Quarantine -- and the TB patient has no symptoms?

After all the scare scenarios (and one compelling ABC TV movie last year) about avian influenza, and after the 2003 SARS epidemic, it sounds ironic that the first federally ordered quarantine in the United States would come from a case of tuberculosis in a man ("patient X") with no symptoms.

This TB XDR appears to be a variant of conventional TB that is resistant to most antimycobaterial antibiotics, and it seems to have a 50% mortality rate in those with active symptoms. But apparently this is not mycobacterium avium intercullulae, a brain tuberculosis that affects only severely immunocompromised patients as those with HIV. This can affect people with normal immune systems, but normally TB is quite hard to catch with incidental contact. The chances are that none of the people on the aribuses were infected.

Still, the government is quarantining someone (as a potential "typhoid Mary") with no symptoms. Imagine this with SARS, bird flu, or smallpox (if it ever came back).

Tuberculosis is called the "white plague" in the 1950 World Book Encyclopedia. Consumption, as it was called two generations ago, was dreaded. People went to sanatoriums.

In the 1980s there was scare talk in the gay community of quarantine for PWA's. HIV is transmitted only through direct blood contact, but it is imaginable that an HIV infected population could "amplify" a semi-opportunistic infection like regular TB that could then affect the outside population. But this has never happened in the developed world, despite the scare talk from the religious right.

When I volunteered to be tested for a GP160 HIV vaccine in 1988 at NIH, I had a thorough physical including chest Xray that found a spot. Nurses said that TB is very hard to catch in normal household or social circumstances. NIH did a cat scan, and found it to be a "calcified lymph node," probably from histoplasmosis exposure when I lived in Texas. (Histoplasmosis is another pseudo-opportunistic infection that often causes no symptoms, but just gets walled off in a spot or two in the lungs or liver.)

Hopefully, patient X would gradually overcome the TB with his own immune system even without antibiotics, and that his body would wall the infection off into isolated lymph nodes that will show up on a cat scan. Without symptoms, this may be happening already. It seems unlikely that he is really a "threat."

TB, though, still strikes some fear. School employees must have a negative tuberculin test or Xray, even though TB is really quite hard to transmit most of the time.

It has been reported that the man, himself an attorney, could face civil liabilities if any other airplane passenger became infected with the same strain of TB. (He got past the TSA no fly lists.) He will not face criminal charges. But I've never heard of a case of civil liability for acting as a "carrier" of an infectious disease sometimes spread by casual contact, only for STD's. Such litigation could have downstream consequences with other medical issues.

Thursday, the patient was identified as Robert Speaker, son-in-law of CDC microbiologist Robert C. Cooksey. There seems to be no chance that the infection could have somehow come from CDC itself. It was probably acquired in travel in southeast Asia.

Update: 6/10/2007

Howard Markel, professor of communicable diseases at the University of Michigan, has an op-ed "Typhoid Andy: Return of the White Plague" on page B1 (commentary) of the June 10, 2007 Washington Post. The link is this.
The article takes the position that an asymptomatic carrier of TB can be very dangerous to others, although generally TB is very hard to "catch" (unlike how bird flu could be if it mutated into a contagious form). Mr. Speaker was reported to have a lesion the size of a tennis ball in his lung, but recent sputum tests have been negative, and he may be allowed out of isolation.

Update: July 3, 2007

Media sources reported a new diagnosis for Mr. Speaker, MDR (multiple drug resistant) rather than XDR (extreme drug resistant), which opens up the possibility of much wider drug treatments without surgery. It is unclear whether isolation is as critical with MDR TB.

Update: July 13, 2007

At least eight passengers filed suit in Canadian court against Speaker for exposing them to tuberculosis. One passenger has tested positive for TB, although it is not clear that it is the same strain. It is not clear how enforceable a Canadian judgment would be. But allowing lawsuits based on exposure to an infectious disease through casual contact from someone without symptoms would seem to set a dangerous legal precedent, allowing frivolous litigation. What do we do if this happens with avian influenza? CNN story here.

Update: Dec. 31, 2007

There has been another case involving a native of Nepal. The CDC is recommending screening of other passengers on a particular international flight. The story in USA Today Dec 31, 2007 is by Steve Sternberg, "CDC seeks fliers exposed to drug-resistant TB," here.

