Managing Public Health Threats That Traverse Geopolitical Borders: A Look at the Impact of SARS

 

By

Monica E. Nussbaum

Updated 19 December 2003

 

“As we look toward a new century, health concerns are increasingly global in scope.  Unexpected diseases have surfaced due to altered patterns of land use, the adaptability of disease pathogens, and other factors.  With the ease and frequency of international travel, disease outbreaks in foreign countries can rapidly cross U.S. borders.  This includes infectious diseases such as the Ebola virus, new variants of the AIDS virus, and dengue fever.  Pollutants in the atmosphere, water, and food chain pose equally insidious risks, contributing to a host of chronic disease and developmental disorders.”[1]

Purpose

This paper introduces readers to societal issues that must be studied from a geopolitical perspective and incorporated into state-level policy-making discussions for the establishment of effective domestic public health policy and legislation.[2]  With the increasing ease of individual travel for business and pleasure, and the transporting of goods across geopolitical borders, public health threats can rapidly traverse the globe and cause detrimental outcomes in multiple locations within human populations, animal populations, and the environment.  This paper briefly discusses the history of the formation of international discourse on public health threats, the development of United States public health policy and law concerning entry into the United States, and the development of the World Health Organization public health policy and law.  This paper will focus primarily on the impact of communicable diseases on health from a geopolitical perspective.  SARS will be an example illustrating the importance of public health powers such as the use of quarantine and isolation.[3]

Introduction

States must develop domestic public health policy by utilizing an international perspective as guidance for potential threats to human, animal, and environmental health.  The interplay between human, animal, and environmental health signifies the importance of ensuring that public health policies and laws are sufficiently broad to provide for health protection and promotion, including but not limited to human health. 

Geopolitical borders – demarcated lines that separate states – constitute the principal boundaries of international politics and law.  Boundaries remain highly significant for jurisdictional purposes; however, boundaries are decreasing in importance regarding trade, economics, development, and global health.[4]  With increasing globalization, increasing interdependencies between states, and increasing travel, existing geopolitical borders, without additional preventive measures, no longer afford sufficient protection for the public health of a state’s population – “[g]lobalization of trade and travel has increased the chances for the spread of infections.”[5]

Communicable diseases easily cross state lines and will continue to do so with ever increasing prevalence, which is why proactive measures must be taken to reduce the spread of public health threats and to counter and control known and future unknown threats.  Consequently, domestic and international barriers impeding public health, such as the General Agreement on Tariffs and Trade (“GATT”) ruling that prohibits the use of trade restrictions for enforcement of public health laws, and those barriers, which also impede the implementation of effective health policy, must be reduced significantly if not eliminated.[6]  The GATT ruling should be revised to allow restrictions to be imposed that are most likely to effectively contain a public health threat until that threat is dissipated.  The impact of SARS during 2003 signifies how “globalization has continued to erode the geopolitical boundaries of nation states, facilitating their permeation by infectious agents from distant places.”[7] 

State governments use health policies as a means of regulating and promoting the social utility of its available medical knowledge and capital.[8]  However, to establish effective public health policy, a state must look beyond strict economics and incorporate human values and ethics.  Human values are the mechanisms by which objectives, priorities, and channels are chosen to establish policy.  Human values can be viewed on an individual level, i.e., how an individual would act; or on a societal/communal level, i.e., the best interests of the community.  Medical care largely focuses on the individual without requiring analysis of the impact on a community.  Public health, by its very definition, must focus on the community and what is in the best interest of the community as opposed to the individual; therefore, in the development of public health policy and legislation, human values must be determined from the societal level.  Ethics bridge health policy and values by examining the moral turpitude of required decisions and seeking to resolve conflicts among values.[9]  States must balance their focus when establishing public health priorities for several reasons.  First, public health laws can significantly impair individual freedoms.  Second, finite resources limit the ability of a state to guard against all threats; consequently, threats must be analyzed according to potential outcomes and characterized by the feasibility of preventing negative outcomes.  For example, a state could vaccinate the entire population against a specific disease; however, that action would expend valuable resources which would then no longer be readily available, and that vaccination might have significant adverse reactions along the human scale, excluding financial cost, such as death or deformities.  In the context of communicable diseases, diseases that do not present short-term death cannot preside in priority status over diseases the cause immediate death.[10]  However, states must create flexible public health policies so that programs and resources can be readily adapted with little notice to reduce the impact that a burgeoning disease may have. 

