blog.bioethics.net

Are You Ready for the Police State?
You Better Be.

This week's Caplan & McGee is an open letter to those who think that politically palatable principles for dealing with pandemic can be written by a task force. The key to management of pandemic is not only "acting locally" but thinking locally:

The message from scientists and public health agencies the world over is clear: A pandemic of avian flu is going to circle the globe, killing millions, and in an age of air travel there will be little advance notice of its impending arrival. It is a time when Americans must believe that their health and safety is in the hands of those whom they can trust. But they don't.

The world is diverting tens of billions of dollars to every measure one can imagine to fight this nasty bug. Experimental vaccines are being rushed to production. Tamiflu and other anti-influenza drugs are being manufactured and stockpiled in overdrive.

But no matter what we do, we will not have enough vaccine or pills to protect even a quarter of the American population any time soon. Only two things can slow the spread of Avian flu, and they are the scariest things in the armamentarium of medicine: quarantine and rationing.

Quarantine was pioneered in 14th-century Venice, where ships were required to wait offshore for 40 days. During the 2003 SARS outbreak in Toronto, quarantine entered the 21st century: 45,000 people in that area were asked to remain in home quarantine for 10 days, and similar measures were ready to go across that nation.

The U.S. Centers for Disease Control says that 85 percent of those whom they polled are willing to stay home and care for themselves or their families. More than half would be willing to limit contact with others for a month or more. About half even said that they would be willing to wait months for a vaccine so that clinicians and other leaders could be vaccinated first.

But researchers have found people won't do any of this if it is called a "quarantine." That term calls to mind images of police and military enforcing what amounts to martial law to protect the well from the sick and the stigmatized.

The name isn't the only problem with public participation in preventative measures before and during a pandemic. Whether you call it, as some suggest, "community shielding" or neighborhood clustering or, for that matter, just a prolonged slumber party, the public will accept public intervention to prevent disease only if they trust the American health care system as well as their government. And they don't.

Trust requires transparency. When public officials fail to reveal in the most public way the stark truth about the plans of cities, counties and states in a pandemic, it is a prescription for panic. Anyone who has read Richard Preston's best-selling book, "The Hot Zone," or seen the movie "Outbreak" knows what could happen when troops start marching and police in gas masks begin painting the doors of those who have infected family members. A lot of people will be exceedingly unhappy to find themselves in a police state.

Citizens of a country where those in one state have "Live Free or Die" on their license plates will not take kindly to being imprisoned in their homes unless those measures have been presented as part of a comprehensive strategy that takes their sacrifice of liberty into account. They would be much more willing to stay home with their families for a month to prevent the disease's spread if they trust those deputized by the national and state agencies that implement the directives of the Centers for Disease Control and the Department of Homeland Security -- and if they are sure that they will not be left to rot while others receive better care.

For these same Americans, rationing is as terrifying as quarantine: If too few drugs, too few health care workers and terrible medical facilities plague our larger urban areas, imagine what could ensue. Cutting in line will be the least of our problems. Americans must believe that the questions about profit in the development and distribution of vaccines and anti-influenza drugs will fly out the window when the bird flu arrives.

American medical schools and medical associations must reinstill a strong sense of professionalism in medical students and health care workers or they may not be there in the face of danger. The public has taken notice that more and more physicians have refused to work weekends or nights. What makes us think that they will work 24-hour days knee deep in highly contagious patients unless they have a strong sense of professional ethics and duty?

The only answer to these challenges is to build trust. If people understand the rationale for quarantine and why some people must be vaccinated ahead of others, they are more likely to accept hard choices. Building trust means immediate public education, town meetings at which officials listen as well as talk and plans sensitive to local concerns. And it means that all health care workers, though many will arrive ready to serve, will have to be read the riot act about availability in a time of crisis.

Medical ethics has never been tested so dramatically. On the one hand, we had better have a government willing to move fast and err on the side of caution, a better public health sentinel system to prevent avian flu from spreading and a public ready to yield some liberties.

On the other hand, the policies under development are frightening and depend for success on public trust that isn't there. As a pandemic looms, billions spent on surveillance, intervention and quarantine will neither stop avian flu nor those who have it unless the public trusts those who will be kicking the military machinery of quarantine into place.