***AFF***

1AC Solvency
DHHS is adequately ensuring private sector compliance with
health privacy protection laws now
Charles Ornstein (senior reporter for ProPublica covering health care and the
pharmaceutical industry) March 20, 2015 Despite A Wave Of Data Breaches, Fed
Says Patient Privacy Isn't Dead http://www.npr.org/sections/healthshots/2015/03/20/394116837/despite-a-wave-of-data-breaches-fed-says-patientprivacy-isn-t-dead
The task of investigating medical data breaches falls to the Office for Civil Rights, a
small agency within the Department of Health and Human Services. Last month,
ProPublica and NPR reported how, as the number of breaches has increased, the
office infrequently uses its authority to fine organizations and health providers that
fail to safeguard patient records. The office's director, Jocelyn Samuels, spoke
Monday to health privacy and security experts gathered in Washington, D.C., for the
National HIPAA Summit, named for the Health Insurance Portability and
Accountability Act. After her talk, Samuels sat down with ProPublica to talk about
the current state of health privacy. The conversation has been edited for length and
clarity. Highlights are below; a fuller version is available on ProPublica's website. To
start off with, the Anthem breach is still at the top of mind for so many people. Does
this change the landscape in terms of health data breaches? We won't know until
after we have investigated what the causes of the Anthem breach are or were, or
whether there are concerns about HIPAA compliance. But I think that it illustrates
both the increasing risks that exist in the cybersecurity space and the need for
covered entities [health providers and others subject to HIPAA's requirements] to
continue to update and evaluate their risk analyses to ensure that their risk
management plans adequately anticipate all of the kinds of threats they may face.
Since HIPAA was passed in 1996, how would you say the state of play has changed
with respect to patient privacy and the security of records? The ability to access
electronic health records is something that we obviously have clarified and
expanded over time since HIPAA was enacted. And I anticipate that we will continue
to evaluate the application of HIPAA standards to emerging issues, whether they are
posed by new technology or new forms of risk that aren't being adequately
addressed. From a macro perspective, we are seeing an explosion of new
approaches to delivering health care, to treating patients, to sharing information.
And that changes on an exceptionally rapid basis, and so ensuring that we are
providing adequate guidance about how HIPAA applies and what the standards are
in these new environments is something that's a high priority. Some people have
suggested that the notion of patient privacy is sort of outmoded and that you really
don't have privacy anymore. Do you accept that? No. I think that you are talking
about some of the most intimate facts about any individual, whether it is their
health condition or their diagnosis or their treatment choices, and that it is really
critical to ensure that they feel confident that that information will be protected
from public disclosure. That's the underlying premise of patient involvement in

health care decision-making, that they can entrust their providers with this really
intimate information knowing that it won't be misused or inappropriately disclosed.
Although there are new threats and cybercriminals get smarter every day, we have
to do our best to keep up and ensure that there are adequate protections in place
so that we can gain the benefits that technology and delivery system reform are
promising. Your office has the ability to issue fines in ways that a lot of federal
agencies can't and in denominations that a lot of federal agencies can't. You've
noted that you used them about two dozen times. Is that enough? You know, each
case depends on its facts and I do think that we have been committed to using
settlement agreements and monetary recoveries in situations where we think that
the conduct has been egregious or where we want to create a deterrent or where
we feel that the monetary settlement will help to reinforce the message that we're
serious about HIPAA compliance. That said, we are very serious about HIPAA
compliance even in situations where we don't seek monetary settlements or civil
money penalties. And I think if you look at our corrective action plans [agreements
in which providers promise to make changes following a complaint], you will see
that those are uniformly robust efforts to ensure that covered entities and business
associates undertake the infrastructure and structural reforms that are necessary to
ensure compliance going forward.

But, emergent public health surveillance models will create

invasive privacy violations and dragnet health data collection
by the federal government - Applying strict scrutiny solves.
The plan forces the government to narrowly tailor surveillance
to further a compelling government interest creates a
consent-based model that stems overreaching medical
surveillance
Margaret Hoppin (J.D., New York University School of Law, licensed attorney for
the District Court For The Southern District Of New York) 2012 OVERLY INTIMATE
SURVEILLANCE: WHY EMERGENT PUBLIC HEALTH SURVEILLANCE PROGRAMS
DESERVE STRICT SCRUTINY UNDER THE FOURTEENTH AMENDMENT
http://www.nyulawreview.org/sites/default/files/pdf/NYULawReview-87-6-Hoppin.pdf
C. Strict Scrutiny Should Apply So far, this Note has suggested in part that emergent
public health surveillance programs invade an extremely important personal privacy
interest. Courts can and should recognize that privacy interest as fundamental for
purposes of the Fourteenth Amendment. Accordingly, constitutional challenges to
emergent public health surveillance should be analyzed under a strict scrutiny
standard.164 Courts can apply a strict scrutiny standard because, contrary to
commentators widespread assumption, a deferential standard of review need not
apply in the context of emergent public health surveillance programs. No court has
considered the privacy implications of programs like the A1C Registry,165 and the
few relevant precedents leave room to adjust Fourteenth Amendment analysis as
public health surveillance develops (much as courts have adjusted Fourth
Amendment analysis in response to developments in security surveillance).166
Courts should do so for at least two reasons. First, the personal privacy interest at

stake satisfies existing tests for a fundamental right. Second, emergent programs
are likely to involve ongoing and increasingly comprehensive surveillance and
analysis of a wide range of personal behaviors. If the interest at stake in emergent
programs is not recognized as fundamental, it is difficult to imagine that
Fourteenth Amendment protection would apply at all to personal privacy outside of
the subject matter domains already specifically identified by courts. The precise
method for determining that a right is fundamentaland therefore protected
under the Due Process Clause of the Fourteenth Amendmentis somewhat
obscure.167 Courts and commentators have suggested that the confusion arises in
part because the Supreme Court employs at least two different tests.168 In
Washington v. Glucksberg, 169 the Supreme Court emphasized the importance of
historical practice and national tradition.170 Since Glucksberg, courts have usually
asked whether the purportedly fundamental right is deeply rooted in this Nations
history and tradition171 to determine whether it is fundamental for the purposes of
the Fourteenth Amendment.172 The first task of a court applying any test is to
characterize the purportedly fundamental interest at stake.173 Emergent public
health surveillance programs present an interesting challenge to doing so, because
they employ new and evolving technologies. As a result, there is not a readily
available concept of the privacy interest actually or potentially invaded, or a
consensus about why it is important. What is clear is that the surveillance at issue
in emergent public health surveillance verges on comprehensive in both depth and
breadth. Given the methods of surveillance and the nature of the health conditions
likely to be targeted, emergent programs may involve the lifetime collection of
information about the behaviors and habits of millions of people. Such surveillance
invades an area of personal privacy that previously challenged programs did not,
and it does so on an unprecedented scale. In addition, there are some
jurisprudential indications that a newand constitutionally significantprivacy
interest is at stake. Courts are currently grappling with the implications for Fourth
Amendment jurisprudence of both continuous surveillance and sophisticated data
analysis capabilities.174 A number of courts have concluded that continuous
government surveillance of public movements has constitutional significance, even
though episodic or shortterm gathering of the same information does not.175
However, even while affirming that there is an important difference between the
privacy interest invaded by information-gathering that is limited in duration or
frequency, and the privacy interest invaded by the continuous gathering of similar
information, courts have generally not explained what it is.176 Fortunately, a
precise definition of the interest invaded by emergent programs is not required: A
fundamental right to personal privacy is deeply rooted in this countrys history and
tradition. A complete account of legal and cultural protections for personal privacy
is far beyond the scope of this paper, but two examples are particularly worth
noting. First, the history of Fourth Amendment jurisprudence demonstrates that the
most sacred of all areas . . . is the home, not because it is a physical structure in
which someone chooses to live, but because there is a societal consensus that
people have virtually unlimited expectations of privacy from intrusions into their
homes.177 A cursory review of Supreme Court cases suggests that we protect the
home at least in part because it serves as a proxy for personal privacy.178
Scholars have made the same observation.179 Moreover, robust Fourth Amendment

protection of the home is a product of a deep national commitment to preventing

government incursions upon personal privacy that dates to the founding era.180
Secondand also relevant in the context of emergent public health surveillance
programsthere is a clear history of judicial and legislative protections against
nonconsensual disclosures of medical information.181 Fourth Amendment
jurisprudence and commentary on security surveillance programs identify features
of modern government surveillance that (i) raise serious concerns about the nature
of the privacy invasion, and (ii) in some cases have prompted courts to expand the
scope of corresponding constitutional privacy protections. The similar- ities between
emergent public health surveillance and security surveillance provide an additional
indication that emergent programs may necessitate heightened constitutional
privacy protections. Recognizing that the privacy interest at stake is fundamental
would trigger strict scrutiny, under which a reviewing court would inquire whether
the challenged surveillance program was narrowly tailored to further a compelling
government interest.182 In one sense, the proposed analysis would not depart from
past practice. Arguably, the public health surveillance programs reviewed by courts
to date have not involved a fundamental privacy interest, due to technological limits
on the breadth and depth of surveillance, the type of information collected, or
program design. In particular, most public health surveillance programs, such as
those that involve anonymized or consensual data collection, do not intrude upon a
fundamental privacy right at all. In addition, the strict scrutiny analysis may be
satisfied when the surveillance model at the heart of emergent programsongoing,
intimate, and individualized surveillance targets people with a highly infectious
disease in order to prevent the disease from spreading. The critical question is
whether emergent surveillance programs satisfy the narrow tailoring requirement of
a strict scrutiny analysis. Part III describes one approach to finding an answer. III
ESSENTIAL FEATURES OF A STRICT SCRUTINY ANALYSIS In Part A, I argue that a
court reviewing an emergent public health surveillance program under a strict
scrutiny standard should focus its narrow tailoring analysis on the efficacy of the
public health interventions enabled by the challenged surveillance program. Many
public health activities would satisfy a stringent efficacy requirement. However, two
kinds of interventions should not: those that are effectively indistinguishable from
surveillance and, in the case of noncontagious, non-exposure related disease, those
that are unlikely to improve the health of the individuals surveilled. In Part B, I
analyze the A1C Registry and conclude that it probably does not survive a narrow
tailoring analysis because it likely cannot enable more than de minimis health
improvements for diabetics. I propose several ways the program can be changed to
comport with the proposed Fourteenth Amendment requirements. A. Efficacy of
Government Intervention Strict scrutiny requires that an emergent public health
surveillance program that infringes upon a fundamental right to privacy be narrowly
tailored to achieve a compelling government purpose. Emergent public health
surveillance programs would likely survive a strict scrutiny analysis in many
contexts, like serious infectious disease and exposure investigations.183 Assuming
that governments have a compelling interest in combatting widespread and costly
chronic conditions, the critical question is whether a particular emergent public
health surveillance program is narrowly tailored to meet that interest. The principal
requirement of a narrow tailoring analysis is that the government intrusion must be

necessary in order to be justified.184 The Supreme Court articulates the standard

as a requirement that the governments chosen means be the least restrictive
alternative that would achieve its goals.185 In the context of public health
programs, asking whether surveillance is necessary should meanat a minimum
asking whether the surveillance enables the government to improve the public
health. Accordingly, to evaluate the constitutional status of emergent public health
surveillance programs, courts should consider whether those programs enable
public health interventions that are more than minimally effective. Surveillance that
targets individuals with non-communicable health conditions but does not enable
interventions that improve the health of the surveilled individuals does not advance
the governments public health goals. By the same token, emergent public health
surveillance programs are not the least restrictive alternative available if equally
or more effective public health measures can be implemented without
comprehensive, individually-identified data.186 Under the proposed narrow tailoring
analysis, a government would have a compelling interest in fighting the obesity
epidemic but an emergent public health surveillance model would be appropriate
only if it enabled interventions that improved health or mitigated risk for the
individuals surveilled.187 Historically, there was no need to make explicit an
efficacy requirement for public health surveillance programs, because governments
can and have effectively combatted the spread of serious communicable disease.
Quarantine and other restrictions may be draconian, but at least they work.188 As
government broadened public health surveillance to include non-infectious disease,
it generally did not engage in extreme invasions of privacy, and it generally
conducted anonymous statistical surveillance only.189 By contrast, emergent public
health surveillance, which in many ways replicates the model deployed to combat
infectious diseases like tuberculosis, and which targets diseases that are not
communicable or exposure-related, raises novel constitutional concerns about
public health surveillance. Diabetes is not infectious; neither is obesity, nor are
obesityrelated chronic conditions. There are no individually-targeted interventions
that can stop a chronic condition from spreading.190 In addition, there is no single
action that fixes or dramatically improves the affected individuals health status.
Instead, secondary prevention (preventing a condition for which one is at risk) and
tertiary prevention (avoiding complications from a condition) both require lifetime
effort by the individuals whose health is at risk.191 For many chronic conditions,
that effort is directed to mundane, but personal, decisions about behavior and
lifestylewhat to eat, how much stress to accept in jobs or personal life, how much
to exercise, and what proportion of limited time and energy to devote to health
management. Accordingly, with respect to noncommunicable, non-exposure related
health conditions, two types of government public health activities should not be
considered sufficiently effective to justify the privacy invasion inherent in the
emergent public health surveillance model. First, activities that are essentially
surveillancelike tracking diseases over time and evaluating the success of public
health initiativesprovide no direct benefit to the individuals surveilled. Moreover,
traditional models of public health surveillance can support disease tracking and
program evaluation.192 Second, government interventions that target lifestyle
conditions should be viewed skeptically under an efficacy standard becauseas
supporters of the emergent public health model frequently arguea persons own

behavior is often the root cause of [obesity and obesity-related conditions like
diabetes].193 It is almost a platitude to say that human habits are hard to change,
even when the human involved desperately wants to change them. With respect to
diabetes, a comprehensive review of diabetes research and literature published
between 1985 and 2001 revealed that simply improving the persons level of
knowledge rarely, if ever, led to the type [of] behavior changes necessary to
manage the disease effectively.194 The public health and medical communities
have not yet found a way to induce the kinds of behavioral changes needed both to
reduce the impact of obesity, diabetes and other chronic conditions, and to rein in
escalating health care costs.195 B. Application: Why the A1C Registry Likely Fails
Strict Scrutiny Most commentators assume that a rational basis standard of review
would apply to New York Citys A1C Registry,196 and accordingly predict that the
program would survive a constitutional challenge.197 However, applying the strict
scrutiny analysis outlined in Part A suggests that the A1C Registry may effect an
unconstitutional invasion of privacy. New York City government has a compelling
interest in preventing both diabetes and diabetes-related complications. The
problem is that the A1Cs surveillance model does not enable sufficiently effective
interventions.198 The Department has explained why it believes the A1C Registry is
valuable,199 but its explanation is far from satisfactory. The Departments public
statements suggest that comprehensive, individualized data is the primary value of
the A1C Registry, because it currently enables the government to deliver
feedback and may enable the government to deliver useful services.200 In
addition, the Department believes the existing A1C Registry interventions can
improve patient health outcomes.201 According to the Department, [p]ersonal
identifiers are essential to enable both accurate surveillance and communication
with health care providers about individual patients.202 The Department also
emphasizes the severity of the diabetes epidemic, which it argues warrants an
urgent public health response.203 The A1C Registry interventions likely do have
some value. The patient letters204 inform by telling people that their blood sugar is
poorly managed, by explaining that high blood sugars have adverse health
consequences, and by advising diabetics to get regular medical care.205 However,
there are at least two reasons why informing patients in this manner should not be
considered sufficiently effective to justify the surveillance component of the A1C
Registry. First, the City government is not the best entity to inform diabetics of their
health status and its associated risks. One alternative is community health
providers, which have the significant advantages of (i) interacting with patients
under normal conditions of confidentiality and (ideally) trust, and (ii) being far
better situated to connect patients with resources that may help in each individual
case.206 More fundamentally, the ravages of uncontrolled diabetes are common
knowledge in the communities most heavily impacted by the disease, even if the
quantified risk level associated with each A1C test result is not.207 Second, the
benefit of an unsolicited letter stating that the recipient is unhealthy seems dubious
at best. After all, far more resourceintensive programs intended to help willing
diabetic participants make needed lifestyle changes have achieved very modest
and short-lived success.208 The letters to health care providers identifying at-risk
patients are arguably more valuable. But again, how valuable? Improving the health
outcomes of a diabetic requires at least the following additional steps: (i) the doctor

