Gene W. Matthews

Assessing Laws and Legal Authorities for Public Health Emergency Legal Preparedness

23 Introduction Public health legal preparedness begins with effective legal authorities, and law provides a key foundation for public health practice in the United States. Laws not only create public health agencies and fund them, but also authorize and impose duties upon government to protect the public’s health while preserving individual liberties.1 As a result, law is an essential tool in public health practice2 and is one element of public health infrastructure, as it defines the systems and relationships within which public health practitioners operate.3 For purposes of this paper, law can be defined as a rule of conduct derived from federal or state constitutions, statutes, local laws, judicial opinions, administrative rules and regulations, international codes, or other pronouncements by entities authorized to prescribe conduct in a legally binding manner. Public health legal preparedness, a subset of public health preparedness,4 is defined as attainment of legal benchmarks within a public health system.5 Law is one of four core elements of public health legal preparedness (the remaining three – competencies, information, and coordination – are each the subject of individual papers that follow). In this paper we briefly describe the evolution and status of essential legal authorities for public health preparedness. Our review focused on three specific preparedness initiatives – health care system surge capacity, the Pandemic and All-Hazards Preparedness Act, and implementation of the International Health Regulations. These issues do not represent the entire range of legal preparedness nor the only relevant perspectives. The limited scope of this paper prevents a comprehensive treatment of these and other issues we considered. Rather, we chose these three initiatives because they exemplify the span of public health legal preparedness from the state and local, federal, and international perspectives. After a brief overview of these initiatives, we describe several themes that emerged during our review. First, the series of events from September 11, 2001 and the anthrax attacks later that year to Hurricane Katrina in 2005 prompted a flurry of legislative and regulatory activities that sought to provide new authorities6 at every level, modernize public health law,7 and reorganize Federal preparedness and response functions.8 Collectively, these legal reforms sought to improve the legal frameworks for the attainment of public health preparedness. Reviewing this legal landscape raises

Legal frameworks supporting public health department accreditation: lessons learned from 10 states.

CONTEXT The existence of different types of accreditation legal frameworks, embedded in complex and varying state legal infrastructures and political environments, raises important legal implications for the national voluntary accreditation program. OBJECTIVE To increase an understanding of accreditation-enabling laws nationwide. DESIGN In 2010 to 2011, the North Carolina Institute for Public Health conducted a study of state legal frameworks supporting public health department accreditation or related programs (ie, certification/assessment, performance management, and quality improvement). First, a mapping study was conducted to identify current programs and their legal frameworks. Ten states were then selected for in-depth qualitative case study. Data were gathered through semistructured interviews with public health practitioners and key stakeholders. RESULTS The findings from the mapping study delineate the accreditation, certification/assessment, performance management, or quality improvement program currently in place and the type of legal framework supporting it. The citations for statutes and regulations are also included. Among the 18 states in the sample, 4 have accreditation programs, 6 have certification/assessment programs, and 8 have performance management/quality improvement programs. Accreditation programs were most likely to have a statutory basis, while performance management and quality improvement programs were most often supported via health department policy. The findings from the case study provide greater detail about each state, reflecting public health structures, programs, legal frameworks, approaches to Public Health Accreditation Board (PHAB) accreditation, and legal strategies for achieving accreditation. CONCLUSIONS Early adopter states have pursued a variety of legal frameworks to develop their accreditation, certification/assessment, performance management, and quality improvement programs. With the voluntary national accreditation program scheduled to go live in late 2011, these 10 states have also carefully considered options for aligning their activities with PHAB accreditation. Lessons derived from this examination can inform public health practitioners, advocates, and elected officials about how to best structure legal frameworks to support accreditation and related activities.

Crafting richer public health messages for a turbulent political environment

Public health leaders are now probing to find better ways to convey our messages in this turbulent political environment. In a prior Management Moment column, we introduced the idea of using some of the framing concepts of Moral Foundations Theory (MFT) to craft richer stories for public health leaders to appeal to broader audiences. In this article, we return to this topic in light of recent events and in the hope that we might enhance our ability to focus our attention to the needs of those communities in despair that are feeling left behind by economic stagnation and a government that seeks to serve them.

Better health faster: The 5 essential public health law services

Successful public health campaigns like tobacco control demonstrate that effective legal interventions can be expeditiously developed, evaluated and diffused, even in the face of powerful opposition. Success for legal health interventions depends on a well-designed and nurtured legal infrastructure that assured the timely delivery of public health law services that are essential to successful policy innovation that improves health. We describe Five Essential Public Health Law Services and suggest investment in the people, methods and tools needed to move major policy initiatives from conception to widespread implementation. The model reflects a transdisciplinary approach integrating public health legal practice with law-related surveillance, evaluation and enforcement functions usually performed by public health practitioners. As an elaboration of law-related activities within the Ten Essential Public Health Services, the framework can be used to define, evaluate and strengthen public health law functions. The framework presented defines the components of a strategic investment that can turn evidence and expertise into better health, faster.

