1. Law as the Basis of Public Health Action Frederic E. Shaw, MD, JD Richard A. Goodman, MD, JD Public Health Law Program, PHPPO Centers for Disease Control and Prevention Atlanta, Georgia "The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

2. Law: The Basics

3. What is the Law? The rules/commands by which we must live Administered by force Defined by: –Rights accorded you as a member of a society. –Duties imposed on you as a condition of living in a society. The concept of justice

4. What is Public Health? What we, as a society, do collectively to assure the conditions for people to be healthy. IOM, 1988

5. What is Public Health Law? The discipline by which the state or other actors use law to change the health of a population, including –The study of the powers and duties of the state or other actors to assure the health of a population, –The limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals in order to assure the health of a population, and –The limitations on the duties of the state to assure the health of a population

6. Eight Types of U.S. Legal Authority U.S. Constitution Treaties Federal statutes Federal regulations State constitutions State statutes State regulations Local authority The common law Higher Lower

7. Judges Make Law, Too Judge decides case and interprets what the legislature meant by the statute Legislature acts; president/governor approves A party is aggrieved by the statute Party files suit in court Other judges are bound to follow interpretation (stare decisis)

8. Core Concepts

9. The U.S. Constitution Drafted 1787 Took effect 1788 Supreme law of the land Limited powers The doctrine of enumerated powers

10. Federalism United States: Not a national government, but a federal government The States: –sovereign, independent governments in themselves –retain all powers not expressly delegated to the U.S. Beauty of federalism –In the tension between state and federal power lies the promise of liberty Gregory v. Ashcroft, 1991 –The states as laboratories for experimentation –Assures decentralized government

11. The Tenth Amendment (1791) The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.

12. The Police Power Natural inherent authority of the sovereign to regulate private interests for the public good Retained by the States, not ceded to the federal government Includes wide powers to: –Restrict a persons personal liberty –Restrict a persons ability to work –Seize property without compensation

13. Examples of the States Police Power Require a child to be vaccinated as a condition of attending school Involuntarily detain a person who has a communicable disease Search, seize, and destroy property in order to control disease spread, sometimes without compensation Throw up a cordon sanitaire around a city to prevent disease spread

14. Regulations Laws created by the executive branch of government Must be based on delegation of authority from legislature Have the full force of law Must be created through a statutory process Must not violate due process (notice, hearing) Violations and punishments are usually civil and can be appealed to judges

15. Example of a Regulatory Delegation: 42 U.S.C. § 264 (1944) The Surgeon General, with the approval of the Administrator [Secretary], is authorized to make and enforce such regulations as in his judgment are necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession.

16. Example of a Regulation: 42 C.F.R. § 70.2 (Aug 16, 2000) Whenever the Director of the Centers for Disease Control and Prevention determines that the measures taken by health authorities of any State or possession (including political subdivisions thereof) are insufficient to prevent the spread of any of the communicable diseases from such State or possession to any other State or possession, he/she may take such measures to prevent such spread of the diseases as he/she deems reasonably necessary, including inspection, fumigation, disinfection, sanitation, pest extermination, and destruction of animals or articles believed to be sources of infection.

17. Balancing the Rights of Individuals With the Needs of the Community

18. Constitutional Rights of Individuals Amendments 1-10 (called the Bill of Rights) ratified in 1791 Others rights added 1795- Most relevant to public health: –1 st (1791)Freedom of religion and speech –4 th (1791) Unreasonable search and seizure –5 th (1791) Due process (federal); takings –14 th (1868) Due process; equal protection

19. The 1st Amendment: Freedom of Religion and Speech Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press …

20. The 4 th Amendment: Unreasonable Search and Seizure The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated ….

21. 4 th Amendment Impact on Public Health Action Public Health Inspections –Governed by the 4 th Am. –Unreasonable presumptively if conducted without a warrant Medical Testing –Collection and analysis of biological specimens from a person is a search –To determine if reasonable, courts balance public health need against privacy –In general, courts accept governments assertions of need

22. The 14 th Amendment: Due Process of Law … nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.

23. Due Process of Law Procedural due process –What process is due? (notice, opportunity to be heard, counsel, right to call witnesses, right to review by a judge) Substantive due process - protection against interference with liberty –Example: The right to privacy