contacts the patient, (ii) the patient visits the doctor, and (iii) the patient
implements the doctors recommendations. The diabetics who testified at the
Departments 2005 hearing strongly contested the utility of provider letters.209
Increasingly, health care providers also recognize that the principal obstacles to
successful diabetes management are practical, not informational. Accordingly, some
experts have called for a new approach to treating diabetes, which emphasizes
identifying and resolving the practical barriers that prevent each individual diabetic
from making needed behavioral changes.210 Easy modifications to the surveillance
component of the A1C Registry surveillance would remove doubt about its
constitutional status. For example, the program could be consent based, like
Vermonts diabetes registry.211 Consent would remove privacy concerns; in
addition, people who opt in to the program are presumably indicating that they
would benefit from reminders about their health status. Alternatively (or
additionally), the A1C Registry could identify patients by community or health
center, instead of by name and personal information. That method would enable
city government to direct resources to the communities that need them most.
Advocates of the A1C Registry describe diabetes in New York City as a public health
crisis, a financial crisis, and a raging epidemic.212 The rhetoric used by public
health officials legitimately concerned about the physical and financial tolls of
chronic disease has been useful in bringing public attention to the destructive
power of conditions that often seem mundane and undramatic.213 But the rhetoric
is also profoundly misleading.214 Those who use the word epidemic argue that
diabetes is so like an infectious disease that it should be treated as one.215 But
diabetes is like an infectious disease only in the sense that it is widespread and
increasingly prevalent. Unlike infectious disease, it cannot be stopped by
government intervention in the lives of people who have it.216 Proponents also cite
the cost of chronic disease and related complications as a justification for emergent
public health surveillance.217 That argument implies, without explaining, that
financial crisisas opposed to a direct threat to the public healthjustifies intimate
medical privacy intrusions. Coupling the rhetoric of crisis with a call for
government action suggests that government action can effectively address the
crisis. My limited claim here is that the A1C Registrys model of ongoing,
comprehensive, and individualized surveillance may not enable government
interventions that sufficiently mitigate risk to the Citys diabetics. CONCLUSION
Emergent public health surveillance programs adopt a surveillance model that was
developed in the context of infectious disease and apply it to non-communicable
health conditions. But the original justification for the extreme privacy invasions at
the heart of individualized surveillance no longer applies. In addition, the emergent
public health surveillance model shares three features with security surveillance, all
of which have been identified as sources of troubling privacy invasions, and at least
one of which is changing Fourth Amendment analysis. Courts should recognize that
diabetes, obesity, and other chronic conditions that threaten the public health
implicate highly personal information, including sensitive medical data and a wide
array of personal behaviors. As a result, ongoing, name-based surveillance of
populations with those conditions effects an extremely intimate privacy invasion.
Applying strict scrutiny to emergent public health surveillance programs would

permit those invasions only to the extent necessary to successfully mitigate the risk
from diabetes and other chronic diseases.

The result of a balanced strict scrutiny standard is flexible privacy regulation and oversight federal implementation is
key
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
In addition, where we do have information about local procedures, it is clear that
there remains significant variation in the use of this tool.293 Furthermore, it is also
difficult to design an effective regulatory scheme in this context because the
technology itself is evolving and because our understanding of whether forensic
DNA profiles may ultimately be used to predict behavioral traits remains limited.294
As such, any proposed regulations should be flexible. With these limitations in mind,
this Section outlines five substantive regulations that should be adopted to oversee
the use of local databases. Two scholars have previously proposed regulations that
would severely curtail law enforcements use of these databases. For example,
Professor Elizabeth Joh has proposed that law enforcement should be required to
obtain a warrant whenever police seek abandoned DNA from a targeted
person.295 Professor Wayne Logan has gone further, recommending that the
government should be barred from using identity evidence secured from a lawful
arrestee for any purpose other than identity verification.296 The recommendations
offered below would not go as far. However, they would help limit many of the
potential negative implications of local databases while at the same time leaving
sufficient room for law enforcement to expand its use of DNA to high-volume crimes.
1. Requiring Adequate Record Keeping Maintaining adequate and accurate
records is crucial to regulating law enforcements use of local databases.297
Agencies using local databases should be required to record aggregate data
regarding the DNA profiles in their databases. This information should include the
percentage of DNA profiles from known individuals versus profiles derived from
crime-scene evidence. Furthermore, the DNA profiles from known individuals should
be further disaggregated. For example, regulations should mandate the collection of
information regarding whether the known profiles were collected by consent, from
abandoned biological material, or surreptitiously. Law enforcement should also be
required to collect information regarding the sources of the known DNA profiles.
That is, was the profile generated from a suspect, a victim, a victims family
member, or a witness? Finally, regulations should require the collection of data on
the age, race, and gender of the individuals whose profiles are in local databases. In
addition to collecting this aggregate data, law enforcement should be required to
track these same categories for each individual officer who collects reference
samples. Finally, this data should be recorded in a manner that makes it readily
accessible. If law enforcement is not required to collect this information, it will be
difficult to monitor whether local databases are utilized in a fair manner and if their
burdens are sufficiently distributed.298 This is particularly true because law

enforcement officials have considerable discretion in who they target.299 For

example, it would be important to know if a law enforcement agency only collects
abandoned DNA samples from young men of color. It would also be helpful to know
if an individual officers practices follow the same pattern.300 Without this
information we will not be able to reliably measure the extent of several of the
potential negative consequences identified in Part II. 2. Regulating Consent As is
demonstrated in Part I.B., law enforcements use of local databases is dependent on
collecting consensual samples from known individuals. In particular, local databases
are different from CODIS because they often include profiles from people police
have identified as suspects or potential future suspects. The reliance on consensual
samples as opposed to legally coerced samplese.g., from arrestees or convicted
individuals renders it important for regulations to address under what
circumstances law enforcement should be able to request a consensual sample.
Regulations should also help to ensure that consent is voluntary. In the absence of
regulation, law enforcement can approach anyone and request a consensual DNA
sample for inclusion in its local database. Furthermore, no external regulation
requires that law enforcement disclose to the targeted individual its plan to add the
profile to the local database. Without regulation, there are only two things limiting
law enforcements ability to request a sample from every person police encounter.
First, despite the fact that DNA processing is significantly less expensive than it was
even five years ago, it is still economically prohibitive to develop DNA profiles from
everyone willing to submit samples. Second, and in part motivated by those costs,
some agencies have adopted minimal internal regulations to limit from whom they
seek reference samples.301 However, these limitations will ease as the cost of DNA
processing declines. As a result, it is reasonable to consider whether law
enforcement should face limits on seeking consensual DNA samples. Privacy
scholars often frame this question as whether one has a right to be left alone.302
Courts have addressed this issue in regulating police-citizen encounters. For
example, New York courts have identified a common law right that provides more
protection than the Fourth Amendment to limit law enforcements ability to initiate
consensual searches. In short, [b]efore the police may stop a person pursuant to
[law enforcements] common law right to inquire there must exist at that moment a
founded suspicion that criminal activity is present.303 In People v. Hollman, New
Yorks highest court applied this right in reversing a narcotics conviction that
resulted from narcotics found after a citizen consented to the search of his bag.304
The court held that the undercover officer did not possess sufficient suspicion even
to seek consent to search the bag.305 Admittedly, the protection offered by
Hollman is limited. It would not prevent officers from seeking consensual DNA
samples from individuals for whom police possessed a reason to stop.306
Furthermore, the Supreme Courts holding in Whren would seem to permit
pretextual stops designed to give police an opportunity to seek consensual DNA
samples.307 However, recognizing a minimal right to be free from law
enforcements request for a consensual samplewhich is often an inherently
coercive interaction given the imbalance of power between law enforcement and
the targetwould limit law enforcements discretion to some degree. Independent
of whether law enforcement should be prohibited from seeking consensual DNA
samples without limitation, whenever seeking samples by consent, law enforcement

should at least be required to disclose its plans for the sample. If those plans include
adding the profile to law enforcements database, then that should be made clear.
Such a requirement would help ensure that the consent was truly voluntary. 3.
Prohibiting the Inclusion of Victim DNA Profiles Regulations should prohibit
local law enforcement from including DNA profiles from victims in local databases.
The practice of including victims profiles is driven by law enforcements
presumption that there is often overlap between crime victims and perpetrators.308
Indeed, many law enforcement officials interviewed during this project repeated
variations on the phrase, Todays victim is tomorrows perpetrator. Without
questioning the accuracy of this presumption, there remain many reasons to
prohibit law enforcement from including victim profiles in local databases. Crime
victims seek the assistance of law enforcement to remedy the wrong they faced. In
the context of the property crimes that are often the focus of local databases,
victims seek to recover their belongings, to obtain a police report needed to file an
insurance claim, or simply to alert law enforcement that an offender has targeted
them so as to help law enforcement identify patterns or develop leads. In reporting
crimes to police, victims voluntarily give up some privacy. Reporting the crime may
mean that law enforcement enters their home, takes a statement from them, talks
to other potential witnesses, and, in some cases, collects a DNA sample for
elimination purposes. To the extent that law enforcement turns the tables on a
victim, making the victim the target of law enforcements broader investigative and
surveillance activities, they undermine the justification for their initial intrusion.
Collecting DNA samples from victims for inclusion in databases adds a significant
cost to what victims must already bear when reporting a crime. Such a practice
requires victims not only to submit to the immediate invasion of privacy that results
from seeking law enforcements help, but it also requires victims to submit to a
lifetime of genetic surveillance. This cost will undoubtedly cause some victims to
avoid calling police. Others may reluctantly seek assistance from police, but they
will remain dismayed that they were required to pay a genetic-surveillance tax in
exchange for police assistance. 4. Time Limits for Suspect DNA Profile
Retention Regulations should address how long law enforcement is able to retain
DNA profiles in local databases. For example, if police collect a consensual sample
from a 22-year-old suspect that an officer stopped while walking down the street in
a manner that caught the officers attention, that profile should be removed
automatically from the database after five or 10 years if, during that period, the
profile had not been matched to a crime-scene DNA profile. Such a regulation would
at least cap what would otherwise have been a lifetime of genetic surveillance for
the 22-year-old for simply appearing suspicious. Given the Supreme Courts holding
in Maryland v. King, in which it upheld the constitutionality of collecting DNA
samples from arrestees,309 the time limit restrictions could be limited to samples
collected from mere suspects, as opposed those arrested or convicted of crimes.310
5. Monitoring Use Regulations should also require adequate procedures to ensure
that individual officers do not abuse the use of local databases.311 For example, the
architect of Palm Bays database emphasized his stern warning that officers not use
the database for personal snooping.312 But stern warnings are not enough. The
infrastructure for local databases already includes the ability to monitor individual
users. For example, SmallPond includes a feature called Audit Trail, which produces

a record of every user interaction with the system, including which searches where
performed and which DNA profiles were uploaded.313 Given that this tool is readily
available, law enforcement agencies should be required to utilize it to help ensure
against misuse.314 D. Implementing Reforms Despite the dearth of statutory or
constitutional restrictions of local databases,315 there is reason to believe that the
reforms outlined above could be adopted. Legislatures have demonstrated the
ability to protect privacy interests in other settings, most notably demonstrating a
remarkable nimbleness in quickly passing legislation regarding law enforcements
use of drones.316 Additionally, the Courts interpretation of the reach of the Fourth
Amendment may evolve.317 Furthermore, the promise of at least some minimal
external regulation is more likely given that some of the early adopters of local
databases have indicated an openness to regulation.318 The most effective way to
implement the reforms recommended in Part III.C. is through federal legislation.
Given that federal laws already regulate law enforcements use of genetic
surveillance in CODIS, there is precedent for federal regulation in this space. One
obvious challenge to such regulation is ensuring that regulations are sufficiently
flexible to allow law enforcement to continue using local databases while limiting
the external costs discussed in Part II. The reforms offered here are designed to
provide that flexibility. A new federal law could follow the statutory model used for
CODIS. For example, current federal law requires states to certify their compliance
with quality standards for DNA processing and with privacy protections for genetic
information in order to qualify for participation in CODIS.319 A new, expanded law
could require that in exchange for participation in CODIS, states certify that local
databases in their jurisdictions follow the five reforms outlined above. There is good
reason to expect that such a law would quickly cause states to comply.320 While
local databases are expanding, states still value their participation in CODIS.321
Such a regulatory structure would also respect the ability of states to adopt stricter
limits on the use of local databases.322 While a federal law would be most effective,
there are other options to achieve some of the benefits of the reforms outlined in
Part III.C. For example, each state could be encouraged to adopt a model statute
that includes these reforms. The prospect of quick action by each state seems
considerably less likely to occur without the stick of being excluded from CODIS that
could be a part of federal regulation. However, Alaska, Vermont, and Washington
have demonstrated that some states are capable of regulating local databases. In
addition, there are options aside from legislation. Existing regulatory bodies could
promote these reforms as best practices for local DNA databases. For example, the
recently created National Commission on Forensic Science (NCFS), a joint project
of the Department of Justice and the National Institute of Standards and Technology
(NIST), describes part of its mission as reduc[ing] fragmentation and
improve[ing] federal coordination of forensic science.323 Similarly, NISTs newlyformed Organization of Scientific Area Committees (OSACs) represents another
potential source for external regulation.324 Whereas the NCSF will outline broad
policies, the OSACs are designed to adopt specific standards and guidelines for
each forensic discipline.325 These organizations, which include national leaders
from law enforcement, practice, and academia, are limited to adopting non-binding
recommendations. However, even recommended procedures could be powerful
forces to alter current practices.

Federal government is key they fund the development and

management of local DNA databases the plan restricts its
domestic surveillance
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
3. Federal Funding Because local, non-CODIS databases are in some ways
duplicative of CODIS, it is reasonable to presume that even if these databases had
strong support from law enforcement officials, their expansion would be limited by
cost-conscious local government officials not eager to fund them. This has not been
the case, in part, because some local databases have been supported by federal,
not local funds.65 It is ironic that after allocating such a significant amount of
money to develop CODIS,66 the federal government is funding non-CODIS
databases that are at least potential rivals to the CODIS network.67 More
importantly, federal funding has allowed local agencies to bypass the local budget
process and the limitations it imposes on other law enforcement surveillance
techniques.68 The primary source of federal funding for local DNA databases are
the federal forfeiture laws that return money to local law enforcement officials in
exchange for their participation in federal task forces.69 These laws allow the
Department of Justice to share the proceeds of the seized property with local
agencies that participated directly in the seizure or forfeiture of the property.70
Local law enforcement agencies have come to depend on this revenue stream,71
and it has been crucial to the evolution of local DNA databases. For example,
resources from federal forfeiture laws fully fund the local database in Bensalem
Township,72 and local officials view this as a reliable source of funds for the
foreseeable future.73 Without this revenue stream, it is unlikely that local databases
would have developed as quickly as they have.

1AC Advantage Health Surveillance

The public is highly conscious of health privacy issues - but the
pressure for access will be enormous it is the historical
cornerstone of doctor-patient confidentiality
Alan Rubel (University of Wisconsin Law School Assistant Professor , Ph.D.,
Department of Philosophy, University of Wisconsin-Madison; J.D., magna cum laude)
2014 Privacy, Surveillance, and Autonomy p. 312
Introduction We all like at least some privacy, and there isn't much dispute that
privacy in health and medical information matters. This is for a variety reasons. One
is that support for privacy protections is strong; public opinion research consistently
indicates that persons care deeply about health privacy. Another is that health
privacy has significant historical roots, dating back to the provisions for physician
patient confidentiality in the Hippocratic Oath. The popular appeal and historical
protections for health privacy make sense because privacy implicates important
interests. Information about a person's health can be used to deny that person
employment, financial, or other opportunities; and learning about a person's
medical condition may lead others to define or view that person disproportionately
in light of that condition. Accordingly, there are a variety of legal protections for
health information privacy. In the U.S., these include the Health Insurance Portability
and Accountability Act, the Genetic Information Nondiscrimination Act, and the
Common Rule covering certain human subjects research. But the sheer usefulness
of health information creates enormous pressure for access. Information about
disease incidence aids in protecting public health; information about the behavior of
patients is useful in providing care; information about drug prescribing and use can
help in enforcing drugs laws; and many kinds of health information can serve as
data for research. Health information can also be important for democratic
governance: Health information may be relevant in determining candidates' fitness
for public office, and government transparency may require that people have access
to information about government-provided health services, even where that
information contains individually identifiable information.