The primary determinants of health are significant when studying international, regional, and local patterns of disease.  The primary constructs of health include: human biology, environment, lifestyle, and medical care.[11]  Of these, only one construct presents significant difficulty for management – human biology, i.e., genetics.  State policy makers have varying measures of power to impact the environment, individual lifestyles, and access to and quality of medical care.  By controlling these factors and thus reducing the risks posed to the public health of a population, states are able to formulate effective public health policy.  However, states must incorporate global awareness into domestic health policy as “[c]ommunicable diseases present enormous transnational (and often global) challenges that are beyond the governance capabilities of individual nation states and require multilateral/global approaches.”[12]  Communicable diseases know no borders, travel extensively and rapidly, and are relatively indiscriminate in choosing victims.[13]  The following table lists many health issues that should be studied and addressed in the formulation of domestic public health policy.

Public Health Issues that Can Cause Disparate Impacts Across Geopolitical Borders

Agriculture

Bioterrorism

Communicable Disease

Drug Trafficking and Use

Environmental Degradation

Genetic Modification:

§         Human

§         Animal

§         Agricultural

Hunger

Individuals Seeking Political Asylum

Medical Care: Access, Quality, and Treatment

Migrant Workers

Prostitution

Pollution

Ports of Entry

Poverty (Individual and State)

Refugees

Terrorism

Tourism

Travel (Public and Private)

§         Airplanes

§         Buses

§         Cruise Ships

§         Subways

§         Taxi cabs

§         Trains

War

War Victims

Weapons of Mass Destruction

The Development of International Discourse on the Globalization of Public Health Threats

“Because communicable diseases do not respect the geopolitical boundaries of nation states, and state sovereignty is an alien concept in the microbial world, all of humanity is now vulnerable to the emerging and re-emerging threats of communicable diseases.”[14]

“The ‘transnationalization’ of infectious diseases across geopolitical boundaries during the European cholera epidemics of 1830 and 1847 catalysed the evolution of the earliest multilateral governance of communicable diseases.”[15]  In 1851, France hosted the first International Sanitary Conference.[16]  Eleven European states attended this conference.  During the next five decades, the international community held ten additional conferences to primarily discuss the proliferation of cholera, plague, and yellow fever across borders.[17]  Although the negotiated conventions were never ratified; therefore, not becoming law, the conferences solidified the importance of addressing the spread of disease across geopolitical borders within the international community.[18]  In 1905, the Inter-American Sanitary Convention mandated notice requirements for incidence of cholera, plague, and yellow fever.[19]  The Pan-American Sanitary Code, instituted in 1924, furthered this effort by requiring either bi-weekly notification or immediate notification for a specified list of communicable diseases, and requiring immediate notification for new contagions likely to traverse geopolitical borders through international commerce.[20]  In 1912, the international community ratified a treaty to control the use of opium.[21]  By the establishment of the World Health Organization (WHO) in 1948, the list of drugs controlled through international regulation had grown to at least eighteen.[22]  Through organizations such as the WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDs (UNAIDS), the United Nations Development Fund (UNDP), United Nations Educational, Scientific and Cultural Organization (UNESCO), and the World Bank, among others, “the United Nations system has been in the forefront of the fight against disease through the creation of policies and systems that address the social dimensions of health problems.”[23]  Today, the WHO “establishes international standards on biological, pharmaceutical and similar substances.”[24]  The WHO has formulated a list of over “306 drugs and vaccines considered essential to help prevent or treat over 80 per cent of all health problems,” and over 140 states have adapted this list.[25]