Health Care System Transformation and Integration: A Call to Action for Public Health:

Restructured health care reimbursement systems and new requirements for nonprofit hospitals are transforming the U.S. health system, creating opportunities for enhanced integration of public health and health care goals. This article explores the role of public health practitioners and lawyers in this moment of transformation. We argue that the population perspective and structural strategies that characterize public health can add value to the health care system but could get lost in translation as changes to tax requirements and payment systems are rapidly implemented. We urge public health leaders to take a more active role in hospital assessments of community health needs and evaluation of the patient outcomes for which providers are accountable.

The Public Health Law Year in Review: Sponsored by the Public Health Law Association

Rick D. Hogan It is expected that development of a vaccine specific to a new strain of influenza with pandemic potential could take as long as five to six months from the time the precise strain is confirmed in the laboratory. This manufacturing lag time heightens the potential role of isolation and quarantine. Many state laws have been amended this year to update provisions concerning isolation and quarantine. Minnesota, Illinois, New Jersey, and Indiana all have new laws modernizing isolation and quarantine restrictions. The newly amended Minnesota law illustrates two important aspects of isolation and quarantine. One very important provision concerns the potential use of force. Public health lawyers field frequent questions from law enforcement, since they are a vital partner with respect to planning and implementation for pandemic influenza preparedness. Minnesota has joined California and Hawaii in defining force which may be used with respect to enforcing quarantine and isolation laws. The second aspect of the Minnesota law concerns mobilization of assets or resources to administer vaccines or anti-viral drugs. Of course, in planning, you have to consider that vaccines, anti-viral agents, and antibiotics are all necessary to treat secondary infections. Additionally, it is well known that medical supplies will be in short supply. Therefore, many of the states have looked at and reevaluated the Emergency Management Assistance Compact (EMAC). The EMAC will make it even more important to identify volunteers and others since there will be a depletion of volunteers and public health resources and workers. Looking back at the EMAC, it will certainly be critical to assess and access all public health resources. Also in addition to vaccines, the concern for stockpiling antiviral drugs is important because it is estimated that it will take at least five to six months before a vaccine can be developed. Also, it will be necessary to treat first responders and vitally important actors as quickly as possible with anti-viral drugs. Anti-viral drugs are distributed based on the population. Some states like Arkansas decided to adopt statutes which allow for the purchase of anti-viral medication. With any massive planning preparation for a disaster, such as pandemic flu, we all have to watch where we step. The lessons learned from SARS regarding good public health practices such as isolation and quarantine may not necessarily be effective to battle a flu pandemic. More of a population approach may be required, such as cancellation of events which bring together mass gatherings. I’m sure many of you have read the very thick book, the National Strategy for Pandemic Influenza. The strategy’s three pillars are: preparedness and communication; surveillance and detection; and response and containment. One very important aspect of the strategy concerns defining the roles and responsibilities of the federal, state, local and private actors. Also important in the Health and Human Services Pandemic Influenza Plan is the legal preparedness checklist. The checklist provides for forming a coordinating committee which is charged first with reviewing state statutory provisions to look specifically for laws and procedures for closing businesses or schools and for suspending public meetings. Second, the committee would review medical volunteer licensure liability and compensation laws in each state. Third, the committee would review quarantine laws and how they apply in a public health emergency. Fourth, the The Public Health Law Year in Review Sponsored by the Public Health Law Association

Globalization, Public Health, and International Law

There is an effort underway to build an international network for public health law in Asia. Public health law in Asia is a relatively new field and is developing at a rapid pace, given the recent experiences of managing international infectious diseases such as SARS and the avian flu. The establishment of a comprehensive public health law network could help to influence each nation in Asia to comply with global governance of public health issues. It could contribute to the creation of public health infrastructures which would help to maintain the health of Asia’s population, and in turn, the health of the international community. The World Health Organization (WHO) is currently in the process of reforming the long-standing International Health Regulations (IHR). When first established, the IHR were proposed as a means of providing “maximum protection” by “minimum restriction ...[ of] ... trade” and were primarily designed for the management of cholera, plague, and yellow fever. As the world community is faced with newlyemerging infectious diseases since that time, such as Ebola and AIDS, there is a newfound need for revising the regulations. As it stands today, host countries cannot be held to the regulations’ enforcement standards for outbreak alerts, dissemination of information, and disease management protocols. Political and economic disparities also contribute to the inconsistent and ineffective application of enforcement measures with daunting consequences. A revised version of the IHR can be adapted to take into account the desirability, feasibility, and clarity of health standards for all member states, particularly those dealing with newly-emerging public health concerns and disease outbreaks. Hence, it is imperative that the Pan-Asian region takes an active role in the revision of the IHR, given the key measures which defined the nature of the recent SARS outbreak and a lack of open communication networks from which to bring a swift and effective response. The new IHR can also take into account newlyrecognized individual human rights. It can specify individual entitlements, set science-based standards and fair protocols for public health enforcement measures, and require states to take measures to prevent public stigma and discrimination against diseased individuals. An international network of public health professionals can assist in the determination of these standards. An international public health system can help achieve both transparency and effective surveillance and response without creating a volatile atmosphere of rumor and inaccuracy, which risk both national security and individual liberties. The revision of the IHR is just one step in creating a model WHO that can provide significant technical and financial support for effective public health action.