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This Is What Democracy Looks Like

Today's Note From a Madman

Monday, June  4, 2007


Soul Searching

"The Cold War is over,"
-President Bush as he begins a six nation, Eastern European trip

Is the Cold War really over, President Bush? Or has a new Cold War just begun? If the latter is true, it's because you couldn't "look into the soul" of Russian leader and former KGB Chief Vladimir Putin as you have previously said you could.

The weakening of our nation's stature hasn't only emboldened our enemies in many Islamic nations, but it has emboldened our new "friend", Russia, to bring about a new Soviet-like process which is restricting the rights of her citizens and aiding our enemies in nations like Iran.

In a time where we should be looking to reduce the number of nuclear arms (or as President Bush might say, "nukular"), we're looking into expanding our arms into Europe to create a "shield" for our allies over there. Putin has vowed, for lack of a better word, revenge.

"If a part of the strategic nuclear potential of the United States appears in Europe and, in the opinion of our military specialists, will threaten us, then we will have to take appropriate steps in response. What kind of steps? We will have to have new targets in Europe." Which could be "ballistic or cruise missiles or maybe a completely new system,"
"If" the Bush administration doesn't change their mind about a European missile shield, "then we disclaim responsibility for our retaliatory steps, because it is not we who are the initiators of the new arms race, which is undoubtedly brewing in Europe,"

Welcome to the New Cold war. Much like "Mission Accomplished," which President bush proclaimed aboard the on the USS Abraham Lincoln, after a spectacular jet landing on the Aircraft Carrier's deck (a landing which the President's mouthpieces originally claimed that President bush, himself, executed), the President is now going to have to prosecute a war we have already apparently won.

As we step backwards in time, noting the regressive moves recently made by the Supreme Court regarding women's rights, the loss of the right to vote for millions of Americans and the return of "The New Robber Barons", we step back into a New Cold War that looks all too familiar as the old Cold War.

This isn't the kind of reminiscing that we were hoping for.

Let's face it, even if you believe that we're safer today than we were on September 10, 2001, the world and especially our allies are in more danger than most of us have seen in our lifetimes. With terrorists attacking our allies in span and England and the placement of our troops as targets to both sides of a civil war in Iraq, the policies of the Bush administration have left the future of the world in jeopardy. Failure to notice this doesn't make it any less so.

And just what is President Bush's response to his "friend" Vladimir Putin's threat? Why he's going to invite the Russian leader to the Kennebunkport, Maine home of his father, Bush(41) for a visit.

If President Bush will looks into Putin's Soul again, I wonder what he'll see?

-Noah Greenberg

by Victoria A. Brownworth
copyright c 2007 Journal-Register Newspapers, Inc.

Andrew Speaker, 31, is now being held in indefinite quarantine under armed guard. The Atlanta personal injury attorney was taken to a Denver hospital on May 28th after a whirlwind two-week international incident that has raised serious questions about how secure the U.S. is from bio-terrorism.

Speaker is not a criminal, nor a bio-terrorist, but he has a dangerous disease: XDR-TB or extensively drug-resistant tuberculosis, the most deadly form of the lung disease. XDR-TB kills half the people infected with it. Speaker is the first individual to be quarantined *involuntarily* under *federal* guidelines since 1963. However, many other individuals are under involuntarily quarantine under state guidelines throughout the U.S. and still more are under voluntary quarantine.

In recent years, the spread of highly infectious diseases has become far easier, due to global travel. The Centers for Disease Control (CDC) lists nine diseases under federal quarantine guidelines: XDR- and MDR-TB, SARS, or severe acute respiratory syndrome, cholera, diphtheria, yellow fever, plague, smallpox, virulent hemorrhagic fevers (Ebola, Marburg, etc.) and pandemic flu.

The furor over Speaker’s decision to fly to Europe, while knowing he was infected with TB and then his furtive return to the U.S. through Canada, is indeed warranted. But although much of the outrage has been focused on Speaker himself, Americans should be more concerned with how utterly both the public health system and Homeland Security failed in stopping one individual who could have spread one of the most deadly diseases on earth to hundreds of people. Issues of public health versus individual liberty are complex and not to be dismissed lightly. A century ago, everyone with TB was put under quarantine in the U.S., because there were few ways to treat it and it was highly contagious. Tuberculosis has killed millions of people over the centuries, including the poet John Keats, the composer Frederic Chopin and the star of *Gone With the Wind,* Vivien Leigh, who died of the disease in 1967 at the age of 53.

Where TB once was rampant, due to crowded conditions, poor air-quality and hygiene, the number of cases have diminished over the years in the U.S. Last year there were just under 14,000 cases in the continental U.S. Of those, fewer than 100 were of the XDR type, but nearly half were of the MDR type, many among people with HIV and in prison populations. Tuberculosis is rampant in some countries–China, Vietnam, South Africa, India, Russia and the former Soviet bloc nations. Recent outbreaks of XDR-TB in South Africa resulted in nearly all the patients and their heath care workers dying. Last year, nearly two million people died of TB worldwide, according to the World Health Organization–twice as many as died of AIDS worldwide.

