Many in the media and academia (myself included) have been discussing the Ebola crisis, and more specifically, the issues that arise as Ebola has traveled with infected patients and health care workers to the United States and infected other US citizens.
These discussions have been fascinating and frightening, but the terrifying truth is that Ebola is just the tip of the iceberg. Diseases have long traveled with patients, and as the phenomena of medical tourism and the more general globalization of health care grow, these problems are likely to grow as well.
Medical tourists are very good targets of opportunities for pathogens. Many are traveling with compromised or suppressed immune systems to destination countries for treatment with relatively high infection rates, including the risk of exposure to multi-drug–resistant pathogens.
Doctors typically distinguish commensals—the bugs we normally carry on our skin, mouth, digestive tracts, etc.—from pathogens, the harmful bacteria that cause disease through infection. But what is commensal for a person in India might be an exotic pathogen for a US population. Medical tourist patients are transporting their commensals and pathogens to the hospital environments of the destination countries to which they travel, and are exposed to the commensals and pathogens of hospitals and population at large in the destination country. These transmissions tax the health care system and the knowledge of physicians in the home country to whom the new microbe may be unknown, and diagnosis and treatment more difficult.
Air travel can involve each of the four classical modes of disease transmission: contact (e.g. body-to-body or touching an armrest), common vehicle (e.g. via food or water), vector (e.g. via insects or vermin), and airborne (although more recent planes are equipped with high efficiency particulate air (HEPA) filters reducing transmission risk, older planes are not).
We have seen several diseases travel in this way. The Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 involved a three-hour flight from Hong Kong to Beijing carrying one SARS-infected passenger leading to sixteen passengers being subsequently confirmed as cases of SARS, with eight of those passengers sitting in the three rows in front of the passenger.
In January 2008, a new type of enzyme was detected in bacteria found in a fifty-nine-year-old man with a urinary tract infection being treated in Sweden. The man, Swedish but of Indian origin, had in the previous month undergone surgeries at two hospitals in India. The enzyme, labeled “New Delhi metallo-beta-lactamase-1 (NDM-1)” was able to disarm a lot of antibiotics, including one that was the last line of defenses against common respiratory and urinary tract infection.
In 2009, a study found that twenty-nine UK patients had tested positive for the bacteria-carrying NDM-1 and that seventeen of the twenty-nine (60%) had traveled to India or Pakistan in the year before. A majority of those seventeen received medical treatment while abroad in those countries, some for accidents or illness while traveling and others for medical tourism, either for kidney and bone marrow transplants or for cosmetic surgery.
High-income countries face significant problems with these infections. A 2002 study estimated that 1.7 million patients (ninety-nine thousand of whom died as a result) developed health care-acquired infections in the United States that year. In Europe these infections have been estimated to cause thirty-seven thousand deaths a year and add US $9.4 billion in direct costs
What can be done? Although in theory airline or national travel rules can prevent infected patients from boarding planes, detecting these infections in passengers is very difficult for the airline or immigration officials, and concerns about privacy of patients may chill some interventions. A 2007 case of a man who flew from the United States to Europe with extensively resistant tuberculosis and who ultimately circumvented authorities who tried to stop him on return by flying to Montreal, Canada and renting a car, shows some of the limits on these restrictions.
Part of the solution is technological. The HEPA filters discussed above on newer model planes reduce the risk substantially, and we can hope for more breakthroughs.
Part of the solution is better regulating the use of antibiotics: overuse of antibiotics when not effective or necessary, underuse of antibiotics when they are needed, failure to complete a full course of antibiotics, counterfeit drugs, and excessive antibiotic use in food animals. This is not a magic bullet, however, and we see problems even in countries with prescription systems such as the United States.
We also need much better transparency and reaction time. Some countries reacted quickly to the report of the NDM-1 cases discussed above in issuing travel warnings and informing home country physicians, while others did not.
Finally, as became evident with Ebola, we need better protocols in place to screen returning medical tourism patients and to engage in infection control when needed.
Headline image credit: Ebola virus virion by CDC microbiologist Cynthia Goldsmith. Public domain via Wikimedia Commons.
The post Traveling patients, traveling disease: Ebola is just the tip of the iceberg appeared first on OUPblog.
