Originally posted in MedPage Today
She is 11, a fifth grader, as prepubescent as nature allows, and utterly terrified.
She hasn’t eaten normally for nearly a month, her mother reports. She sleeps poorly, reports nightmares, and cleans her hands so obsessively that she is literally bleeding raw.
Her fifth grade peer group typically does not guard its language nor govern its remarks, so every utterance is attention-demanding, black-and-white, dripping with drama. And she hears the constant drumbeat reporting of wave upon wave of flu anecdotes, of vaccine and medication shortages, of absenteeism, hospitalizations, death . . . even more than the history lesson, more than the math, more than the reading.
School had become nightmarish enough with the onset of puberty, but all this tension has quite collapsed any sense of security. Even mom acts afraid.
And this tension is reinforced by the endless health warnings delivered by faculty, administration, and media. She must learn a new way to cough, into her sleeve they say, but her school uniform is short-sleeved; and she has to use Purell® but her eczema is on fire from the alcohol. And now with a sore throat and her fear that a cold will kill her, she and her mother finally seek medical attention, convinced that the worst is soon and inevitable.
What is the impact on children and families when every 15 minutes there is an “update” on the latest H1N1 news? The Health Department serves up statistics and guidelines to professionals with incredible frequency these days: hospitalization plus morbidity/mortality rates, availability of medication, utilization of medication, changes in vaccine availability and guidelines for use and/or delivery plus demographics as to who is to be vaccinated and who isn’t.
All this interspersed with items reporting U.S. vaccine production shortfalls, then vaccine distribution plans through commercial, big-chain pharmacies and supermarkets but not physician offices, or to special groups on Wall Street or at Guantanamo.
It is all bewildering enough to the professional. What must this be like for the patient, for the child told they are at greatest risk, or the pregnant woman, or the elderly who are advised that they “don’t need it”?
Let’s examine crisis management now that a “Declaration of H1N1 National Health Emergency” has been evoked, especially since we clearly have an inadequate supply of vaccine, an appearance of inequitable distribution of those limited supplies, and, perhaps, inadequate or unavailable supplies of antiviral medications.
A recent New England Journal of Medicine article addresses mandatory vaccination of healthcare workers in N.Y. State (Nov. 6, 2009). “Mandatory vaccination of healthcare workers raises important questions about the limits of a state’s power to compel individuals to engage in activities in order to protect the public.”
Workers in N.Y. assert that compulsory vaccination violates the 14th amendment (deprivation of liberty without due process), but a 1905 case about mandatory smallpox vaccination (Jacobson v Massachusetts) established the government’s (Health Department’s) authority to impose restrictions on private rights for the sake of public welfare.
Such measures include immunization requirements for school entry and continued attendance, quarantining (PC note: now called “sheltering-in-place”), restrictions on access and travel, authorized healthcare personnel selection, seizure and/or destruction of property, and so on. The law includes criminal penalties for those who refuse.
In effect, the law allows, once an emergency is declared, that the Public Health Authority can compel treatment (vaccination as well as anything else deemed necessary and appropriate), enforce travel restrictions (say, to a school or hospital declared contaminated and thus part of a containment zone), commandeer, ration, and control water, food and medication supplies, and use medical and/or public facilities as deemed necessary for the management of the health crisis.
Under the U.S. Constitution, state and local governments have the primary responsibility and legal authority for public health. Also part of their mission and duties is the repetitious cycle of public information, believed by the Public Health community to reinforce the notion that its comportment is “for the public good” and to achieve its mission.
The notion that we are in full crisis mode is recognizable, especially when school children are as much victimized by the virus as the constant alarms being rung.
It is interesting to note that the Australians and New Zealanders who are now looking backwards at their flu season, have published data that suggests that their recent season was far less severe than originally feared. Lots of folks down under heard the warning and got vaccinated. Interestingly, the Canadians are not vaccinating for H1N1 but rather emphasizing the “regular” flu vaccine; and the Mexican events are much less turbulent now than before. And note that any separate pandemic novel A(H1N1) vaccination programs in the European Union (Great Britain, France, Germany, plus Sweden, Belgium and Denmark) have not even made the news cycle.
While the numbers affected look significant, the results seem manageable. Perhaps we can tone down the sky-is-falling just a bit? And besides, most Americans are aware and pursuing the advice of their physicians. We get it.
Our 11-year-old will need counseling, but she will be all right. What may not survive, however, is the trust that we have placed in Public Health Programs that are based on force and coercion and are relics of the 19th century — 21st century public health depends on good science, consistent statements, good communications, and trust that public health officials engage only in apolitical truth-telling.
Constitutional rights should be an ally rather than an enemy of public health — 21st century public health requires preserving personal liberty.
Jeffrey Hall Dobken is an assistant clinical professor of pediatric immunology and allergy, and certified bioethicist, at Weill Cornell School of Medicine in New York City.
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