Effect Measure

If a worker refused to report for work because it was a demonstrably dangerous workplace they would be within their rights, with a few exceptions. One of the exceptions in some states seems to be health care workers (HCW) who refuse to work during a pandemic. A HCW, like any other worker, might not report for work for a variety of reasons: fear for their own safety, fear for the safety of their families should they bring home an infectious disease like influenza, need to care for their family if one is sick or has not caretaker (say, because the schools are closed). In at least two states, Maryland and South Carolina, those HCWs can be ordered to work. The two states in question took as their starting point a Model State Emergency Health Powers Act (MSEHPA), which, if enacted at the State or Federal level, would provide health authorities power to order HCWs “to assist in the performance of vaccination, treatment, examination or testing of any individual as a condition of licensure, authorization, or the ability to continue to function as a health care provider in this State.” Wnile the Model Law has been subject of serious criticism in the bioethics and health law literature (see George J. Annas. “Terrorism and Human Rights” In In the Wake of Terror: Medicine and Morality in a Time of Crisis. Jonathan D. Moreno, editor. Basic Bioethics Series. Cambridge, Massachusetts: The MIT Press, 2003), the Maryland law goes beyond MSEHPA by providing fines or jail if a HCW disobeys a direct order to report for work. A thoughtful Commentary in the Journal of the American Medical Association by Coleman and Reis (Seton Hall Law School and affiliations with WHO) examines the issues and makes the case that these laws or model laws are significantly different than “laws and penalties for failing to fulfill voluntarily assumed employment or contractual obligations”:

An HCP [Health Care Professional] who affirmatively agrees to treat patients leads hospitals and patients to rely on his or her presence and, as a result, to refrain from making alternative arrangements. If the HCP fails to follow through on the commitment to treat, those individuals and institutions that have relied on it will be worse off than if the promise had never been made. By contrast, laws that penalize HCPs for disobeying public health officials’ orders to work, regardless of the HCP’s employment or contractual responsibilities, cannot be justified as mechanisms for enforcing prior commitments. The fact that an individual is qualified to treat patients does not necessarily mean that he or she has promised to do so. (Coleman and Reis, JAMA)

Coleman and Reis discuss a variety of rationales for penalties against HCW refusals and conclude none are persuasive. They also point out that the ethical (not legal) obligation to help those in need if one has the skills to do so possibly conflicts with obligations to other patients and to the HCW’s family. They are of the opinion that penalties for HCW who refuse to report for duty are unjustified.

Laws or no laws, we know it will happen in a pandemic. Surveys suggest a significant proportion of HCWs would not report for work. But these surveys are done before the event and present hypotheticals. It is historical experience that in emergencies ordinary people rise to the occasion and do extraordinary things. This was true of HCWs in Hong Kong and Canada during the SARS outbreak and will, I have no doubt, be true if and when there is a catastrophic influenza pandemic.

As a physician I can’t predict what I would do. I hope I would act honorably and effectively in a way compatible with my sense of professionalism and my desire to help others. In truth, no one knows how they will act or for what reasons. Two things I feel quite confident about, however. One is that my actions won’t be dictated by a law of doubtful ethical standing. The other is that however I act, there will be many others who will rise to the occasion. That’s the way it has always been.

In the meantime health care institutions can maximize the incentives for any critical worker to report to work in a pandemic by providing adequate social service support for families, adequate facilities and resources, including workplace protection and personal protective equipment for HCWs, and protection of brave volunteers from liability.

Not least, we can talk encouragingly and positively about how we are all bound together as a community and owe a duty to each other. You don’t promote that idea by threatening people with sanctions.

Comments

  1. #1 mdcatlin
    April 2, 2008

    Thanks Revere,

    There is a critical need for healthcare institutions, in general, to change their approach to employee health and safety. Rather than opposing OSHA regulations (as with the fight over Tb respirator fit testing) and resisting implementing good practices (such as safer sharps and lifting), they should be creating a culture of safety that expects and champions worker health and safety protections that far exceed minimal OSHA requirements. Workers should not have to fight for proper protection before treating a Tb patient, as is often the case today.

    The recent 2007 Institute of Medicine report, Preparing for an Influenza Pandemic, Personal Protective Equipment for Health Care Workers has this culture change as a key recommendation. That report is available at (http://www.iom.edu/CMS/3740/29908/46095.aspx )

  2. #2 emeldafeline
    April 2, 2008

    Revere, having worked in health care in Toronto during the SARS outbreak (hard to believe that it’s been five years), I can state with some certainty that many health care workers will have serious reservations about working during another similar episode.