Many states restrict tourists and immigrants infected with specific diseases from entering their territory.  Some states test all arriving foreign residents for specific diseases while others test specified groups.  For example, the United States remains the only Western country to either completely bar entry or require special waivers for entry for foreigners with AIDS.[26]  With the emergence of the new and highly communicable disease SARS in late 2002 and 2003, many states reviewed and updated their domestic public health laws and policies and their regulations imposed on persons engaged in travel to and from sites with known SARS cases whether the travel was domestic or international, including the potential usage of quarantine and isolation.[27]

The History of US Policy and Law: Communicable Disease as a Geopolitical Threat

In the United States, medically screening immigrants is not a new phenomenon.[28]  During the late 19th and early 20th centuries, individuals infected with specified contagious diseases were prohibited from entering the United States.  In 1987, Congress prohibited entrance of HIV-infected immigrants and travelers into the United States.[29]  Through the Fogarty International Center (FIC), the United States has provided training for over 1000 scientists and health professionals from over 80 countries in AIDS prevention.[30]  The individuals trained at the FIC’s AIDS International Training and Research Program constitute important geopolitical links in the battle against the spread of HIV/AIDS. 

The CDC is one of the primary public health agencies in the United States and is focused on promoting “health and quality of life by preventing and controlling disease, injury, and disability.”[31]  Today, the CDC includes the Division of Global Migration and Quarantine to reduce “morbidity and mortality due to infectious diseases among immigrants, refugees, international travelers and other mobile populations that cross international borders.”[32]  The Division of Global Migration and Quarantine also focuses on “promoting border health and preventing the introduction of infectious” diseases into the United States.[33]

Executive Order 13295, dated April 4, 2003, grants the CDC authority to apprehend or detain individuals to prevent the introduction, transmission, or spread of the following specified communicable diseases: “Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named.”[34]  In addition, the Executive Order added the newly discovered disease SARS to the list of quarantinable diseases. 

Title 42 section 71 of the United States Code regulates foreign quarantine by specifically regulating those diseases that are quarantinable, reporting measures for various methods of travel, sanitary inspection requirements upon arrival at US ports, and how to handle imported goods.  Title 42 of the United States Code (42 U.S.C. §§264-272) specifies the regulations controlling communicable diseases, the regulations for quarantine, and the applicable penalties for violations.  Section A provides for promulgation and enforcement by the Surgeon General.[35]  Section B provides for the apprehension, detention, or conditional release of individuals.[36]  Section D provides for the apprehension and examination of persons reasonably believed to be infected with a communicable disease in a communicable stage.[37] 

42 U.S.C. 265 regulates “the suspension of entries and imports from designated places to prevent spread of communicable diseases.”[38]  The CDC operates eight fully staffed quarantine stations in the United States.  In addition, the CDC places quarantine inspectors at United States’ borders and ports of entry to respond to possible illnesses in arriving individuals and to ensure that appropriate medical steps are taken.[39] 

A Brief History of WHO Policy and Law: Communicable Disease as a Geopolitical Threat

In 1951, the World Health Organization created and adopted the International Sanitary Regulations, which was subsequently modified and renamed as the International Health Regulations (IHR).[40]  The IHR, a legally binding set of regulations, constitutes “one of the earliest multilateral regulatory mechanisms strictly focusing on global surveillance for communicable diseases.”[41]  The fundamental principle of the IHR is to keep interference with world traffic at a minimum while ensuring maximum security against the spread of diseases.[42]  The WHO requires member states to report outbreaks of specified communicable diseases.  In addition, during outbreaks of specific diseases, the IHR requires travelers from infected areas to present health and vaccination certificates.[43] 

