SESSION 5:  Legal, Surveillance, and Response Aspects of Public Health Preparedness

Discussion chair: Lawrence O. Gostin (Johns Hopkins & Georgetown Universities)
Reporter:  Patrick Kelley (IOM)
Participants: Approximately 12 persons including the above, Jim Curran, Peggy Hamburg, Roger McClellan, and 6 or 7 IOM staff and other members

Synopsis:  The discussion began with a brief enumeration by Patrick Kelley, Kathleen Stratton, and Jim Curran of recent IOM reports that address aspects of public health preparedness. 

Out of this discussion came a consensus that there is a problem with the legal authority for assurance that an appropriate public health network is in place.  The concept of “authority” in this context was clarified as encompassing a capability to assure that adequate surveillance and response capability was present nationally.  This would include trained people, labs, and an authority structure.

The “authority problem” was graphically illustrated by noting that infectious disease reporting is at the pleasure of the states.  The question was posted as to whether infectious disease control is a national issue just as crime is and whether there should there be a national authority to fight infectious disease comparable to the national crime fighting authority embodied in the FBI? 

It was noted that the Constitution treats public health as primarily an autonomous state function and as such, input from above is largely in the form of guidance.  In the current era this is starting to not make sense, and it is associated with too much fragmentation and inefficiencies of scale.  There is a need for a mechanism to ensure accountability at all levels: local, state, and national. 

It was suggested that the IOM could play a role in developing federally assured standards for public health preparedness.  These would depend on assured funding and consistency.  These national standards could help foster accountability at all levels. 

The problem of one-year bioterrorism funding was highlighted as not being suitable to yield a sustainable solution to preparedness.  Current preparedness indicators are not sensitive to the criticality of relationships between agencies at different levels.  The state of state health commissioner posts was characterized as being filled in only about 25-30% of cases with outstanding individuals.  The remaining positions were described as either being vacant or having more politically than technically qualified incumbents.

The question was raised of how one might develop a constitutional federal mechanism to foster accountability and/or control over spending power, that is, how states use federal dollars.  It was suggested that public health reporting could be tied to a financial incentive. 

One participant claimed that the multiplicity of state and local structures often gets in the way of public health work and that larger scale regional approaches to surveillance, the delivery of laboratory services, etc., would be desirable.  Newborn screening was offered as an example of good larger scale regionalization.

Some discussion took place around quarantine as an issue encompassing legal issues, surveillance, and response in the public health readiness context.  The IOM's potential role in illuminating this issue, especially in the aftermath of SARS, was covered. Developing a common parlance relevant to quarantine and quarantine modeling was seen as a potentially useful contribution.

The discussion again returned to issues of accountability in public health and the desirability of developing a mechanism to accredit or otherwise ensure that public health officers were qualified.  The IOM was seen as having a potential role in advancing the idea of accreditation for public health agencies just as hospitals, residencies, and academic institutions are accredited.

The group summarized its thoughts on legal aspects of surveillance and response by listing several potential contributions of the IOM:

>Advancing the establishment of public health standards of practice through identifying how budgetary influence, accountability, and accreditation can play a role.

>Fostering relationships across levels of the public health hierarchy.

>Examining issues of quarantine, especially modeling, ethics, and international law.

>Illuminating the role of the Department of Homeland Security in public health.