>> Good morning everybody.
My name is John Anderton and I will be your host today as we go
into our TEDMED at CDC.
Gregory Sunshine oversees the Disaster
and Public Health Emergency Declaration Law project as well
as a number of other public health law research topics
on Emergency Preparedness and Response.
Prior to coming to CDC he coordinated Bioterrorism
Preparedness and Emergency Response
at the Baltimore City Health Department, including events
such as Hurricane Sandy.
Today, Gregory is going to be talking to us
on "Ebola Monitoring and Movement Protocols:
Does CDC's Opinion Even Count?"
>> Thank you.
I'm going to talk about the role that CDC plays
in our public health and legal systems.
Basically, does our opinion count?
Who has to listen to what we say?
So I want to start with a quick anecdote and many
of you might be familiar with this story.
The story of John Snow, who is credited
with being the Father of Epidemiology.
In London in the 1850s there was this severe cholera epidemic
in a certain neighborhood, and John Snow was the first person
to take a map and actually plot on that map
where each ill person lived.
And through this he was able to determine
that they likely used the same water pump,
and that's epidemiology.
Thanks to that we now know that cholera is spread
through contaminated water, and that's where the story ends
in public health schools.
But we'd like to tell people that he then continued
and actually petitioned the city council to remove the handle
from the pump, and that's public health law.
That's using government authority to take action
to better the publics health and well-being.
But unfortunately the story doesn't end there,
because once the epidemic started to subside,
people started to get better and they were frustrated
with how far they had to walk to get their water.
They actually put the handle back on the pump,
and more people got sick.
So I want you think about those three aspects
of the story throughout my presentation.
Finding the pump, taking the handle off
and keeping the handle off.
So this is an approximation
of global air travel in a 24-hour period.
Thanks to this, people and their diseases can circumnavigate the
globe in less than a day, and so any kind
of international public health issue is also a
domestic concern.
That's why, on October 10th, WHO reported
that over 4,000 people had died at that point
in the Ebola epidemic.
So the next day, CDC announced entry screening
at five U.S. airports to identify travelers
from West Africa and screened them for signs
and symptoms of Ebola.
Actually, in the first month, over 2,000 people were screened,
and they had destinations in almost all 50 states.
Since then, thousands more have been screened and monitored
for signs and symptoms of Ebola.
Now, a few weeks after screening began a healthcare worker
in New York who had served
in Guinea tested positive for Ebola.
The next day, the governors of New York
and New Jersey announced that they were implementing a policy
that required mandatory quarantine
for healthcare workers who served in West Africa.
This was on a Friday.
That Monday, CDC released interim guidance
for the monitoring and movement of persons
with potential Ebola virus exposure,
and this updated previous guidance
by establishing risk assessment categories,
monitoring requirements - like reporting your temperature
to the Health Department, and movement restrictions -
like avoiding public transportation.
Now, unlike the New York and New Jersey policies,
these did not include mandatory quarantine.
After this eventful weekend,
some states began issuing policies
that were equal to or aligned with the CDC's recommendations.
But others did not follow CDC guidance, and issued
or maintained policies that required mandatory quarantine.
And this creates a problem,
because when we have potential responders who are unsure
as to how they're going to be treated when they return,
how does that affect the response?
According to Dr. Rajiv Shah, then Administrator of USAID,
"When we saw the actions taken in New Jersey in particular,
partners immediately had to withdraw their proposals
and say instead of building two
or three Ebola treatment units, we can only do one,
because so many doctors have backed out
because understandably we don't know what the situation is
going to be like when they return."
So uncertainty hurts response.
But then who said that states could just pass their own
policies without having to follow CDC guidance?
Well, these guys.
The framers of the Constitution,
when they wrote the Constitution,
they gave specific, enumerated powers
to the federal government.
This is found in Article I, Section XIII,
and these include the power of interstate commerce,
the power to tax and spend, and the power
to provide national defense.
Now, for the states, they get everything else,
and this is because in the Bill of Rights,
specifically the 10th Amendment which states,
"The powers that are not delegated
to the United States are reserved to the States."
This is the broad power, everything we haven't given
to the federal government goes to the States.
And in this broad power we find the police power,
which is the power to take extraordinary action
to protect the public.
So to pass laws and regulations to protect the public's health,
welfare, morals and promote the common good.
And this has been supported by the Supreme Court,
that it's the state's 10th Amendment police powers
to take measures to prohibit or mandate certain actions.
And through this we get a separation of powers -
I refer to as federalism, or in more delectable terms,
a layer cake of authorities
where at the top we have the federal government
with its enumerated powers, and this includes the power to tax
and spend, so that's how we can make grants or tax exemptions
to promote certain actions. But in the middle
it's the states, they have everything else.
They have the police powers of public health control.
And in some instances,
localities can be delegated certain powers as well,
so we have the bottom layer.
Because of federalism, states can make their own policies even
with clear federal guidance.
But this creates a problem.
When you're trying to mount a national response
to an international health emergency.
So for clarity, the public health law program was asked
to create a resource that collected all these policies
and coded them to determine what each state was doing
and how they differ from CDC guidance.
So Dawn Pepin, another attorney in our office,
and I conducted a systematic collection
of each state's monitoring and movement policies.
Not every state issued an executive border
and no state passed specific laws or regulations
for returning travelers, so when I say policy, I'm referring
to official government statements
of what their intent was for returning travelers.