Health surveillance expansion will be perceived - that will

shatter trust and result in disengagement from the health care
system
Brase 13 (Twila Brase. President Citizens Council for Health Freedom. Patient
Privacy and Public Trust: How Health Surveillance Systems Are Undermining Both.
August 2013. P. 7. http://www.cchfreedom.org/pr/50%20States%20Databases
%20Full%20Report.pdf)//EMerz
Furthermore, in the future, health officials may use a patients private data to
restrict certain access to care if medical records indicate a persistent unwillingness
to submit to government-endorsed vaccinations, a history of unhealthy behaviors or
ongoing engagement in unhealthy lifestyles, such as smoking, drug use, overeating,

or a failure to exercise. For example, the Patient Protection and Affordable Care Act
of 2010 (Obamacare) requires federal officials to gather outcomes data from
employers who provide employees with access to wellness programs.254 As the
public learns about government patient tracking and health surveillance, hospitals
and clinics may be seen as intrusive arms of the governments data
collection process rather than caring and trusted institutions. Thus,
government health surveillance through state and federal reporting mandates
threatens to diminish patient trust and violates the freedom and privacy rights of all
Americans. As government lays hold of the most private of individual data, patients
may also lose access to the full realm of private medical choices. Their willingness
to engage with the health care system may be limited by their unwillingness to give
up their privacy rights. A 1999 study found 15 percent of Americans already
engaged in privacy-protecting behaviors that compromise their access to timely and
accurate medical care.2

Privacy protective behavior will wreck the entire medical

system the result if epistemologically and methodologically
bankrupt medical decision-making faulty data destroys the
integrity of all medical research
Goldman, from the College of Physicians and Surgeons, Columbia University,
November 1998 (Janlori, Protecting Privacy To Improve Health Care, published in
HealthAffairs volume 17 number 6)//roetlin
the relationship between people and their doctors bears the greatest
burden in the health privacy debate; this relationship is the hot spot, the
originating point on the health information continuum. In this setting people are routinely
In many ways,

asked to disclose detailed, sensitive information about themselves and their family members.4 They are beginning
to understand, however, that the open-ende waivers for disclosure signed by patients as a condition of treatment
and payment leave them vulnerable to a wide array of uses and reuses of their health information. In reaction,

people are developing privacy-protective behavior to shield themselves from

what they consider to be harmful and intrusive uses of their health information . To
protect their privacy, patients may pay out-of-pocket for medical care, doctor-hop to avoid
having all of their health information entrusted to one provider , withhold
information, lie, or even avoid care altogether .5 The consequences of such privacyprotective behavior are significant:(1) The patient may receive poor-quality care, risking
undetected and untreated conditions . (2) The doctors abilities to diagnose and treat
accurately are jeopardized by a lack of complete and reliable information from the
patient. (3) A doctor may skew diagnosis or treatment codes on claim forms, may keep
separate records for internal uses only, or may send on incomplete information for
claims processing, to encourage a patient to communicate more fully . (4) The
integrity of the data flowing out of the doctors office may be undermined. The
information the patient provides, as well as the resulting diagnosis and treatment,
may be incomplete, inaccurate, and not fully representative of the patients care or
health status. Ultimately, if doctors and other health care providers are receiving
incomplete, inaccurate information from patients, the data they disclose for
payment, research, public health reporting, outcomes analysis, and other purposes
will carry the same vulnerabilities. In essence, information that lacks integrity at

the front end will lack integrity and reliability as it moves through the
health care system.

Our solvency claim is reverse causal

Pritts 13 (Joy L. Pritt. The Importance and Value of Protecting the Privacy of
Health Information: The Roles of the HIPAA Privacy Rule and the Common Rule in
Health Research. 2013. P. 6-8.
http://iom.nationalacademies.org/~/media/Files/Activity
%20Files/Research/HIPAAandResearch/PrittsPrivacyFinalDraftweb.ashx)//EMerz
If privacy is essentially having or being in a relatively personal space, it is difficult to
think of an area more private than an individuals health or medical information.
Medical records can include some of the most intimate details about a persons life.
They document a patients physical and mental health, and can include information
on social behaviors, personal relationships and financial status. It is hardly
surprising that when surveyed, people consistently report that they are concerned
about protecting the privacy and confidentiality of such personal information. In one
recent survey, 67% of respondents said they were concerned about the privacy of
their medical records, with ethnic and racial minorities showing the greatest
concern. When presented the possibility that there would be a nationwide system
of electronic medical records, 70% of respondents were concerned that sensitive
personal medical-record information might be leaked because of weak data
security, 69% expressed concern that there could be more sharing of medical
information without the patient's knowledge and 69% were concerned that strong
enough data security will not be installed in the new computer system. People have
identified being in control of who could get information about them; being able to
share confidential matters with someone they trust; and controlling what
information is collected about them as three of the facets of privacy that were most
important to them.39 Half of the respondents in a recent survey believed that
[P]atients have lost all control today over how their medical records are obtained
and used by organizations outside the direct patient health care such as life
insurers, employers, and government health agencies. These public opinions about
the privacy of health information reflect in a very real way the practical
importance of privacy to members of the public. They desire control over and
security and confidentiality of their health information. They want to know who is
using their information and why. A significant portion of Americans are concerned
enough about the privacy of their health information that they take matters into
their own hands. In response to a recent California HealthCare Foundation survey,
one out of eight respondents reported that they had engaged in a behavior
intended to protect his or her privacy, including taking such actions as avoiding
their regular doctor, asking their doctor not to record their health information or to
fudge a diagnosis, paying out of pocket so as not to file an insurance claim and
even avoiding care altogether.41 In very functional terms, adequately protecting
the privacy of health information can help remedy these concerns and,
hopefully, reduce this behavior. Ensuring privacy can promote more
effective communication between physician and patient, which is essential
for quality of care, enhanced autonomy, and preventing economic harm,

embarrassment and discrimination.42 A number of studies suggest that the

relative strength of confidentiality protections can play an important role in peoples
decisions whether to seek or forgo treatment, particularly with respect to mental
health and substance abuse. The willingness of a person to make self-disclosures
necessary to such mental health and substance abuse treatment may decrease as
the perceived negative consequences of a breach of confidentiality increase.44
Privacy or confidentiality is particularly important to adolescents who seek health
care. When adolescents perceive that health services are not confidential, they
report that they are less likely to seek care, particularly for reproductive health
matters or substance abuse. These studies show that protecting the privacy of
health information is essential to ensuring that individuals will obtain quality care.
Protecting privacy is also seen by some as enhancing data quality for
research and quality improvement initiatives. When individuals avoid health
care or engage in other privacy protective behaviors, such as withholding
information or doctor shopping, inaccurate and incomplete data is entered into
the health care system. This data, which is subsequently used for research,
public health reporting, and outcomes analysis carries with it the same
vulnerabilities. Ensuring individuals that the privacy and confidentiality of health
information will be protected should reduce these behaviors and result in more
complete and accurate data for these research, public health and quality purposes.
Protecting the confidentiality of health information also protects against the
perceived and real potential for economic harm resulting from discrimination in
health insurance and employment. Polls consistently show that people are most
concerned about insurers and employers accessing their health information without
their permission. This concern arises from fears about employer and insurer
discrimination. Concerns about employer discrimination based on health
information, in particular, increased 16% between 1999 and 2005 with 52% of
respondents in the later survey expressing concern that their information might be
seen by an employer and used to limit job opportunities. Reports of major
employers such as Wal-Mart basing their hiring decisions on the health of applicants
appear to justify these concerns. Studies focusing on genetic information show that
individuals go to great lengths to keep their genetic information private and out of
the hands of their insurers and employers. Even health care providers are affected
by these concerns. In a survey of cancer-genetics specialists, more than half
indicated that they would pay out of pocket rather than bill their insurance
companies for genetic testing, for fear of genetic discrimination. While surveys do
not reveal a significant percentage of individuals who have experienced such
discrimination, geneticists have reported that approximately 550 individuals were
refused employment, fired or denied life insurance based on their genetic
constitution. In addition, studies in the United Kingdom suggested that while
insurers in that country do not have a full grasp on the meaning of genetic
information and do not assess or act in accord with the actuarial risks presented by
the information. There is, therefore, some legitimate basis to individuals concerns
about potential economic harm and the need to protect the privacy of their
genetic information. In addition to these utilitarian reasons for protecting privacy,
some privacy scholars emphasize the value of protecting the privacy of health
information in its own right, seeing it as a fundamental human right.53 They believe

that respecting privacy (and autonomy) is a form of recognition of the attributes

that give humans their moral uniqueness. Thus, there are a variety of reasons, both
concrete and perceived, functional and philosophical, for placing a high value on
protecting the privacy, confidentiality and security of health information.

We control the determining factor high quality clinical trials

are a pre-requisite to ANY quality research
Sean Tunis (Centers for Medicare & Medicaid Services, Baltimore, Md) Daniel
Stryer (Agency for Healthcare Research and Quality, Rockville, Md) and Carolyn
Clancy (Agency for Healthcare Research and Quality, Rockville, Md) 2003
Practical Clinical Trials http://umassmed.edu/uploadedFiles/QHS/Content/Tunis
%20article1.pdf
The production of high-quality clinical trials will increase significantly when health
care decision makers decide to consistently base their decisions on high-quality
evidence. Research sponsors (public and private) will be motivated to provide the
type of clinical research required by decision makers. Payers and purchasers can
clearly indicate to the drug and device industry that favorable coverage and
payment decisions will be expedited by reliable evidence from PCTs. In particular,
manufacturers will be motivated to perform head-to-head comparative trials if these
are required to justify payments higher than the existing less expensive
alternatives. Physicians and medical professional organizations can also increase
the degree to which care of individual patients and professional society clinical
policy are guided by attention to reliable evidence. Patients and their advocacy
organizations have a critical stake in the quality of clinical research. The
fundamental premise of improving health care through informed patient choice
cannot be realized if unreliable evidence is used to inform patients. Patient
advocacy organizations should become more insistent on the production of
highquality evidence and work with research funders to increase support for PCTs.
These groups could also facilitate the research by encouraging patients, physicians,
and health care organizations to participate in clinical trials in those situations for
which current evidence is uncertain. Many years and lives could have been saved
had advocates worked to ensure the rapid completion of clinical trials on bone
marrow transplantation for breast cancer, instead of putting pressure on state and
federal policymakers to force payers to cover this procedure when supportive highquality data were lacking.58

Its vital for developing any effective new drugs

Norrgard 8 PhD, Department of Human Genetics at Virginia Commonwealth
University
(Karen, Human Subjects and Diagnostic Genetic Testing, Nature Education
1(1):82)
There is a vital need for human subjects in research related to drug development,
but can we properly balance the welfare of human research subjects with the need
for experimental data? Medical and psychological studies involving human subjects

remain a critical factor in advancing our scientific knowledge. Despite historical

episodes of tragically unethical treatment of humans in the name of medical
science, such as the Tuskegee study, the need for human subjects in biomedical
research is vital for the development of any new drug. But how can we balance
the welfare of human research subjects with the need for valuable data from human
experimentation? Several solutions to this conundrum have been proposed, but
none is without its flaws. Learning from the Tuskegee Study Sadly, there is a long
history of the unethical treatment of human subjects in various types of medical
and biological research. For example, one of the most notorious clinical studies of all
time was initiated in 1932, with the goal of tracking the progression of untreated
syphilis infection. At the time, treatments for syphilis included highly toxic mercury,
bismuth, and arsenic-containing compounds of questionable effectiveness. The
study was a collaboration between the Tuskegee Institute and the U.S. Public Health
Service in Alabama, and was intended to determine the progression of the disease,
the effectiveness of treatments at different stages, and modes of disease
transmission. Doctors recruited 399 black men thought to have syphilis, as well as
201 healthy black men as controls. Study participants were kept unaware of their
diagnosis of syphilis but, in return for participating in the study, the men were
promised free medical treatment if they tested positive, rides to the clinic, meals,
and burial insurance in case of death. The initial aim of the Tuskegee Study of
Untreated Syphilis in the Negro Male, as it was known, was perfectly legitimate: to
gather medical knowledge. However, during the mid-1940s, when penicillin had
been shown to be a highly safe and effective cure for syphilis infection, the
researchers did not abandon the study, but continued to subject their unwitting
participants to painful complications and death due to syphilis infection until 1972,
when a story about the study appeared in the national press. Public outcry caused
an abrupt end to this research, followed by the filing of a class action lawsuit
against the U.S. government on behalf of the survivors. In spite of the ethical
dilemmas associated with the use of human subjects, no new drugs could ever be
developed without thorough human testing to demonstrate their effectiveness; this
process of testing is known as a clinical trial. Clinical trials occur at the end of the
incredibly lengthy and expensive process of drug discovery. Only one of about every
5,000 screened substances that are originally synthesized or identified from natural
products makes it through the clinical trial process and is approved as a new
medicine (Pritchard, 2003).

Only new research can keep up with disease evolution

Cangelosi 5 Prof of Environmental and Occupational Health Sciences and
Adjunct Prof of Epidemiology and of Global Health at the University of Washington,
PhD in Microbiology from UC Davis
(Gerard A., Nancy E. Freitag, PhD, Prof in the Dept of Microbiology and Immunology
at the University of Illinois Chicago School of Medicine, and Merry R. Buckley, Ph.D.
in environmental microbiology at Michigan State University, From Outside to Inside:
Environmental Microorganisms as Human Pathogens,
http://academy.asm.org/index.php/environmental-microbiology-ecology-

evolution/553-from-outside-to-inside-environmental-microorganisms-as-humanpathogens)
The key difference between environmental pathogens and other human pathogens
is their ability to survive and thrive outside the host. Their widespread occurrence
in the environment makes them difficult to monitor and control. Inroads have been
made to understand the persistence of these organisms in the environment, the
reservoirs they inhabit, the ways they exchange virulence factors, and their
diversity, but a great deal more research is needed. By grouping together
phylogenetically diverse organisms under the umbrella of "environmental
pathogens," it is hoped that the topic can gain the critical mass needed for
sustained progress. Colloquium participants examined other research needs for
the field, including the diagnostic and environmental technologies that will be
necessary for taking the next steps. It was agreed that because of the complex
nature of studying organisms that can exist in the environment and in human hosts,
work in this area is best carried out in an interdisciplinary fashion with coordinated
input from medical, molecular, and environmental microbiologists, specialists in
host responses, epidemiologists, ecologists, environmental engineers, and public
health experts. The development of improved diagnostic techniques is critical for
accurate assessment of health risks and potential human or animal population
impact associated with environmental pathogens. If the impacts of these diseases
are to be effectively controlled, the techniques used to monitor and control
infections by environmental pathogensincluding interventions, exposure controls,
drugs, and vaccines require improvement. The processes surrounding drug and
vaccine development must be tailored to the special problem of environmental
pathogens, which often strike small numbers of individuals or individuals in less
developed areas of the world and, therefore, offer less potential for drug
development profit than more common diseases. A challenge exists, therefore, in
meeting the need for targeted, specific interventions, including development of
drugs and vaccines for infections by environmental agents, in the face of a lack of
financial incentive for development of these tools.

