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A Health System Primed to Fail

Commentary and Analysis | BIOTERRORISM

November 04, 2001|M. GREGG BLOCHE and LAWRENCE O. GOSTIN | M. Gregg Bloche and Lawrence O. Gostin teach health law and policy at Georgetown and Johns Hopkins Universities, and they co-direct the two schools' joint program in law and public health

Although sexually transmitted diseases, tuberculosis and other infectious illnesses by no means disappeared and continued to disproportionately afflict the nation's poor, many in the middle and upper classes believed mankind's age-old struggle against contagion had ended in triumph. In 1969, the U.S. surgeon general told Congress as much, concluding that the nation could "close the books on infectious diseases."

No longer frightened by contagion, middle-class Americans increasingly saw health as a private matter, looking to high-tech medicine for the next great advances. Federal spending on medical research surged as state and local public-health spending ebbed.

As the perceived need for robust public-health measures diminished, concern about violation of personal autonomy in the health sphere soared. Revelations of Nazi medical atrocities and reports that American clinical researchers exposed unknowing people to radiation and other life-endangering hazards inspired a large shift in medical ethics, toward patient autonomy as the central principle. The civil rights revolution of the 1960s and 1970s quickened this transformation.

Then came the AIDS epidemic in the 1980s and 1990s. AIDS activists battled successfully for public-policy responses that intruded minimally on personal autonomy and privacy. The AIDS paradigm for coping with a public health crisis treated government as more of a threat than a solution. This civil-libertarian response to AIDS was of a piece with the individualism and the cult of the entrepreneur that have flourished in American culture for the past 20 years.

So, what remains in the public health sphere is a profoundly flawed system, chronically starved of funds, without political support and founded on antiquated laws. These laws actually thwart decisive public-health action. They prohibit data-sharing between public health, law enforcement and emergency management agencies; and they do not provide adequate powers for controlling property and persons in the event of bioterrorism.

In an era of intercontinental travel, the U.S. is vulnerable to epidemics of potentially massive proportion. Think about the resurgence of multidrug-resistant tuberculosis, AIDS and the West Nile Virus. Or think about the prospect of natural or intentional spread of smallpox or Ebola, both highly contagious and untreatable. These naturally occurring and terrorist-created threats could produce mass civilian casualties, straining the public health system far beyond the current anthrax threat.

There is an urgent need for new federal and state laws to mobilize the needed resources and to permit, indeed require, information-sharing and other cooperation among public health, law enforcement and emergency-management agencies. Our medical technology--powerful antibiotics, vaccines and the science base necessary to develop myriad new biological security measures--is sufficient to cope with the threats we face. The challenge ahead is a matter of organization and resources--and willingness to see the virtues of personal autonomy against the larger backdrop of the common good.

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