrorism concerns
         
State v. Federal Powers
  - Governor wants everyone to leave, and federal government wants everyone to stay. What happens when the border control is called in to control the borders? How much does the leadership of the day impact response?
- Related issue: Who talks to the press? Who controls the press?
- If there is a conflict between state and federal, who can resolve it? Who wins in the emergency?
         
Disease Identified as Suspected Bioterrorist Agent
  - Who confirms the bioterrorist activity?
- What agencies get involved?
- Compare the involvement of the FBI (criminal issues) to the need to treat patients suffering from an unknown disease.
- Discussion point: What entities have a legal obligation to treat? Compare to the situation early on with reactions of physicians to treatment of HIV. Is it moral or a legal obligation to treat?
         
Surveillance
  - Epidemiological Surveillance?risk assessment
- Security related surveillance
- How do the two relate? How does criminal surveillance for building a criminal case interact with or hinder public health related surveillance for treatment?
         
Ideas for Problems
 
Have the students define bioterrorism
  - What do we see as the core elements of bioterrorism
- Introduce a fact scenario and identify whether it is bioterrorism or not

- Definition of bioterrorism
    o Model State Emergency Health Powers Act '104
  - Each of the five elements need to be explored
- Terrorism is defined different ways by different statutes
    o Public health definition versus national security definition, Patriot Act, etc.
         
An example that doesn't fit:
  - HIV positive person that tries to infect others
- Public health response is the same, but the criminal response may be different.
         
Scenario:
  - Real versus unreal cases
- Lacing illegal drugs with certain elements and delivered to specific persons in the population
- Using drugs as tools for delivering because people won't confess to using them
- If a rogue group makes it its intention to do that it would be hard to identify
- Politically? how many people care about drug addicts? However, they are going after general population through drug addicts.
         
Scenario:
  - Ways that we can genetically create pathogens that will only affect specific ethnic populations
         
Scenario:
  - Combine a real and a hypothetical situation and have the students work it out
         
Scenario:
  - Introduction of a genetically altered pathogen by a suicidal terrorist
- Would raise special liberty and authority problems