WENDY E. PARMET

The favorite [American] exports seem to be the market economy and privatization, along with the rule of law.

Summer 2007 | Faculty Deliberations

Stranger than Fiction

By Wendy E. Parmet

THE STORY OF ANDREW SPEAKER, the Atlanta attorney and first American quarantined by the federal government in more than 40 years, reads like a Hollywood screenplay, a global action thriller, in which government agents track down a tubercular killer. As Hollywood might tell the tale, Speaker was a selfish man who threatened the lives of innocent travelers. Cast in this light, the script suggests that what we need to spare us from the dreaded XDR-TB is Jack Bauer of “24” fame, who can track down and detain the dastardly patient — or perhaps the public health version of the Patriot Act.

Speaker was likely not very contagious. Nevertheless, his story raised anew the debate over the use of quarantine. According to CDC Director Dr. Julie Gerberding, there is a “covenant of trust” between public health officials and TB patients. Government should quarantine only when someone breaks the covenant and disobeys public health recommendations.

The question should be asked, however, was the covenant broken and by whom? Speaker is certainly not the only person to ignore public health recommendations. We all do. We all fail to floss, and we all forget sometimes to cover our coughs. Moreover, looking out for oneself is the American way. Constant public health messages tell us about how we can and should take responsibility for our own health. Is it then surprising that Speaker ignored advice and decided to get himself home to medical care he felt he could trust?

Consider too that during the SARS epidemic, governments in Canada and Asia passed laws to provide people with compensation while under quarantine. In the US, despite moves to modernize quarantine, income replacement remains off the table (the Family and Medical Leave Act only guarantees unpaid leaves for some ill employees). And astonishingly, in proposed quarantine regulations, the CDC fails to commit to provide all necessary health care to those it might quarantine.

The most significant breach of the covenant of trust with respect to TB, however, is the failure to adequately support prevention and treatment. Although funding for TB control has recently risen, US support remains paltry. On the same day that the CDC proclaimed Speaker’s quarantine, the Stop TB Partnership, a network of more than 500 international TB control organizations, reported a 60 percent funding shortfall. In the past year, the US gave the Partnership only $19 million; Canada gave it $77 million. Domestically, federal public health funds have focused on “preparedness,” to the detriment of TB prevention and control programs.

In the movies, tough guys and strict laws can keep us safe. In reality, drug-resistant TB requires a less exciting, more expansive approach. Until we find a better way to adequately treat and respond to infectious disease, the covenant, like most movies, will remain fiction at best.

Professor Wendy E. Parmet is a health law expert and coauthor, with Patricia Illingworth, of Ethical Health Care (Prentice Hall, 2005). A version of this article originally appeared as a commentary in the “Bioethics Forum” at www.bioethicsforum.org