24. The Right to Privacy Supreme Court has struck down state laws on privacy grounds: –Prohibiting teaching of foreign languages at home (Meyer, 1923) –Requiring children to attend only public schools (Pierce, 1925) –Compulsory sterilization (Skinner, 1942) –Prohibiting the use of birth control (Griswold, 1965) –Regulating abortion in first trimester (Roe, 1973)

25. Equal Protection The concept that similarly situated persons should be treated similarly by the government Government may discriminate between groups of people, but must have a reason Example: Quarantining nonvoters but not voters in an epidemic area –Courts would examine using strict scrutiny

26. JACOBSON v. MASSACHUSETTS SUPREME COURT OF THE UNITED STATES 197 U.S. 11; 25 S. Ct. 358; 49 L. Ed. 643; 1905 U.S. LEXIS 1232 Argued December 6, 1904 February 20, 1905

27. Jacobson: Key Holdings Police power upheld No absolute right to be wholly free from restraint. Restraints necessary for the common good Deference for legislature Courts approval of public health intervention depended on: –Public health necessity –Reasonable means –Proportionality –Harm avoidance

28. The Legal Basis of Public Health Action in Emergencies

29. Smallpox, Boston 1901

30. Sources of Authority for Emergency Control of Disease Federal –Commerce Clause The Congress shall have power … To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes; Art 1, Sec 8. –Tax and spend power –Federal statutes State –Police powers –State statutes

31. Bioterrorism Most legal authorities needed already exist Five instructive events –Anthrax – need for joint training and cooperation between public health and law enforcement –West Nile Fever – law around chemical abatement –Smallpox vaccine – liability and compensation –SARS – quarantine and isolation –Monkeypox – integration of federal and state agency efforts

32. Bioterrorism Legal Issues Collection of records and data: disease reporting, surveillance, and privacy Control of property Management of persons: quarantine, detention, and isolation Legal immunity Access to communications

33. Example of a State Statute California Government Code Section 101040. The county health officer may take any preventive measure that may be necessary to protect and preserve the public health from any public health hazard during any state of war emergency, state of emergency, or local emergency, as defined by Section 8558 of the Government Code, within his or her jurisdiction.

34. Example of a State Statute California Government Code Section 100170. The department may commence and maintain all proper and necessary actions and proceedings for any or all of the following purposes: –(a) To enforce its regulations. –(b) To enjoin and abate nuisances dangerous to health. –(c) To compel the performance of any act specifically enjoined upon any person, officer, or board, by any law of this state relating to the public health. –(d) To protect and preserve the public health.

35. Draft Model Emergency Health Powers Act Commissioned by CDC after 9/11 Current public health laws too antiquated and inadequate to ensure a strong emergency response? A tool for states to use in assessing adequacy of relevant public health laws

36. New Pressures, New Partners: CDC Forensic Epidemiology Training Course Course Scope –Concurrent criminal and epidemiological investigation Background –Issues identified during Fall 2001 (e.g., similarities / differences in investigative methods and operational implications).

37. Public Health and Law Enforcement Goals Compared Law Enforcement: Stop further crimes Protect health and safety of public Apprehend and convict criminals Public Health: Stop further cases of disease and outbreaks Protect health and safety of public Build science base for future prevention

38. Public Health and Law Enforcement Investigations Compared CharacteristicsPublic HealthLaw Enforcement Event RecognitionSurveillance or call from clinicianAnnounced by attacker or is evident Challenges to RecognitionFew syndromes are clearly the result of BT; difficulty distinguishing natural from BT origin Large number of hoaxes and non- credible threats; delays in notification by PH; copycat threats Initial Data CollectionHypothesis generation; shoe leather epidemiology and comparative studies Hypothesis generation; questioning of witnesses and suspects; follow-up of tips Confirmatory Data Collection and Analysis Controlled by comparative epi studies; limited by scientific rules of causation Controlled by circumstantial and lab evidence, witnesses, confessions; limited by Constitution and rules of evidence Validation of ConclusionsEffect on disease control; acceptance by scientific peer reviewers Acceptance by judges, grand and petit juries GoalDisease prevention and controlConviction of criminals; prevention and deterrence Adapted from Butler, et al., 2002

39. Law as a Public Health Tool

40. Ten Great Public Health Achievements, United States, 1900-1999 Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard

41. Example: Control of Hepatitis B

42. http://www.phppo.cdc.gov/od/phlp/