Using the Law to Prepare for Global Health Emergencies

CDC country office sign in Liberia

Countries need to be prepared to handle emergencies. Having the right laws in place is an important part of the preparation.

When laws are not clearly defined, responders can have a hard time figuring out what to do during a public health emergency and who has the authority to take action. When a deadly disease outbreak hits, this can have devastating consequences.

Liberia knows firsthand what can happen when laws don’t match the needs in the field. Their experience with the recent Ebola epidemic exposed gaps in legal authority during the response. This is one reason why Liberia’s government recently reached out to the GHSA Public Health Law Project. The project team is helping them document issues that could be improved by updating Liberia’s public health law, which was last fully revised in 1976.

Advancing the Global Health Security Agenda

Bucket of bleach for washing of hands before entering public buildings and entering counties
Ebola preventive measures in Liberia: Buckets of chlorine solution to wash hands before entering public buildings and entering counties.

The GHSA Public Health Law Project takes a close look at how the law can help (or hinder) countries as they prepare to handle public health emergencies through the Global Health Security Agenda (GHSA). Right now, over 50 countries around the world are working through the GHSA to improve their ability to prevent, detect, and rapidly respond to infectious disease threats. The GHSA Public Health Law Project currently covers nearly half of the GHSA countries. The team helps analyze the laws of a country and provides training to country officials to help them understand the importance of law as a public health tool.

The team begins its work by gathering information about existing laws and talking to experts about how public health law works in their country. In Liberia, the team found that people felt unclear about their roles during the Ebola response. As one country health official told the team, “There is confusion about roles in an emergency and enforcement. What is the role of the police? The ministry of health? The military? [This] needs to be better defined.”

Public Health Law in Liberia

Before the CDC team arrived in Liberia, the Ministry of Health’s Legal Counsel were already taking the lead to help modernize the law. This is a massive undertaking that the Government of Liberia hopes to accomplish as soon as possible.

The Liberian Ministry of Health’s (MOH) Legal Counsel and CDC’s Country Office Director invited the CDC project team to help them reach this goal through research and analysis of where there may be gaps in the law. The project team worked with a team from the University of North Carolina’s School of Government, who were invited for public health law support by Liberia’s Chief Medical Officer.

CDC Public Health Law team
From Left to Right: Jeff Austin (University of North Carolina), Emily Rosenfeld (CDC), Akshara Menon (CDC), Tomik Vobah and Aimee Wall (University of North Carolina)

Liberia will be able to use the information gathered by the team as they update their public health law. Once the laws are updated, the next step is making sure people are aware of them. A county health official laid out the problem he saw in Liberia: “Fundamentally, what is wrong is that the public health law is not widely known.” This official had been a practicing doctor for 11 years, but he had only read Liberia’s public health law for the first time two weeks prior to talking with the team.

Planning for the Future

The GHSA Public Health Law Project is being done collaboratively between CDC’s Center for Global Health and the Public Health Law Program. The project is compiling the laws from these countries into a single, searchable database to give a more complete picture of the legal landscape relating to the GHSA. The legal data obtained from this project will be a valuable resource when countries want to update their public health laws.

This initial legal mapping phase is only the beginning. What is really vital is how countries will use this information to help guide their work. The law can be an effective tool in meeting global health security goals and protecting people’s health — not only when a crisis hits, but every day.

Tiny Turtle–Serious Health Threat

Turtle, on the rocks, illuminated by the sun

By Abigail Ferrell, JD, MPA

As children, my brother and I talked our very patient mother into letting us have a wide variety of creatures as domestic pets. Nothing too exotic—mostly cats, dogs, and vermin (read: hamsters)—but my brother was also famous for catching wild creatures. We lived near a pond and my brother’s summers were spent feeding, wading, fishing for, and catching all kinds of aquatic life. He was usually allowed to keep a creature for an afternoon but then had to release it back to its home.

 Wild, freshwater turtles are difficult to catch and, other than a couple of accidental catches while fishing, I don’t remember many interactions with wild turtles. But once he caught two different turtle species on the same day: a common snapping turtle and a painted turtle. He commandeered two of our grandmother’s buckets and kept the turtles for a few hours before releasing them unharmed, but not before looking them up in our grandmother’s wildlife books and wearing himself out running back and forth between the two buckets and the house.Young boy looking through magnifying glass at a turtle
I hadn’t thought about my brother’s captive turtles in years, but they came to mind when CDC’s Public Health Law Program (PHLP) and National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) began researching state laws directed at turtle-associated salmonellosis. As the attorney in charge of PHLP’s communications outreach, in cooperation with Aila Hoss and Don Benken, PHLP’s attorney subject matter experts, and the Office for State, Local, Tribal and Territorial Support’s communication team, I helped write our communications plan and identify the audiences who would most benefit from our research. Reading Ms. Hoss’ research and NCEZID’s background information about past turtle-associated salmonellosis, I suddenly remembered why my brother was discouraged from catching wild things (it’s dangerous and, in most states, illegal) and especially warned away from turtles. Turtles, particularly small turtles, can carry Salmonella—the bacteria that causes salmonellosis.

Salmonella causes an estimated one million illnesses in the United States every year, resulting in about 19,000 hospitalizations and 308 deaths. Most people infected with Salmonella develop diarrhea, fever, and abdominal cramps between 12 and 72 hours after exposure. The illness usually lasts four to seven days, and most people recover without treatment. In critical cases, the infection can spread from the intestines to the bloodstream and then to other body sites. In those cases, salmonellosis can cause death, unless the person is treated promptly with antibiotics. Elderly persons, infants, and those with impaired immune systems are more likely to get a severe illness, though those at highest risk for salmonellosis are children under age five.

wordsSmall turtles are often sold as pets for young children, which is a problem because small children might not wash their hands after handling turtles or items that have been touching the turtle or the turtle’s habitat. Also, small children might view turtles as toys and kiss, lick, or place the turtles in their mouths, as they might any other small object. In 2012, there were eight multi-state outbreaks of turtle-associated salmonellosis in the US and in Puerto Rico, resulting in 78 hospitalizations; 70% of those affected were children under age 10.

Federal law prohibits the sale of “viable turtle eggs and live turtles with a carapace length of less than 4 inches” (a standard deck of playing cards is about 3.5 inches long). Federal law allows for limited exceptions; turtles may be sold for “bona fide scientific, education, or exhibition purposes, other than use as pets.” In addition to this federal law, many states have also passed laws regulating the sale of turtles or have incorporated the federal law into their state codes by reference.

Although the federal law applies to all states, the preemption doctrine allows states to establish more stringent requirements than the federal law regarding the sale of turtles. Preemption issues are complex, but generally, if state requirements are less stringent, the federal law prevails. Some states select to enact their own laws to ensure that state resources can be used for enforcement, or if the federal standard changes.

PHLP and NCEZID have created several resources explaining turtle-associated salmonellosis, including a menu of each state’s laws  and an infographic explaining the trouble with tiny turtles. It is important to understand how illnesses like these occur and can be prevented. It is also important to recognize how law can be—and often is—used as a tool to improve public health. Take a peek under the proverbial shell and see how your individual state regulates turtle sales.

Looking back, I think my brother was pretty lucky not to get sick—other reptiles and amphibians can also carry Salmonella. Since his turtle-catching days, he has gone on to earn a degree in wildlife biology. Now he is much better informed about the hazards of interfering with wild animals. For the most part, he leaves the wild things to the wild.

Tiny Turtle infographic