Government accounting hides true national debt per citizen; Barack Obama on health care

A provocative story by Dennis Cauchon in the Tuesday May 29, 2007 USA Today, “Rules ‘hiding’ trillions in debt: liability $516,348 per U.S. household,” discusses the fact that federal law does not require the US government to follow normal FASB accounting rules in dealing with the national debt. The liability would be less per individual than per household.

Normally, public companies must account for their liabilities as they are incurred. So do state and local governments, but not the federal government. The government reports an official deficit of $248 billion when the actual loss according to standard accounting rules would be $1.3 trillion. The difference is that entitlements (social security and Medicare being the largest) are paid out over time so federal accounting rules do not require this of the government.

If accounting rules were changed, havoc would ensue in financial markets. It’s easy to imagine a financial doomsday scenario where ordinary Americans are “garnished” for their personal share of the debt. The average liability probably exceeds net worth for most Americans.

One possibility could be that social security eventually faces pressure for means testing, and that families be expected to take more responsibility for elderly relatives (filial responsibility laws).

I recall the doomsday discussions in New York City in 1975 as it faced default and a financial crisis, and the fear of general police strikes. I was living there then. (Remember the NY Daily News Story” Ford to City: Drop Dead! (wiki account). “They would never let that happen” naïve people would say. Times have sure changed.

The debt issue certainly can be a downside to arguing for a single payer style health care solution for Americans. Today Barack Obama announced his plan for health care reform, by creating a “National Health Insurance Exchange” and assisting people in purchasing coverage and requiring all employers to participate. It does not sound like he is willing to sever the connection between employment and coverage, a nexus that may well interfere with job growth. It remains to be seen if he could guarantee that individual purchases have access to the tremendous in-network discounts normally offered in group plans (even before deductibles are met).

"Everyone Serves" website

Yesterday a visitor brought to my attention a new website called “Everyone Serves.” The site promotes the idea of mandatory national service. The site has a petition, authored apparently by Rob Johnston, to support a law supporting mandatory national service, which would be broader than a military draft, as it would allow civilian options like the Peace Corps, inner city work, perhaps restoration from storms, hurricanes and tornadoes, and the like.

The arguments presented there seemed a bit simplistic but sincere. But one idea that struck me: here is a petition that the government should have the ability to barge into my life and use force or aggressive to force me to comply with the moral agendas of others. That certainly goes against my libertarian background (and previous activities in the Libertarian Party in the pre 9/11 era).

I say this with the face of Janus. I was a “child” of the Cold War and came of age in a time when student draft deferments for the “privileged” came across as one of the moral outrages of the day (especially in the LBJ days before the public really began to realize that we could “lose” in Vietnam). In those days, there was more of a sense of public morality that included the notion that indeed “everyone serves” (that is, all men take their turn with the “risk” of military service to protect others), and then everyone has a family (an idea that would start to unravel in the 60s).

Indeed, one of the reasons why the military gay ban (transmogrified in 1993 into the infamous “don’t ask don’t tell” policy) is so obnoxious is that implies that gay people cannot perform their fair share of burden sharing necessary to protect freedom. Any national service program has to deal with this question, as other forms of service involve people working and living in conditions of forced intimacy, although problems like the military policy for gays have not been widely reported. Most other “western democracies” and Israel have been able to lift their gay bans in the military without real problems.

National service could be promoted by carrots (such as scholarships, reducing future student loan problems) as well as sticks. Some activities, such as inner city or poverty area teaching, could be regarded as service, and they raise issues of socialization and “intimacy” that can ambush people who contemplate this kind of service. Increased forms of family responsibility that apply to everyone (not just those with their own kids) such as eldercare, can color the service debate, too. Service could be something that occurs continuously or continually throughout life and is not just applied to young adults.

I’m reminded of all this, too, by an LDS (Mormon) film “God’s Army” (2000), where a young missionary-to-be is told, “Now you will spend a period of your life doing things for other people rather than yourself,” with a certain degree of moralizing. One issue, there, however, is that some people believe that “saving” others in a religious sense is a form of service, whereas others in a pluralistic society see it as proselytizing.

