By Adil E. Shamoo, Ph.D. (guest blogger)
Public health policy is derived from promoting public good to protect millions of people from pain and suffering; an effective policy ultimately should enhance health and happiness. The coercive powers of federal and state governments and to enforce public health policy are derived from police powers to provide safety and security to the public. The President has those powers from the plenary powers, unnamed in the constitution, but implied in those powers that protect the security of the nation. The Bill of Rights is the cornerstone that protects individual liberties against the tyranny of the coercive power of government. Here lies the tension between autonomy (self-determination/civil Liberty) and public good (safety and security). There must be strong justification to override self-determination, and in the case of contagion of a deadly disease, this must be examined.
Several parameters were raised by ethicists regarding the conditions where public health policies are needed, especially in national crises such as HIV and Ebola (Barbera et. al., 2001, Kass, 2001, Shamoo, and Moreno, 2002). In short, the conditions for the promulgation of a new policy in public health should attempt to answer the following: Is the policy needed? Is there adequate means to carry out the policy? Is the benefits/risk ratio favorable? Can we guarantee transparency? and, Are the procedures least restrictive to liberty?
Let us examine the recent Ebola case and attempt to answer the above questions and discuss those questions that are in dispute. The potential for a deadly Ebola epidemic is real and therefore there is a national crisis. There are yet no means to carry out a broad policy since scientific opinion is varied and continues to evolve. Further, the economic consequences of a wide national panic, along with the fear of stigmatizing health care workers and individuals from affected countries have led to minimal restrictions. Nevertheless, the situation is improving. We now have better guidelines from the Center for Disease Control and quarantine facilities across the country are better – but few in number. As long as the number of patients is limited, the current number of beds in the U.S. for quarantine is sufficient. The benefits/risks are favorable and need to be continuously re-evaluated. There should be transparency for how and why the policies are carried out. The process of how to deal with the epidemic is improving but it could use more centralization and transparency. Finally, are the procedures least restrictive? On this question there is no consensus.
Two groups are affected by the isolation/quarantine policy. Those in the first group are identified as having been infected by Ebola. Those in the second group are individuals who have been exposed to infected persons. There is now a consensus that those patients with the infection in the U.S. should be quarantined while in treatment and all of their healthcare providers should exercise the agreed upon latest CDC measures.
It is the second group- those who have been exposed to infected persons-that are at the epicenter of the Ebola policy debate. The controversy centers on the possible quarantine and/or isolation of symptom – free individuals who have been exposed-to or cared-for, patients with Ebola (Drazen, 2014, Gonslaves and Staley, 2014).
Moreover, the possibility of travel restrictions to and from the epidemic area is being called into question. The guidelines from Doctors Without Borders and many other organizations do not call for the isolation/quarantine for the symptom-free returnee healthcare providers. In a recent editorial in the New England Journal of Medicine, Farrar and Piot of Wellcome Trust diplomatically criticized the current inadequate actions dealing with the Ebola epidemic (Farrar and Piot, 2014). The editorial cautioned that Ebola is spreading and it could become endemic and infect others outside West Africa. The editorial states “Ebola epidemic…is in grave danger of spiraling out of control”.
The White House, CDC and many public health luminaries do not call for quarantine of healthcare providers returning from treating Ebola patients in West Africa. Government officials claim it is not necessary because it is not “science-based” and we should base our policy on science. For the same reasons just described, there are no restrictions on travel to and from the affected areas. Unfortunately, the use of “science-based” is narrowly construed in this case. The normal variables used in medicine such as those used for diagnosis, treatment, and related medical variables are being used. However, equally important variables such as education, fear, transparency, ethics, and public trust must be considered. Moreover, any factor of the epidemic could change. For example, the Ebola virus could mutate and may not behave in exactly the same way as it has in the past (Ebola is very unlikely to become air-borne – i.e. lungs as the primary site of virulent infection). For example, the life cycle of the Ebola virus in Zaire in 1976 was about 12 days while the current one is 21 days. These variables are of prime importance since they will have a large impact on the outcome of the disease epidemic. Most of us understand the role of education of the public with facts, transparency, and public trust in public health issues and many of us advocate it. Education and transparency engender public trust in the actions taken by public officials and government. Trust reduces suspicion and myths. Suspicion and myths increase fear. Fear could result in an outcry of the public that could result in draconian policies we will all come to regret. Therefore, it is scientific to deal with all of these variables in order to enhance the application and effectiveness of the public policy in question. Hard science or medical science alone is not sufficient.
An analysis of the public health practices of isolation and quarantine for the control of an outbreak of the deadly Ebola virus yields certain conclusions. It is worthy of note that the isolation/quarantine period may delay the epidemic and this will provide some time to develop drugs and vaccines.
In order to garner public trust, we must inform the public adequately and refrain from dismissing information that is inconvenient. Science-based policies do not deny the principles of social science, political science, and public policy science. In all of these fields, there is an interwoven area of ethics. Above all, science begins with philosophy and logic.
Editor’s Note: Part III will be published later this week