    I was quarantined, and went to funerals of other health care people that died from SARS. It took a toll on me and most of my colleagues that many of us are still working to get over.

    The Campbell report on SARS in Toronto recommended that the system implement the “precautionary principle” and assume the worst and provide the best level of protection for health workers. And yet, the hospital where my spouse works only fit tests for N95 when absolutely forced to.

    I’m not saying that the system would collapse because of staff refusals to work, since most of us actually care about our patients, but we would all think long and hard. It’s a tough call asking me to balance my professional and ethical desire to work to help others against the real fear that I could get sick and die if I do it.

  3. #3 SusanC
    April 2, 2008

    this issue was recently debated at the Flu Wiki forum here.

    I’m putting a link over there as well, to this blog. thanks, revere for highlighting this issue.

  4. #4 M. Randolph Kruger
    April 2, 2008

    Medical types HAVE to go to work for this to have an outcome with any sort of semblance of society afterwards. But before we jump off the cliff with the law and the states, understand that in a state of emergency it doesnt matter what the laws says. Its what the governor or his designee says. In most cases this is the EMA of each state or the DHS from a federal level.

    That same law says that these people also have to have equipment and training on its use. Sorry, but a goddamn N-95 or M-100 paper or composition mask just doesnt meet that rung on the ladder. Me I will go because I do have a sense of honor and to try to make sure as many people make it as possible. Its that Tennessee Volunteer thing partially, the rest is the way I was raised. My kids will bail back to the house with Mom and they will lock and load and hope they never have to use it. I and a group of employees (mostly the single kids) will report to the airport in full chemical/bio gear and work until we cant from exhaustion, lack of food, water, or God forbid BF. We have the suits, the masks, the boots and gloves. Shelter, food and water, and we are heavily armed. But this is proactive rather than reactive. HCW’s other than by designation know nothing about protection, decontamination etc. They never have to the best of my knowledge been able to show they ever put on a suit or a mask before. Therefore, the government may not deprive anyone of life, liberty, pursuit of happiness, or property without due process of law. Until they are willing to provide that equipment, train those people in a bio hazardous environment I would tell them that I lost my licenses to practice. Else sending them in is a death sentence for them and their families. Who in Hell here buys that the government will provide care and services for THEIR families during this? I certainly dont because its assumed that they themselves will not get sick while caring for the families.This one is a BS suggestion and an even bigger assumption.

  5. #5 victoria
    April 2, 2008

    Can I come and work for you Randy?

    No one can predict what will happen during a pandemic. No one, it appears is prepared to predict what the severity of the next pandemic will be. No one has categorically said that there will be a low mortality rate. One can only guess or assume that the mortality rate will be fairly high.

    The logistics of keeping a population alive during a pandemic are mind blowing. Will there be enough good will to go around. How many doctors would be prepared to risk their lives and the lives of their families?

    Assuming the worst case scenario, wouldn’t it be more prudent to have enough doctors alive to treat the survivors of the pandemic?

  6. #6 Tom DVM
    April 2, 2008

    Revere. You are quite right.

    In emergencies in the past, volunteers have stepped up and risked life and limb for others less fortunate. During two world wars, for example, young men and women stepped up to protect their communities. Many brave souls didn’t come home.

    However, as you explained in…’natural history of influenza infection in human volunteers’…a pandemic is clearly unique.

    Risking your own life in the service of others is one thing…risking your own life while potentially and unknowlingly infecting your family is quite another.

    This is a risk that only will be excepted out of ignorance…and healthcare workers are no longer ignorant.

    We lost brave souls in Ontario. They and their infected family members have been largely forgotten by the community they died to protect.

  7. #7 mdcatlin
    April 2, 2008

    I keep hearing of the need for healthcare workers to step up to this challenge. I expect that most will act heorically, given the conditions they will be forced to work in by their employers decisions. Where is the call from the professional societies, government and others for healthcare employers and institutions to do their part to do proper preparedness? What would be said about a fire department that would not provide proper SCBAs, turnout gear, training and other protections for their employees?

    Healthcare employers must be held to a higher standard for worker health and safety.

  8. #8 M. Randolph Kruger
    April 2, 2008

    MDC-Well I agree but here is the rub that we would apply to it from my side of the fence. If all things were equal and they arent and you only took the requisite food items and water that would need to go around there simply isnt enough money on this planet for it, nor is there a distribution system to get it to the people.

