Legislation, International Law, and Infectious Diseases
Legislation, International Law, and Infectious Diseases
While national infectious disease laws and legislation are essential, globalization demands increasingly international solutions as epidemic diseases do not respect national boundaries. International cooperation among national governments and between governments and international non-government agencies (NGOs) is facilitated by a basic set of international public health and infectious disease laws.
The body of international infectious disease law is composed of different types of agreements among nations, including: treaties, accords, conventions, and agreements. Also, nations may contribute to international infectious disease law by participating in international organizations such as the United Nations, World Trade Organization, or World Bank. Furthermore, several nations may sponsor or aid the missions of various NGOs, agreeing to let their members assess and respond to infectious disease outbreaks within their national borders.
The earliest attempts at systematized government responses to epidemic disease arose out of the persistent threat of plague in Europe. Quarantine (the confinement of persons who have been exposed to a disease, but do not show symptoms of the disease) was widely used to control epidemic plague. From the time of the Black Death, during which one-third of Europe's population perished from the plague, those who could afford to leave densely plague-infested cities often retreated to residences in the countryside. This exodus from the cities may have saved some from being exposed, but also helped spread the disease. After the Black Death, many small municipalities forbade entry to those fleeing the cities. In rural Italy, a Catholic priest wrote the Vatican asking for a decree permitting monasteries to close their doors on plague victims and refugees. Instead, the Church viewed plague as punishment for peoples’ sins and instructed noncloistered orders of lower-level clergy across Europe to minister and aid the sick.
When epidemic plague struck England in 1665, the royal government left the city. The mayor and alderman were left in charge of governing the city through the epidemic. Isolation and quarantine were again employed. Businesses, public spaces, restaurants, and inns were closed—churches, however, remained open, undermining the efficacy of the health laws. The city government hired physicians and regulated burial practices, criminalizing the dumping of bodies into the River Thames. Some plague-infested inns and public housed were ordered burned. When the plague escaped the confines of London to the village of Eyam, the villagers isolated the sick and quarantined the village. Nearly 75% of its inhabitants died, but surrounding villages were largely spared from the epidemic.
The often-conflicting laws—the result of a lack of understanding about disease transmission—proved limitedly effective against plague. While it was never epidemic in London after the Great Fire of 1666, plague continued to arise periodically in European cities until the late eighteenth century. The disappearance of epidemic plague was less a victory for infectious disease law and more likely the result of diminishing numbers of its vector—the decline of black rat populations and their plague-carrying fleas. When epidemic cholera hit Europe in the 1830s, officials looked to the historical example of public health measures and laws enacted to combat plague as a foundation.
The genesis of modern infectious disease law is often traced to the cholera pandemic in Europe from 1829 to1851. From 1816 to 1826, a cholera pandemic spread through India, Southeast Asia, and China. Three years after the pandemic subsided in China, it reached parts of Europe. In 1831 and 1832, cholera was epidemic in several of Europe's major cities. In 1849, cholera again spread through several European, and then U.S., cities. Many historians note that the time period was one of rapidly increasing immigration and trade, a dangerous situation for infectious disease. Medicine and modern scientific research were newly emerging, but scientific knowledge of disease had limitedly progressed in the preceding century. The cholera epidemics prompted substantial change in medicine, public health, and infectious disease law.
In 1954, John Snow identified polluted public water supplies as the source of cholera. Snow advocated radical changes in sanitation and water safety, persuading the London city government to approve construction of new water systems and enact laws protecting the water supply. Sanitation and hygiene laws, championed by the growing sanitation and public health movement, helped reduce incidence of cholera and other water-borne diseases.
In 1851, the First International Sanitary Conference convened in Paris, France—cholera identification and prevention was a primary concern of the attendees. Pandemic cholera spurred diplomacy between nations. England and France both sent public health officials to medical academies and hospitals abroad to study the disease and possible treatments. Infectious disease and sanitation laws that proved effective in one location were often adopted elsewhere. From 1851 to 1900, ten international sanitary conferences met to discuss the international impacts of infectious disease. Eight international conventions were drafted, though few were adopted into force by national governments.
