The ethical view for the scientist

In our free, democratic society, policy makers tasked with the authority to protect the public’s health must also consider the individual’s civil and political rights of liberty, privacy, association, assembly, and expression. Gostin writes that it is not improper to restrain the enjoyment of liberty, privacy, or property per se, but it is improper to do so unnecessarily, arbitrarily, inequitably, or brutally. This restraint can take place when government acts against a threat that is invalid or one that is not based on objective, reliable scientific knowledge. Protecting public health is difficult to do when an uncertain, evolving illness begins to affect individuals and there is limited acquisition of dynamic relevant information. Many illnesses appear the same early in the course of the illness, and it is not until later that the diagnosis can be affirmed. Consider such an illness affecting dozens, hundreds, or thousands of people spread over continents, with fear mounting and governments pressed into acting immediately. It would be the government’s burden to defend and rigorously evaluate the effectiveness of a public health measure adopted to contain and treat this mystery illness in real time. Certainly, a known illness for which research has identified the agent, vectors, susceptible hosts with evidence-based diagnostics, treatment, and cost to society can be addressed by an effective public health policy. The challenge to a public health agency is to reach this familiarity with a new syndrome or toxidrome in short order. The balance between the establishment and maintenance of health and the prevention or reduction of transmission of illness with subsequent inhibition or reduction of the individual’s rights should follow the doctrine of least-restrictive alternative to reduce the risk or ameliorate the harm. Legal scholars can assume this role alongside public health authorities who are not versed in the ramifications of invasiveness, the intrusion of an intervention on the individual’s rights, or the scope and selection of individuals to receive an intervention. The duration of the intervention should be proportionate to the desired effect, with ongoing review to reduce untoward effects that would limit an individual’s rights.

This relationship of individual rights and public health places policy efforts at the crossroads of justice and autonomy. The need to properly and respectfully restrain the public will likely limit individuals’ autonomy, but, at some level, it will be considered acceptable. Moreover, the policy has to do so from the outset with a carefully designed public information and education strategy and implementation with avenues to contemporaneously accept concerns put forward by scholars and citizens alike to modify actions deemed unnecessary, capricious, or onerous. Within this spectrum think of the struggle to accept the use of seatbelts and the prohibition of smoking in public areas leading to the demonstrated scientific proof of improved public health. A fair public health policy benefits those in need and burdens those who endanger the public’s health. Public health policies should not discriminate against sex, ethnicity, or other demographic factors unless scientifically proven to be accurate and, if applied evenly, will achieve the intended outcome. For example if a toxic chemical release was deemed a threat to a population, then the population must be protected, which may include mass evacuation or the order for mandatory sheltering-in-place at a moment’s notice, or the population that is proven to receive contaminated water through the public water supply may be given simple explicit instructions of water use regardless of the restrictions to daily living and the cost to residents and businesses. A means to address perceived inequalities or lack of sensitivity to individual rights is due process. This checks-and-balances opportunity of an individual to independently determine the merits of a public health intervention in a timely manner may reduce any further effects of a misapplied policy or ineffective course of action. This unbiased informed decision can fashion redress to rectify any misapplication or unintended consequences of policies. This form of process improvement will achieve more appropriate future policy and build trust in government that permits justice to be served. Unfortunately, time is of the essence when a public health agency is pressured to act against an unknown illness. Review during the course of the dynamics of the response to the threat can and should occur simultaneously to scale back any restrictions on individual rights as the science of the event is established. The uninformed public must trust government to achieve compliance with public health mandates as the event unfolds before a wary media. Focused discussions in an open forum can be used to disseminate information as a systemic management tool to make it easier for the implemented public health plans to be accepted and thus achieve the intended end. Equally important will be the attraction of unknown individuals or groups to further the policy through their involvement in the process. The common good for the public as a whole can be met by the involvement of the community of individuals. Transparency flushes facts, quells rumors, and dispels myths. Protection of an individual’s rights can be ensured if the creation of public health policy adheres to necessity of action through proportional, nondiscriminatory, and fair means.

Evacuation orders: “you may want to heed this advice for your own good”