The expectation of universal service might take the edge off the personal competitiveness of our “society” and the paradoxes it presents in describing moral behavior. Personal expression that seems acceptable in today’s culture might become excessively self-indulgent in a culture where national but personalized service is going to become expected or even required.

The debate on this is heating up, even more as the backdoor draft for Iraq drags on.

Here is a riddle: is raising one's own family a kind of "service"?

Update: June 24, 2007

Sen. Christopher Dodd (D-CT, and 2008 presidential candidate) proposed on CNN-360 tonight a nearly mandatory service program for middle and high school students.

Earlier posting on Congressional Digest entry on this matter, here.

Media reports, new book on slavery in modern America

ABC World News Tonight had a report by Pierre Thomas, “Slavery in Modern America: Slavery in the U.S.: A Survivor’s Story : Slavery in America, 2007.” .” (Go to http://abcnews.go.com and key in “slavery” into the search box.) There were two case histories, including one Filipino girl enslaved for 19 years in California, another girl from Egypt, and another girl from Cameroon enslaved in Silver Spring MD for years. Apparently they are brought into the country illegally and held in captivity by “masters.”

Frank Eltman of the Associated Press wrote a story (from SoutotBoston.com) "Wealthy N.Y. Couple Charged with Slavery," about a couple who operated a home-based perfume business and keeping Indonesian women as slaves. The women had apparently entered the country legally but the Long Island couple stole their paperwork. The story is here.

On March 15, ABC had a story about Zach Hunter and his “loose change to loosen chains” campaign to fight slavery. Zach has written a book Be the Change: Your Guide to Freeing the Slaves and Changing the World. The March story is at this link: I have a review of the book on blogger here.

In 1997, Steven Spielberg directed the film Amistad about the African slave trade, written by David Franzoni; it would become a book by Alexs Pate, who would be invited to speak at ReliaStar in Minneapolis, where I worked, in 1999. Hunter's book discusses the 2007 independent film Amazing Grace.

Of course, we can get into the debate about illegal immigrants doing almost slave-like jobs (migrant workers, poultry shops) that Americans do not want or could not do.

Reason reviews the RFRA and religious and native American "exceptions" to drug use laws

Jacob Sullum has an article in the June 2007 issue of Reason, “Spiritual Highs and Lows: The power and peril of religious exemptions from drug prohibition”, p. 42. In great detail, Mr. Sullum goes to the rational roots of problems trying to have a prohibitionistic policy against mind altering drugs or substances, but then crying to carve out exceptions for Native Americans and, in a different set of principles, certain religious practices. Congress has always felt a certain deference to tribal practices of native Americans and has wanted to leave them autonomous on this issue, as with gaming. With religion, even social conservatives have trouble avoiding contradictions. They don’t want to have to define what constitutes legitimate religious practice, but they want to defer to it.

The article discusses in some detail the Religious Freedom Restoration Act of 1993. In 1990 the Supreme Court, in Employment Division v. Smith, had maintained that Oregon could fire a state drug counselor for tribal drug (peyote) use. In 1997, the Court rules that Congress had to show a compelling state interest when burdening religious practices at the federal level, but that it could not incorporate this idea to the states.

We get back to the inevitable observation that our country’s drug laws do stem, in some part, as a vestige of notions of public morality, however weakened in other areas like the family.

Federal agencies tend to cover up whistleblowers

Daniel Schulman has a disturbing article in the June 2007 Mother Jones, “Don’t Whistle While You Work.” The article discusses the tenure of Office of Special Counsel Scott Bloch’s alleged tendency to suppress whistleblowing, while trying to undermine federal protections for gay civil servants. (Get it, the urban legend was that homosexuals can’t whistle.)

The story gives some detailed case histories in its oblique sidebars. Joseph Darby, (in)famous for reporting the abuse of prisoners at Abu Ghraib, was told by the Army he should not return to his home town of Cumberland, Maryland (end of the C&O toe path), at the foot of the Alleghenies where strip mine country starts) because his buddies in his guard unit are from there. The sidebar says, “still fears for his life.” Richard Levernier was “retired” after his security clearance was pulled when he was too successful with mock attacks against domestic weapons depots (maybe like the Tooele depot, more here or the plutonium breeder reactor sump in South Carolina. In fact, concerns over loose domestic materials might rival those of materials loose from the former Soviet Union (so well dramatized on the Fox show “24”).