Trust key to medical research advances

Jacobs, 5 MD; Boston University professor of medicine [Alice, director of Cardiac
Catheterization Laboratory and Interventional Cardiology, "Rebuilding an Enduring
Trust in Medicine," Circulation, 2005,
circ.ahajournals.org/content/111/25/3494.full#xref-ref-3-1,]
To be sure, we will learn about the emerging science and clinical practice of cardiovascular disease over the next

there is an internal disease of the heart that confronts us as scientists, as

physicians, and as healthcare professionals. It is a threat to us allinsidious and pervasiveand one
that we unknowingly may spread. This threat is one of the most critical issues facing our
profession today. How we address this problem will shape the future of medical care. This issue is the
erosion of trust. Lack of trust is a barrier between our intellectual renewal and our
ability to deliver this new knowledge to our research labs, to our offices, to the bedside of our
patients, and to the public. Trust is a vital, unseen, and essential element in diagnosis,
treatment, and healing. So it is fundamental that we understand what it is, why its important in medicine,
four days. But

its recent decline, and what we can all do to rebuild trust in our profession. Trust is intrinsic to the relationship

between citizens around the world and the institutions that serve their needs: government, education, business,
religion, and, most certainly, medicine. Albert Einstein recognized the importance of trust when he said, Every
kind of peaceful cooperation among men is primarily based on mutual trust.1 In our time, trust has been broken,
abused, misplaced, and violated. The media have been replete with commentaries, citing stories of negligence,
corruption, and betrayal by individuals and groups in the public and private sectors, from governments to
corporations, from educational institutions to the Olympic Organizing Committee. These all are front-page news.
Perhaps the most extreme example is terrorism, in which strangers use acts of violence to shatter trust and splinter
society in an ongoing assault on our shared reverence for human life. Unfortunately, we are not immune in our own
sphere of cardiovascular medicine. The physician-investigator conflicts of interest concerning enrollment of patients
in clinical trials, the focus on medical and nursing errors, the high-profile medical malpractice cases, the mandate to
control the cost of health care in ways that may not be aligned with the best interest of the patientall of these
undermine trust in our profession. At this time, when more and more public and private institutions have fallen in
public esteem, restoring trust in the healthcare professions will require that we understand the importance of trust
and the implications of its absence. Trust is intuitive confidence and a sense of comfort that comes from the belief
that we can rely on an individual or organization to perform competently, responsibly, and in a manner considerate
of our interests.2 It is dynamic, it is fragile, and it is vulnerable. Trust can be damaged, but it can be repaired and
restored. It is praised where it is evident and acknowledged in every profession. Yet it is very difficult to define and
quantify. Trust is easier to understand than to measure. For us, trust may be particularly difficult to embrace
because it is not a science. Few instruments have been designed to allow us to evaluate it with any scientific rigor.

trust is inherent to our profession, precisely because patients turn to us in their most
vulnerable moments, for knowledge about their health and disease. We know trust
when we experience it: when we advise patients in need of highly technical procedures that
are associated with increased risk or when we return from being away to learn that our patient who
Yet,

became ill waited for us to make a decision and to discuss their concerns, despite being surrounded by competent

leaders in the medical field understand the

importance of trust.3 When asked whether the public health system could be
overrun by public panic over SARS and bioterrorism, C enters for D isease C ontrol and Prevention
Director Julie Gerberding replied, You can manage people if they trust you. Weve
put a great deal of effort into improving state and local communications and scaled up our own public
affairs capacitywere building credibility, competence and trust.4 Former H ealth and H uman
S ervices Secretary Donna Shalala also recognized the importance of trust when she said,
If we are to keep testing new med icine s and new approaches to curing disease, we
cannot compromise the trust and willingness of patients to participate in clinical
trials .5 These seemingly intuitive concepts of the importance of trust in 21st century medicine actually have
colleagues acting on our behalf. Many thought

little foundation in our medical heritage. In fact, a review of the early history of medicine is astonishingly devoid of
medical ethics. Even the Codes and Principles of Ethics of the American Medical Association, founded in 1847,
required patients to place total trust in their physicians judgment, to obey promptly, and to entertain a just and
enduring sense of value of the services rendered.6 Such a bold assertion of the authority of the physician and the
gratitude of the patient seems unimaginable today. It was not until the early 1920s that role models such as
Bostons Richard Cabot linked patient-centered medical ethics with the best that scientific medicine had to offer,6
and Frances Weld Peabody, the first Director of the Thorndike Memorial Laboratory at the Boston City Hospital,
crystallized the ethical obligation of the physician to his patient in his essay The Care of the Patient.7 In one
particularly insightful passage, Peabody captures the essence of the two elements of the physicians ethical
obligation: He must know his professional business and he must trouble to know the patient well enough to draw
conclusions, jointly with the patient, as to what actions are indeed in the patients best interest. He states: The

The care of the patient must be completely

personal. The significance of the intimate personal relationship between physician and patient
cannot be too strongly emphasized, for in an extraordinarily large number of cases
both diagnosis and treatment are directly dependent on it. Truly, as Peabody said, The
secret to the care of the patientis in caring for the patient.7 This concept that links the quality of
the physician-patient relationship to health outcomes has indeed stood the test of
time. Trust has been shown to be important in its own right. It is essential to patients, in
their willingness to seek care, their willingness to reveal sensitive information, their
treatment of a disease may be entirely impersonal:

willingness to submit to treatment, and their willingness to follow

recommendations. They must be willing for us to be able.\

A new outbreak can emerge at any time and have unimpeded

virulence its only a question of when
[Roger Highfield director of external affairs at the Science Museum Group Ebola
Shows the World Is Primed for the Perfect Microbial Storm 8/13 14]
The deadly outbreak of Ebola, the largest in recorded history, comes as little surprise to
scientists. In the light of recent research, expect to see more global public health emergencies,
faster spreading scourges and more novel diseases . True enough, modern technology has brought us a
range of extraordinary tools, from diagnostics to drugs to global, instantaneous communications. But the relentless rise
of modern civilisation has also made the possibility of a pandemic greater
than at any time in history. Emerging diseases that have devastating
effects internationally, with millions infected and billions spent, are all foreseeable
consequences of changes in the way we live our lives. This is not simply the price of our success in dominating the planet and its

The Ebola
emergency reminds us that we now have the conditions for a perfect microbial
storm. Most human infectious diseases originated in animals and, as human populations and their
road networks expand, as we clear more land for agriculture, hunt for wildlife and trade
more animals, they are coming into contact with more animal diseases , explains Angela
ecosystems but, importantly, of allowing so many of the planet's human inhabitants to live in poverty.

McLean of Oxford University's Institute for Emerging Infections. Meanwhile, we are increasingly farming vast numbers of domestic

There are also

unprecedented opportunities for rapid spread, thanks to air travel, as in
the current Ebola outbreak. The role of wild animals in the origin of novel diseases was laid bare in 2008 when
animals that can provide reservoirs for existing bugs and fertile breeding grounds for new ones.

Peter Daszak, now president of the EcoHealth Alliance, Kate Jones of the Institute of Zoology and University College London, and
colleagues from Columbia University, New York, analysed 335 emerging diseases from 1940 to 2004. Maps which correlated disease

disease emergence events

have roughly quadrupled over the past 50 years. Some 60% of the diseases spread from
animals to humans such diseases are called zoonoses and the majority of those came from wild creatures. The HIV/AIDS
with human population density, rainfall and wildlife biodiversity revealed that

pandemic started from human contact with chimps and sooty mangabey monkeys; recent outbreaks of SARS (Severe acute
respiratory syndrome) originated in Chinese bats; CJD (Creutzfeldt-Jakob disease) in cattle; and MERS (Middle East Respiratory
Syndrome) to camels. The Zare subtype of the Ebola virus responsible for human outbreaks in Gabon and the Republic of the Congo
was linked to the handling of the carcasses of great apes that in turn had been infected by fruit bats. The global map of emerging
disease revealed the hotspots span sub-Saharan Africa, India and China, with smaller spots in Europe, and North and South America.
They tend not to be in the richer countries in the North that can afford surveillance but in relatively impoverished areas such as the
tropics, a region rich in wildlife species and under increasing human pressure, and in dense human populations, where one would
expect them to take hold more easily. The risks are now worse than suggested in their 2008 study, says co-author Marc Levy,
deputy director of the Center for International Earth Science Information Network at Columbia University in New York. They had
assumed populations would fall faster than they have. Moreover, political violence and instability has "led to refugee flows and
deliberate incursions into wild areas where rebels find timber, wildlife and minerals to finance their activities. In the case of Ebola,
we have also seen that it is

difficult to deal with effectively when public trust in a government

is low". In 2010, another study also involving Jones and Daszak, showed that species losses in ecosystems spur rises in
pathogens as we intrude into areas of high biodiversity. This is significant because current extinction rates are estimated
at 100 to 1,000 times higher than in past epochs, and are projected to increase at least a thousand times
more in the next 50 years.

Medical innovation solves antibiotic resistance

ONeill 15 Syndicate @ Guardian

(Jim, A call to antimicrobial arms, February, The Guardian,

http://www.theguardian.com/business/2015/feb/10/a-call-to-antimicrobial-arms)
Resistant
infections already claim more than 700,000 lives a year. Unless action is taken,
antimicrobial resistance will kill 10 million people a year by 2050 more than the number of
people who currently die from cancer. It will also have a cumulative cost of at least $100tn, more than 1.5 times todays annual global GDP. We
are not doing nearly enough to combat this danger. The world urgently needs new
drugs to replace the antibiotics, anti-malarial regimes, antiretroviral Aids and HIV medications, and tuberculosis
treatments that are losing effectiveness. But we do not invest enough in research and
development. It is critical that we find new sources of funding to support the academic researchers and small
companies whose discoveries are laying the foundations for tomorrows medicines . That is why I am
In December, I reported the first findings of the Review on Antimicrobial Resistance, which I chair. The news wasnt good:

calling on international donors philanthropic and governmental alike to work with the Review on Antimicrobial Resistance to create a new fund to
support R&D in this important area. The fund will provide grants for blue-sky science and act as a non-profit incubator for promising discoveries. Over the
coming months, the Review will be working out the details of how such a fund could operate effectively. The problem is straightforward: as valuable as
scientific breakthroughs may be, it takes a lot of work to turn them into marketable drugs. And, because antibiotics generally produce low and
sometimes even negative returns on investment for the pharmaceutical makers that develop them, many companies and venture capital funds steer
clear. The Review is studying ways to align financial incentives for developing new antimicrobial drugs more closely with these medicines true social

time is of the essence

value. But
. New drugs take decades to discover and develop. Even if we were to fix every problem in the
development pipeline today, it would be at least another 10 years before the first new antibiotics became commercially available. In the coming months,
the Review will make recommendations regarding market incentives for developing new antibiotics and searching for potential alternatives such as
vaccines to the use of these drugs in agriculture. The Review will also highlight innovative approaches to addressing resistance. In its most recent paper,

a starting point for the fight against antimicrobial

resistance. The first is the creation of the innovation fund to support early research. In addition to providing money for efforts to
the Review has identified specific measures that could provide

develop new drugs, the fund should encourage research into diagnostic tools, surveillance methods, techniques to slow the development of resistance,

basic research is where medical innovation

starts, and the sums involved need not be huge to make a significant difference. We should also invest more in the
and social and economic studies of consumer behavior. This kind of

people who will solve the problem. Evidence seems to show that young scientists and doctors are reluctant to enter fields related to antimicrobial

We need to nurture the next generation of academics, scientists, hospital workers, and
pharmaceutical technicians.
resistance.

The impact is extinction

Engelhardt 8 PhD, MD, Professor of Philosophy @ Rice
(Hugo, Innovation and the Pharmaceutical Industry: Critical Reflections on the
Virtues of Profit, EBrary)
The volume opens with Engelhardt's examination of the central place of the market,
especially in liberal, secular, pluralist, limited democracies. As is argued, the market
and the pursuit of profit have their central place by default and because of their
cardinal benefits. First, the market is a cardinal place for peaceable cooperation in
the face of moral disagreement. As Engelhardt argues, when moral strangers meet,
the market, along with limited democracies and contracts, offers one of their major
means for morally authoritative collaboration. Even when persons cannot agree
about anything else, they can at least agree to buy and sell goods and services. This
essay explores why the market and the pursuit of profit are not only a default
mechanism for collaboration in a world marked by intractable moral controversy
and diversity; it is also indispensable if one is interested in securing human
survival and in decreasing morbidity and mortality risks. If the allure of profit drives
innovation in the pharmaceutical and medical-device industry, then one should be
concerned with any policies that limit profit in these industries as compared to
others. Any attempt to curtail profit will likely lead not only to slower advances in
the ability to lower morbidity and mortality risks, but it may as well threaten the

capacity of humans to adapt to new microbial (such as multi-drug-resistant

tuberculosis) and other threats. Critical concerns for policies that limit the
profitability of the pharmaceutical and medical-device industries should also include
a re-assessment of easily acquired, poorly grounded, and large liability judg-ments
against the manufacturers of pharmaceuticals and medical devices. These concerns
should also include a critical regard of policies that would limit profits through the
breach of patents by developing countries. Such limitations will encourage virtuous
stewards of invest-ment capital to avoid investing in the cure of diseases found
primarily in such countries. The very character of human finitude places money,
market and profit as central elements in the project of improving the human
condition.

1AC Advantage Genetic Surveillance

States are circumventing status quo federal precedent and
statutory law huge expansion of genetic surveillance is
coming now oversight, regulations, and limiting federal
budgetary authority are key
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
The past five years have seen a dramatic, and until now wholly unexamined,
splintering of genetic surveillance by law enforcement. Investigators have shifted
from using the FBIs centralized, national DNA database network to a growing
number of unregulated local databases.1 These databases operate outside the
federal laws and rules that govern law enforcements use of the FBIs national DNA
database network. As a result of this regulatory void, police departments have
pushed the boundaries of genetic surveillance, using this tool in ways not previously
permitted.2 The aggressive use of local databases has helped police to increase
clearance rates and decrease crime rates.3 But the story is not all positive. The
expansion of this surveillance tool at the local level has unleashed significant
negative forces that threaten privacy and dignity interests, exacerbate racial
inequities in the criminal justice system, and undermine the legitimacy of law
enforcement. This Article analyzes these costs and proposes reforms to minimize
them while preserving law enforcements ability to use this tool on the local level.
The Article is the first full-scale examination of these unregulated, local DNA
databases. It is supported by original qualitative empirical research based on
interviews with law enforcement officials, prosecutors, and representatives from the
major firms developing these local databases. This Article makes three claims. First,
cutting-edge genetic surveillance issues are playing out on the local level, free from
federal regulation and, often, in the absence of state or local laws.4 Second, this
Article responds to Professor Rachel Harmons challenge to scholars to help law
enforcement establish harm-efficient policing practices by identifying and
measuring external harms generated by policing that are not captured by law
enforcements narrow focus on solving crime.5 In this sense, this Article is a case
study in regulating law enforcements use of rapidly evolving surveillance
technology. Third, contrary to the proposals of many scholars who have advocated
for the devolution of power to the local level in the criminal justice system,6 this
Article urges that national standards are needed to address the costs of genetic
surveillance. The expansion of locally-controlled DNA databases follows two decades
of federal oversight of law enforcements use of genetic surveillance. Since 1994,
when Congress authorized the creation of a national network of DNA databases
commonly referred to as CODIS,7 the FBI has overseen what has become one of the
largest genetic surveillance tools in the world.8 CODIS includes DNA profiles from
over 12.9 million known individuals and from over 565,000 crime scene samples.9 It
has been built with millions of dollars in federal funding,10 and law enforcement
officials and politicians routinely support its expansion.11 CODIS has survived every

legal challenge it has faced.12 And it has delivered many law enforcement
victories.13 Nonetheless, many local agencies have turned away from CODIS to set
up their own local databases.14 Despite the emergence of local databases as a core
investigative tool, scholars and courts have not focused on their creation or use.15
This is in stark contrast to the comprehensive attention paid to CODIS.16 This
Article seeks to shift scholarly attention from CODIS to these local databases. The
analysis of local databases usually amounts to a paragraph or a few sentences in a
larger critique of CODIS, in which the commentator either pans their use, labeling
them "rogue" databases, or notes their promise as a new tool that can reduce
crime, lock up offenders who would have otherwise escaped detection, and
generally revolutionize policing. This paltry coverage contrasts with the buzz local
databases have received in other circles. The topic has received significant
attention in police trade publications,17 and early adopters have offered
unvarnished praise.18 Proponents of local databases argue that freedom from
CODISs regulations allows police to maximize the potential of genetic surveillance
to solve crime. This belief has led several early adopters to become evangelists for
local databases, recruiting other police departments to create their own
databases.19 These proponents herald local databases as a solution to an
assortment of policing challenges, arguing that they increase clearance rates while
using fewer resources than other investigative methods; deter criminal activity;
decrease the opportunity for latent biases and negative stereotypes to affect
policing decisions; and strengthen the publics perception of the police.20 No doubt,
this list of positive attributes is what the Supreme Court envisioned when it
concluded that DNA has the potential to significantly improve both the criminal
justice system and police investigative practices.21 It is true that law
enforcements use of local databases has the potential to yield positive
outcomes,22 but these benefits must be weighed against the negative effects of
expanded use. The external harms of local databases arise from the gulf between
how law enforcement is permitted to use CODIS and the wild west of genetic
surveillance practices currently permitted with local databases.23 For example, like
CODIS, local databases include genetic profiles from convicted individuals and
arrestees. However, they also often include genetic profiles of suspects (including
juvenile suspects), witnesses, crime victims, family members of victims, and
citizens who responded to police DNA dragnets, which sometimes follow violent,
unsolved crimes. Furthermore, local agencies are free to search these databases
however they see fit, unconstrained by the regulations Congress adopted when it
authorized CODIS24 and the additional regulations the FBI promulgated for
CODIS.25 As a result, local databases amplify some of the same external harms
generated by CODIS while simultaneously generating new ones. These harms
include exacerbating racial inequities, threatening privacy and dignity interests, and
undermining the legitimacy of law enforcement. While local databases have the
potential to mitigate some of the racial inequities in the criminal justice system by
replacing police reliance on intuition and hunches with more reliable investigative
leads based on DNA evidence,26 local databases increase distributional inequities
because local police have total discretion about who to target for inclusion in these
databases. This has resulted in police seeking out the usual suspectspoor
people of colorto secure DNA samples for these databases.27 These databases

threaten privacy and dignity interests in several ways. With respect to privacy, they
increase surveillance on innocent, lawabiding citizens, expand the use of familial
DNA searching, and have the potential to limit self-expression and selfdetermination for targeted individuals.28 Furthermore, they impose dignity costs in
the short- and longterm. There is the immediate indignity and stigma associated
with being stopped by police in public to provide a DNA sample.29 And there is the
long-term dignity cost when these stops communicate that someone needs to be
watchednot because he was arrested or convicted, but based on law
enforcements belief that he will be a future criminal. Collectively, these costs carry
the potential to undermine the legitimacy of law enforcement.30 As local agencies
circumvented the federal regulations that govern CODIS by creating their own
databases, legislatures and courts have remained aloof, allowing these databases to
evolve with little oversight. However, the external costs generated by local
databases demonstrate the need for regulation; the current reliance on selfregulation is not sufficient. Law enforcements success is commonly measured by a
narrow focus on crime rates and clearance rates. As a result, police chiefs lack
incentives to identify and measure external costs of surveillance practices.31
Current external regulations of genetic surveillance are also insufficient. The vast
majority of local databases operate outside of federal and state statutory
regulations.32 Furthermore, these databases operate largely beyond the reach of
the Fourth Amendment because of their extensive reliance on obtaining DNA
samples by consent or from abandoned DNA.33 This freedom from regulation was
welcomed by early adopters of local databases. It was a driving force behind their
creation.34 However, even proponents of local databases recognize the value in
embracing some external regulations.35 This Article offers five modest yet effective
proposals for reform.36 First, the Article calls for a robust mandatory record-keeping
scheme designed to minimize the potential for local databases to diminish privacy
and dignity interests and to exacerbate existing racial inequities in the criminal
justice system. This requirement will largely monitor the inputs of local databases
e.g., what profiles are included, from whom were they collected, and in what
manner were they secured. Second, the Article proposes that law enforcement must
have some minimal level of suspicion before seeking consensual DNA samples from
people who cannot be compelled to provide DNA samplesi.e., people other than
arrestees and convicted individualsand that, when seeking consensual DNA
samples, law enforcement must clearly disclose its intent to add the resulting profile
to its local database. This will curb law enforcements ability to populate local
databases with the usual suspects, a practice that will result in a disproportionate
number of profiles from people of color and other demographic minorities. Third, the
Article calls for prohibiting the inclusion of DNA profiles from victims. This will limit
the crime-solving power of local databases because the line between victims and
perpetrators often shifts over time. Nevertheless, it will help to ensure that victims
do not have to pay a genetic surveillance tax in exchange for police assistance.
Fourth, the Article proposes a time limit for retaining DNA profiles from suspects to
counter the negative implications of the necessarily over-inclusive nature of local
databases and to minimize the privacy costs they inflict.37 Finally, the Article
proposes comprehensive monitoring of local databases, including tracking what
searches are performed in order to monitor outputs and to deter deliberate misuse.

