The ethics of fighting bioterrorism
I have resisted writing about the events of September 11 and their aftermath, feeling like there is little I can say of import in the face of overwhelming tragedy and terror. But as the monstrous large-scale attacks on the World Trade Towers and the Pentagon have given way to the psychological terror of unseen threats in the mail, interesting issues are arising in our public health response to potential biological terrorism.
Is our public health infrastructure sufficient and well-prepared enough to deal with the possibility of needing to treat potentially millions of Americans? What can we do in the face of large outbreaks of infectious disease, and what ethical issues are beginning to surface in the face of the prospect of many people ill from or exposed to anthrax?
Conscripting health care
The prospect of wide anthrax exposures via the mail or other routes has raised questions about the ability of the U.S. public health infrastructure to deal with epidemic levels of infection. Lines of postal workers waiting to be tested for anthrax exposure are evidence of the sorts of stress on the health care system that would come with a wider attack. The problem is related to both the number of facilities, as well as to the number of health care workers available to treat large numbers of people.
In truth, there is probably no shortage of physicians or other health care workers in the U.S., but the vast majority don't work in what could even loosely be construed as public health. So in a public health disaster, what would Americans do? Many would go to their private physician or to their local hospital or clinic, but a doctor would quickly be overwhlemed if a substantial number of patients showed up for treatment on the same day.
So what can we do to assure that we can protect the health of our nation?
Suggestions include conscripting health professionals into service, as part of an organized response to any bioterrorism and the public health challenges it would bring. This would be an unprecedented intrusion on the professional lives of physicians, nurses, lab technicians, and others, but may well be the only way to assure both adequate numbers of professionals, and more importantly, allow for an organized and effective response.
Even with a sufficient professional response, our country would still require huge amounts of drugs or vaccines to adequately treat or protect the potentially millions of people affected.
This has become clear in the federal government's efforts to guarantee a sufficient supply of the antibiotic Cipro to treat anthrax exposure. Until the government was able to agree on a reduced price of 95 cents a tablet for 100 million tablets, there was discussion about whether and how Congress could invalidate Bayer Pharmaceutical's patent on Cipro in the interest of national security.
At its base, the claim is that there is an overriding ethical issue at stake: The national interest in affordable and available drugs to fight specific terrorist threats is greater than patent protections guaranteed by longstanding laws.
But how far should arguments that amount to claims of eminent domain -- the same law that allows the government to buy your house so that a new freeway can be built through your neighborhood -- be allowed to go? In the end, Bayer and the U.S. government were able to come to terms about a lower price for many millions of doses of Cipro, but the case will not likely be the last, given growing worries about threats from other biological weapons, and the realization that public health is not just a national, but a worldwide problem.
When communities and populations are the focus, individual rights, whether they are of health professionals or pharmaceutical companies, must often take a back seat. The challenge is finding the right balance between the two -- something that will continue to confront us all in the days after September 11.
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