And yet despite this, XDR- and MDR-TB are not as readily contagious as any of the other eight diseases on the CDC mandatory quarantine list. Exposure to Ebola virus or smallpox, for example, would result in hundreds of cases within a 48 hour period and thousands within a week. Pandemic flu is so virulent that it could conceivably wipe out a fifth of the world’s population within a year, according to WHO.

Fortunately for those testing the system, the patient who got away–Speaker–had the least contagious of all the most dangerous diseases.

Fortunately–*this time.*

But what about next time?

The manifold ways in which the public health system and Homeland Security failed America and Europe is astonishing, given the funding being spent to track actual bio-terrorism. This was one man *known* to be infected and also known *not* to be a terrorist. If we couldn’t stop him, how exactly would we stop someone *planning* to spread a deadly disease through bio-terrorism?

Speaker is *not* a bio-terrorist, of course. But in terms of his disease, he was being tracked as one. And at every turn the system failed. The CDC noted that it relies on “the honor system” when it comes to people with dangerous diseases; the CDC expects that people will agree to *voluntary* quarantine.

That’s a delightful theory, but most people, when scared, run.

Which is exactly what Speaker did. A letter specifically telling him *not* to travel was sent to Speaker from the Georgia Public Health Department, but by the time it arrived, Speaker had already left the country.

When he fled the U.S., he came into contact with hundreds of people over a two-week period. During that time he took two transcontinental flights and four shorter flights between Czechoslovakia, Italy, Greece and France. The smaller airlines have no means of contacting their passenger lists, nor did the CDC originally realize that he had been on these flights. The two transcontinental flights have contacted passengers–many of whom are expressing their fear and outrage at what they perceive as incredible selfishness on the part of Speaker for traveling when he was told he would infect others.

Speaker and his wife have tried to present themselves as victims in the debacle, saying that they were never told that he was contagious. But the true victims are the American, European and Canadian public who were failed by every component of the U.S. government set to stop just such an incident from happening.

Speaker should not have been *able* to travel, either from the U.S. or back to North America. He was on a no-fly list, which should have been disseminated to all available airlines. It wasn’t.

Yet even that is not the most egregious breakdown in the system. One of the most catastrophic failures was at the border between Canada and the U.S.

Speaker was on a stop list. This means he was supposed to be stopped and held in detention if he attempted to enter the U.S. The computer tracking his passport was specific and succinct: Any border guard encountering Speaker was to detain him, don protective gear and have Speaker do the same.

But the border guard decided Speaker *looked healthy to him* and therefore let him through, thus allowing Speaker to come into contact with many more people and also utterly disregarding the command of Homeland Security. (What if Speaker had been a terrorist but didn’t “look like it” to the border guard?) Speaker later turned himself in.

The case has caused great debate among the public, but also in Washington. Congress is taking up the question of how Speaker could get back into the country on June 6th, when the House will hold a hearing before the Homeland Security Committee. The Committee is set to review how Speaker was allowed to pass by border guards unstopped when the directives were clear to stop him. Sen. Charles Schumer (D-NY) is particularly concerned, since Speaker came in through New York state. In a statement released to the media, Schumer said, “While the failure to detain the individual so he could be quarantined exposed a gaping hole in the country's system to protect the public from disease, it also underscored the nation's vulnerability to stopping terrorists from slipping past border guards and gaining entrance.”

Or, for that matter, bio-terrorists who have infected themselves with a deadly disease in the manner of a suicide bomber.

The question of quarantine is a weightier one that the fairly simple issue of following directives at the border. If the directive is to detain someone at the border, then detain them.

But what about quarantine and what about the so-called “honor system” being employed by the CDC and the federal government? Where does society draw the line between what is fair and right for an individual and what is essential for the greater good?

The Speaker case has raised that question definitively, particularly in an era when bio-terrorism isn’t just the plot of a science fiction thriller, but is being worked on by scientists in this country and others.

Andrew Speaker tested positive for multi-drug resistant TB in January. But the profile to isolate the type of MDR-TB, what turned out to be XDR-TB, took months to culture. By that time, Speaker was off to Greece to get married. Ironically, Speaker’s father-in-law, Robert Cooksey, is a microbiologist specializing in the spread of TB. (Cooksey denied any link to his new son-in-law’s infection and said that he is regularly checked for TB, as is his family. Yet rumors have spread that Speaker was purposefully infected to test the system. Even if that were true, the system clearly failed.)

There is some debate over how vociferous the CDC was insisting that Speaker remain in the U.S. and not fly. What is clear, is that once Speaker was in Europe, he was notified that he was infected with the most virulent and deadly form of the disease and was told to turn himself in to authorities.

He did not. Instead, he took a flight to Canada, because the CDC told him he had been placed on a no-fly list to the U.S. Then he entered the U.S. at the border.

Now he is being quarantined, under armed guard because he did not comply with initial requests.