Compliance with the WHO IHR appears to be lax as member states are fearful about consequences, such as trade restrictions, if outbreaks are reported.  Consequently, the WHO, through revision, has focused on “five key areas: global health security (epidemic alert and response), public health emergencies of international concern, routine preventive measures, national IHR focal points, and the need for synergy between the IHR and other related international regimes.”[44]  Additionally, international organizations, not formally associated with healthcare and public health, are beginning to understand the impact of public health threats across a broad spectrum of arenas.  For example, the World Trade Organization (WTO), an international organization outside of the health sciences field, adopted the Doha Declaration, in recognition of “the gravity of the public health problems afflicting many developing countries, especially HIV/AIDS, tuberculosis, malaria, and other epidemics.”[45]  Additionally, the Declaration on the TRIPS Agreement and Public Health, adopted on November 14, 2001, outlined seven issues related to the promotion of public health by the World Trade Organization, including intellectual property rights for pharmaceuticals and allowing members to take necessary steps to protect public health.[46]

In 1988, the WHO established a partnership to combat river blindness in West Africa.  This partnership was more recently was expanded to include thirty endemic countries in Africa.[47]  In addition, the WHO launched the Global Polio Eradication Initiative in 1988 with the mission of eradicating transmission of wild poliovirus by the end of 2000.[48]  In 1997, the WHO initiated a program to combat meningitis and rabies.[49]  In 1999, the WHO began to target malaria and tuberculosis.[50]

The Importance of Public Health Protective, Preventive, and Containment Measures during the SARS Outbreak of 2002 and 2003

            Recently, individuals located not only in one geographic region but also around the world have contracted the relatively new and unknown disease known as Severe Acute Respiratory Syndrome (SARS).  The rapid spread of this highly contagious disease greatly taxed the public health systems of numerous states.  “As bacteria and viruses become resistant to anti-microbials and new emerging infections appear, it can be expected that personal restrictions and isolation will again be a core strategy in public health.”[51]  The outcomes of outbreak, which initiated in Asia and rapidly spread to neighboring countries and to over two dozen countries in four continents, perhaps were not as catastrophic as could have been because of specific public health measures including the use of quarantine and isolation.  Quarantine is a public health tool whereby individuals who have been in contact with infected individuals or localities are prohibited from activities outside a specified area for a specified time in order to ensure that the individual does not develop the disease and subsequently spread that disease to others.  Isolation is a tool in which infected individuals are isolated until the likelihood of spreading the disease to others has subsided.  The difference between quarantine and isolation is that with quarantine the movement of non-infected persons is restricted, whereas with isolation the movement of infected persons is restricted.  An individual in quarantine who contracts the disease will be moved to isolation.  Although these protective measures have been implemented for hundreds of years, these “[p]ersonal restrictions pose two legal problems: they violate an individual’s right of autonomy, and they can be an invasion of privacy to the extent that they must be publicly known.”[52]  As of mid-April 2003, 3,200 individuals had contracted SARS and 154 had died from this disease.  SARS did not come to the attention of the global public health scene until March 2003; however, the first known cases were identified as early as November 2002.  Due to the rapid spread of SARS around the world, the WHO issued its first-ever travel warning in early April 2003 advising individuals against traveling to Hong Kong and the Guangdong province unless absolutely essential.[53]  Between “November 1, 2002 and May 14, 2002, a total of 7,628 SARS cases were reported to the WHO from 29 countries” and “587 deaths . . . have been reported.”[54]  To understand why quarantine and isolation are effective public health tools that must be kept in the repertoire of methods for controlling the spread of disease, it is useful to analyze the impact of SARS on those states that were most severely impacted: China and Taiwan.  Additionally, a look at how the United States managed the SARS epidemic provides comparative data about the impact of quarantine and isolation. 

