Public Health and Law Enforcement:
Intersecting Interests, Collegiality
and Cooperation
William S. Duffey, Jr., JD
United States Attorney, Northern Distriet of Georgia
hank you for the privilege of being with you
T today. One unexpected reward of my job as
United States Attorney has been my introduc-
tion to the public health community. The only other
encounter I can recall having with you was in the six-
ties when I went to the county health office to take
doses of the Sabin vaccine against polio.
Until this assignment my world as a lawyer did not
intersect with your world of public health. That we
didn't intersect more is interesting because we are
engaged—in different ways—in a variety of issues in
which both of our communities have a critical inter-
est—especially since 9/11. For example, bioterrorism
has extremely important health and law enforcement
threats; in violent crime we focus on the defendant
while you focus on his or her effect on the public; in
the area of controlled substances we focus on the traf-
fickers, you on substance abuse issues.
In addressing these issues, we have similar obliga-
tions even if we fulfill them in different ways. In the
end we have shared goals and each seek to:
• Protect citizens
• Redress wrongful conduct
• Deter, and
• Prepare to respond
Is the reason we have not more closely worked
together because we did not recognize our inherent
mutual interests? Or was it inadvertent oversight?
Or did we believe—do we believe today—there are
impediments to us working together in areas of com-
mon interest? I don't think we can discount the pres-
ence of at least a disincentive to seek out each other's
cooperation and coordination. And I think that may
be because the methods we use to reach our respective
objectives are inherently different.
In law enforcement our flexibility to experiment is
SPECIAL SUPPLEMEN-r • THE PUBLIC'S HEALTH AND THE LAW IN THE 21ST CENTURY
more constrained; we hold to a strict standard dealing
only with admissible evidence with the focus on a
provable result. For us there are evidentiary and con-
stitutional standards and rules for what is presented
to a jury for it to decide. For us it is citizen review. We
also often work secretly. We don't disclose what we
know to avoid tipping off a suspect or because our
legal rules require secrecy.
Public health, on the other hand, discloses com-
prehensive information in order to better warn and
treat. Public health uses inductive reasoning to look
beyond core facts to hypothesize and test theories.
Hypotheses which lead to action are better than
allowing a problem to go unaddressed or undisclosed.
For you it is peer review, not citizen review.
I understand your world to this extent: playing the
percentages is important to protect the public health.
Like baseball—putting in a left handed pitcher to
pitch to a left-handed batter. The odds urge this
choice. To put it in the vernacular: Law enforcement
believes you are too imprecise for us.
You are too quick to respond, willing to act on spec-
ulation and conjecture. Public health, however,
believes law enforcement is too narrow-minded, rigid
and pedantic, too conservative and too reluctant,
wanting to follow every lead before reaching a firm
conclusion on which to act.
What we have are colliding worlds where we ration-
alize that it is easier, more efficient and less frustrat-
ing to go our own ways rather than walk together.
What has been the historical result? Incomplete reso-
lution to problems which would have been better
addressed with a comprehensive solution.
Is the environment the same today? Do failures in
cooperation still occur? Do you remember the movie
Outbreak? It was the story of an African hanta virus
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PLENARY SESSIONS
transported to California. You recall the story: (a) The
military's need to keep the virus—especially the anti-
body—a secret for national security reasons; and (b)
the CDC wanted full understanding of the threat and
an immediate public health threat response. The mil-
itary and public health officials claimed they would
work together. Instead, they worked against each
other.
This is the question for us all: Do we work together
or apart? Our experience suggests that we serve the
public more efficiently and comprehensively when we
cooperate and coordinate. I'd like to explore with you
four examples which I submit prove that point. They
are:
• Terrorism/bioterrorism response
• "Project Safe Neighborhood" gun violence initiative
• Drug abuse and trafficking, and
• Human trafficking
There probably is no clearer, more contemporary
example of public health's and law enforcement's
intersecting interests than in the area of terrorism and
bioterrorism. Criminal laws have been enacted to pro-
tect the pubhc health. 18 U.S.C. Sec. 2332 says it is a
crime when any person who, without authority, "uses,
threatens, or attempts or conspires to use, a weapon of
mass destruction," including any biological agent,
toxin, or vector....against any person within the United
States."
In a bioterrorism response there are two compelling
interests, both embodied in this statute: (a) the need
to understand the health threat and to protect the
public, and (b) the need to hold the bioterrorist crim-
inally accountable. Public health and law enforcement
interests are undeniably intertwined in this legislation.
But there are inherent tensions as these two duties
are fulfilled. The immediate need to protect human
health butts heads with the more methodical, delib-
erate processing of evidence for a criminal case. We
have seen these interests run head-on before. In the
Tylenol contamination incident the focus was on the
company's response to protect the public health. Law
enforcement's interests were a secondary considera-
tion.