WORDS TO KNOW
EPIDEMIC: From the Greek epidemic, meaning “prevalent among the people,” is most commonly used to describe an outbreak of an illness or disease in which the number of individual cases significantly exceeds the usual or expected number of cases in any given population.
GERM THEORY OF DISEASE: The germ theory is a fundamental tenet of medicine that states that microorganisms, which are too small to be seen without the aid of a microscope, can invade the body and cause disease.
ISOLATION: Isolation, within the health community, refers to the precautions that are taken in the hospital to prevent the spread of an infectious agent from an infected or colonized patient to susceptible persons. Isolation practices are designed to minimize the transmission of infection.
LATENT INFECTION: An infection already established in the body but not yet causing symptoms, or having ceased to cause symptoms after an active period, is a latent infection.
PANDEMIC: Pandemic, which means all the people, describes an epidemic that occurs in more than one country or population simultaneously.
QUARANTINE: Quarantine is the practice of separating people who have been exposed to an infectious agent but have not yet developed symptoms from the general population. This can be done voluntarily or involuntarily by the authority of states and the federal Centers for Disease Control and Prevention.
VECTOR: Any agent, living or otherwise, that carries and transmits parasites and diseases. Also, an organism or chemical used to transport a gene into a new host cell.
By the dawn of the twentieth century, science drove infectious disease law. The professionalization of medicine and scientific training of physicians in universities, the wide acceptance of germ theory, and the discovery of antisepsis revolutionized public health. Infectious disease laws became more effective as researchers were better able to identify the sources of disease and understand how diseases spread. By the outbreak of World War I (1914–1918), international agencies already operated to assess sanitation conditions and identify and treat disease outbreaks across national borders. The Red Cross and Pan American Sanitary Bureau helped draft international conventions on infectious disease prevention. International treaties and agreements outlined infectious disease controls associated with trade and immigration. National governments had passed laws outlining effective isolation and quarantine measures, adopted food safety regulations, instituted comprehensive health screening for arriving immigrants and restricted entry to healthy individuals, and established national public health agencies.
IN CONTEXT: SABIN HEALTH LAWS
Florence Sabin (1871–1953) was the first woman to graduate from the Johns Hopkins Medical School. She then became the first woman appointed to a full professorship at Johns Hopkins and was elected the first woman president of the American Association of Anatomists. After becoming the first lifetime woman member of the National Academy of Sciences, Sabin ultimately expanded her work to include research on understanding the pathology and immunology of tuberculosis.
Sabin's methods of blood analysis became important indictors of various disease states, and her work was important in attempts to combat tuberculosis. Near the end of World War II (1939–1945), Sabin was called upon to chair a study on public health practices in her home state of Colorado. As part of her work, Sabin conducted studies on the effects of water pollution and the prevention of brucellosis in cattle, At the time, brucellosis, especially in infants, often resulted from exposure to contaminated and unpasteurized milk from diseased cows.
The result of Sabin's work was the passage of the Sabin Health Laws, which signaled a critical change in public health policy. The Sabin Health Bills mandated stringent regulations regarding infectious disease, milk pasteurization, and sewage disposal.
After World War II (1939–1941), the availability of antibiotics and the rapid development of modern vaccines again changed the ways in which health officials were able to respond to diseases. International agreements provided for the sharing and distribution of vaccines and antibiotics. The founding of the United Nations created a global organizational structure for international public health programs and laws. The World Health Organization was created on July 22,1946, to promulgate international public health regulations and promote public health laws worldwide.
