Friday, July 29, 2016

First cases of Zika transmission in the U.S. are reported in Florida today

Today, CNN was the first to break the story that four cases of Zika have been found in Miami-Dade and Broward Counties, Florida. The Florida governor made the announcement at a press conference. In an unprecedented legal step, the counties' public health authority is going door to door to test the urine of residents in this one zip code area to determine if there are other infections. The urine test is less invasive of privacy interests than a blood test, and will also be easier to administer with less skill required to do the testing. Based on the call for voluntary testing from the public health department in other notices, this door-to-door testing is likely voluntary, not mandatory. It will be interesting to see how the county may deal with refusals for a urine test. If the public health authority ordered the residents in the zip code to submit to a urine test, the judicial test to issue an order would be that the public health interest outweighed the privacy interest, and there was no less invasive way of accomplishing the governmental goal. It is unlikely we will see that case, but the question may arise in some other context in the future. 

Wednesday, July 27, 2016

A Legal anthropological look at the impact of Zika in Brazil

The prevalence of Zika in Brazil is a national crisis. There may be some irony in the quandry of a nation that is 65% Catholic being faced with knowledge that many of their next generation of children have microcephaly at the first or second trimester, making this all the more painful and gut-wrenching for the Brazilians, as the rest of the world looks on. As of early July 2016, the World Health Organization reports there have been 1656 confirmed cases of Zika in Brazil, a number that dwarfs every other country by almost 100 times. Zika, the documentary, a resource noted by the Medical Anthropology section of the American Association of Anthropology (of which I am a member) highlights the flow of expectant mothers into the clinic who are told their babies have been affected by their infection with Zika, displaying the harsh reality of the decisionmaking process. 

Most of the parents seem accepting and are often given hope by the medical advice that it is the degree of microcephaly that is important. The possibility of Guillain-BarrĂ© Syndrome (GBS) is another diagnosis that could come later, and not mentioned, at least in the film. What this film adds to dozens of internet videos on Zika is the impact on the lives of Brazilians and the future of a generation or more of children with microcephaly, as well as the mental anguish and family impact of the experience with the pregnancy, birth and afterbirth period. As depicted in the film, the resources for traveling to clinics for "stimulation" or for treatment, as well as other care is a government benefit, and many are still waiting for it. Clinics that care for infants with microcephaly are state-supported, as well. One mother was unable to continue working due to the requirements of care of her infant with microcephaly. Many other families may have husbands who are out of work, and the mother's job was the only one providing resources for the family. 

The upshot is that Brazil is in for a massive requirement for resources in so many ways for the future, that it is frightening, for any country no matter how wealthy. This will include special education, special care, workforce shifts, national productivity, increasing burdens on social benefits that are going to be reduced by the drop in productivity and potentially a drop in GDP, a measure of the health and stability of a government. 

As a largely Catholic country, the termination of pregnancy is highly unlikely unless the health of the mother is at risk. However in 2012, the Supreme Federal Court ruled that a pregnancy could be terminated for anencephaly, or the absence of part of the brain. In at least one case in the film, the cerebellum was missing from the baby. But it was not without a fight. It started in 2004 when the National Federation of Health Workers filed a case to declare women who could not legally abort a fetus that was destined to die within 24-48 hours after birth because it was a violation of human dignity, i.e., the UN Declaration of Human Rights. The Attorney General brought the 2012 case, but over the objection of the Council of Bishops in Brazil.  The Supreme Federal Court vote was 9-2 in favor of changing the law to include anencephaly to rape and life of the mother reasons for abortion. 

Zika is making its way on a rapidly unfolding global itinerary and there is little to no plan to address it. The EU just had its first case of microcephaly attributed to Zika. Who/WHO should be leading an effort to confront this global threat? Is WHO doing enough? On February 1, 2016, rather late, the WHO took action under international law, using the International Health Regulations to declare a Public Health Emergency of International Concern (PHEIC). Since, WHO has deployed 95 WHO experts, globally as of July 16, 2016 in their mission to address Zika. Is there a cohesive strategy? The WHO strategy for the Americas is simply to diagnosis and research the problem, and not one word is expended on killing mosquitos, which is the most effective way to avoid the problem.  However, by March 2016, recommendations were finally issued by the WHO Public Health Emergency committee convened under the International Health Regulations which focused on mosquito control.

Tuesday, July 26, 2016

Always worry when Russia has an anthrax outbreak

The report of an anthrax outbreak and evacuation in Russia in the Yamalo-Nenets autonomous region of northern Russia where 1200 reindeer "suddenly" died is not typical of a few reindeer being exposed to an unearthed diseased animal, the Russian's stated diagnosis. The last time there was an outbreak in what is now Russia, and a swath of sheep "suddenly" died, with a few dozen humans; the USSR claimed it was caused by contaminated meat that was purchased on the black market. Thirty years later, the true reason came to light, that the source of the anthrax infection was actually a leak from a bioweapons plant in Sverdlovsk. If you try to do a Google search today for Sverdlovsk, you probably will not find very much about the city -- they changed the name of the city after the incident.

The reported evacuation of 63 nomadic families in the region and emergency evacuation of two children, is not an infection from contaminated reindeer, but suggests inhalation anthrax, a highly uncommon infection unless spores are aerated and present in a high enough concentration to cause infection -- also inconsistent with a claim that an infected animal was unearthed by a few reindeer.

Getty images
Reportedly, the last anthrax outbreak in the region was 1941. 

Let's hope we don't have to wait 30 years this time to find out the reason for an anthrax outbreak that covers a land mass the size of Turkey.

Monday, July 25, 2016

Forgotten Tragic Deaths from Smallpox in the Revolutionary War

The notice of a ceremony to recognize those prisoners of war who were disgorged onto the Long Island to die by a British warship, reminded me of how horrific the threat of smallpox was during the Revolutionary War, yet it is rarely mentioned as a cause of so many casualties. But this ceremony to honor those who died of smallpox is a story that will make you grimace. 

The American soldiers were captured in the Battle of Long Island, August 27, 1776, the first major battle on American soil after the USA declared independence in July. By December 1776, the British must have decided the prisoners of war, who were all sick with smallpox, would just be left to die when they dumped them on the shore of Long Island Sound. Note the temperature was probably in the 20s given the historical record of the Battle of Trenton in December 1776.  

There were no governing laws of war in 1776 other than international humanitarian customary laws of war, some of which had begun to build on humanitarian customs.  Gen. George Washington, after the Battle of Princeton, January 1777, put in charge Lt. Col. Samuel Blatchley Webb, to ensure British soldiers were treated in a humanitarian manner. Gen. Washington wrote, "You are to take charge of privates of the British Army . . . Treat them with humanity, and Let them have no reason to Complain of our Copying the brutual example of the British Army." (See, Gary D. Solis, The Law of Armed Conflict: International Humanitarian Law in War, p.14, Cambridge Univ Press, 2016). One can only assume, Gen. Washington might have included in his reference the treatment of smallpox-infected prisoners of war. 

So, what was the motive in dropping off 46 smallpox-infected prisoners of war on the shores of Connecticut in Milford, a heavily populated area for the time, if not in hopes that they might all disperse to their homes and infect the civilians of Connecticut? A possible biological attack that has been overlooked? The British were fans of biological terrorism which we know from Sir Jeffrey Amhearst's letter outlining his plan to give infected smallpox blankets to the Pequots. We may never know.