In another case, in 1984, the followers of Bhagwan
Shree Rajneesh contaminated salad bars and coffee
creamers in Oregon with salmonella in an attempt to
influence a local election: 751 people became ill; 45
were hospitalized. The initial response was to treat
this as a public health issue. But years later, in an
unrelated matter, authorities discovered the 1984 con-
tamination had been a terroristic attack. Clearly, there
should have been an aggressive law enforcement
response in 1984.
Again, in October 2001, a 67-year-old photo editor
20
for the Sun in Florida was sickened by anthrax. What
began as a public health probe became a criminal
investigation. We still struggled with balancing the
public health/public safety interests in this terrorist
attack. This is the post-9/ll terrorism reality. Six
months later the doctor who diagnosed the case—ini-
tially, it was considered an isolated case—said he
believed the federal government's reluctance to rec-
ommend other anthrax-fighting antibiotics in addi-
tion to Cipro during the earliest days of the outbreak
created a bigger problem: "...this scare and this scarci-
ty and this black market for Ciprofloxacin didn't have
to occur." We were beginning to think differently, but
our response in this new world is still confusing.
The consequences of these acts still are unexpected,
expensive and complicated. American Media sold its
anthrax-contaminated former headquarters to a
developer for just $40,000 for a 68,000-square-foot
building on five acres of land but he would have to pay
up to $10 million for decontamination.
This incident did do one thing—it began to make us
think that while the public health and law enforce-
ment missions are different, they are equally impor-
tant. As each incident occurs and failure of coordina-
tion reoccurs, the evidence builds that we need a new
paradigm. We need to acknowledge that we have dif-
ferent jobs to do, that each is important. We need also
to acknowledge that we still struggle with each other.
In Washington, D.C, in 2003 public health officials
learned about the ricin contamination of the Dirksen
Senate Office Building from news reports. The Secret
Service reported that it did not notify public health
officials or other law enforcement agencies for five
days. We thought the need to know was limited.
My tour of the CDC in 2002 brought home to me
how unfamiliar we are with each other. During my
visit I looked down from a bridge that connected two
buildings. There below me was a trailer that I was told
was used to test ricin and other suspicious substances
and where it also could be processed as evidence—two
very important functions in a temporary, unsecured
facility. It seemed to me it was a place where law
enforcement could be invited in but kept out of the
way. Yet these are two very important functions, one
of which should be integrated into and not kept out of
the work of the other agency. The overriding question
is: How do you harmonize these two important inter-
ests to bring about coordination, cooperation and col-
legiality? It is an issue I have thought deeply about
and about which I have developed deeply-held views.
I'd like to share them with you for you to consider. I
think these missions are harmonized when the follow-
ing happens:
• Cooperation and coordination occur most often
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when there are strong personal relationships.
• Strong personal relationships create collegiality.
• Collegiality allows people to plan and look for-
ward rather than react hy looking hack.
That has heen the course we have followed with pub-
lic health officials, especially those at the CDC. We
have addressed issues of suhstance, hut in a manner
that forges personal relationships. And we have used
those personal relationships as the hasis for develop-
ing cooperative strategies and plans that allow puhlic
health and law enforcement communities collectively
to achieve their objectives. What we have tried to do
is create "the culture of cooperation" through:
• Joint seminars, conferences, and discussions
• Joint tahle top exercises
• Fostering personal interaction
The result is that it is harder to work against another
community's interests.
I would like to give you three more successful
examples of creating cultures of cooperation where
law enforcement and puhlic health have intersecting
interests: gun violence, methamphetamine ahuse,
and human trafficking.
One example is "Project Safe Neighborhoods"
which focuses on gun violence. This is a huge public
health issue. Teenagers in America are more likely to
die from gunshot than from all other natural causes
of death comhined. We can enforce all day and never
address this public health/social issue. It is clear that
this is a public health and a puhlic safety concern.
"Project Safe Neighborhoods" is working in an at-risk
Atlanta neighhorhood because we finally have recog-
nized hoth issues, and through relationships have
hegun to address them cooperatively. It was a puhlic
health goal that did the trick for me. What did we do?
We measured results. Bernie Kerik, the former New
York City Police Commissioner, told me once: "If you
don't measure it, it won't get done." What a truth! Dr.
Art Kellerman's suggestion was that we should meas-
ure emergency room admissions at Grady Hospital
here in Atlanta for gunshot wounds. Grady treats 85
percent of all shooting victims in Fulton and DeKalh
counties here in metro Atlanta. My reaction was
"Come on, get real. Art." This won't tell us anything.
What do admissions have to do with stopping crime?
