TerriHaute
Hoosier Gardener
http://www.forbes.com/sites/scottgo...rantines-will-grow-larger-and-more-troubling/
The critical reckoning over forced quarantines is still to come.
Consider this scenario.
Sometime in January or February – as the Ebola epidemic explodes out of West Africa – we’ll start experiencing larger, more frequent outbreaks in American cities. With the flu as a background to confound suspected cases of Ebola, public health departments will be hard pressed to “track and trace” all of the potential “contacts” when perhaps dozens of Ebola cases pop up in their cities.
Unable to pinpoint who might have come in close contact with Ebola, and be at risk of contracting the virus, they will reach for their most absolute tool – forced quarantine – as a way to mitigate threat amidst uncertainty. The number of people who will be placed into forced quarantines could easily number in the hundreds.
If this scenario sounds far fetched, take a closer look at the accelerating epidemic in West Africa. If the rate of spread doesn’t start to subside soon (there are some encouraging signs of deceleration in Liberia, but spread is accelerating in Guinea and Sierra Leone) it’s just a matter of time before Ebola breaks out to a region with closer connections to the U.S. — like Latin America. Once it goes to such a market, and becomes epidemic, the U.S. would be importing far more than the sporadic case.
This begs the question, how will state and federal governments exercise their authority to quarantine people in such a scenario. As we have seen from recent events, that legal power is sweeping, intrusive, poorly defined, and absolute.
Under current law, the federal government is responsible for quarantining individuals traveling from outside the U.S. or between states, while state governments have quarantine authority over people traveling within state boundaries.
Federal and state governments must have a factual basis to support a quarantine. There must be a plausible reason to believe that a person placed in quarantine was exposed to a suspect pathogen, or might be incubating the disease. But it’s left mostly up to the government to develop that basis. And it needn’t be a high bar.
The quarantine also needs to be discriminating. The government can’t quarantine an entire city, for example. But the government could quarantine an entire plane if it was believed that an airborne pathogen was released inside; or an entire classroom of children if one child might have exposed others to a virus.
The Bush Administration attempted to set out more parameters around how quarantine would be used in a public health emergency such as a bioterrorist act, by issuing a new regulation interpreting the decades-old legal authority. But in trying to spell out some general parameters, the Bush-era rule also exposed just how absolute and intrusive the underlying legal authority is. It spooked civil libertarians.
And before one begrudges the CDC the decision of putting its people in the field in Africa while we face risks at home, our eventual fate rests on what happens in West Africa. If we don’t break the virus there, it will arrive on our shores with a vengeance.
To be sure, Frieden is the Obama Administration’s spokesperson on this issue. But he has not been made their quarterback. The White House is still holding the ball, or better yet, hiding it in some kind trick play while the defense chases after Frieden.
And even now, the CDC is learning from their mistakes in a prompt fashion — not on government bureaucracy time. On private sector time, on Google GOOGL -0.14% time.
The CDC has changed the protocols for how they will treat patients. They are moving toward a strategy of creating “centers of excellence” to manage cases, so they can assert more control over the clinical parameters of how patients are cared for.
This is no easy feat. Compare the CDC’s real-time learning and situational awareness with the Food and Drug Administration.
The FDA told Bloomberg this week that it would likely require placebo-controlled trials for the testing of Ebola therapeutics, despite the urgency of expediting access to promising drugs, the well-understood lethality of the disease, and the grim fate faced by those obligated to placebo. The CDC is adjusting to match the scope of the threat. FDA is turning to its traditional toolbox.
Finally, there is the issue of leadership. And here Frieden deserves more benefit of our many doubts. If we manage to get the Ebola epidemic under control in West Africa, and stave off larger outbreaks in the U.S., a lot of the credit will go to this man. When we look back, the turning point, or at least the start of the beginning of the turning point, may well be the trip Frieden took to West Africa earlier last month.
When he returned, he had a grim report that clearly instigated the White House to begin a more robust relief effort. His dire warnings and outspoken portents were unusually frightening, and exceptional rhetoric for a public health leader to use. It was perhaps unprecedented for a CDC head in modern times.
Frieden got well in front of his boss, The President of the United States. He forced the White House to action. This is not an easy task for a subordinate leader in a political system, and seems to be an even harder task in Obama’s Washington.
Frieden is being scapegoated in the media. He might have earned some of the scorn by taking so many turns at the podium.
My hunch? A White House that didn’t want to own another evolving debacle abandoned him on the lectern and forced him to the microphone.
Lot’s of tests still remain for the CDC. When the outbreaks in the U.S. grow in scope and frequency, how will the CDC use its expansive quarantine authority, which it has failed to fully define? Out of a sense of urgency, or panic, will it implement this broad authority with no frills, trampling people’s rights? Will the CDC be able to manage a growing volume of cases with their current pool of epidemiologists? Will the CDC adapt its advice and protocols should the virus evolve its biology? And are the agency’s scientists poised to understand this evolution in time to modify their policies?
We stand at a precarious moment — with the virus accelerating it’s spread in West Africa. If that contagion continues, and grows, the virus will move to more populous nations like Nigeria, and then eventually emerging markets — where it may well become epidemic. India and Latin America are at grave risk in this circumstance.
If that happens, we will be battling here in the U.S. increasingly larger and more frequent outbreaks. We will be in this fight for a long time. Absent a drug or vaccine that can thwart Ebola, at that point the virus could literally change human history.
The stakes are that high. But the CDC is not the nexus of the problem. And so far, it has been the only agency coming up with practical solutions, and learning what it doesn’t know. They are on the ground. They are adapting to the fight. We would be better prepared if our other agencies, and our President, shared their aplomb.