    A local EMA guy likened it to the fall of Corregidor in the Phillipines in WWII. Slowly, inexorably over several months it will wade in as the Japanese did (figuring high path of course) until ultimately it will take those who gave it up. Revere postures rightly or wrongly that beefing up the health care system is the way to go. He can jump in here if he wants. But in doing so it costs money and a lot of it. In the same breath though, there isnt any current treatment that works so beefing it up for what? So you cant store food, you cant beef up the health care to improve the outcomes to some new exciting level so what do you do? Not much really you can do. This bug has laid us bare and if it gets cranking its going to be ugly even at 5% rather than the year rate of 83%.

    So it drops right back into the personal responsibility thing. I have taken measures to ensure the protection of family first, employees second, and anyone else that comes down the pike third. My neighborhood is an armed, well stocked camp and they will make it I am sure. OTOH I have committed to the state that I would be there to handle transportation problems in the W. Tennessee, N, Mississippi and E. Arkansas areas. If they come up with a vax I am going to have people in commandeered airplanes delivering vax, food, other medicines and keeping the infrastructure moving. Tennessee is # 3 or 5 cant remember on the total hit list based upon deaths, impact on the local economy and the US economy. If the center holds…….

    Can we do it? Only if we can sit in the houses and let it burn itself out. If they go foraging they are going to get sick in all likelyhood. There are no answers for this one and I have said it before they will die with a look on their faces and it will be astonishment. We saw what Katrina would do and that would pale in comparison. Wont even get to play politics with this one because everyone is going to get to taste the big nasty planetary pie.

    Toms Canucks have a huge history in BF because I think due to location they got a really nasty hit. Just cold enough to really protract it longer than the States. If everyone stocks up, stays away from the hospitals and HCW/HCP’s the case numbers will stay lower. Lower than what? Well, lower than it would have been. All ambiguous until Mr. Scratch comes calling.

    Victoria, yup you can come here and work. At least you’ll get a working mask with filters, food and water and a chance to restart. A lot of people wont.

  9. #9 pft
    April 2, 2008

    Threats for HCW to report to work are absurd, but not a surprise in the Dark Ages in which we now live, where government rules by fear and threats.

    Keep in mind any pandemic infleunza will last months and the virus will linger for some years. Many people live from paycheck to paycheck so will want to work, provided it is not suicidal, and it should not be.

    Many resources will be tied up in a pandemic, yet people still need treatment for non-influenza issues. So part of any planning will include designating which hospital and clinics are to be influenza or URI only. Those designated for non-influenza status, workers and patients are screened before entering, and during work or residence, to prevent outbreaks in the hospital or clinic by removing any symptomatic person immediately. HCW in the non influenza facilities will presumably not have any issues in reporting to work. It might even make sense to arrange for in-house residence for HCW at these facilities to minimize exposure outside.

    The problem is with those having to work in the influenza patient settings.

    First, you have to accept the quality of care in a pandemic will not be the same as in a non-pandemic period, especially if a 1918 like outbreak occurs.

    There will be shortages of beds and staff. Since schools will be closed, the solution rests in converting schools to HC settings and obtaining staff from the schools whom have had some training as part of the pandemic planning. Those willing to volunteer, continue to be paid so long as the school is closed. Those who do not, will not be paid until the schools reopen. Obviously, this needs to be negotiated with the unions in advance. Other city and state workers in non essential services would be free to volunteer with full pay. In the private sector, many will be discouraged from volunteering as 47 million have no health insurance.

    Doctors will not be as important in a pandemic as nurses and those assistants who help feed and clean the patients. Those elderly with breathing difficulties will have the lowest priority for ventilators which will be in short supply and reserved for the younger patients.

    Remember, there is no cure for influenza. The patients immune systems do the curing. Patients are simply given a bed, food, drink, are are cleaned, to sustain them while they fight it. They should all be given antibiotics to prevent secondary infections that cause pneumonia. They will recover or not. The fact they are in a hospital setting, and not all influenza infected will require this, means they will die in much higher rates than those who stay home, since they are sicker. HCW should be made to understand this.

    Part of the planning should include educating people in order they don’t scare themsleves to death. SARS was an unknown disease. Pandemic influenza is still the flu, just a nastier version, it is not an unknown. Fatality rates will not be 60%. Many people will not get it due to they have some lucky or immunologicall resistant. Not all who get it will die, even in 1918 it only had a 3-5% fatality rate and many died asa result there were no antibiotics to treat secondary bacterial pneumonias. Also, 1918 was a time of great stress with World War I being fought under difficult conditions, and young men all crowded into cramped barracks that was a perfect setting for it to spread like it did. Also, the cities were full of poor immigrants living under poor conditions. People travelled in crowded trains or trolley cars.