China: Between March and July of 2003, approximately 2,521 probable cases of SARS were reported.[55]  Consequently, an estimated 30,000 Beijing residents were quarantined in their homes or quarantine sites.  Initially, the Chinese Ministry of Health required quarantine to last for fourteen days for persons who met specified criteria for contact with a known SARS infected person.  The period was later reduced to ten days and subsequently to three days.[56]  Additionally, persons who entered Beijing with fevers greater than 100.4 degrees Fahrenheit and who arrived from SARS infected locations were also placed under quarantine.[57]  All persons who were placed under quarantine received daily visits from quarantine officers and were provided with necessities such as food and medicine.  If an individual contracted the disease then he/she was transferred from home quarantine to a hospital for isolation.[58]  The Chinese Center for Disease Control and Prevention (China CDC) conducted a survey to determine the efficacy of quarantine and to guide future policy decisions.  Within the Haidian District, 5,186 persons were quarantined at some point during March 1 through May 23.  After May 26, 1,210 residents were sampled with an eighty-five percent response rate.  Of these individuals, 232 acquired probable SARS during their quarantine period, and only individuals who had a history of contact with a SARS patient acquired SARS during the quarantine period.[59]  This survey is significant because it illustrates which populations are most likely to contract SARS and, therefore, should be placed under quarantine.  By “focusing only on persons who had contact with an actively ill SARS patient . . . the numbers of persons quarantined [would have been reduced] by approximately 66% . . . .”[60]  However, it is important to note that the survey conducted is subject to several limitations, including but not limited to the following: 1. It is an initial survey.  2. The survey was not representative of all persons quarantined.  3. It was subject to self-reported data.  4. The infection status of the participants was not based on clinical diagnosis.[61]

Taiwan: In Taiwan, 131,132 persons were placed under quarantine, of this 50,319 persons had close contacts with SARS patients and 80,813 were travelers from WHO-designated SARS-affected areas.[62]  The quarantine was extensive because “unrecognized cases of SARS led to nosocomial clusters and subsequent spread,” which “resulted in substantial morbidity and mortality and resulted in the closure of several large health-care facilities.”[63]  In Taiwan, quarantined persons were required to take their own temperature several times per day and to seek immediate medical care if any of the following symptoms were present: cough, fever, shortness of breath, and other respiratory symptoms.  Additionally, Taiwan quarantined persons on two levels that allowed varying degrees of activity outside of the quarantine site.  However, trips outdoors were recorded to ease in possible future investigations.[64]  As of yet, an analysis of the impact of quarantine and isolation has not been conducted in Taiwan.

United States: By May 14, 2003, 345 SARS cases were identified in the United States and reported from thirty-eight states.[65]  Sixty-four of these cases were classified as probable SARS which is more serious than suspect SARS.  Of these cases, approximately ninety-seven percent were attributable to international travel within ten days prior to onset of illness.[66]  The United States, in contrast to China and Taiwan, did not incur significant secondary spread and consequently did not utilize quarantine as a preventive measure; however, infected individuals were isolated.[67]  During the SARS outbreak in the United States, CDC quarantine officials:

§         Provided information about SARS to air travelers and to persons traveling via cargo and cruise ships who were arriving, directly or indirectly, from East Asia,

§         Distributed over 20,000 health notices advising travelers that they might have been exposed to SARS and how to monitor their health,

§         Assessed symptoms of individuals on airplanes to ensure they do not have SARS, and

§         Updated government agencies, and state and local health departments.[68]

Conclusion

“Public health is no longer the prerogative of physicians and epidemiologists.  International health law, which encompasses human rights, food safety, international trade law, environmental law, war and weapons, human reproduction, organ transplantation, as well as a wide range of biological, economic, and sociocultural determinants of health, now constitutes a core component of global communicable disease architecture.”[69]  Specific behaviors and related diseases disproportionately affect developing countries, which already have fragile health and social infrastructures.  For example, the increase of injecting drug users in developing countries presents threats of outbreaks of HIV and hepatitis C.[70]  To effectuate scientific solutions for global health threats, the international community must make a coordinated global response.  Dr. John Evans, Chairman of the Commission on Health Research for Development, aptly remarks in testimony before the United States House Appropriations Committee, “that with increased awareness of global interdependence in health, self-interest should reinforce humanitarian concerns’ in our efforts to improve global health.”[71]  One mechanism by which to achieve improved global health is to shift public health education from focusing primarily on research to preparing and enabling providers to implement appropriate public health practices.[72]  However, to effectively combat the spread of highly communicable diseases, especially those diseases which are new and the pathology of which is not yet understood or known, it is imperative for states to inform the international community of local public health problems.  The spread of SARS might have remained much more localized if China, the first state to see the disease, had informed the WHO and the international community of the unknown pathogen when the pathogen first appeared.  As previously stated, the first case of SARS was diagnosed in China in November of 2002; however, the international community did not become aware of the virus until March of 2003, at which point, the disease had already spread to many states and infected many persons.  Although detrimental economic effects might befall a state when that state reports an unknown and highly communicable disease to the international community, the economic effects will most likely be temporary and the international community will aid in addressing the disease and preventing further spread, and thus protecting the public health of many states.  “The international spread of disease underscores the need for strong global public health systems, robust health service infrastructures, and expertise that can be mobilized quickly across national boundaries to mirror disease movements.”[73]