The critical reckoning over forced quarantines is still to come.
Consider this scenario.
Sometime in January or February – as the Ebola epidemic explodes out of West Africa – we’ll start experiencing larger, more frequent outbreaks in American cities. With the flu as a background to confound suspected cases of Ebola, public health departments will be hard pressed to “track and trace” all of the potential “contacts” when perhaps dozens of Ebola cases pop up in their cities.
Unable to pinpoint who might have come in close contact with Ebola, and be at risk of contracting the virus, they will reach for their most absolute tool – forced quarantine – as a way to mitigate threat amidst uncertainty. The number of people who will be placed into forced quarantines could easily number in the hundreds.
If this scenario sounds far fetched, take a closer look at the accelerating epidemic in West Africa. If the rate of spread doesn’t start to subside soon (there are some encouraging signs of deceleration in Liberia, but spread is accelerating in Guinea and Sierra Leone) it’s just a matter of time before Ebola breaks out to a region with closer connections to the U.S. — like Latin America. Once it goes to such a market, and becomes epidemic, the U.S. would be importing far more than the sporadic case.
This begs the question, how will state and federal governments exercise their authority to quarantine people in such a scenario. As we have seen from recent events, that legal power is sweeping, intrusive, poorly defined, and absolute.
Under current law, the federal government is responsible for quarantining individuals traveling from outside the U.S. or between states, while state governments have quarantine authority over people traveling within state boundaries.
Federal and state governments must have a factual basis to support a quarantine. There must be a plausible reason to believe that a person placed in quarantine was exposed to a suspect pathogen, or might be incubating the disease. But it’s left mostly up to the government to develop that basis. And it needn’t be a high bar.
The quarantine also needs to be discriminating. The government can’t quarantine an entire city, for example. But the government could quarantine an entire plane if it was believed that an airborne pathogen was released inside; or an entire classroom of children if one child might have exposed others to a virus.
The Bush Administration attempted to set out more parameters around how quarantine would be used in a public health emergency such as a bioterrorist act, by issuing a new regulation interpreting the decades-old legal authority. But in trying to spell out some general parameters, the Bush-era rule also exposed just how absolute and intrusive the underlying legal authority is. It spooked civil libertarians.
And before one begrudges the CDC the decision of putting its people in the field in Africa while we face risks at home, our eventual fate rests on what happens in West Africa. If we don’t break the virus there, it will arrive on our shores with a vengeance.
To be sure, Frieden is the Obama Administration’s spokesperson on this issue. But he has not been made their quarterback. The White House is still holding the ball, or better yet, hiding it in some kind trick play while the defense chases after Frieden.
And even now, the CDC is learning from their mistakes in a prompt fashion — not on government bureaucracy time. On private sector time, on Google GOOGL -0.14% time.
The CDC has changed the protocols for how they will treat patients. They are moving toward a strategy of creating “centers of excellence” to manage cases, so they can assert more control over the clinical parameters of how patients are cared for.
This is no easy feat. Compare the CDC’s real-time learning and situational awareness with the Food and Drug Administration.
The FDA told Bloomberg this week that it would likely require placebo-controlled trials for the testing of Ebola therapeutics, despite the urgency of expediting access to promising drugs, the well-understood lethality of the disease, and the grim fate faced by those obligated to placebo. The CDC is adjusting to match the scope of the threat. FDA is turning to its traditional toolbox.
Finally, there is the issue of leadership. And here Frieden deserves more benefit of our many doubts. If we manage to get the Ebola epidemic under control in West Africa, and stave off larger outbreaks in the U.S., a lot of the credit will go to this man. When we look back, the turning point, or at least the start of the beginning of the turning point, may well be the trip Frieden took to West Africa earlier last month.
When he returned, he had a grim report that clearly instigated the White House to begin a more robust relief effort. His dire warnings and outspoken portents were unusually frightening, and exceptional rhetoric for a public health leader to use. It was perhaps unprecedented for a CDC head in modern times.
Frieden got well in front of his boss, The President of the United States. He forced the White House to action. This is not an easy task for a subordinate leader in a political system, and seems to be an even harder task in Obama’s Washington.
Frieden is being scapegoated in the media. He might have earned some of the scorn by taking so many turns at the podium.
My hunch? A White House that didn’t want to own another evolving debacle abandoned him on the lectern and forced him to the microphone.
Lot’s of tests still remain for the CDC. When the outbreaks in the U.S. grow in scope and frequency, how will the CDC use its expansive quarantine authority, which it has failed to fully define? Out of a sense of urgency, or panic, will it implement this broad authority with no frills, trampling people’s rights? Will the CDC be able to manage a growing volume of cases with their current pool of epidemiologists? Will the CDC adapt its advice and protocols should the virus evolve its biology? And are the agency’s scientists poised to understand this evolution in time to modify their policies?
We stand at a precarious moment — with the virus accelerating it’s spread in West Africa. If that contagion continues, and grows, the virus will move to more populous nations like Nigeria, and then eventually emerging markets — where it may well become epidemic. India and Latin America are at grave risk in this circumstance.
If that happens, we will be battling here in the U.S. increasingly larger and more frequent outbreaks. We will be in this fight for a long time. Absent a drug or vaccine that can thwart Ebola, at that point the virus could literally change human history.
The stakes are that high. But the CDC is not the nexus of the problem. And so far, it has been the only agency coming up with practical solutions, and learning what it doesn’t know. They are on the ground. They are adapting to the fight. We would be better prepared if our other agencies, and our President, shared their aplomb.