If reforms are not adopted, the negative effects of local databases will remain
unchecked. Future empirical work will be needed to accurately measure these
external costs, but it is certainly possible that they will outweigh the immediate
crime-solving power of local databases. If that turns out to be the case, two options
remain for regulating local databases. First, states could follow Vermonts lead and
abolish all non-CODIS databases.38 Second, states could take the opposite
approach and pursue population-wide databases. The latter option at least would
address some of the negative externalities of local databases by more fairly
distributing the burdens of genetic surveillance across the population. Having
outlined its path in detail, the Article proceeds as follows. Part I sets the landscape,
documenting the fragmentation of genetic surveillance and explaining its causes.
These causes include law enforcements perception that CODIS is over-regulated,
advancements in forensic DNA processing combined with decreasing costs, federal
funding that has allowed agencies to bypass local political and budgetary processes,
and a nascent genetic surveillance-industrial complex. After describing the
expansion of local databases, Part I provides a detailed description of the operations
of the local databases in Palm Bay, Florida; Bensalem Township, Pennsylvania; and
the state of Arizona. This Section fills a large hole in our collective knowledge of law
enforcements use of genetic surveillance. Part II identifies and examines the
implications of the expansion of local databases, including analyzing their external
costs. This analysis is particularly important because the issues raised by local
databases do not map directly onto those raised by CODIS. This critique sets the
stage for Part III, which identifies five reforms for local databases and explains how
these reforms can be implemented.

Emergent health surveillance models are creeping into

genetics and DNA databases the federal government will
wildly repurpose databases and push to make them
comprehensive genetic surveillance society coming soon
Candice Roman-Santos (Corporate Counsel and Manager, Healthcare
Compliance at Nevro, Associate, Enterprise Regulatory Law Group, Juris Doctor,
Certificate in Health Law & Policy, Health Law at University of California, Hastings
College of Law) 2011 Concerns Associated with Expanding DNA Databases 2
Hastings Sci. & Tech. L. J. 267 http://hstlj.org/articles/concerns-associated-withexpanding-dna-databases/
VIII. Privacy Implications of DNA Privacy is not threatened by the means of obtaining
DNA samples, but rather the information inherent in DNA and the individuals lack of
control over such information.[cliii] There are few subject areas more personal and
more likely to implicate privacy interests than that of an individuals health or
genetic make-up.[cliv] The concern is that as the uses for and access to the DNA
database increases, the threat to privacy also increases.[clv] DNA samples have
been analogized to medical information stored on a computer disk because both
can be read by the application of technology.[clvi] Though medical information
may be strongly correlated with particular diseases, DNA is inherently linked to one
person (except in the case of identical twins).[clvii] An individuals medical

information may change over the course of his or her lifetime (e.g., people being
diagnosed with diabetes, asthma, high cholesterol, or heart disease well into
adulthood), but with the exception of mutations, DNA does not change over time.
[clviii] An individuals medical information may have implications for others (e.g., a
virus infection has implications for others as the infected person may get others
sick), just as DNA has implications for individuals other than the person from whom
the information was derived.[clix] However, the implications of medical information
are not as serious as those of DNA, which involve invading the privacy of a persons
family when no family member is guilty of any wrongdoing. Close relatives such as
parents, siblings and children share about fifty percent of each others genetic
variants and STR lengths, and more distant relatives such as uncles, aunts,
nephews, nieces, grandparents, grandchildren, and half-siblings share about twentyfive percent of each others DNA variants.[clx] Thus, using partial matches to
identify potential suspects radically expands the power and purpose of DNA
databases, implicating a number of people who may have nothing to do with the
original crime. There are substantial differences between DNA profiles and ordinary
fingerprints and it trivializes DNA to call a DNA profile a genetic fingerprint.[clxi]
Fingerprints are two-dimensional representations of the physical attributes of
fingertips and provide no information about a person other than identity.[clxii] In
addition to providing an individuals identity, DNA can also provide medical
characteristics, physical attributes, who the individual may be related to, and other
personal information that, in the wrong hands, can perpetuate discriminatory
practices.[clxiii] Whereas a latent fingerprint provides a fixed amount of information,
all of which is used by the forensic scientist, a DNA sample provides a wealth of
information and the forensic scientist has substantial control over the amount of
information to be obtained from the sample.[clxiv] DNA is more probative than
fingerprints because unlike fingerprints which establish that a suspect was present
at a location and does not automatically imply guilt, it is more difficult to advance
innocent reasons for the presence of DNA in the form of bodily fluids.[clxv] These
differences are relevant to how DNA databases should be used and maintained,
especially considering the privacy concerns unique to DNA. Proponents of DNA
databases claim that DNA profiles consist merely of junk DNA that is incapable of
revealing information about an individuals genetic make-up or health.[clxvi]
However, a British team has discovered that the standard DNA profile contains a
subtle signature which can be linked to a persons susceptibility to type 1 diabetes.
[clxvii] This research was buried in an academic paper, did not comment on the
implications for forensic science, and has been overlooked by the forensic and legal
communities.[clxviii] DNA forensic testing relies on the principle that DNA profiles
are only useful for identification, which is how people justify storing DNA profiles on
law enforcement computers because they do not infringe anyones medical privacy.
[clxix] Sir Alec Jeffreys was a member of the research team that made this
discovery, and he predicted that further troubling links between DNA fingerprints
and disease will emerge as scientists probe the completed draft of the human
genome.[clxx] The U.S. has failed to employ comprehensive privacy regulations
that would prevent the government from sharing DNA profiles in a DNA database
with other groups, such as insurance companies, employers, or academia.[clxxi]
DNA database statutes can be grouped into broad categories based on authorized

uses of both DNA profiles and raw DNA samples: 1) statutes that allow access to
DNA for non-law enforcement purposes, 2) statutes that allow access to DNA
information to public officials other than law enforcement, 3) statutes that allow law
enforcement to use DNA evidence for purposes other than identification, and 4)
statutes that do not require expungement of DNA records upon reversal.[clxxii]
Some state laws, such as Massachusetts, Louisiana and North Carolina, include a
vague, open-ended authorization that allows the database to be used for other
humanitarian purposes. [clxxiii] Alabamas statute explicitly authorizes the creation
and use of a DNA population statistical database to provide data relative to the
causation, detection and prevention of disease or disability, as well as to assist in
educational or medical research.[clxxiv] Mississippis law authorizes the Mississippi
Crime Laboratory to determine any restrictions, and Utahs law provides insurance
companies, psychologists, and other third parties with access to information in the
state DNA database.[clxxv] Some argue that creating a whole-population database
is logical because a larger database is more useful than a smaller one, and it has
the added effect of purging racial bias from the system, thereby avoiding criticisms
of discrimination that result from selective sampling of the population.[clxxvi]
However, this alone is insufficient to justify a whole-population database, and for
many the critical factor is not merely the creation of a whole-population database of
genetic profiles, but the retention of all of the DNA samples used to generate the
genetic profiles. The potential for the government to use the DNA samples for a
purpose not originally conceived of at the time that the DNA sample was obtained is
frightening. The problem of function creep will be explored in the next section. The
United States, Germany, and other countries have been guilty of implementing
national programs in the name of eugenics that clearly violated human rights.
[clxxvii] The eugenics movement lost credibility after the rise of Nazism in the
1930s, but re-emerged as a scientific endeavor and social issue following the
advent of biotechnology in the 1970s.[clxxviii] Science fiction literature and movies
have dealt with the issue of new eugenics the use of technology to make
directed changes to human evolution.[clxxix] These works convey the danger that
the ability to manipulate an individuals genetic makeup will result in removing
physical and behavioral traits not desired by society as a whole.[clxxx] The movie
GATTACA is an example projecting, from current knowledge and technology, a world
where the new eugenics is a reality.[clxxxi] If researchers are able to access the
DNA profiles or DNA samples accumulated pursuant to a DNA database statute,
they will inevitably try to identify the genes responsible for particular traits.
Thousands of citizens would essentially be contributing to this future reality without
their knowledge or consent. This reality is not as far off as some may think.
President George W. Bush enacted the Newborn Screening Lives Act in April 2008,
which mandates the screening of the DNA of all newborn babies in the U.S., and
sections of the bill make it clear that the DNA may be retained and later used in
genetic experiments and tests.[clxxxii] In addition, all 50 states now routinely
provide the results of such tests to the Department of Homeland Security.[clxxxiii]
The National Conference of State Legislatures has created a list of the various
statutes or regulatory provisions by state under which newborns DNA is being
collected.[clxxxiv] IX. Function Creep State and federal DNA database statutes
include no provisions for destroying DNA samples once a DNA profile for inclusion in

CODIS has been generated.[clxxxv] Proponents of forensic DNA testing claim that
retaining DNA samples is necessary because science and technology is constantly
improving and these samples may yield more information in the future.[clxxxvi] Paul
Ferrara, Director of Virginias DNA program, additionally claims that retaining DNA
samples is necessary so that agencies can rerun DNA profiles to verify cold hits
before notifying law enforcement agencies to further investigate, and that agencies
encounter many different situations requiring consultation with original database
samples.[clxxxvii] The term function creep refers to the operationally driven use of
the existing resource for new purposes not envisaged when the resource was
established, which is made possible by technological innovation and lack of
inhibiting measures like public opposition or legislation.[clxxxviii] Historically,
databases that were created in the U.S. for a discrete purpose were eventually
assigned new functions and purposes.[clxxxix] The government began issuing
drivers licenses in the name of public safety, and yet the average adult American
citizen now has more direct dealings with government through licensing and
regulation of the automobile than through any other single public activity.[cxc]
Eventually, states began earning millions of dollars per year from selling drivers
personal information to direct marketers, charities, political campaigns and various
commercial interests.[cxci] An unintended consequence of this practice was the real
threat to public safety. In some instances, abuse of drivers personal information
lead to murders.[cxcii] Congress reacted by passing the Drivers Privacy Protection
Act, which effectively prohibits the disclosure of personal information obtained in
connection with a motor vehicle record for unauthorized uses unless the individual
waives his or her right to privacy.[cxciii] The U.S. Supreme Court upheld the
constitutionality of the Drivers Privacy Protection Act, reasoning that it is a proper
exercise of Congress authority to regulate interstate commerce under the
Commerce Clause and does not violate principles of federalism contained in the
Tenth Amendment.[cxciv] The government introduced social security numbers
(SSNs) to track individuals accounts within the Social Security Program in 1935.
[cxcv] Executive Order 9397, issued in 1943, expanded its use by requiring federal
agencies to use SSNs exclusively whenever a new identification system for
individuals needed to be created.[cxcvi] Eventually, the Internal Revenue Service
adopted the SSN as its official taxpayer identification number and the Department
of Defense began using SSNs to identify Armed Forces personnel. [cxcvii] Then
during the 1970s, the Bank Records and Foreign Transactions Act required all
financial institutions to obtain the SSNs of all of their customers, the Privacy Act
authorized local governments to use SSNs, and the Tax Reform Act authorized
registration authorities of a state or local tax, welfare, drivers license, or motor
vehicle registration to use SSNs to establish identities.[cxcviii] Finally, in 1987, the
Social Security Administration began automatically issuing SSNs to newborns when
the birth was registered by the State, and currently all 50 states, plus Washington
D.C. and Puerto Rico, participate in this program.[cxcix] Once intended to track
individuals accounts within the Social Security Program, SSNs have become a
universal identifier for individuals within the U.S. The U.S. Constitution expressly
states that an enumeration shall be made within three Years after the first Meeting
of the Congress of the United States, and within every subsequent Term of ten Years
in such Manner as they shall by Law direct.[cc] Census records are a constitutional

requirement used to allocate congressional seats, electoral votes and government

program funding. Though the Constitution only requires a head count, a substantial
amount of data is collected during a census.[cci] More and more detailed
information has been gathered over the years, including data on race/ancestry,
health, housing, and transportation.[ccii] After the Japanese Attack on Pearl Harbor,
census records were used to facilitate the internment of Japanese-Americans.[cciii]
Presently, however, census data cannot be used for any purpose other than its
intended statistical purposes, and no federal agency is allowed to access census
reports.[cciv] The Texas Tribune recently published a story about how the
Department of State Health Services in Texas turned over newborn DNA samples to
an Armed Forces lab to build a national and, someday, international mitochondrial
DNA registry.[ccv] However, the newborn blood samples were stored without
parental consent and records uncovered government efforts to limit the publics
knowledge of the state newborn blood program.[ccvi] Parents sued officials over
these actions, but the state settled the case quickly before anything could be
revealed in the discovery phase.[ccvii] As of 2004, the Department of Defense
(DOD) had collected three million biological samples from service personnel for
the stated purpose of identifying remains or body parts of a soldier killed on
duty.[ccviii] However, samples are retained for fifty years, which greatly exceeds
the subjects time with the military. Further compounding the issue, the DOD has
refused to establish regulations to guard against third parties accessing the
accumulated biological samples.[ccix] It is not hard to foresee pressures mounting
to use these biological samples for purposes other than identifying soldiers killed on
duty, such as identifying criminal suspects and medical research.[ccx] Although
there is a Fourth Amendment concern associated with obtaining DNA samples, the
Fourth Amendment applies only to government action and is inapplicable to private
parties who do not act as agents of the government.[ccxi] This doctrine, however,
does not preclude the possibility that law enforcement may be able to access
existing repositories of DNA from cooperative private hospitals or laboratories,
provided that the government had no involvement in how the DNA was originally
obtained and that the state is not engaging in any search or seizure in acquiring
DNA in this way.[ccxii] The National Bioethics Advisory Commission estimated that
as of 1998, more than 282 million human biological specimens were collected and
stored in the U.S. for research studies, newborn screening tests, organ banks, blood
banks, forensic DNA databases, and for other purposes, which increases at a rate of
20 million samples per year.[ccxiii] The issue lies in the fact that an individual
undergoing diagnostic tests or donating samples for clinical or research purposes
has a reasonable expectation of privacy that their test results and DNA will not be
shared with a non-medical third party without his or her consent.[ccxiv] Function
creep has already begun with DNA databases as law enforcement has expanded
DNA collection to include new categories of people.[ccxv] Examples of future uses
of DNA databases include research to increase understanding of patterns of criminal
behavior, research to correlate genetic variation with disposition to certain
behaviors, and creation of a universal database by combining all existing databases
to facilitate data sharing.[ccxvi] X. Conclusion DNA database statutes provide
inadequate privacy protections. There is a lack of national oversight, no uniform
quality control process of obtaining DNA samples and maintaining DNA databases,

and there is no consistency regarding who may access DNA databases and for what
reasons. DNA is a useful crime-fighting tool, but its potential makes it likely to be
abused. Because DNA databases already exist, it is hard to imagine that their
viability will diminish in the future. Therefore, leaders must work to ensure that all
DNA profiles and DNA samples are used for the limited purpose for which they were
collected, and advocates should push for the eventual destruction of all DNA
samples once DNA profiles have been generated so that no one will be tempted to
use them for purposes that go beyond forensic identification. The way cold hit
statistics are used to determine guilt or innocence in litigation is another area of
potential abuse. Increasingly, convictions are relying on DNA evidence alone.
Moreover, when the DNA evidence is a partial match on less than 13 loci, the risk of
injustice is greater, as evidenced by the report of Arizonas DNA database in 2005. It
is frightening that most people are blinded by a belief that DNA is the panacea of
crime detection and do not recognize the potential threat to privacy and other civil
liberties. Researchers should be provided with access to the genetic profiles within
CODIS after all of the personal identifiers have been removed so that they can
conduct independent scientific scrutiny to ensure the scientific integrity of DNA
forensic science. The NDNAD in the UK is even more controversial than the DNA
databases in the U.S. Despite negative media coverage and successful legal
challenges to DNA collection and retention practices, British leaders are forging
ahead with the hope of one day expanding the database to cover the entire UK
population. Given the history of eugenics and discrimination in the U.S. and abroad
and the atrocities that have befallen millions of innocent human beings, everyone
should be aware of and fear the dangers associated with becoming a genetic
surveillance society. If people are not vocal in opposing current DNA database
practices, the only people who will be shaping the future of how DNA is used are
those with a political agenda who are not as concerned with individual privacy and
the ethics of their actions. As science and technology continue to advance, visions
of a brave new world that are the substance of science fiction movies like GATTACA
may no longer be a distant reality.