As fate yields opportunity, the writing of the first edition of this chapter began with the author under the voluntary evacuation issued for coastal South Carolina in response to the then-impending threat of Hurricane Charley (August 13, 2004). New evacuation measures had been put into place after the infamous 1998 mandatory evacuation of the Charleston, South Carolina area, in advance of Hurricane Floyd. That evacuation distressed families in that some sat in traffic for 18 hours along a more-than-150-mile stretch of Interstate Highway 26 leading up to Columbia. At the time of Hurricane Floyd, roughly one seventh of the South Carolina population participated in the evacuation of the entire coastline, with Hurricane Hugo still fresh on most residents’ minds. The public outcry after the flawed Hurricane Floyd evacuation enabled the retrospective science of disaster medicine to produce significant changes to the entire data-gathering process that the South Carolina governor would use to declare a mandatory evacuation under state law. Exercises have proven that lane reversals, new highway construction, and strategic placement of hundreds of South Carolina law enforcement officers and department of transportation workers, in concert with computer-aided scenarios, have been successful in reducing the time of evacuation by up to 10 hours, despite a surge of migration from at-risk coastal South Carolina areas. Shortly after the Hurricane Floyd evacuation, honest assessments took place that led to the identification of additional data that can be used to make the executive decision to issue a mandatory evacuation order. An evacuation order can cost a state millions of dollars, disrupt local economies dependent on tourism, and further decrease an already waning public trust. In an effort to make an evacuation easier, the 2003-2004 South Carolina General Assembly voted to amend a 1976 law to allow the governor to order that traffic lanes be reversed so that all lanes in an evacuation area flow in one direction away from the evacuation area. The failure to heed evacuation orders by some who could leave and the ineffective plans to evacuate those who could not leave without assistance during Hurricane Katrina in 2005 had fatal consequences, leading to numerous government agencies, academicians, and other scholars to issue recommendations across the spectrum. In January 2014 as a rare ice storm approached the Atlanta metropolitan area, the lack of a timely coordinated evacuation order paralyzed highways, as schools, businesses, and governmental agencies simultaneously released their personnel to begin the trek home. Georgia Governor Deal convened the Severe Weather Task Force and implemented immediate reforms for winter storm warnings, which was prescient, producing a smoother evacuation 2 weeks later when another ice storm hit the area.

Lessons learned from Katrina, tsunamis in the Indian Ocean in 2004 and Japan in 2011, computer modeling using satellite Geospatial Information System (GIS), and other technology fueled by the climate change debate have enabled government agencies to dedicate more resources to better define the science of evacuation planning. ^, The 2012 Superstorm Sandy evacuation orders were adhered to in known evacuation zones in multiple states and cities, with success measured by decreased loss of life in most areas, particularly in the usual beachfront areas where evacuation is expected, and these residents left accordingly. Despite advance notice using many means of communication, lives were lost in areas rarely if ever confronted with evacuation orders. Emergency managers still face challenges from those who do not want to leave and are capable of leaving; those unable to leave and unable to communicate that they cannot leave; and rapidly changing storm conditions creating storm surges that exceed announced established flood zones.

An outbreak and the emergency medical treatment and labor act: patient care ensured

The key to any containment strategy is for the local government executive to issue an emergency order or proclamation, establishing a new set of operating procedures for public health authorities, the health care delivery system, and other government agencies. If an outbreak were local, the county executive or county council would issue the order or proclamation through a well-defined process. If an outbreak were to occur across counties, the governor would issue the order or proclamation. The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 permits regionalization of prehospital care to afford the best possible medical care for victims of trauma; those suffering from an acute cerebrovascular accident (CVA); and patients requiring special services such as pediatrics, obstetrics, and, increasingly, psychiatry. Under an executive order to mitigate the threat of a public health emergency (PHE), patients who meet predetermined criteria developed in a collaborative effort using the most accurate, timely, and, if possible, evidence-based determinations, can be directed to an established health care facility (e-HCF) or a newly created facility, which may be at an alternative site (a-HCF), and is staffed with the necessary personnel, equipment, and supplies to meet the need. This plan can be accomplished ahead of time in anticipation of an outbreak of known pathogens or in the early phases of a new illness pattern detected through the triggers of syndromic surveillance. To assure that civil liberties are respected, without alarming the affected population, the lead government agency has to incorporate transparency through effective public communication using all available means that may include print, radio, television, and social media. Timeliness and accuracy is the best course to take to effect positive outcomes, especially early in the PHE, with invitation by key community leaders and learned citizens to join the process accordingly to accomplish the all-important public acceptance and participation. This will require more government staff to process solicited and unsolicited volunteers, vetting credentials for appropriate deployments. Governments have to factor-in worker fatigue and workers who become ill, as well as worker families who become ill, in the creation of all aspects of the PHE response.