So this means any government statement
that we could find online.
So press releases, informational websites,
and even the health alerts if they're posted online.
We only use official government documents because we wanted
to make sure that this was exactly what the state
governments were communicating to the public.
So we didn't use any news websites
and we excluded private correspondence,
because we didn't want to rely on any information
that not everyone else could obtain.
Remember, the point of this was clarity
and to reduce any kind of confusion.
And if we were relying on a document
that was sent directly to us
but not everyone else could access,
then the whole purpose is lost.
We collected these documents through basically a lot
of Googling and we coded them as "more restrictive," "equal to,"
or "less restrictive" than CDC guidance.
More restrictive meant that states had policies
that described more burdensome reporting requirements
or more stringent movement restrictions.
So, for instance, CDC guidance from its high,
people categorized in the high-risk to leave their home
as long as they remain at least three feet away
from other individuals, don't use public transportation
and don't engage in public gatherings.
Now, if the state required someone to stay at home for
21 days and have no contact with anyone else
then that state will be categorized as more restrictive.
And this also referred to monitoring requirements as well.
So for example, CDC guidance does not require people
in the no identifiable risk category
to report their temperature to the health department
but if the state did require them
to report their temperature then that state
would be categorized as more restrictive.
Now, for states that equaled CDC guidance,
they mirrored the guidance or they issued a statement saying,
"We are following CDC recommendations."
Less restrictive are policies that are less stringent
than CDC recommendations, and this could be a situation
where a state is allowing everyone who is returning to go
to work regardless of the risk level,
when CDC guidance recommends that people in the high
or some risk categories stay home from work for 21 days.
Now, policies that are ambiguous are marked as unclear.
In the beginning this was usually a situation
where a state provided a link to the CDC guidance
but didn't say whether they were following that guidance
or just providing the link for informational purposes.
In some instances we weren't able
to find a policy at all.
Those are marked as "no policy."
And once we collected everything, we put it in this
in one stop shop table where we have the exact text
that we were relying on, and the categorization.
So people could look at this table,
and see exactly what their state was doing.
We also put it into a nice colored map
so people could see exactly what the landscape was on this issue.
This was then posted online and also sent directly
to health officers and the health department attorneys.
So how do states feel about this?
We had six states reach out and have questions
about their categorization.
We explained our protocol that we can only rely
on publicly available documents, decoding criteria,
and we showed them the exact text that we were relying on.
In all those instances,
the states either updated their language, added new documents
or we were able to use a new resource to update the
ah, language that we were relying on.
So what did we find?
In 19 states that were more restrictive, 34 that are equal,
none that are less restrictive, one territory is unclear -
and this is a situation where there is a press release
that predated the screening process
and provides general advice
that travelers should monitor their temperature.
And it wasn't clear that this is actually the policy
that the state is implementing for returning travelers. And two
territories where we have not been able to find a policy.
So does CDC's opinion count?
Yes. First, 60% of the states are following CDC guidance.
All the states are at least incorporating the direct act
of monitoring recommendations, and no states
or territories are less restrictive.
Also, when we first posted this research online back
in December we had 14 states and territories
that had no policy or they were unclear.
Now there's only three.
And last, let's look at a highly publicized case or one
of these state-monitoring policies was actually
challenged in court.
So Kaci Hickox was a healthcare worker
who served in Sierra Leone.
After she returned, she spent some time in New Jersey,
she went back to her home state of Maine.
And there the health department required her
to quarantine at home for 21 days.
She challenged this in court and forced the health department
to justify its actions to a judge.
And here's what the judge had to say.
I will paraphrase for the sake of clarity.
At this point in time, the only information that the
court has before it regarding
the dangers of infection, derives from the Director of
the Maine Health Department, together with the attachments
from the U.S. Centers for Disease Control.
And from this information, he concludes
that while Ms. Hickox must continue with directive act
of monitoring the state has not proved
that limiting her movements
to the degree requested is necessary
to protect other individuals from the dangers of infection.
According to the information presented to the court,
Hickox currently does not show any symptoms of Ebola
and is therefore not infectious.
That's a judge, considering only the science and evidence put
before him to determine the freedom of a person,
and CDC guidance plays a pivotal role
in making this decision.
So that's what counts.
CDC's presentation of good,
evidence-based scientific guidance.
When we do our jobs, courts of law listen
and our guidance becomes legally significant
because even though we have federalism
and the federal government can't mandate
or prohibit certain actions,
we can issue carefully crafted messages articulating the
science and that's how we better the public's health
and well-being.
So recall the story of John Snow from earlier.
That's what counts.
We find the pump, the states can take the handle off the pump,
and we have the vital role
in making sure the handle stays off.
Thank you.
[ Applause ]
>> I love the picture of Jonas Salk lecturing at CDC.
>> Yeah, I wanted to make sure that we had a win up there.
>> Kaci Hickox, former CDC employee and former EIS officer,
that you referred to may have had more knowledge than most
as she went up against the State.
What do you think the impact of that was in her case?
>> I think it helped.
It showed that she had a lot of knowledge
about her risk, what would put her at risk.
She was able to clearly articulate exactly what she did
when she was over in Sierra Leone
so she could clearly tell them what kind
of risk exposure she had, and I think that helped
to create a lot of legitimacy in making her case to the court
who had to consider this evidence and look at her history
in determining whether she would be a risk or not to the public.
>> Thank you.
[ Applause ]