Racial biases have been routinely documented in study after

study genetic surveillance codifies a new Jim Crow database
that results in a new wave of biopolitical eugenics
Dorothy Roberts (Kirkland & Ellis Professor, Northwestern University School of
Law; faculty fellow, Institute for Policy Research) 2011 Collateral Consequences,
Genetic Surveillance, and the New Biopolitics of Race 54 Howard L.J. 567 20102011, HeinOnline
II. THE COST OF SURVEILLANCE Government DNA data banking began as a targeted
procedure to assist law enforcement in identifying perpetrators of a narrow set of
crimes.51 It has expanded into a form of state surveillance that ensnares innocent
people or petty offenders who have done little or nothing to warrant the collateral
intrusion into their private lives. Databanks no longer detect suspects-they create
suspects from an ever-growing list of categories. Even so, the public shows little
alarm about the massive retention of genetic information because the balance

between protecting individual privacy and keeping the streets safe seems to fall in
favor of more law enforcement. DNA profiling is a far more precise and objective
method of identifying suspects compared to less sophisticated law enforcement
techniques, such as eyewitness identification or smudge fingerprints found at a
crime scene.o Far from feeling threatened by this gigantic storehouse of genetic
data, many Americans see it as a surefire way of catching criminals and ensuring
that only guilty people are convicted of crimes.61 Storing an innocent person's DNA
seems a small price for such a great public good. The countless cases where DNA
data banking either yielded no benefit or produced erroneous identifications
received little attention from the media. Moreover, the public does not hear from
the thousands of innocent people whose DNA was seized and stored against their
will. Although DNA testing has shed light on the injustice of false convictions, it
cannot solve the underlying problems that lead innocent people to be convicted in
the first place. Most wrongful convictions result from deep biases in the criminal
justice system that make poor, minority defendants vulnerable to police abuse,
misidentification, and inadequate representation. 62 False confessions coerced by
the police are one of the main causes of wrongful convictions. According to the
Innocence Project, "In about [twenty-five] percent of DNA exoneration cases,
innocent defendants made incriminating statements, delivered outright confessions
or pled guilty."64 Coerced false confessions were a factor in fifteen of thirty-three
exonerations won by the Center on Wrongful Convictions.65 It makes no sense to
correct a problem created by law enforcement's abuse of power by handing over
even more authority to law enforcement in the form of DNA collection. The way to
reduce wrongful convictions is to remove the biases based on race and class that
corrupt our criminal justice system. Extending the reach of state surveillance does
just the opposite. Besides, contrary to the public's belief that DNA evidence is
infallible, there have been numerous cases of errors in the handling and analysis of
DNA that have led to false accusations and convictions of innocent people.6 6 These
weaknesses in the state's use of DNA data banking as a tool for reducing crime
make it harder to justify the resulting breach of individual privacy. Society
recognizes that the government violates its civil liberties if it taps our telephones or
secretly searches our homes without court permission. 7 Collecting and storing our
DNA is also a serious intrusion into our private lives because DNA is a part of the
body; taking it without consent violates our bodily integrity. In addition to this
material aspect, DNA contains sensitive personal information that can be used to
identify our family members and us, can be matched with other private records,
including medical files. 8 Society tolerates the state forcibly extracting highly
personal data from people convicted of serious crimes because these offenders
have a diminished right to privacy as a result of their antisocial conduct. 9 But as
the categories of people who are compelled to submit DNA broaden, it becomes less
clear why the state should have so much power over them. Once compelled DNA
collection goes beyond murderers, rapists, and armed robbers, law enforcement's
need for a sus- pect's DNA lessens and the right to retain control over their private
information strengthens.70 Although people convicted of heinous crimes may forfeit
their claim to privacy, there is no such justification for seizing genetic samples from
someone who has, say, forged a check. State agents should be required to obtain
informed consent to take or test DNA from anyone who has not been convicted of a

serious crime. Although U.S. courts have been slow to recognize this threat to civil
liberties," in 2008, the European Court of Human Rights unanimously held that the
United Kingdom's storage of DNA for purposes of criminal investigation infringed
privacy rights protected by Article 8 of the European Convention.72 The European
Court was especially troubled by the indefinite retention of genetic information
taken from children and adults who were never convicted of a crime,73 stigmatizing
them as if they were convicted criminals. This equation of the innocent and the
guilty disregards the presumption of innocence accorded to citizens in a democracy.
Massive government collection of DNA transforms the relationship between citizens
and their government in ways that contradict basic democratic principles.74
Government becomes the watchdog of citizens instead of the other way around.
Although they are guilty of no wrongdoing, huge segments of the population are
perpetually under suspicion. Citizens can no longer rely on the state to safeguard
their privacy by forgetting their past behavior because evidence about them is
stored forever. The state has the authority to take citizens' private property-in this
case, their genetic information-without due process. 76 Those are features of a
totalitarian state, not a liberal democracy. III. JIM CROW DATABASES These privacy
violations are exacerbated by the racial inequities that plague every part of the U.S.
criminal justice system. The most stunning aspect of this injustice is the mass
incarceration of African American men." Radical changes in crime control, drug, and
sentencing policies over the last thirty years produced an explosion in the U.S.
prison population from three hundred thousand to two million inmates."
Additionally, the United States has the highest rate of incarceration in the world at a
magnitude unprecedented in the history of Western democracies.79 The gap
between black and white incarceration rates has increased along with rising inmate
numbers.o Black men are eight times as likely as white men to be behind bars.8 '
One in nine black men aged twenty to thirty-four is in prison or in jail.82 In fact,
most people sentenced to prison today are black. In her 2010 book, The New Jim
Crow, legal scholar Michelle Alexander demonstrates that black incarceration
functions like a modern-day Jim Crow caste system because it "permanently locks a
huge percentage of the African American community out of the mainstream society
and economy," replicating the subjugated status of blacks that prevailed before the
civil rights revolution.8 4 The targeted imprisonment of black men is translated into
the disproportionate storage of their genetic profiles in state and federal databases.
We can look to the United Kingdom to gauge the likely racial impact of our own
federal database now that it has surpassed theirs in size. Their database reveals
that 40% of all black men and 77% of black men aged fifteen to thirty-five,
compared with only 6% of white men, were estimated to have genetic profiles in the
UK national DNA database in 2006.8 Also in 2006, Stanford bioethicist Hank Greely
estimated that at least 40% of the genetic profiles in the U.S. federal database were
from African Americans, although they make up only 13% of the national
population. 86 Sheldon Krimsky and Tania Simoncelli arrive at a similar estimate in
which 41 % to 49% of CODIS profiles are from African Americans." The extension of
DNA collection by the federal government and a number of states to people who are
only arrested-as opposed to charged or convicted-brings many more whites into the
system, but it is also on its way to creating a nearly universal database for urban
black men.88 These men are arrested so routinely that upwards of 90% would be

included in databases if the collection policy is strictly enforced.8 9 In April 2010,

Arizona Governor Jan Brewer signed a controversial law giving police broad
authority to detain anyone suspected of being in the country illegally.90 This law is
held up as a model for immigration enforcement policy in other states.91 When
combined with congressional authorization of DNA sampling from all federal
detainees,92 these immigration laws will cause the number of Latino profiles in
CODIS and state databases to skyrocket. Police routinely consider race in their
decision to stop and detain an individual.93 A New York Times/CBS News Poll
conducted in July 2008 asked: "Have you ever felt you were stopped by the police
just because of your race or ethnic background?" 94 Sixty-six percent of black men
said yes, compared to only 9% of white men.95 The United States Supreme Court
has authorized police to use race in determining whether there is reasonable cause
to suspect someone is involved in crime. 96 Michelle Alexander calls the Court's
license to discriminate the "dirty little secret of policing." 97 In recent decades, a
conservative Supreme Court has eroded the Warren Court's protections against
police abuse in ways that promote the arrest of blacks and Latinos-relaxing, for
example, the standard for reasonable suspicion- and has blocked legal channels for
challenging racial bias on the part of law enforcement." There is overwhelming
evidence that police officers stop motorists on the basis of race for minor traffic
violations, such as failure to signal a lane change, often as a pretext to search the
vehicle for drugs.99 One of the first confirmations of this was a 1992 Orlando
Sentinel study of police videotapes that discovered that, while blacks and Latinos
represented only 5% of drivers on the Florida interstate highway, they comprised
nearly 70% of drivers pulled over by police and more than 80% of those drivers
whose cars were searched." A study of police stops on the New Jersey Turnpike
similarly found that, although only 15% of all motorists were minorities, 42% of all
stops and 73% of all arrests were of black drivers.1ox In Maryland, only 21% of
drivers along a stretch of 1-95 outside of Baltimore were African Americans, Asians,
or Latinos, but these groups made up nearly 80% of those who were stopped and
searched.o 2 Likewise, an Illinois state police drug interdiction program, known as
Operation Valkyrie, targeted a disproportionate number of Latinos, who comprised
less than 8% of the Illinois population but 30% of the drivers stopped by drug
interdiction officers for petty traffic offenses.os Police officers also make drug
arrests in a racially biased manner. Although whites use drugs in greater numbers
than blacks, blacks are far more likely to be arrested for drug offenses-and,
therefore, far more likely to end up in genetic databases. 104 The latest National
Survey on Drug Use and Health, released in February 2010, confirms that young
blacks aged eighteen to twenty-five years old are less likely to use illegal drugs than
the national average.os Yet, black men are twelve times more likely than white men
to be sent to prison on drug charges." This staggering racial disparity results in part
from the deliberate decision of police departments to target their drug enforcement
efforts on urban and inner-city neighborhoods where people of color live. Indeed,
the increase in both the prison population and its racial disparity in recent decades
are largely attributable to aggressive street-level enforcement of the drug laws and
harsh sentencing of drug offenders. 0 7 A crusade of marijuana arrests in New York
City in the last decade provides a shocking illustration. 0 Since 1997, the New York
Police Department ("NYPD") has arrested 430,000 people for possessing tiny

amounts of marijuana, usually carried in their pockets." o' In 2008 alone, the NYPD
arrested and jailed 40,300 people for the infraction."f0 Even more alarming is the
extreme racial bias shown in whom the police target for arrest. Although U.S.
government studies consistently show that young whites smoke marijuana at the
highest rates, white New Yorkers are the least likely of any group to be arrested."1 '
In 2008, whites made up over 35% of the city's population but less than 10% of the
people arrested for marijuana possession. 112 Instead, the NYPD has concentrated
arrests on young blacks and Latinos. Police arrested blacks and Latinos for
marijuana possession at seven and four times the rate of whites, respectively."13
The racist marijuana policing strategy is based on the routine police practice of
stopping, frisking, and intimidating young blacks and Latinos. According to Harry
Levine, the City University of New York sociologist who exposed the arrest
campaign, "In 2008, the NYPD made more than half a million recorded stop and
frisks and an unknown number of unrecorded stops, disproportionately in black,
Latino and low-income neighborhoods."1 14 Although New York City is the
"marijuana arrest capital of the world," other cities like Atlanta, Baltimore, Denver,
Houston, Los Angeles, Philadelphia, and Phoenix are also arresting and jailing huge
numbers of blacks and Latinos for marijuana possession.1 1 5 The widespread
arrests of young blacks and Latinos for marijuana possession and other petty
offenses, such as truancy, skateboarding, and playing loud music, have devastating
consequences. A first-time offender who pleads guilty to felony marijuana
possession has a permanent criminal record that can block him or her from getting
a student loan, a job, a professional license, food stamps, welfare benefits, or public
housing.' Even if they avoid prison on a first offense, those who are arrested a
second time risk a harsh sentence for being a repeat offender."17 In addition to
harsh sentencing, a lifetime of genetic surveillance can now be added to the long
list of collateral consequences created by discriminatory arrests. IV. RACIAL HARMS
Racial disparities in DNA databanks make communities of color the most vulnerable
to state surveillance and suspicion."' The disproportionate odds faced by blacks and
Latinos of having their DNA extracted and stored will, in turn, intensify the racial
disparities that already exist in the criminal justice system. People whose DNA is in
criminal databases have a greater chance of being matched to crime scene
evidence. While a guilty person may have no right to complain, that is no excuse for
unfairly placing certain racial groups at greater risk of detection. Blacks and Latinos
have greater odds of being ge- netically profiled largely because of discriminatory
police practices.119 Moreover, people whose profiles are entered in DNA databases
become subject to a host of errors that can lead to being falsely accused of a crime.
As the federal government and a growing number of states extend the scope of DNA
collection to innocent people, they are imposing this unmerited risk primarily on
minorities. The problem is not only that all of these harms are placed
disproportionately on people of color, but also that the dangers of state databanks
are multiplied when applied to blacks and Latinos because these groups are already
at a disadvantage when they encounter the criminal justice system. Blacks and
Latinos have fewer resources than whites to challenge abuses and mistakes by law
enforcement officers and forensic analysts.120 They are stereotyped as criminals
before any DNA evidence is produced, making them more vulnerable to the myth of
DNA infallibility.121 "The experience of being mistaken for a criminal is almost a rite

of passage for African-American men," writes journalist Brent Staples.122 One of the
main tests applied by a disturbing number of Americans to distinguish law-abiding
from lawless people is their race. Many, if not most, Americans believe that black
people are prone to violence and make race-based assessments of the danger
posed by strangers they encounter. 23 One of the most telling reflections of the
presumption of black criminality is biased reporting of crime by white victims and
eyewitnesses.124 Psychological studies show a substantially greater rate of error in
cross-racial identifications when the witness is white and the suspect is black. 25
White witnesses disproportionately misidentify blacks because they expect to see
black criminals.126 According to Cornell legal scholar Sheri Lynn Johnson, "This
expectation is so strong that whites may observe an interracial scene in which a
white person is the aggressor, yet remember the black person as the
aggressor."127 In numerous carefully staged experiments, social psychologists have
documented how people's quick judgments about the criminal acts of others are
influenced by implicit bias-positive or negative preferences for a social category,
such as race or gender, based on unconscious stereotypes and attitudes that people
do not even realize they hold.' 28 Whites who are trying to figure out a blurred
object on a computer screen can identify it as a weapon faster after they are
exposed to a black face.129 Exposure to a white face has the opposite effect.130
Research participants playing a video game that simulates encounters with armed
and unarmed targets react faster and are more likely to shoot when the target is
black.' The implicit association between blacks and crime is so powerful that it
supersedes reality; it predisposes whites to see black people as criminals. Most
wrongful convictions occurred after witnesses misidentified the defendant.132
Databanks filled with DNA extracted from guilty and innocent black men alike will
enforce and magnify the very stereotypes of black criminality that lead to so many
wrongful convictions in the first place. Collecting DNA from huge numbers of African
Americans who are merely arrested, with no proof of wrongdoing, embeds the
sordid myth of black criminality into state policy. As databanks swell with DNA from
black people who are arrested or convicted on petty offenses and as their relatives
also come under suspicion in states with familial searching, the government
effectively treats every black person in many communities as a criminal suspect. It
seemingly also legitimizes the myth that blacks have a genetic propensity to
commit crime. In 2010, Florida State University criminologist Kevin Beaver
published a widely reported study claiming to show that young men with the lowactivity form of the monoamine oxidase A ("MAOA") gene-dubbed by the press as
the "warrior gene"-were more likely to join gangs than those who had the highactivity version of the MAOA gene.'33 He concluded that "male carriers of low MAOA
activity alleles are at risk for becoming a gang member and, once a gang member,
are at risk for using weapons in a fight."' 34 The public, who already implicitly
associates blacks with violence, may link research claiming that genes cause
gangbanging and aggression to the disproportionate incarceration of African
Americans along with the disproportionate banking of African Americans' genetic
profiles, to reach the false conclusion that blacks are more likely to possess these
crimeproducing traits-or even that most blacks actually possess them. Americans
will become even more indifferent to racial injustice in law enforcement if they are
convinced that black people belong behind bars because of their genetic