Adding to the gloom is the recent Supreme Court ruling in Garcetti v. Ceballos (2005), which maintains (with the help of Alito) “when public employees make statement pursuant to their official duties, they are not speaking as citizens for First Amendment purposes, and the Constitution does not insulate their communications from employer discipline.” Duke university discussion here; Opinion (pdf) here.

Of course, in the more mundane world of employment, people should not continue in jobs where they know what is going on is illegal. I once quite a telemarketing job when a recipient of a caller complained that I had called after 9 PM, and that this was illegal. We worked until 9:30 PM but he was right.

For many people "honor" (and the related concept of "integrity") seems to have more to do with "loyalty" to a social or political hierarchy or a blood family than with any absolute values held by the self.

Coalition to Advance Healthcare Reform

Steve Burd has an op-ed on p A19 of the May 7, 2007 The Washington Times in which he discusses The Coalition to Advance Healthcare Reform.

The Coalition advances "conservative" solutions to health care public policy fiancing problems.

It does advocate mandatory individual health insurance, with major assistance for low income families and individuals. It advocates that the same discounts (and pre-tax premium purchaes and especially in-network discounts) be available to individual purchasers as for employer-based groups, and that no one be penalized for pre-existing conditions. The model sounds a little bit like state-mandated auto liability insurance.

He also advocates incentives for healthful lifestyle choices. So far, the recommendations are not that specific, but would presumably encourage cessation of cigarette smoking. It is not clear how STD's and HIV could be handled, but some behaviors increase the risk of HIV, HBV, HepC, and so forth.

There have been comments that the huge in-network discounts usually available with group policies reflect lower administrative costs, although that can hardly explain 70% discounts not available sometimes to individuals paying for their own health care. The in-network discounts seem more related to "volume discounts" a practice well known in all business systems (what you learn as a "piece-wise function" in Algebra I !). It is critical that in any scheme to reform individual health insurance and make it mandatory, that individual consumers have access to the same in-network discounts as would employees of large companies. Can someone comment on this?

It would appear that this group favors keeping some element of "personal responsibility" or moral hazard built into public policy, but that employers should no longer be responsible for delivering health insurance, as this seriously hurts job growth. This plan seems to group health insurance carriers and BCBS plans into a basket-like "single payer," even though there are separate companies. The Coalition does advocate some elements of market competition in delivery of customer service.

The report for the state of Minnesota is here.

Health care: "moral hazard" and small employers

Milt Freudenheim has a disturbing story (in the Saturday May 5, 2007 The New York Times, p. A1) about the health care crisis, “At a Small Business, One Illness Can Send Insurance Costs Soaring,” here
(may require login or subscription). The story concerns Varney Book Store, in Manhattan Ks, where a major claim in 2001 by one employee led to a 28% increase in premiums for the other employees in 2002. Since the business is books, the story incidentally raises another issue: the pressure on small local bookstores from the large chain stores (and online e-commerce stores) with economies of scale.

The unpalatable concept is “moral hazard” and certainly can lead smaller companies that do offer health insurance to try to avoid hiring older employees or those with indirect evidence of health problems or pre-existing conditions. States have different percents that they allow group premiums to rise from one year to the next, but in some cases even in group policies (in some states) companies can be penalized if one employee fails to disclose it.

There is a related story “Many of the Self-Employed Are Simply On Their Own”, here in the same issue, also by Fruedenheim. One problem with individual insurance is that consumers lose the huge discounts on prices that providers charge when they are under contracts with group policies (these apply even before the consumer meets his deductible or annual out-of-pocket).