There are huge changes taking place in the world of biosciences, and whether it’s new discoveries in stem cell research, new reproductive technologies, or genetics being used to make predictions about health and behavior, there are legal ramifications for everything. Journal of Law and the Biosciences is a new journal published by Oxford University Press in association Duke University, Harvard University Law School, and Stanford University, focused on the legal implications of the scientific revolutions in the biosciences. We sat down with one of the Editors in Chief, I. Glenn Cohen, to discuss the rapidly changing field, emerging legal issues, and the new peer-reviewed and open access journal.
Why have you decided to launch Journal of Law and the Biosciences?
This is an incredibly exciting time to be working in these areas and in particular the legal aspects related to these areas. We are seeing major developments in genomics, in neuroscience, in patent law, and in health care. We want to be in the forefront of this, and we think that a peer-review journal led by the leading research institutions working in this area in the United States is the way to go.
How has this subject changed in the last 10 years?
The genomics revolution, the reality of cheap whole genome sequencing, further developments in the ability to examine neuroscience, the realization that biosciences are a crucial aspect of criminal investigations, and the importance of research ethics have all become more prominent, as have roles that law and the biosciences play in the criminal justice system, health care delivery, and our understanding of ourselves.
What are the major intersections of law and the biosciences?
Neuroscience, genetics, research ethics, human enhancement, development of drugs and devices in biologics, and medical ethics, and many others.
What is it that makes this such a fast growing area of law?
First, we are fuelled by development in the biosciences, which is moving at an increasingly fast pace since we can build new technologies over old technologies. Second, there is increasing interest by jurists and by lawyers in these areas. Third is an increase in interest in health care and sciences more generally. From President Obama’s announcement of a major enterprise in studying the human brain to the passing of the Affordable Care Act, we are seeing a golden age in this field.
What do you expect to see in the coming years from both the field and the journal?
The ethical issues that have always been in the background are going to be made much more pressing, such as with cheap whole genome sequencing, fetal blood tests called non-invasive genetic testing, and increasingly science-based attempts to restrict abortion rights. All of these are raising questions that have always been present but are making them more pressing and also making it more likely that courts and legislatures will have to be the ones to wrestle with them correctly. We are hoping that the journal plays a role in answering those questions.
Last year, with the Advanced Notice of Proposed Rulemaking (ANPRM) and revisions to the common rule in human subjects’ research, there has also been a lot more emphasis and rethinking about the rules by which science operates at the level of human subject research regulation.
What do you hope to see in the coming years from both the field and the journal?
Increasing number of law students and non-lawyers realizing the important role that law has to play in these disputes and enabling discourse at a deeper level than we have seen to this date.
What does Journal of Law and the Biosciences expect to focus on within the field (trends / new approaches)?
Stem cell technology, reproductive technologies, law and genetics, law and neuroscience, human subjects’ research, human enhancement, patent law, food and drug regulation, and predictive analytics and big data . . . but those are just off the top of my head. We are hoping to get submissions in many more areas as well.
Nita Farahany, I. Glenn Cohen, and Henry T. (Hank) Greely are the Editors of the Journal of Law and the Biosciences. I. Glenn Cohen, JD, is Professor of Law and Co-Director of the Petrie-Flom Center for Health Law Policy, Biotechnology & Bioethics at Harvard Law School. Cohen’s current projects relate to reproduction and reproductive technology, research ethics, rationing in law and medicine, health policy, and medical tourism. Nita Farahany, PhD, JD, is Professor of Law & Philosophy at Duke Law School and Professor of Genome Sciences and Policy at the IGSP. Since 2010, she has served on Obama’s Presidential Commission for the Study of Bioethical Issues. Henry T. (Hank) Greely, JD, is the Deane F. and Kate Edelman Johnson Professor of Law at Stanford University, where he directs the Center for Law and the Biosciences. He chairs the California Advisory Committee on Human Stem Cell Research, is a founder and director of the International Neuroethics Society, and belongs to the Advisory Council for the National Institute for General Medical Sciences and the Institute of Medicine’s Neuroscience Forum.
The Journal of Law and the Biosciences (JLB) is the first fully Open Access peer-reviewed legal journal focused on the advances at the intersection of law and the biosciences. A co-venture between Duke University, Harvard University Law School, and Stanford University, and published by Oxford University Press, this open access, online, and interdisciplinary academic journal publishes cutting-edge scholarship in this important new field. The Journal contains original and response articles, essays, and commentaries on a wide range of topics, including bioethics, neuroethics, genetics, reproductive technologies, stem cells, enhancement, patent law, and food and drug regulation.
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The post An interview with I. Glenn Cohen on law and bioscience appeared first on OUPblog.