predilection to crime. CONCLUSION Despite the racial harms of DNA data banking,
civil rights advocacy groups have done little to challenge the threat posed by
government genetic surveillance. Their silence stems from a tension surrounding
DNA testing. Although it is serving an unjust criminal justice system, DNA
technology is also responsible for one of the biggest successes in criminal justice
reform. As of 2010, more than half (151 out of 254) post-conviction DNA
exonerations involved African Americans.1' There could not be a better publicrelations campaign for DNA than the compelling stories of falsely imprisoned people
released after DNA testing. As criminologist Simon Cole notes, "At first glance, postconviction DNA exonerations appear to be a powerful example of the use of
technoscience to offset social inequality."' 36 Civil rights organizations that may
have ordinarily opposed the expansion of DNA databanks because of their intrusion
into communities of color instead embrace DNA technology as a result of its ability
to exonerate victims of the system. However, while it appears DNA databanks would
decrease mass incarceration, this Article has argued that DNA databanks are
actually more likely to intensify it and its collateral consequences. Champions for
racial justice who support expanded DNA databanks or are silent about them should
not make the mistake of embracing DNA technology without analyzing its full role in
the criminal justice system.' 7 Although DNA testing can correct injustices when
used narrowly to confirm a suspect's guilt or innocence, the massive genetic
surveillance we are witnessing threatens to reinforce the racial roots of the very
injustices that need to be corrected. Wrongful convictions are a symptom of our Jim
Crow system of criminal justice, which is systematically biased against blacks and
Latinos. 38 Creating a Jim Crow database filled with their genetic profiles only
intensifies this travesty of justice, adding yet another collateral consequence of
criminal injustice and fortifying a dangerous biopolitics of race.

Racism makes all forms of violence inevitable, it must be

rejected in every instance.
Memmi 2k - MEMMI Professor Emeritus of Sociology @ Unv. Of Paris Albert-;
RACISM, translated by Steve Martinot, pp.163-165
The struggle against racism will be long, difficult, without intermission, without
remission, probably never achieved, yet for this very reason, it is a struggle to be
undertaken without surcease and without concessions. One cannot be
indulgent toward racism. One cannot even let the monster in the house,
especially not in a mask. To give it merely a foothold means to augment
the bestial part in us and in other people which is to diminish what is
human. To accept the racist universe to the slightest degree is to endorse
fear, injustice, and violence. It is to accept the persistence of the dark history in which we
still largely live. It is to agree that the outsider will always be a possible victim (and which [person] man
is not [themself] himself an outsider relative to someone else?). Racism illustrates in sum, the inevitable
negativity of the condition of the dominated; that is it illuminates in a certain sense the entire human

The anti-racist struggle, difficult though it is, and always in question, is

one of the prologues to the ultimate passage from animality to
humanity. In that sense, we cannot fail to rise to the racist challenge. However, it
condition.

nevertheless

remains true that ones moral conduct only emerges from a choice: one has to want it. It is a choice
among other choices, and always debatable in its foundations and its consequences. Let us say, broadly

speaking, that the choice to conduct oneself morally is the condition for the establishment of a human order for

One cannot found a moral order,

let alone a legislative order, on racism because racism signifies the exclusion of the
other and his or her subjection to violence and domination. From an ethical point of view, if
one can deploy a little religious language, racism is the truly capital sin.fn22 It is not an
which racism is the very negation. This is almost a redundancy.

accident that almost all of humanitys spiritual traditions counsel respect for the weak, for orphans, widows, or
strangers. It is not just a question of theoretical counsel respect for the weak, for orphans, widows or strangers. It is
not just a question of theoretical morality and disinterested commandments. Such unanimity in the safeguarding of

we have an interest in
banishing injustice, because injustice engenders violence and death. Of
the other suggests the real utility of such sentiments. All things considered,

course, this is debatable. There are those who think that if one is strong enough, the assault on and
oppression of others is permissible. But no one is ever sure of remaining the strongest. One day,

All unjust society contains within itself the

seeds of its own death. It is probably smarter to treat others with respect so that they treat you with
perhaps, the roles will be reversed.

respect. Recall, says the bible, that you were once a stranger in Egypt, which means both that you ought to
respect the stranger because you were a stranger yourself and that you risk becoming once again someday. It is

In short,
the refusal of racism is the condition for all theoretical and practical
morality. Because, in the end, the ethical choice commands the political
choice. A just society must be a society accepted by all. If this contractual
principle is not accepted, then only conflict, violence, and destruction will
be our lot. If it is accepted, we can hope someday to live in peace. True, it is a wager, but the
stakes are irresistible.
an ethical and a practical appeal indeed, it is a contract, however implicit it might be.

1AC Impact Framing

Their impacts are a function of neuroscientific biases and
heuristics reject their risk framing war, terrorism, and mass
political conflict wont happen and wont escalate
Rauch 03/2015 (Jonathan Rauch, senior fellow at the Brookings Institution, contributing editor
of National Journal and The Atlantic. Be Not Afraid, published in the March 2015 issue of The Atlantic
http://www.theatlantic.com/magazine/archive/2015/03/be-not-afraid/384965/)
It often befalls presidents to be most criticized in office for what later turn out to have been their particular
strengths. Disparaged at the time as simplemindedness, timidity, and slickness, Ronald Reagans firmness, George
H. W. Bushs caution, and Bill Clintons adaptability look in hindsight like features, not bugs. (Unfortunately, George
W. Bushs bugs still look like bugs.) President Obama catches flak for his supposed underreaction to crises in the
Middle East, Ukraine, and elsewhere. Instead of leading, the professorial president lectures the American public not
to be so darned worried. If you watch the nightly news, it feels like the world is falling apart, he said last August.
I promise you things are much less dangerous now than they were 20 years ago, 25 years ago,
or 30 years ago. This is not something that is comparable to the challenges we faced during the Cold War. Blame
social media, he tells us, for shoving so much upsetting stuff in our faces. Naturally, Obamas pontifications draw
protests. I strongly disagree with the presidents assertion last night that America is safer, said Senator John
McCain. By no objective measurement is America safer. Danger abounds! In 2012, General Martin Dempsey, the
chairman of the Joint Chiefs of Staff, pronounced the world more dangerous than it has ever been. That was
before the Islamic State, or ISIS, took over swaths of Iraq. Senator Lindsey Graham has warned that failure to defeat
ISIS will open the gates of hell to spill out on the world. Obama appears to have his doubts: a few months after
Chuck Hagel, then the defense secretary, pronounced ISIS an imminent threat, not just to the United States but
to every stabilized country on Earth, Obama sacked him. The American people deserve to hear complex,
multifaceted debates about any number of complex, multifaceted matters. This is not one of them. Obama is simply
right. The alarmists are simply wrong. America is safer than it has ever been and very
likely safer than any country has ever been, a fact that politicians and the public are curiously reluctant to believe.
Danger is a broad category. In principle, it includes everything from workplace accidents and natural disasters to
infectious diseases and pollution. In pretty much all of those categories, were doing well, although we have much
work to do. For present purposes, however, lets limit ourselves to threats in the usual political sense: malevolent
violence against Americans. The major menaces here would be warfare, crime, and terrorism.

Historically,

warfare has been the biggest violent killer of humans. According to Steven Pinker, the author of The
Better Angels of Our Nature: Why Violence Has Declined , today is probably the most peaceful time in
human history. By the numbers, he writes, the world was a far more dangerous place
in the 1960s, 70s, and 80s. According to the Uppsala Conflict Data Program, armed conflicts have
declined by almost 40 percent since right after the end of the Cold War. Today, write Micah Zenko
and Michael A. Cohen in Foreign Affairs, wars tend to be low-intensity conflicts that , on average,
kill about 90 percent fewer people than did violent struggles in the 1950s. War between
major nation-states has dwindled to the verge of extinction . In the context of human
evolution, this is an astounding development. Of course, the world remains turbulent, but most of todays
military conflict, as in Syria right now, takes the form of civil war rather than war between
nations, and implicates American interests but not American lives (unless America enters
the fighting). The United States faces no plausible military invader or attacker . All we
are really talking about, when we discuss threats from Iran or North Korea or ISIS, is
whether our margin of safety should be very large or even larger. No great power
in world history comes close to enjoying the traditional state security that the United
States does today, writes Stephanie Rugolo in A Dangerous World? Threat Perception and U.S. National
Security, a new collection of essays from the Cato Institute. Here at home, criminal violence is, as ever, a serious
problem. But its reduction over the past couple of decades is one of the great success stories of our time. The
violent-crime rate (which excludes homicides) has declined by more than 70 percent since the early 1990s. The
homicide rate has declined by half, and in 2011 it reached the lowest level since 1963. According to the National
Crime Victimization Survey, between 1995 and 2010 the rate of rape and sexual assault fell from five per 1,000
females to two. And how do

Americans celebrate this extraordinary success? By denying it. Every

year Gallup asks whether crime has gone up or down since the previous year. Every year, rain or shine, the public
insists, usually by overwhelming margins (63 percent to 21 percent in 2014), that crime has risen. Most Americans
Unaware of Big Crime Drop Since 1990s, announced the Pew Research Center in 2013; only 10 percent of those
surveyed knew that gun crimes had gone down since the 1990s. Criminologists say that many people get angry

Perception is even more skewed where terrorism is

concerned. Terror-ism Worries Largely Unchanged, ran another Pew headline, also in 2013. That year, 58
percent of the public was worried about another terrorist attack in the United States, a
rate not all that much lower in October 2001, immediately after the 9/11 attacks, when 71
percent of the public was worried. A few months ago, perhaps influenced by ISIS s atrocities, a large
plurality of respondents told NBC News/Wall Street Journal pollsters that the country is less safe
than it was before 9/11. Reality, once again, tells us otherwise . State-sponsored
international terrorism, writes the intelligence analyst Paul R. Pillar in Catos A Dangerous World?, is
today only a shadow of what it was in the 1970s and 1980s. As for the risk posed by
terrorism inside the United States, to characterize it as trivial would be very generous.
Americans are about four times as likely to drown in their ba thtub as they are to die
in a terrorist attack. John Mueller of Ohio State University and Mark G. Stewart of Australias
University of Newcastle estimate the odds of such deaths at one in 950,000 and one in 3.5 million,
respectively. Surely we can at least agree to worry about a nuclear Iran, or nuclear
terrorism, or ISIS? All are indeed worrisome, but Mueller p ersuasively argues that none
merits the alarm it begets. Since Nagasaki in 1945, the few countries that have obtained
nuclear weaponsincluding dangerous rogue states like Maos China, the Iran of its day
have consistently found them militarily and diplomatically useless, except as ego
boosters and perhaps as defensive weapons to forestall attack. The odds of terrorists obtaining
and deploying nuclear weapons are much lower than most people appreciate, for a
host of technical and political reasons. ISIS , meanwhile, is an unusually vicious and destabilizing
actor in a region that is full of them, but its menace has been almost entirely local . (In this issues cover
when told that crime is decreasing.

story, Graeme Wood examines this threat, and the appropriate response, in detail.) Pinker, a psychologist at
Harvard, mused in a recent speech about Americans odd refusal to appreciate their security. The bad news for

people are hardwired to

overreact to threats, real or perceived. In todays world, where intricate social systems
keep us safer than our forebears could ever have imagined, overreaction is
maladaptive: it is often more disruptive and damaging than whatever provoked it . In
Obama, if Pinker is correct, is that presidential palaver will have no effect, because

the world we evolved for, however, humans needed to be hyperalert. Something rustling in the bush was more

people are biased

to overestimate the likelihood of the sorts of events that stand out in our memory,
as violence and mayhem do, and as peace and quiet do not. Add alarmisms
usefulness to politicians and pressure groups, and you have a standing order for
overreactionalways, not just now. Still, now is special. Given how safe we are, and how frightened people
nonetheless feel, it seems unlikely that Americans threat perception has ever before been
quite as distorted as it is today. Never have so many feared so little, so much. In an era of overreaction, a
likely to be a predator or an enemy than a friend with glad tidings. Moreover, Pinker says,

president who lectures the public about its insecurities, instead of pandering to its fears, necessarily seems
impolitic, out of touch, tone-deaf, pedantic, negligent, complacentchoose your adjective. For precisely that
reason, we can be grateful his instinct is to underreact. Historians will thank him, even if we dont, for his
steadfastness in the face of unprecedented safety.

Miscalculation and escalation are not things warfare and

conflicts will not go nuclear
Quinlan 9 (Sir Michael Quinlan, Former Permanent Under-Secretary of State UK
Ministry of Defense, Thinking About Nuclear Weapons: Principles, Problems,

Prospects, p. 63-69, The book reflects the author's experience across more than
forty years in assessing and forming policy about nuclear weapons, mostly at senior
levels close to the centre both of British governmental decision-making and of
NATO's development of plans and deployments, with much interaction also with
comparable levels of United States activity in the Pentagon and the State
department, 2009)
There have certainly been, across the decades since 1945, many known accidents
involving nuclear weapons, from transporters skidding off roads to bomber aircraft
crashing with or accidentally dropping the weapons they carried (in past days when
such carriage was a frequent feature of readiness arrangements it no longer is). A
few of these accidents may have released into the nearby environment highly toxic
material. None however has entailed a nuclear detonation. Some commentators
suggest that this reflects bizarrely good fortune amid such massive activity and
deployment over so many years. A more rational deduction from the facts of this
long experience would however be that the probability of any accident triggering a
nuclear explosion is extremely low. It might be further nested that the mechanisms
needed to set of such an explosion are technically demanding, and that in a large
number of ways the past sixty years have seen extensive improvements in safety
arrangements for both the design and the handling of weapons. It is undoubtedly
possible to see respects in which, after the cold war, some of the factors bearing
upon risk may be new or more adverse; but some are now plainly less so. The years
which the world has come through entirely without accidental or unauthorized
detonation have included early decades in which knowledge was sketchier,
precautions were less developed, and weapon designs were less ultra-safe than
they later became, as well as substantial periods in which weapon numbers were
larger, deployments immure widespread arid diverse, movements more frequent,
and several aspects of doctrine and readiness arrangements more tense. Similar
considerations apply to the hypothesis of nuclear war being mistakenly triggered by
false alarm. Critics again point to the fact, as it is understood, of numerous
occasions when initial steps in alert sequences for US nuclear forces were embarked
upon, or at least called for, by indicators mistaken or misconstrued. In none of these
instances, it is accepted, did matters get at all near to nuclear launch
extraordinary good fortune again, critics have suggested. But the rival and more
logical inference from hundreds of events stretching over sixty years of experience
presents itself once more: that the probability of initial misinterpretation leading far
towards mistaken launch is remote. Precisely because any nuclear weapon
processor recognizes the vast gravity of any launch, release sequences have many
steps, and human decision is repeatedly interposed as well as capping the
sequences. To convey that because a first step was prompted the world somehow
came close to accidental nuclear war is wild hyperbole, rather like asserting, when a
tennis champion has lost his opening service game, that he was nearly beaten in
straight sets. History anyway scarcely offers any ready example of major war
started by accident even before the nuclear revolution imposed an order-ofmagnitude increase of caution.