    Once you get it though, and recover, you will be immune from subsequent infection, and thats a good thing, you don’t have that hammer hanging over your head. Those who get it first may be better off than those who get it later (like in 1918). You can run but you can’t hide. Once it goes pandemic it is likely to stick around for a few years, as it becomes endemic. You will get it sooner or later if you are immunologically predisposed to the particular strain.

  10. #10 victoria
    April 2, 2008

    pft

    Thank you. Your posting is well written, it is easy to read and understand, and contains a good deal of common sense. I agree, there is no need to panic. Preparation and isolation are what is needed.

  11. #11 Andrew Jeremijenko
    April 3, 2008

    Revere,
    I believe telemedicine could potentially be useful in a pandemic. Many influenza cases may be able to be treated at home, and history tells us many will improve. We now have the technology with telemedicine, to be able to review people safely (a videoconference through a mobile phones is now very simple to do and home BP machines, thermometers and perhaps electronic stethoscopes can give us much of the information required.) Of course there will still be need for hospitals, ICUs and health care workers for those severely ill and we hope adequate PPE will be available. For many non-immune health workers in a pandemic, we perhaps should be exploring safer ways to treat infectious people. (I am currently working in an emergency department, but have begun a company called emergency telemedicine, to connect remote and rural workers and their families with the hospital, more to improve access to health care. It may end up a safe way to spend a pandemic.) I too hope that when the time comes, health workers will rise to the occasions, but also hope health workers will be allowed to protect themselves and their families.

  12. #12 Jonathon Singleton
    April 3, 2008

    PFT, “You will get it sooner or later if you are immunologically predisposed to the particular strain.”

    Howdy, just a quick question: How does a mammal have innate protection against a transgenic pathogen which has never existed before in the history of existence?

    I can understand how a mammal eg. a U.S. nutritionist would be immunologically better off than your average malnourished third worlder! I can understand the new reality — for my Xgen, at least — of personalized pre-emptive healthcare ie. psychoneuroimmunology. To keep your body “topped-up” with vitamins, minerals, etc… But that takes money and the extreme luck of living in a stable environment like AmericanOz!

    Cheers:*0 to you Victoria — yeah, I’m flattered to think of you as my big sister (mostly boys in my ol’ family)…

    H5N1 Blog — A human/avian flu co-infection reported (March 17, 2008) by Crof
    http://crofsblogs.typepad.com/h5n1/2008/03/a-humanavian-co.html

    Excerpts from postings by Jonathon Singleton, March 18/21, 2008:

    Anyway, “Please Explain” the evolutionary paradigm of Horizontal Gene Transfer and Recombination — the set of genetic operations most probably driving a cross-species transgenic pathogen like A/H5N1: To use the clever analogy of Randy Kruger’s (see EffectMeasure), H5N1 has become the pumped-up creature it now is due to genetically modified organism (GMO) “steroids” — the viral promoters used in these artificial products are unstable and act like steroids released into the environment…

    Victoria, the eight year old ISIS abstract by Mae-Wan Ho (linked below), explains and outlines the hazards of horizontal gene transfer from genetic engineering:

    Eg. The Generation of new cross-species viruses that cause disease [well, aint this what H5N1 is!?!] + the spreading of new genes and gene constructs that have never existed before [again, aint this H5N1!?!]…

    EffectMeasure — Indonesian virus sharing and “God’s Plan” (March 2, 2008) by revere

    http://scienceblogs.com/effectmeasure/2008/03/indonesian_virus_sharing_and_g.php?utm_source=email-a-friend&utm_medium=email

    ISIS — Horizontal Gene Transfer The Hidden Hazards of Genetic Engineering (18 August 2000) By Dr. Mae-Wan Ho

    http://www.ratical.org/co-globalize/MaeWanHo/horizontal.html#p3

    The H5N1 situation in Indonesia is not unlike George Bush’s “Iraq War” — a mishandled mess with science and pragmatism held captive by a delusional ideology and agendas (eg. health minister Supari and her book which suggests transgenic A/H5N1 was created in a US bioweapons lab rather than from probable confluences of a decade-long release of unstable viral-based GMOs released into the global environment re:ze evolution paradigm of accelerated horizontal gene transfer and recombination)…

  13. #13 Jonathon Singleton
    April 3, 2008

    PFT, “You will get it sooner or later if you are immunologically predisposed to the particular strain.”

    Howdy, just a quick question: How does a mammal have innate protection against a transgenic pathogen which has never existed before in the history of existence?