 



[1]     Schambra, Dr. Philip E.  “Testimony on the Fogarty International Center’s FY 1998 Budget.”  Before the House Appropriations Committee, Subcommittee on Labor, Health and Human Services, Education and Related Agencies.  March 5, 1997.  Available at: http://www.hhs.gov/asl/testify/b970305e.html.  Accessed on: January 29, 2003.

[2]     Many of the issues discussed are to some extent reflected upon by international health organizations for the formulation of international governmental and organizational policies; however, this paper serves to illustrate the importance of incorporating these issues into the formulation of domestic public health policy to safeguard against threats and to ensure a healthy public.

[3]     See Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, New York: Touchstone, 2001, for an interesting discussion of the flu pandemic of the early twentieth century.

[4]     Klare, Michael T.  “Redefining Security: The New Global Schisms.”  Current History.  November 1996: 353-358.  SIRS Database.

[5]     Basic Facts About the United Nations. New York: United Nations, 1998 (164).

[6]     GATT’s restriction has one exception: trade restrictions can be used to enforce public health law only if the state can show that the state is using the least trade restrictive policy possible.  Breslow, Marc.  “How Free Trade Fails: How GATT & NAFTA harm democracy, ecology, & the Third World.”  Dollars and Sense.  October 1992: 6-9.  SIRS Database.

[7]     Aginam, Obijiofor.  “International Law and Communicable Diseases.”  Bulletin of the World Health Organization 2002.  Available at: http://www.who.int/bulletin/pdf/2002/bul-12-E-2002/80(12)946-951.pdf.  Accessed on: February 5, 2003.

[8]     Bankowski, Zbigniew.  “Ethics and Health.”  World Health.  April 1989: 2-6.  SIRS Database.

[9]     Id.

[10]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Great Decisions.  New York: Foreign Policy Association.  1992: 69-78.  SIRS Database.

[11]   Foster, Harold D.  “Reducing the Incidence of Disease – Clues from the Environment.”  Environment.  April 1989, Volume 31, Number 3.  Published by Heldref Publications.  SIRS Database. 

[12]   Aginam, Obijiofor.  Supra note 7.

[13]   Infectious diseases largely do not discriminate between persons; however, individual risk factors, including age, general health status, and co-infections, do impact both the likelihood that an individual will acquire a specific disease and the impact of that disease on the individual.  Although the average of persons with SARS was in the range of thirty to forty years of age, young children and olders persons, and persons with other health problems were much more likely to have significantly worse outcomes, including death, brought on by the SARS virus.

[14]   Aginam, Obijiofor.  Supra note 7, at 946.

[15]   Id. 

[16]   Id at 947.

[17]   Id. 

[18]   Id. 

[19]   Id. 

[20]   Id. 

[21]   “Global Drug Use and NIDA.”  NIDA Invest Newsletter.  Edition: Summer/Fall 2002.  National Institute on Drug Abuse. Available at: http://drugabuse.gov/about/organization/International/INVESTSummer02/Invest1.htm  Accessed on: January 29, 2003. 

[22]   Id.

[23]   Basic Facts About the United Nations.  Supra note 5, at 165.

[24]   Id at 167.

[25]   Id at 164.

[26]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Supra note 10.