But he was right. Improving the public's health is
what propels support and cooperation. I think it was
our most important measurement.
"Project Safe Neighborhoods" is making a signifi-
cant puhlic health and public safety difference. We
can see what actually happened in two ways. First, 9-
1-1 firearms calls dropped by 33 percent in the third
quarter of 2003 over the same quarter in 2002; they
dropped hy 39 percent in the fourth quarter of 2003
SPECIAL SUPPLEMENT • THE PUBLIC'S HEALTH AND THE LAW IN THE 21ST CENTURY
William S. Duffey, Jr.
over the same quarter in 2002. Second, Grady saw 28
percent fewer shooting victim admissions in 2003
compared with 2002. This data is real and it gives us
a real goal. People understand these results. They point
out the human impact of our work. Law enforcement,
puhlic health officials, and the community see the
difference we really are making. It is, I think, the hest
measure of success.
The next example is in the area of methampheta-
mine ahuse. Let's review the drug trafficking organi-
zations' trafficking patterns in our region. When you
focus on the destinations it hits you that every desti-
nation is a puhlic health issue.
Methamphetamine presents a puhlic health threat
on many levels. Impact on the user is the single best
example of a drug-induced brain disease, according
to Richard Rawson, PhD, Associate Director of the
UCLA Integrated Suhstance Abuse Programs. The
effects on users include: disturbed sleep pattern, bad
teeth, anorexia, itching/welts, nausea/vomiting,
aggressiveness, twitching/lip smacking/tongue pro-
trusion, sexual dysfunction, kidney/liver/lung dam-
age, and brain damage.
How about the effect on families? Children are at
an especially high risk of neglect and abuse. The fire
risk alone is sobering. This year two parents were
sentenced for killing their child in a meth lab explo-
sion. But there also is a risk of gun violence, and risk
of exposure to toxins. That's only part of it, however.
There are environmental risks as well. One pound of
meth generatesfiveto six pounds of toxic waste. Clean-
up averages $5,000 and can cost as much as $150,000.
Contamination includes underground water.
The only way to attack the meth prohlem is through
a coordinated approach. For example, legislation can
he enacted to limit the sale of precursor chemicals
such as cold tahlets, and to provide civil immunity for
good faith reporting of someone suspected of buying
precursors for meth production. And we should be
advocating each of these together. Judicial steps can
he taken through drug courts and intervention with
offenders. Puhlic health can conduct outreach and
treatment.
My final example is human trafficking. Our office
has prosecuted seven cases of slavery and prostitution
in which we locked up very had people. We made a
difference hut only a slight one. This is a terrible
problem and it grieves me that our aggressive efforts
only make a slight, incremental difference. The prob-
lem is significant but under-appreciated. Here is an
example of the travesty mentioned by U.S. Department
of Health and Human Services Deputy Secretary
Claude Allen about a year ago: A thirteen-year-old
girl was promised a job in the United States as a wait-
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PLENARY SESSIONS
ress. When she got liere, she was forced into prostitu-
tion. "She was brutally gang-raped to induct her into
the business. For the next six months, she v^^as forced
to service ten to fifteen men a day. Twice she was
impregnated, twice forced to have an abortion, and
twice she was back in the brothel the next day. The
traffickers circulated her through the trailer brothels
and private parties, where she was passed around. She
was pistol-whipped and raped if she resisted. The girl
was rescued when two girls ran to neighbors who
called police. She had multiple sexually transmitted
diseases, scar tissue from forced abortions, and was
addicted to drugs and alcohol. She had posttraumatic
stress syndrome, including severe depression and sui-
cidal thoughts. She was physically, mentally, and spir-
itually broken."
Closely related is the issue of human trafficking. As
we saw in a recent case in Texas, traffickers, in com-
plete disregard for human life, smuggled illegal aliens
across the Mexican border by stuffing them in a trac-
22
tor trailer. In the hot sun of the southwest border the
trailer literally baked its cargo. Is this a public health
as well as a law enforcement issue? You decide.
I believe that a new "rescue and respond" model is
in order. The rescued are our greatest law enforce-
ment response. The public health community is our
greatest law enforcement resource. Why didn't we
work together before? The answer is because we were
myopic, looking at the problems through the lenses of
our own interests rather than looking to confront the
problem comprehensively.
In conclusion, I have shared with you today four
examples showing how we can work together. I pledge
to continue to make our case. This conference is
another step in the right direction, hut there are many
more to he taken. We need to work even harder at our
personal relationships to cultivate cooperation, coor-
dination and collegiality. This is important work—you
need to continue to do it because, ultimately, our com-
munities are counting on us to make a difference.
THE JOURNAL OF LAW, MEDICINE & ETHICS