    I can understand how a mammal eg. a U.S. nutritionist would be immunologically better off than your average malnourished third worlder! I can understand the new reality — for my Xgen, at least — of personalized pre-emptive healthcare ie. psychoneuroimmunology. To keep your body “topped-up” with vitamins, minerals, etc… But that takes money and the extreme luck of living in a stable environment like AmericanOz!

    Cheers:*0 to you Victoria — yeah, I’m flattered to think of you as my big sister (mostly boys in my ol’ family)…

    H5N1 Blog — A human/avian flu co-infection reported (March 17, 2008) by Crof
    http://crofsblogs.typepad.com/h5n1/2008/03/a-humanavian-co.html

    Excerpts from postings by Jonathon Singleton, March 18/21, 2008:

    Anyway, “Please Explain” the evolutionary paradigm of Horizontal Gene Transfer and Recombination — the set of genetic operations most probably driving a cross-species transgenic pathogen like A/H5N1: To use the clever analogy of Randy Kruger’s (see EffectMeasure), H5N1 has become the pumped-up creature it now is due to genetically modified organism (GMO) “steroids” — the viral promoters used in these artificial products are unstable and act like steroids released into the environment…

    Victoria, the eight year old ISIS abstract by Mae-Wan Ho (linked below), explains and outlines the hazards of horizontal gene transfer from genetic engineering:

    Eg. The Generation of new cross-species viruses that cause disease [well, aint this what H5N1 is!?!] + the spreading of new genes and gene constructs that have never existed before [again, aint this H5N1!?!]…

    EffectMeasure — Indonesian virus sharing and “God’s Plan” (March 2, 2008) by revere

    http://scienceblogs.com/effectmeasure/2008/03/indonesian_virus_sharing_and_g.php?utm_source=email-a-friend&utm_medium=email

    ISIS — Horizontal Gene Transfer The Hidden Hazards of Genetic Engineering (18 August 2000) By Dr. Mae-Wan Ho

    http://www.ratical.org/co-globalize/MaeWanHo/horizontal.html#p3

    The H5N1 situation in Indonesia is not unlike George Bush’s “Iraq War” — a mishandled mess with science and pragmatism held captive by a delusional ideology and agendas (eg. health minister Supari and her book which suggests transgenic A/H5N1 was created in a US bioweapons lab rather than from probable confluences of a decade-long release of unstable viral-based GMOs released into the global environment re:ze evolution paradigm of accelerated horizontal gene transfer and recombination)…

  14. #14 M. Randolph Kruger
    April 3, 2008

    Andrew J-The only problem with this is that if its highly pathogenic and the power grid snaps and it likely will because there hasnt been any additional stockpiling of coal (50% of US power is coal fired) we are going to be wading in deep and fast. We have only a 25 day supply of coal at most of the power production plants. If the GDP drops to nearly zero then the money becomes worthless (experiencing that kind of like now) and we wont be buying any oil. We will be trading for it. Our ace in the hole is the military on that one. Would we attack to get oil at that time? Different topic.

    I really dont have any answers for anyone other than stockpiling of all things needed. If its in your house and you can get to it, then its not a bad thing. No vax, no health care, dead HCW’s and HCP’s that close to additional new cases to me is what will happen. It could be much lighter but here in Tennessee its supposed to be 5% and thats 57,000 dead and going in a nervous and gurgling way. Not to mention the estimated 2 million that will be sickened immediately. We have beds BTW for only 19,000 and thats ALL of the beds in the state and we provide them for Miss, Arkansas too. The better part though is that a lot of this is rural and infection via contact will be much more limited.

    Its not a pretty picture that anyone can paint.

    PFT-WADR but how can you say it wont be 60% or more? Most pandemics have lost a lot of their CFR’s but this one seems to be increasing its capability. In fact its a GOOD thing that it is because it kills the hosts so quickly. That is unless you are the one that has it. You could be right but man it doesnt seem to want to play by any rules we have come to understand so far.

    Also, subsequent infection mutation is not unknown with the flu. This could mutate into a whole new strain and give it right back to them if my drinking buddy virologist is correct. He isnt stupid and this stuff scares him to death without it being here. I can only say that the basics will get you thru better than anything else out there right now. Tamiflu doesnt seem to be working too well either. UT is underway with Revere’s statin study, but its a perilous one I am told because you really wont know it will work until you give it to someone who either has the BF or that you infect with it and then try your little game on. Not nice to test on human subjects….. dim view of it from the medical community.

    But you also could be right in greater or lesser degrees. We wont know until the bus pulls up and BF gets off. Until then, keep the faith.

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