This lecture considers public health law in the United States. An important part of control of contagious disease, such as the Ebola virus, is legal preparedness. Understanding who has what authority and how that legal authority may be used. In this lecture, we will consider the most commonly used public health control measures, including quarantine, screening, and contact tracing. All of these are subject to federal or state law, and are critical to the containment of any contagious disease. Control of Ebola and other contagious diseases is, first of all, a matter of each nation's quarantine and isolation laws, as well as its public health infrastructure and capability. This lecture considers the situation in the United States. These legal tools protect the public by limiting exposure to infected persons or to persons who may be infected. Another lecture in this course addresses international law. But I begin with noting there's an overlap, as represented by this diagram. As you can see, international law, federal law, and state law all intersect to some extent. And I hope that will be made clear by the end of this session. Laws relevant to entry in the United States will be our first subject. The federal government is in charge of the border. Then we will look at the public health control measures within the United States that are under the authority of a state government and subject to state law. So let's start with evacuation of a medical worker from another country into the United States. U.S. Customs and Border Protection. This is the first point of entry for anyone outside of the U.S. This department is under the Department of Homeland Security, and it partners with CDC quarantine stations. We are going to examine the legal authority of the federal government to stop and screen travelers, and to require quarantine or isolation for persons entering the United States in two areas. First, planned evacuations, and second, travelers on commercial airlines. For the first Ebola patients transferred from Liberia to Emory Hospital, both had a right of return on the basis of their citizenship, but not a right to choose where they could travel within the United States. Hence, the cooperative effort of Emory Hospital officials, the Centers for Disease Control, U.S. Customs and Border Protection, and the Federal Aviation Administration. These, together with Georgia officials, paved the way for the transfer of the first two patients from Liberia to Emory. The Liberian government also agreed to the transportation plans for those two American patients. While normally, a nation may not prevent a non-citizen from leaving, it can do so temporarily for health reasons. The Liberian government, for example, could have prevented movement of any patients out of local isolation or quarantine, if travel within that country posed undue health risks for others. It was necessary, then, to negotiate with the Liberian government against this backdrop of their national legal authority. Flight evacuations of healthcare workers include several steps for regulatory approval. In addition to advance approval by the U.S. State Department and the Federal Aviation Administration, pilots must receive clearance to enter and depart from the country where the patient is. Upon return to the United States, the flight and crew must clear customs, as would any flight arriving in the U.S. The Department of Homeland Security has designated Dallas-Fort Worth Airport as the only entry point for inbound flights with Ebola patients evacuated from another country. Furthermore, only one air transportation company, Phoenix Air, has the capability to transport Ebola patients, because it has the only approved isolation tents for medical evacuations. Prior to the Ebola outbreak in West Africa, the CDC contracted with Phoenix Air to construct three containment systems capable of transporting persons with serious communicable disease, built to CDC specifications and approved by the U.S. Department of Defense. The containment system is termed an Aeromedical Biologic Containment System. To date, Phoenix Air has transported all of the Ebola patients brought to the United States, and it has also evacuated patients to Europe. All U.S. patient evacuations have been funded privately, not by the federal or a state government. A medical team accompanies each flight, and there has been no transmission of the virus to them or to pilots and ground crew. Decontamination procedures following a flight are extensive, as you can imagine. Those procedures are governed by federal and state regulations, as well as the company's own standards. This permission to enter the United States is an example of any nation's authority over its sovereign borders and internal affairs. Some West African nations closed their borders to other nations. The United States has not restricted incoming air travel, as it relies on, and assists with screening for outbound flights in areas with Ebola. The World Health Organization urges nations not to close borders with each other because it complicates relief efforts and disrupts commerce. The Department of Homeland Security has implemented enhanced screening at points of entry in the United States. Border Patrol agents have been told to ask travelers about possible exposure to the virus. Arriving passengers at five major U.S. airports will be checked for fever if they have traveled from West Africa. And all travel from West Africa is directed to those five airports. At this point, I will focus on laws governing quarantine and isolation. The two terms have different definitions. Isolation separates ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. The other legal term we will use is quarantine. Quarantine separates and restricts the movement of well persons who may have been exposed to a communicable disease to see if they become ill. These people may not be aware of exposure to a disease, or they may have the disease but do not show symptoms. Quarantine of persons without symptoms can take a variety of forms, ranging