Since the 1960s, economic and trade organizations have played an increasing role in international infectious disease laws. Free trade agreements often carry requirements that exports will meet quality and safety standards or that nations can decline imports if they pose a general health threat. Trade agreements on agricultural, animal, and food products typically stipulate regulations for disease testing, hygienic packaging, safe handling, and inspection. Sometimes, trade agreements contain public health provisions, such as aid for combating endemic parasites or infectious diseases.
Even with the rise of trade organizations and the formation of the United Nations and the WHO, public health laws remain uneven throughout the world. Most international public health laws are non-binding or difficult to enforce without total cooperation by participating nations. UN and trade organization member nations have full national sovereignty, meaning they reserve the power to adopt and enforce laws within their national borders. Adding to the inequalities in national healthcare systems, sanitation systems, and resources for combating diseases, some nations do not recognize international infectious disease conventions or do not participate in WHO-led anti-disease programs. International infectious disease conventions sometimes fail completely in conflict-torn nations, often areas where infectious disease monitoring, prevention, and response are needed most. NGOs (non-governmental organizations), such as the International Red Cross and Doctors without Borders are often effective at responding to epidemic disease in these regions.
Today, laws that govern response to infectious diseases are increasingly international. Increased migration and trade has expanded the reach of once-localized diseases. While globalization has aided in the spread of some diseases, it has also opened new channels for combating infectious disease. Once the exclusive domain of local and national governments, laws governing reporting and responding to infectious diseases are increasingly international.
Infectious Disease Response, Civil Liberties, and Medical Privacy in the United States
The expansion of scientific research capabilities and computerized information systems has aided the global fight against infectious disease. Researchers and public health officials are better able to identify, study, respond to, and communicate about disease outbreaks. However, disease prevention and containment measures can impede personal civil liberties or impact personal privacy.
In the United States, Executive Order 13295 provides for government authority to detain, seize, apprehend, quarantine, or isolate persons potentially sickened by or exposed to cholera, diphtheria, emerging pandemic influenza, infectious tuberculosis, plague, severe acute respiratory syndrome (SARS), smallpox, yellow fever, and viral hemorrhagic fevers. States have passed varying forms of the Model State Emergency Health Powers Act (MSEHPA), outlining state and local epidemic disease response plans and powers. Some critics assert that governments can too greatly encroach on freedoms of travel and association in when responding to epidemic disease by instituting quarantines or isolation orders.
Several nations have responded to concerns about personal privacy by passing laws safeguarding patients’ personal information. In the United States, concerns of medical privacy were addressed through the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996. The primary aim of the legislation was to protect access to private health insurance for workers who lose or change their employment. However, the legislation also contains several provisions on privacy and security. Under HIPAA, a patient's health status, medical history, payment history for medical services, and private identifying information must be protected. While insurers still have access to some of this information to facilitate payment of patient claims, patients have greater control over how much information insurers may obtain and doctors may release. Patients must be notified of any use of their personal health information or sign a waiver.
While patient privacy advocates applaud the legislation, several researchers have asserted that HIPAA hampers the ability to conducted needed avenues of research, especially those that formerly involved studying past patient medical charts. Furthermore, some researchers have noticed a drop in follow-up survey responses, complicating research on recovery and relapse.
HIPAA does not affect the reporting of notifiable diseases to federal and state health officials. The Centers for Disease Control and Prevention (CDC) National Electronic Disease Surveillance System (NEDSS) is also unaffected as individually identifiable health information is available for public health research use without consent, but cannot include personal identifiers such as name or address.