[27]   For further information, see generally the Centers for Disease Control and Prevention website at www.cdc.gov and the World Health Organization website at www.who.int.

[28]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Supra note 10.

[29]   Id.

[30]   Schambra, Dr. Philip E.  Supra note 1.

[31]   “About CDC.”  Centers for Disease Control and Prevention.  Available at: http://www.cdc.gov.  Accessed on: April 10, 2003.

[32]   “Division of Global Migration and Quarantine.”  Centers for Disease Control and Prevention: National Center for Infectious Disease.  Available at: http://www.cdc.gov.  Accessed on: April 10, 2003.

[33]   Id.

[34]   Exec. Order No. 13,295: Revised List of Quarantinable Communicable Diseases, revoking Exec. Order No. 12,452 of December 22, 1983.

[35]   42 U.S.C. § 264(a).

[36]   42 U.S.C. § 264(b).

[37]   42 U.S.C. § 264(d).

[38]   42 U.S.C. § 265.

[39]   “The SARS Investigation: The Role of CDC’s Division of Global Migration and Quarantine.”  The Centers for Disease Control and Prevention.  March 31, 2003.  Available at: http:www.cdc.gov.  Accessed on: April 13, 2003. 

[40]   Aginam, Obijiofor.  Supra note 7, at 947.

[41]   Id.

[42]   Id. 

[43]   Id. 

[44]   Id at 948.

[45]   Id at 949. 

[46]   “Declaration on the Trips Agreement and Public Health.”  Adopted November 14, 2001.  Available at: http://www.wto.org/english/thewto_e/minist_e/min01_e/mindec1_trips_e.htm.  Accessed on: December 16, 2003.

[47]   “WHO In Partnership: Examples of Work With The Public and Private Sectors to Fight Infectious Diseases.”  Fact Sheet No 235, October 1999.  Available at: http://www.who.int.  Accessed on: April 10, 2003.

[48]   Id.

[49]   Id.

[50]   Id.

[51]   Edward P. Richards, III and Katharine C. Rathbun, “Public Health Law,” Public Health and Preventive Medicine, 14th Edition, New York: McGraw-Hill, 1998 (1153).

[52]   Id.

[53] “SARS: Timeline of an Outbreak.”  April 15, 2003.  WebMD with AOL Health.  Available at: http://aolsvc.health.webmd.aol.com.  Accessed on: April 15, 2003.

[54]   “Update: Severe Acute Respiratory Syndrome – United States, May 14, 2003.”  May 16, 2003 / 52(19):436-438.  Available at: http://www.cdc.gov.  Accessed on: December 12, 2003.

[55]   “Efficiency of Quarantine During an Epidemic of Severe Acute Respiratory Syndrome – Beijing, China, 2003.”  October 31, 2003 / 52(43); 1037-1040.  Available at www.cdc.gov.  Accessed on: December 12, 2003.

[56]   Id.

[57]   Id.

[58]   Id.

[59]   Id.

[60]   Id.

[61]   Id.

[62]   “Use of Quarantine to Prevent Transmission of Severe Acute Respiratory Syndrome – Taiwan, 2003.”  Available at: www.cdc.gov.  Accessed on: December 12, 2003. 

[63]   Id.  

[64]   Id.

[65]   “Update: Severe Acute Respiratory Syndrome – United States, May 14, 2003.”  Supra note 54.

[66]   Id.

[67]   Id.

[68]   Id.

[69]   Aginam, Obijiofor.  Supra note 7.

[70]   “Global Drug Use and NIDA.”  Supra note 21.

[71]   Schambra, Dr. Philip E.  Supra note 1.

[72]   Sternberg, Steve.  “Better Public Health Training Urged: Preparation for Terror Attacks Needed.”  Gannet News Service or USA Today.  November 5, 2002.  SIRS Database.

[73]   “Update: Outbreak of Severe Acute Respiratory Syndrome – Worldwide, 2003.”  March 28, 2003 / 52(12): 241-248.  Available at: www.cdc.gov.  Accessed on: December 12, 2003.