A duty to the healthy and the sick

The Baltimore Sun

The multicountry odyssey of Andrew Speaker, infected with an ultra-rare type of tuberculosis that resists some of our best drugs - and the first person placed under a federal quarantine order in more than 40 years - has raised concerns about biosecurity, infection control, personal responsibility and public health powers. The incident set off an international uproar; accusations about right and wrong behavior are still flying back and forth across the oceans.

When someone like Mr. Speaker has a severe, contagious disease, when should we intervene with something as drastic as isolation? How do we know if we should strip citizens of their personal freedoms? And what do we owe them if we do?

Bioethics instills a perennial duty to identify the least-restrictive and least-onerous interventions available to achieve our goals. If public health officials locked up everyone with a contagious condition (as some proposed during the initial outbreak of HIV in the 1980s), it would be inappropriate and unfair. When citizens have the ability to protect themselves against the spread of disease, it is unfair to burden the infected by significantly restricting their freedoms.

Thus, in almost all situations and with almost all infectious conditions, public health authorities rarely restrict the movements of those who are infected. Even with seasonal influenza, a highly infectious respiratory disease that kills 40,000 people annually in the United States, health departments encourage, but do not force, sick people to remain at home.

A few situations are different, however. On rare occasions, those with infections like TB don't listen. And when the infection is both lethal and so easily transmitted (e.g., by coughing) that prudent people cannot reasonably protect themselves, public health officials must intervene. For this reason, public health agencies a century ago were granted "police powers." That means public health departments have the legal authority to shut down unsafe restaurants, force individuals to be vaccinated, and, occasionally, to isolate someone whose condition poses a severe threat to others. But public-health police powers can only be used to prevent future harm to others, never to punish for past actions.

From a public health perspective, individuals with XDR-TB in the United States must be isolated until they no longer pose a threat to others. But the responsibilities of public health do not stop there. To protect those with contagious conditions and to protect the rest of us, public health must take care of the sick. Perhaps, if public health authorities had communicated to Mr. Speaker their dual commitment to attending to his need for high quality care and the need to prevent transmission of his deadly infection, his fugitive flight could have been averted.

Taking care of the public's health along with the sick person's health protects the rest of us, which is public health's primary duty. It also reminds citizens that their government and their doctors are there to help them. And, perhaps most importantly, it works. If what Andrew Speaker says is true, he got on planes and drove across borders when he knew it was forbidden, only because he felt he had no other choice. If he had been assured that he would be taken care of, he likely would have cooperated with public health authorities, and none of the passengers on the commercial flights coming home would have been put at risk.

Mr. Speaker's case is highly anomalous. He is a well-educated American. He has resources. His father-in-law is a TB expert at the Centers for Disease Control and Prevention. Most XDR-TB patients throughout the world are poor, have limited access to health care and are unlikely to even know they have XDR-TB before it kills them. If we treat XDR-TB as a form of bioterrorism, and those who have it as potential criminals, we do the victims of this disease a terrible injustice. By failing to earn their trust and cooperation, we also fail as a global public health community.

As we face other threats to the public's health, we must remember what we owe to the healthy and the sick alike. We do this not only because as a health care community, and as a human community, we must maintain our compassion for the sick. We do this because it has the best chance of working.

Nancy Kass is deputy director for public health at the Johns Hopkins Berman Institute of Bioethics. Her e-mail is nkass@jhsph.edu. Dr. Richard Chaisson is a professor of medicine at the Johns Hopkins School of Medicine. His e-mail is rchaiss@jhmi.edu.

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