IN CONTEXT: REAL-WORLD RISKS
In June 2007, Atlanta-based attorney Andrew Speaker flew aboard a commercial aircraft to Europe for his wedding. Before he left, Speaker consulted doctors in Atlanta, where he was diagnosed with a latent (dormant) tuberculosis (TB) infection. While he was honeymooning in Italy, scientists at the Centers for Disease Control and Prevention (CDC) identified Speaker's tuberculosis as a potentially rare, often deadly form of TB, known as XDR-TB, that is resistant to almost all known anti-biotics. CDC officials contacted Speaker in Italy and instructed him not to fly home on a commercial jet and to proceed to Italian health authorities for further instructions and treatment. Speaker defied the request, flew to Canada, and entered the U.S. via New York by car. Once inside the U.S., health officials issued a federal order for isolation for Speaker, the first federal isolation order issued since the 1960s. Speaker was later flown by CDC aircraft to the national Lung Institute in Denver, Colorado, for treatment, and an international cooperative effort was launched to trace fellow passengers and air crew who came into close contact with Speaker during his international flights. Preliminary tests showed the risk for Speaker transmitting XDR-TB to others was low, but the incident highlighted the need for rapid international communication and cooperation when attempting to prevent the transmission of infectious diseases across international borders.
Fighting Epidemic Disease across National Borders
There is no universally accepted international body of law. Thus, international anti-infectious disease regulation is typically the result of participation in United Nations initiatives by member nations or through voluntary cooperative efforts governed by treaty. Not all nations participate in or acknowledge the authority of various international laws governing infectious diseases. Other nations participate in some programs and treaties while opting out of others.
Problems may also arise when national legal systems are in conflict with international law mandates. For example, many international laws are based on the assumption that national governments have broad power over local police, health officials, and healthcare facilities. The United States often adapts international regulations to fit within its system of federalism, which delegates significant powers to state and local governments. While laws governing patient privacy or federal quarantine orders apply to the whole nation, states may enact supplemental public health laws. In contrast, many other nations have centralized public health and healthcare systems that are only governed at the national level.
As infectious disease threats, treatment options, and prevention mechanisms change, so too must international law governing disease response. On July 25, 1951, WHO member states adopted the International Sanitary Regulations, later renamed the International Health Regulations (IHR), to “ensure the maximum protection against the international spread of disease with minimum interference with world traffic.” IHR guidelines require that nations notify other countries about disease outbreaks within their borders, maintain accurate records about such outbreaks, establish public health protocols at national points of entry and exit (such as border crossings or airports), and that substantial restrictions on trade for disease-prevention be based on scientific evidence of a public health concern. Nations may require vaccine certificates or health screenings of travelers and immigrants, and adopt hygiene, disinfection, isolation, or quarantine protocols at points of entry as needed. Diseases that the IHR guidelines currently address include cholera, yellow fever, plague, smallpox, polio, severe acute respiratory syndrome (SARS), and new strains of human influenza.
Many aspects of the IHR remain difficult to enforce. Member nations have adopted several provisions of the IHR, while abandoning others. National laws governing reporting of diseases are sometimes not as stringent, or nations have failed to report epidemics. The annual World Health Assembly approved revised IHR in May 2005, addressing these issues and updating the list of targeted diseases to include new threats such as SARS and pandemic influenza. The revised regulations, which were accepted by the United States in December 2006, took effect in June 2007.
Fidler, David P. International Law and Infectious Diseases. Oxford: Clarendon Press, 1999.
Fluss, Sev S. “International Public Health Law: An Overview,” Oxford Textbook of Public Health, 3rd ed. Roger Detels, Walter W. Holland, James McEwen, and Gilbert S. Omenn, eds. Oxford: Oxford University Press, 1997.
Roemer, Ruth. “Comparative National Public Health Legislation,” Oxford Textbook of Public Health, 3rd ed. Roger Detels, Walter W. Holland, James McEwen, and Gilbert S. Omenn, eds. Oxford: Oxford University Press, 1997.
United States Department of Health and Human Services. “Medical Privacy—National Standards to Protect the Privacy of Personal Health Information.” <http://www.hhs.gov/ocr/hipaa/> (accessed June 8, 2007).
World Health Organization. “International Health Regulations (IHR).” <http://www.who.int/csr/ihr/en/> (accessed June 8, 2007).
Adrienne Wilmoth Lerner