All of this renews the debate on the attractions of a Canadian style “single payer” system, for everybody, not just the elderly (Medicare, especially. Part A). (The Canadian system would retain individual choice of physician and would not be socialized medicine like Britain’s.) Although there is a lot of work to do on waiting lists, the American experience in being offer advanced surgery (like coronary bypass) on Medicare even to the extreme elderly (even without available family care) argues well for the idea that single payer may be more feasible than many people think. On the other hand, it has the political disadvantage (more important in a country with a large, pluralistic population) of not being able to penalize unhealthy lifestyle behaviors, since taxpayers pick up the tab (but maybe taxpayers pick it up anyway). The argument could even be posed regarding HIV (fortunately not considered in Lawrence v. Texas), even as HIV disease becomes much more manageable, as the argument can also be posed about now-legal behaviors regarding consumption of tobacco, fats, and alcohols. A right to privacy discourages government for penalizing (with criminal statutes or indirect discrimination) individual behaviors, yet the taxpayer in theory has an legitimate interest in it.

In 2001, I was traveling in Europe, and talked about health care with a French family while waiting for a train in Toulouse. (I would later meet the Dalai Lama, by accident, at Schipol in Amsterdam on that trip!) The father said, “Well, it [European government provided health care] certainly works for us.” Ideological considerations about “morality” or personal choice seem to matter little to Europeans.

Healthy Families Act bill

Democrats have promoted limited mandatory paid family and medical leave (up to sever days a year) with bills H.R. 1542 in the House and S. 910 in the Senate.

As usual, some Republicans criticize the bill as a burden on small businesses (the bill applies to employers with 15 workers or more), and might encourage larger employers who already offer some paid family leave (especially to longer tenured associates) to scale back to the minimum of the law. Democrats counter that the bill would help counter "presentism" which can be dangerous during epidemics (such as influenza). Most countries in the west outside of the US offer some paid family leave, with Sweden leading the pack.

One obvious question is whether such a law could affect "W-2" contracts that are common in information technology. There has been a gradual trend in the past year or so, however, for staffing companies in information technology to offer "corp to corp" (salaried) with more benefits (including health care) and ability to pay when "on the bench"; many companies offer new hires a choice, as retirees, for example, may already have their own health insurance or may prefer flexibility of hourly pay, to avoid unpaid overtime with salaried or certain potential legal conflicts with other activities.

The National Council of Women's Organizations has a support petition here.

HR Magazine has an article on the new proposed "paid family and medical leave act" by Bill Leonard in the May 2007 issue on p. 21.

Allen Smith has an article on p. 22 advising employers against unnecessary credit checks, as they could have an illegal disparate impact on hiring of minorities.

Rosie and John agree on tort reform

Today, news media carried stories of a lawsuit for millions of dollars against a family dry cleaning business, making all kinds of claims of emotional distress and the like. On ABC's The View short-timer (not exactly lame duck) Rosey O'Donnell came out for tort reform and the British system of "loser pays" to curb nuisance "whining" lawsuits. John Stossel has suggested this before on "Give Me a Break" on 20/20. Electronic Frontier Foundation has discussed SLAPP lawsuits against speakers, along the same lines.

The "disturbia" of this case is that the suit is being filed by an administrative law judge in the District of Columbia, and the complaint amount of $65 million comes from a literal calculation from DC's consumer protection law, $1500 per violation per day per employee, over 1200 "days" (for 12 "violations" -- the incident occurred in May 2005). What is the point of this?

Here are a couple of references:

News story-blog in The Washington Post blogs, by Emil Steiner "Real Strange News: D.C. Judge Wants $65 Million for Lost Pants; Panel Considers Reappointing Judge Roy L. Pearson, Jr.", here.

The AP story appeared in the Minneapolis-St. Paul Star Tribune on May 3, 2007, at this link.

Brian J. Taylor: "Loser Pays is winning at the state level" Oct. 1995, Reason, here.

Point of Law website.

Center for Justice and Democracy "mythbuster!" (which opposes many of these tort reforms)

Cato Institute posting by David E. Bernstein

Institute for Legal Reform (has ad in Examiner).

Anti-SLAPP Resource Center (California)

Update: June 25, 2007

A DC Superior Court judge ruled against the administrative law judge plaintiff suing the dry cleaner, and the plaintiff will have to pay court costs and maybe later (after another hearing) even attorneys fees for defendants. It's not clear if the law requires this in the case of a frivolous claim. NBC4 news story is here.