Forthcoming book funded by Carnegie Corporation of New York will provide lessons for lawmakers and frame public debate on governmental response to pandemics
When Polly J. Price, professor of law and global health at Emory University, was named an Andrew Carnegie Fellow in 2017, she set out to write a book on how governments confront contagious disease. The forthcoming book Plagues in the Nation, to be published by Beacon Press, aims to provide lessons for lawmakers and frame public debate on how government may best respond to health threats in the future.
In the three years since her Andrew Carnegie fellowship, and with the onset of the coronavirus pandemic, Price’s research and perspectives have received widespread media attention from CNN to the National Constitution Center, the New York Times, NPR, and Time. An adviser to the National Governors Association and the National Conference of Commissioners on Uniform State Laws, Price describes her interest in pandemics, how her Andrew Carnegie fellowship advanced her research, and some considerations for the future.
During the 2014 Ebola crisis, the federal Centers for Disease Control and Prevention (CDC), just up the street from my office, were on the frontlines in West Africa and in the political spotlight for preventing the spread of Ebola to the United States. Emory University Hospital treated the first evacuated American health workers, over protests (including bomb threats) by some members of the public. Fear intensified following the death of an Ebola victim in Dallas and the subsequent infection of two nurses. Fortunately, there was no further spread of Ebola in the U.S.
But the response of state governors and local health departments seemed to me at times chaotic and exposed fault lines in our ability to control a fast-moving pandemic. In our nation’s recent experience with Ebola, an understandable but unwarranted public panic led to missteps by political leaders that undermined confidence in the government’s ability to prevent an epidemic. Several state governors squabbled publicly with the federal government about who was in charge, about whether to close the borders, and about which persons should be quarantined.
Epidemic control in the U.S. is unique and controversial because of our deep culture of individual rights and constitutional values. It is also made more difficult because the U.S. has one of the most decentralized public health systems in the world.
From my study of earlier outbreaks in U.S. history, I already knew that while we expect government to keep us safe from epidemics, we continue to work with outdated laws — some from the nineteenth century — that dictate whether government officers can order business closures or legally quarantine entire groups of people. Epidemic control in the U.S. is unique and controversial because of our deep culture of individual rights and constitutional values. Epidemic control is also made more difficult because the U.S. has one of the most decentralized public health systems in the world.
My forthcoming Corporation-funded book, Plagues in the Nation, is built on this premise: the history of epidemic outbreaks in the U.S. shows effective disease control to be a matter not only of containing pathogens but also of effective law and governance. I had worked with the CDC and local health departments for several years on the control of infectious disease within the United States. But I had also studied epidemics in America’s past and knew the weak points in its ability to respond to epidemics — that the key issues were not really about Ebola itself, for example. I knew that with the next epidemic we could expect turmoil within our government, and I knew the underlying reasons for what Americans would be seeing.
The Andrew Carnegie Fellowship provided leave time and the opportunity to work with public health departments and the CDC in the U.S.–Mexico border region. In the context of drug-resistant tuberculosis, I learned how state and local health departments, with CDC assistance, work to overcome the many problems created by jurisdictional boundaries. I also participated for over a year in planning and presenting an outbreak simulation exercise involving seven health departments in the El Paso/Ciudad Juárez region, an exercise to understand intergovernmental coordination in a public health emergency and how it might be improved.
During my fellowship, I published two articles. The 2018 article “Do State Lines Make Public Health Emergencies Worse?” explored the potential conflict between federal, state, and local quarantine authority in the event of an epidemic in the U.S. The 2019 article “Immigration Policy and Public Health” noted the shortsighted exclusion of noncitizens from access to services essential for population health in the event of an outbreak with the new federal “public charge” rule a particularly dangerous example, because it penalized noncitizens from accessing health care to which they were entitled by law. This article concluded with a call for Congress to reauthorize pandemic preparedness funding, which had been allowed to lapse in 2018 but was later restored.
One observation from my 2018 article has received wide attention:
“Any intervention by the federal government over the objections of a state or territory can be highly politically charged. Environmental, scientific, and medical recommendations can be hijacked for political purposes at any level of government. Perhaps the most pressing problem is a crisis of trust in governmental institutions.”
A national strategy to confront an epidemic in the U.S. is made difficult because of federalism and the lack of a national public health agency. We depend on more than two thousand state, local, and tribal health departments to spot and contain outbreaks. Many of these are poorly funded and understaffed and have little access to quality lab processing and personal protective equipment for health care workers. Even with the best expertise in the world, the CDC can only advise state governors and lend personnel on a limited basis.
The U.S. depends on more than two thousand state, local, and tribal health departments to spot and contain outbreaks. Many of these are poorly funded and understaffed and have little access to quality lab processing and personal protective equipment for health care workers.
In February, I wrote about this situation for The Atlantic, “A Coronavirus Quarantine in American Could be a Giant Legal Mess.” I pointed out that the U.S. defense against epidemics is divided among more than two thousand individual public health departments and that this makes implementing a national strategy very difficult. I followed up with an additional article in The Atlantic, “How a Fragmented Country Fights a Pandemic,” noting that the U.S. has one of the most decentralized public health systems in the world.
My book, Plagues in the Nation, forthcoming from Beacon Press, will discuss what we have learned from COVID-19 and how to be better prepared for the next pandemic.
The unintended timeliness of my publications in 2018 and 2019 brought my expertise to the attention of journalists, and I have been interviewed and quoted extensively by major outlets. I view my contributions as a form of public service, a way to help the public understand the limitations within which our government works in a public health emergency and the need for public trust and accountability.
Beginning in March 2020, I have served as an expert adviser to the National Governors Association on matters pertaining to social distancing, state and local authority for business closures, and other issues. This work is ongoing. In addition, the National Conference of Commissioners on Uniform State Laws has appointed me to a new “Study Committee for Public Health Emergency Authorities.” The goal of this group is to provide states with nonpartisan well-conceived and well-drafted legislation that brings clarity and stability to critical areas of state statutory law.
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