Patients who enter the health care system after a telephone call to 911 (or other phone number) for emergency medical transport may be evaluated by an emergency medical technician (EMT) when the ambulance arrives. Currently, certain systems will permit an EMT-paramedic (EMT-P) evaluation for appropriateness of transport via emergency medical services (EMS). This evaluation is based on strict criteria developed by off-line medical direction that is approved by county officials with appropriate documentation and, more importantly, communication between the EMT crew, online medical control, and subsequent review of each call. In a PHE, the most practical extension of this on-scene or field triage process, the PHE field evaluation team (FET), is for an EMS crew with an EMT-P, a registered nurse (RN), or a midlevel provider (physician assistant or nurse practitioner) to perform an evaluation of the patient for preset criteria. These criteria can be determined de novo, as the PHE evolves by the assembled collaborative team process or from prior known, reviewed, and learned outbreak responses. This process must include appropriate education about the outbreak; issuance of equipment, supplies, and personal protective equipment (PPE) to the first responders; and a screening process to exclude responders who may be more susceptible or less-than-adequate, placing them more at risk. The patient will enter the PHE evaluation and treatment process, and anyone else at the field evaluation site must be considered a contact person and enter the PHE evaluation process. The field evaluation site must be assessed for epidemiologic concerns and adjudicated accordingly. The dispatch of the FET can be accomplished through use of priority medical dispatch or a similar 911 operating system. In a PHE, a person who calls the 911 system (or another telephone number for ambulance service for those regions not yet using 911) will undergo caller interrogation specific for the symptoms and any other information that can be learned. The caller will then be given instructions on first aid for laypersons or the establishment of containment strategies pending arrival of the FET. Priority medical dispatch or a similar system can then send the FET to the scene to perform the evaluation, separate from the usual standard EMS. As of May 15, 2014, major wireless service providers in the United States will make text-to-911 widely available. Even though the Federal Communications Commission (FCC) still recommends a voice call over a text, this method of communication will provide 911 access to people who cannot verbally communicate due to handicap or other situation, further expanding communication with potential patients affected by the contagion.

If this evaluation determines that the patient is a potential victim of a PHE, the EMS crew can transport the patient to an e-HCF or a-HCF established to evaluate and treat the presenting symptom complex. If the patient is in distress, he or she will be attended to as per standard operating procedures and then transported to the appropriate HCF. The EMS crew will be told what containment strategies and procedures the designated HCF has undertaken for the patient. During the executive-declared PHE, the destination HCF may not be a standard HCF, such as the closest hospital, but it may be a “fever hospital” or an HCF specifically created for the PHE at an alternative site. This location will have health care workers (HCWs) who are trained, equipped, supplied, and clothed in appropriate PPE. It may be on the grounds of the closest hospital, public health clinic, or in another building in the community, with appropriate air exchanges, water, heating and air conditioning, food preparation, restrooms, and showers to contain the PHE, thus allowing other hospitals and HCFs to attend to their usual patient loads without an influx of PHE patients. In a short period, such an alternative HCF can be fully operational with prepositioned stores and vendor agreements.

Guidelines can be created, extensively reviewed from the go-forward plan, and adapted as the outbreak proceeds. If a patient meets predetermined criteria, then treatment will continue until the patient is either discharged home, perhaps with home health care or other monitoring using available communication assets, or transferred to another HCF for long-term care or containment. If the patient does not meet criteria he may receive initial care at that location and then be transported to an acute-care HCF (hospital, clinic, or physician office) for further treatment and discharge. The vehicle used to transport the patient and the accompanying personnel will have to undergo containment strategies from the initial PHE HCF to the next location. EMTALA requires that the dedicated emergency department (ED) of an HCF perform a medical screening examination (MSE) for patients who present asking for a medical evaluation or when the MSE is requested by another person. Patients who self-refer to the ED during a government-executive-declared PHE could receive an MSE by the hospital designated RN or midlevel provider clothed in appropriate PPE. This HCW can be screened to ensure that he or she is fit for the assignment, vaccinated accordingly, and knowledgeable of the threat at hand. The patient will receive an MSE and be stabilized at the initial HCF, accepted by the physician at the PHE HCF, and transferred with the appropriate EMTALA documentation with containment strategies observed. At the HCFs, containment strategies should include training of all employees to the specific presenting symptoms and signs of the PHE, use of PPE for those who routinely meet and greet people at their work stations, and limitations on entrance locations to the public. HCF-designated HCWs positioned to act as screeners can direct people entering the HCF to a receiving area for a more rigorous evaluation, separate from the ED, if they are coming to the HCF as a visitor or to conduct other business. More importantly, if a patient seeking medical attention enters the HCF though any entrance, containment strategies can commence accordingly. Signage specific for the PHE can direct patients presenting to the HCF for evaluation to containment areas designed for this initial evaluation.

It is plausible for specially trained HCWs, in tandem with personnel from law enforcement, public safety, department of transportation, or another like agency, to assist in the sorting of patients that self-refer to the HCF at roads removed from the entrance of the HCF.

To reduce drunk driving for the public good, law enforcement personnel currently set up road blocks, at which they check driver’s licenses, registration, and insurance cards. They also screen for impaired drivers and passengers or vehicles suspected of being involved in illegal activities. An executive PHE can extend certain powers to law enforcement to assist the public health effort to contain the illness. Queues of traffic at locations safely established en route to a hospital can act as a checkpoint for screening, as previously noted, with direction of patients to the PHE HCF or their usual HCF containment area for an MSE. The vehicle and person(s) in the vehicle will undergo the epidemiologic evaluation and containment process. If the PHE HCW screening determines that a person fits the PHE symptom complex, the PHE FET can be deployed to conduct further evaluation and transport. The vehicle that carried the patient(s) will then have to be isolated, evaluated for contamination, and decontaminated accordingly.