Speaker is not the only person in the U.S. under involuntary quarantine. Robert Daniels, 27, has been held in the prison wing of a Phoenix hospital for nearly a year, but he is not a criminal–just someone who refused to comply with treatment for his disease. He contracted XDR-TB from being non-compliant with his medication for MDR-TB while in Russia. During that time, Daniels traveled between the U.S. and Russia, also possibly infecting hundreds on his travels.

In the 1990s, I wrote extensively about the increase in MDR-TB for many national publications, including the Philadelphia Inquirer. The disease was on the rise for several reasons. First, HIV/AIDS had made some people more susceptible to the disease. Another reason was and is because treatment for TB is slow–six to nine months of daily treatment–and unpleasant and patients tire of it. Many begin to feel better, and then stop taking the prescribed medications. This means another line of medications will need to be used the next time. Soon there are no drugs left to treat the now-multi-drug resistant form of the illness in that patient.

This would not be such a problem if the disease were not communicable. But it is–through coughing, spitting, even laughing. If an infected person comes in contact with a person whose immune system is depleted, the risk of contagion is even greater.

The risks are also greater in enclosed spaces, like airplanes or prisons. MDR-TB has been found more and more in prison populations where the rate of HIV infection can be as high as 20 percent. According to the CDC, the incidence of TB is three times as prevalent in prisons as in the general population. If a prisoner has not completed his or her drug regimen while incarcerated, and then returns to the mainstream, that person may stop taking their medication or not be able to get it. Which would result in another case of MDR-TB.

The CDC acknowledges that MDR-TB cases are not all followed up because the funding is not available. Which means that there may be far more cases that have been reported, particularly if the person with MDR-TB is also HIV or AIDS positive–that person could die of MDR-TB and it might be noted as AIDS, instead.

The Speaker case has reminded us all–or should have–that a public health system is only as good as its enforcement. Diphtheria, for example, is prevented solely by vaccination. Children are vaccinated against the disease before they are a year old with the DPT vaccine. But in developing countries or in nations in flux, such vaccinations are not routinely administered. After the fall of the Soviet Union, for example, diphtheria cases rose exponentially–with a quarter of a million cases within two years–because vaccinations had not been given. (The Guinness Book of World Records noted diphtheria as the “most resurgent disease,” due to these outbreaks.)

The Speaker case in the U.S. and the situation with diphtheria in the former Soviet bloc are both indicators of the importance of maintaining a clearly delineated public health system.

In the U.S., there is no routine testing for TB, even among people with HIV/AIDS or among those entering the country as immigrants from parts of the world with a high incidence of the disease, like Asia and Africa.

The CDC has long recommended routine testing for HIV among people between the ages of 13 and 64, because the agency believes as many as a million Americans have the disease and don’t know it. How many people may be carrying TB in a dormant form could be just as high, said one source at the agency.

A decade ago, I reported from Riker’s Island Prison in New York, where TB was becoming prevalent in a large HIV-infected prison population. Yet most prisons do not routinely screen for TB.

No one knows how Speaker contracted the disease. He was recently in Asia and may have contracted it there. Now he will likely face surgery to remove the infected parts of his lungs, as the treatments available for this form of the disease are more difficult to administer and less likely to work. How long he will be in quarantine is unclear–at least a month, but likely far longer. Doctors will need to be certain that he will be compliant with his medical regimen and that he will remain in voluntary quarantine.

There are many questions that should be raised in the hearing June 6th. One is about why Homeland Security guards who do not follow orders are not fired; the guard who let Speaker into the country has not been reprimanded nor fired, just moved to a different duty. All the agency will say is that the system worked, except for the failure of the individual.

As important as the query about border guards is the one about quarantine. Is it fair to individuals or the society as a whole to leave the question of quarantine up to the sick person? Consider how many people are driving with suspended licenses, from Paris Hilton to the guy down the block. Can we expect people who are suffering from an unseen and in many cases unfelt disease to voluntarily quarantine themselves for close to a year or longer?

Which means the government *must* set clear guidelines for quarantine. The current standards were set in the 18th century during the yellow fever epidemic which killed thousands. Updating–particularly given the appearance of new, deadly diseases like Ebola and Marburg–is essential.

Andrew Speaker could be liable and might be sued if anyone with whom he came in contact during his two weeks abroad becomes infected with the XDR-TB. But litigation isn’t the answer. It’s easy to say Speaker should have taken personal responsibility, knowing he had TB and had been asked to remain stateside. But what about the CDC? Speaker’s own father-in-law tracks this disease. Why didn’t he tell Speaker to stay home? To have the Dr. Julie Gerberding, director of the CDC say after the fact that Speaker’s wishes ran counter to that of the CDC, seems disingenuous, if not downright dangerous.

Speaker has apologized for flying with the disease--cold comfort to those on the various flights he took, or who otherwise came in contact with him. For years to come these people–some of them children–will have to be tested repeatedly and have this possibility hanging over their heads.

The CDC and Homeland Security have *not* apologized, and they have far more to answer for than does Andrew Speaker.

A catastrophic epidemic was avoided, this time. Next time we might not be so lucky.

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-Noah Greenberg