from confinement at home or in a facility, to less onerous travel and social isolation measures, along with self-reported symptoms. The most radical form of quarantine, which is discouraged by the World Health Organization, is known as a geographic quarantine. A geographic quarantine might be used, for example, to separate a group of persons who may have been exposed to a disease until it can be determined that they are not ill. As reported in Liberia, the attempt to cordon off a large slum in the capital led to panic and violent repression of persons trying to escape. Residents, quite understandably, believed that the government had imposed a death sentence on them. In addition, as mentioned earlier, five African countries at one time closed their borders with each other, another example of a geographic quarantine. In the United States, quarantine authority is divided between states and the federal government. This is a concept known as federalism. If a communicable disease is suspected or identified in a person arriving at the U.S. border or a port of entry, the federal Centers for Disease Control may issue a federal isolation or quarantine order. Federal regulations also allow the CDC to take measures to prevent the spread of communicable diseases from one state into another. Including anytime the CDC director determines that the actions taken by the health authorities of a state are insufficient to prevent the spread of communicable disease. The communicable diseases subject to quarantine are listed in an Executive Order of the President. This image shows quarantine stations at the United States. The federal government's authority at that point is quite limited. It's primarily in an advisory and support role, but it can act with the consent of a state. The federal government can also act to prevent air travel by persons by adding them to a Do Not Board list. And for this reason, federal quarantine and isolation authority is considered secondary to that of states. The Ebola virus is different in at least two key respects from the usual application of quarantine law in the United States. Our experience to now has been primarily with quarantine and isolation of tuberculosis patients. By contrast, there is yet no test to determine whether someone who has been exposed to the Ebola virus will develop the disease. And the length of time from exposure to disease development is as long as three weeks. This means that monitoring persons with potential exposure, but who have no symptoms, is necessary to prevent spread of the disease for up to 21 days. This can be a substantial restriction of a person's civil rights and liberties. If an airline passenger is suspected of carrying the virus, they would be quarantined immediately. Because border officials will test for fever, which can have any number of causes other than Ebola, there will likely be many false positives, who will have their liberty restricted for a period of time. This is a trade-off in the balance of individual liberties and public health concerns, necessitated by a new disease, new situations, and new conditions, at least with respect to experience in the United States. Public health officials have extensive legal authority to respond quickly. Judges have very limited jurisdiction and are also inclined to defer to medical experts on the need for emergency measures. The likelihood in most states is that judges would postpone review of individual claims until well after the need for such actions has past. Were health authorities in the United States to impose a geographic quarantine, similar to that which we discussed in Liberia, it is quite likely that a significant police or military presence would be required to enforce it. Such quarantines raise substantial human rights issues. The thread must be immediate and severe. The quarantine must be in the least restrictive manner necessary for its purpose. And persons quarantined are entitled, as a matter of law, to appropriate healthcare. Screening for potential carriers of the disease also raises a number of concerns. Who makes these decisions and who coordinates enforcement are of vital importance and must be part of public health preparedness. So to summarize briefly, the federal government acts to prevent the entry of communicable diseases into the United States. Quarantine and isolation may be used at any U.S. entry point. The federal government may also assist state and local authorities In preventing the spread of communicable diseases and provide expert guidance and resources. And it also maintains a Do Not Board list, preventing air travel for patients with any infectious disease that is a potential public health threat to passengers. Persons are added to the Do Not Board list only with reliable medical information provided by a state public health official. And following a reviewed approval process by the U.S. Department of Health and Human Services. State public health authorities, on the other hand, are responsible for all public health matters within that state. Among those powers, they initiate isolation and quarantine within their borders. Relying on local law enforcement officers to enforce public health orders. They assume primary responsibility for tracing contacts of persons who may have been exposed to the virus. Thus, two quarantine laws are relevant for Ebola. As an example of this interaction, consider the first Ebola patients treated in the United States at Emory University Hospital. The two patients required federal approval by the CDC's Division of Global Migration and Quarantine in order to enter the United States. CDC officials also coordinated transfer of the patient to Emory through the Georgia Department of Public Health, which assumes quarantine authority within the territorial boundaries of the state. The Georgia Department of Public Health has authority to order isolation if compliance by an individual is in doubt, and could also impose a geographic quarantine. Although neither the federal government nor any state has exercised this authority.