It was occasionally conjectured that nuclear war might be triggered by the real but
accidental or unauthorized launch of a strategic nuclear-weapon delivery system in
the direction of a potential adversary. No such launch is known to have occurred in
over sixty years. The probability of it is therefore very low. But even if it did happen, the
further hypothesis of its initiating a general nuclear exchange is far-fetched. It fails
to consider the real situation of decision-makers , as pages 63-4 have brought out. The notion
that cosmic holocaust might be mistakenly precipitated in this way belongs to
science fiction. One special form of miscalculation appeared sporadically in the
speculations of academic commentators, though it was scarcely ever to be
encounteredat least so far as my own observation wentin the utterances of practical
planners within government. This is the idea that nuclear war might be erroneously triggered, or
erroneously widened, through a state under attack misreading either what sort of attack it was being subjected to,

The postulated misreading of the nature of the attack referred

the hypothesis that if a delivery systemnormally a missilethat was known
to be capable of carrying either a nuclear or a conventional warhead was launched in
a conventional role, the target country might, on detecting the launch through its
earlywarning systems, misconstrue the mission as an imminent nuclear strike and
immediately unleash a nuclear counter-strike of its own . This conjecture was voiced, for
or where the attack came from.
in particular to

example, as a criticism of the proposals for giving the US Trident SLBM, long associated with nuclear missions, a

it is
hard to regard this particular apprehension as having any real-life credibility. The
flight time of a ballistic missile would not exceed about thirty minutes, and that of a
cruise missile a few hours, before arrival on target made its characterconventional
or nuclearunmistakable. No government will need, and no non-lunatic government
could wish, to lake within so short a span of time a step as enormous and
irrevocable as the execution of a nuclear strike On the basis of early-warning information alone
without knowing the true nature of the incoming attack. The speculation tends moreover to be
expressed without reference either to any realistic political or conflict-related
context thought to render the episode plausible, or to the manifest interest of the
launching country, should there be any risk of doubt, in ensuringby explicit
communication if necessarythat there was no misinterpretation of its
conventionally armed launch. It may be objected to this analysis that in the cold war the two opposing
capability to deliver conventional warheads. Whatever the merit of those proposals (it is not explored here),

superpowers had concepts of launch-on-warning. That seems to be true, at least in the sense that successive US
administrations declined to rule out such an option and indeed included in their contingency plans both this and the
possibility of launch-under-attack (that is launch after some strikes had been suffered and while the sequence of
them was evidently continuing). The Soviet Union was not likely to have had more relaxed practices. But the
colossal gravity of activating any such arrangements must always have been recognized. It could have been
contemplated only in circumstances where the entire political context made a pre-emptive attack by the adversary
plainly a serious and imminent possibility, and where moreover the available information unmistakably indicated
that a massive assault with hundreds or thousands of missiles was on the way. That was a scenario wholly unlike

The
other sort of misunderstanding conjecturedthat of misread ing the source of attack
that implicit in the supposition that a conventional missile attack might be briefly mistaken for a nuclear one.

envisaged, typically, that SLBMs launched by France or the United Kingdom might erroneously be supposed to be
coming from US submarines, and so might initiate a superpower exchange which the United States did not in fact
intend. (An occasional variant on this was the notion that 'triggering' in this way might actually be an element in
deliberate French or UK deterrent concepts. There was never any truth in this guess in relation to the United

The unreality in this category of

conjecture lay in the implication that such a scenario could develop without the US
government making the most determined efforts to ensure that Soviet (or now Russian)
leaders knew that the United States was not responsible for the attack, and with
Kingdom, and French thinking is unlikely to have been different.)

those leaders for their part resorting, on unproven suspicion, to action that was
virtually certain to provoke nuclear counter-action from the United States. There used
occasionally to be another speculation, that if the Soviet Union suffered heavy nuclear strikes known to come from
France or the United Kingdom, it might judge its interests to be best served by ensuring that the United States did
not remain an unscathed bystander.

But even if that were somehow thought marginally less

implausible, it would have been a different matter from misinterpretation of the
initial strike. As was noted earlier in this chapter, the arrangements under which nuclear-weapon inventories
are now managed are in several important respects already much less open to concern than they were during much
of the cold war. Worries voiced more recently sometimes relate to 'cyber-attack' hostile
interference, whether by states or by other actors such as terrorists, with information systems used in the control of

It is highly unlikely, though details are (again understandably) not made public,
that regular reviews of control arrangements are oblivious to any such risks .
armouries.

Perceptions of them do however reinforce the already-strong case that whatever arrangements still remain in place
for continuous high readiness to launch nuclear action at short notice should be abandoned. Chapter 13 returns to
this.

Structural violence outweighs

Scheper-Hughes and Bourgois, 4 professor of anthropology and Cal-Berkeley;
professor of anthropology at University of Pennsylvennia (Nancy and Philippe,
Introduction: Making Sense of Violence, in Violence in War and Peace, 2004, pg.
19-22) //RGP
This large and at first sight messy Part VII is central to this anthologys thesis. It encompasses everything from
the routinized, bureaucratized, and utterly banal violence of children dying of hunger and maternal despair in
Northeast Brazil (Scheper-Hughes, Chapter 33) to elderly African Americans dying of heat stroke in Mayor Dalys
version of US apartheid in Chicagos South Side (Klinenberg, Chapter 38) to the racialized class hatred expressed by
British Victorians in their olfactory disgust of the smelly working classes (Orwell, Chapter 36). In these readings
violence is located in the symbolic and social structures that overdetermine and allow the criminalized drug
addictions, interpersonal bloodshed, and racially patterned incarcerations that characterize the US inner city to be

Violence also takes the form of class,

racial, political self-hatred and adolescent self-destruction (Quesada, Chapter 35), as well as of
useless (i.e. preventable), rawly embodied physical suffering, and death (Farmer, Chapter 34). Absolutely
central to our approach is a blurring of categories and distinctions between wartime
and peacetime violence. Close attention to the little violences produced in the
structures, habituses, and mentalites of everyday life shifts our attention to pathologies
of class, race, and gender inequalities. More important, it interrupts the voyeuristic tendencies of
normalized (Bourgois, Chapter 37 and Wacquant, Chapter 39).

violence studies that risk publicly humiliating the powerless who are often forced into complicity with social and
individual pathologies of power because suffering is often a solvent of human integrity and dignity. Thus, in this

we are positing a violence continuum comprised of a multitude of small

wars and invisible genocides (see also Scheper- Hughes 1996; 1997; 2000b) conducted in the
normative social spaces of public schools, clinics, emergency rooms, hospital wards, nursing homes,
courtrooms, public registry offices, prisons, detention centers, and public morgues. The violence
continuum also refers to the ease with which humans are capable of reducing the
socially vulnerable into expendable nonpersons and assuming the license - even the duty - to kill,
anthology

maim, or soul-murder. We realize that in referring to a violence and a genocide continuum we are flying in the face
of a tradition of genocide studies that argues for the absolute uniqueness of the Jewish Holocaust and for vigilance
with respect to restricted purist use of the term genocide itself (see Kuper 1985; Chaulk 1999; Fein 1990;

is absolutely
necessary to make just such existential leaps in purposefully linking violent acts in
normal times to those of abnormal times. Hence the title of our volume: Violence in War and in
Chorbajian 1999). But we hold an opposing and alternative view that, to the contrary, it

Peace. If (as we concede) there is a moral risk in overextending the concept of genocide into spaces and corners
of everyday life where we might not ordinarily think to find it (and there is), an even greater risk lies in failing to
sensitize ourselves, in misrecognizing protogenocidal practices and sentiments daily enacted as normative behavior

by ordinary good-enough citizens. Peacetime crimes, such as prison construction sold as economic development
to impoverished communities in the mountains and deserts of California, or the evolution of the criminal industrial
complex into the latest peculiar institution for managing race relations in the United States (Waquant, Chapter 39),
constitute the small wars and invisible genocides to which we refer. This applies to African American and Latino

These are
invisible genocides not because they are secreted away or hidden from view, but
quite the opposite. As Wittgenstein observed, the things that are hardest to perceive are
those which are right before our eyes and therefore taken for granted . In this regard,
youth mortality statistics in Oakland, California, Baltimore, Washington DC, and New York City.

Bourdieus partial and unfinished theory of violence (see Chapters 32 and 42) as well as his concept of
misrecognition is crucial to our task. By including the normative everyday forms of violence hidden in the minutiae
of normal social practices - in the architecture of homes, in gender relations, in communal work, in the exchange
of gifts, and so forth - Bourdieu forces us to reconsider the broader meanings and status of violence, especially the
links between the violence of everyday life and explicit political terror and state repression, Similarly, Basaglias
notion of peacetime crimes - crimini di pace - imagines a direct relationship between wartime and peacetime
violence. Peacetime crimes suggests the possibility that war crimes are merely ordinary, everyday crimes of public
consent applied systematic- ally and dramatically in the extreme context of war. Consider the parallel uses of rape
during peacetime and wartime, or the family resemblances between the legalized violence of US immigration and
naturalization border raids on illegal aliens versus the US government- engineered genocide in 1938, known as
the Cherokee Trail of Tears. Peacetime crimes suggests that everyday forms of state violence make a certain kind
of domestic peace possible. Internal stability is purchased with the currency of peacetime crimes, many of which
take the form of professionally applied strangle-holds. Everyday forms of state violence during peacetime make a
certain kind of domestic peace possible. It is an easy-to-identify peacetime crime that is usually maintained as a
public secret by the government and by a scared or apathetic populace. Most subtly, but no less politically or
structurally, the phenomenal growth in the United States of a new military, postindustrial prison industrial complex
has taken place in the absence of broad-based opposition, let alone collective acts of civil disobedience. The public
consensus is based primarily on a new mobilization of an old fear of the mob, the mugger, the rapist, the Black
man, the undeserving poor. How many public executions of mentally deficient prisoners in the United States are
needed to make life feel more secure for the affluent? What can it possibly mean when incarceration becomes the
normative socializing experience for ethnic minority youth in a society, i.e., over 33 percent of young African

it is essential that we recognize the existence of

a genocidal capacity among otherwise good-enough humans and that we need to
exercise a defensive hypervigilance to the less dramatic, permitted, and even
rewarded everyday acts of violence that render participation in genocidal acts and policies possible
American men (Prison Watch 2002). In the end

(under adverse political or economic conditions), perhaps more easily than we would like to recognize. Under the
violence continuum we include, therefore, all expressions of radical social exclusion, dehumanization, depersonalization, pseudospeciation, and reification which normalize atrocious behavior and violence toward others. A
constant self-mobilization for alarm, a state of constant hyperarousal is, perhaps, a reasonable response to
Benjamins view of late modern history as a chronic state of emergency (Taussig, Chapter 31). We are trying to
recover here the classic anagogic thinking that enabled Erving Goffman, Jules Henry, C. Wright Mills, and Franco
Basaglia among other mid-twentieth-century radically critical thinkers, to perceive the symbolic and structural
relations, i.e., between inmates and patients, between concentration camps, prisons, mental hospitals, nursing
homes, and other total institutions. Making that decisive move to recognize the continuum of violence allows us
to see the capacity and the willingness - if not enthusiasm - of ordinary people, the practical technicians of the
social consensus, to enforce genocidal-like crimes against categories of rubbish people. There is no primary impulse

mass violence and genocide are born, it is ingrained in the common sense
of everyday social life. The mad, the differently abled, the mentally vulnerable have often fallen into this
out of which

category of the unworthy living, as have the very old and infirm, the sick-poor, and, of course, the despised racial,
religious, sexual, and ethnic groups of the moment. Erik Erikson referred to pseudo- speciation as the human
tendency to classify some individuals or social groups as less than fully human - a prerequisite to genocide and one
that is carefully honed during the unremark- able peacetimes that precede the sudden, seemingly unintelligible

Collective denial and misrecognition are prerequisites for mass

violence and genocide. But so are formal bureaucratic structures and professional roles. The practical
outbreaks of mass violence.

technicians of everyday violence in the backlands of Northeast Brazil (Scheper-Hughes, Chapter 33), for example,
include the clinic doctors who prescribe powerful tranquilizers to fretful and frightfully hungry babies, the Catholic
priests who celebrate the death of angel-babies, and the municipal bureaucrats who dispense free baby coffins
but no food to hungry families. Everyday violence encompasses the implicit, legitimate, and routinized forms of
violence inherent in particular social, economic, and political formations. It is close to what Bourdieu (1977, 1996)
means by symbolic violence, the violence that is often nus-recognized for something else, usually something
good. Everyday violence is similar to what Taussig (1989) calls terror as usual. All these terms are meant to reveal
a public secret - the hidden links between violence in war and violence in peace, and between war crimes and

peace-time crimes. Bourdieu (1977) finds domination and violence in the least likely places - in courtship and
marriage, in the exchange of gifts, in systems of classification, in style, art, and culinary taste- the various uses of
culture. Violence, Bourdieu insists, is everywhere in social practice. It is misrecognized because its very
everydayness and its familiarity render it invisible. Lacan identifies rneconnaissance as the prerequisite of the
social. The exploitation of bachelor sons, robbing them of autonomy, independence, and progeny, within the
structures of family farming in the European countryside that Bourdieu escaped is a case in point (Bourdieu,
Chapter 42; see also Scheper-Hughes, 2000b; Favret-Saada, 1989). Following Gramsci, Foucault, Sartre, Arendt,
and other modern theorists of power-vio- lence, Bourdieu treats direct aggression and physical violence as a crude,
uneconomical mode of domination; it is less efficient and, according to Arendt (1969), it is certainly less legitimate.
While power and symbolic domination are not to be equated with violence - and Arendt argues persuasively that
violence is to be understood as a failure of power - violence, as we are presenting it here, is more than simply the
expression of illegitimate physical force against a person or group of persons. Rather, we need to understand
violence as encompassing all forms of controlling processes (Nader 1997b) that assault basic human freedoms
and individual or collective survival. Our task is to recognize these gray zones of violence which are, by definition,
not obvious. Once again, the point of bringing into the discourses on genocide everyday, normative experiences of
reification, depersonalization, institutional confinement, and acceptable death is to help answer the question:

What makes mass violence and genocide possible ? In this volume we are suggesting that mass
violence is part of a continuum, and that it is socially incremental and often experienced by
perpetrators, collaborators, bystanders - and even by victims themselves - as expected,
routine, even justified. The preparations for mass killing can be found in social sentiments and institutions
from the family, to schools, churches, hospitals, and the military. They harbor the early warning
signs (Charney 1991), the priming (as Hinton, ed., 2002 calls it), or the genocidal continuum (as we call
it) that push social consensus toward devaluing certain forms of human life and
lifeways from the refusal of social support and humane care to vulnerable social
parasites (the nursing home elderly, welfare queens, undocumented immigrants, drug addicts) to the
militarization of everyday life (super-maximum-security prisons, capital punishment; the technologies of
heightened personal security, including the house gun and gated communities; and reversed feelings of
victimization).

1AC Plan
The United States Federal Government should apply strict
scrutiny to federally funded public health surveillance
programs.

***Solvency***

Solvency Informed Consent

Breach notifications fulfill informed consent increases trust
Pritts 13 (Joy L. Pritt. The Importance and Value of Protecting the Privacy of
Health Information: The Roles of the HIPAA Privacy Rule and the Common Rule in
Health Research. 2013. P. 9-10.
http://iom.nationalacademies.org/~/media/Files/Activity
%20Files/Research/HIPAAandResearch/PrittsPrivacyFinalDraftweb.ashx)//EMerz
Under the principles of fair information practices, patients should be given notice, in
plain language, of the information practices of those who generate and maintain
their health information. The notice should inform patients how information will be
used and to whom it will be disclosed. Notices can also serve to bolster trust
between health care providers and patients to the extent they remove the element
of surprise about the use and disclosure of health information. Although there
seems to be little dispute that the principle of providing a notice of information
practice is a sound one, only a few states require health care providers to Under
accepted principles of fair information practices, those who maintain identifiable
health information should have in place appropriate safeguards to protect
unauthorized use or disclosure of the information. These safeguards identify the
means by which a provider protects the confidentiality of health information. A few
states such as California, Florida and Washington have statutorily required providers
to undertake security measures to ensure that health information is used and
disclosed properly. Florida, for example, requires those who maintain medical
records to develop and implement policies, standards, and procedures to protect
the confidentiality and security of the medical record, and to train their employees
in these policies, standards, and procedures.

Solvency Data Deletion

Congress should delete DNA databases- not doing so enforces
the panopticon
McNeal 13 (Gregory S. McNeal. Associate Professor of Law and Public Policy at
Pepperdine University. Congress Should Act To Protect DNA From Genetic
Surveillance. June 3, 2013.
http://www.forbes.com/sites/gregorymcneal/2013/06/03/congress-should-act-toprotect-dna-from-genetic-surveillance/)//EMerz
Its time for innocent people to open their mouths for royal inspection and DNA
collection by agents of the government. That is the likely consequence of the
Supreme Courts opinion in Maryland v. King, at least in the view of Justice Scalia
who believes that innocent people wrongfully arrested may now have their DNA
collected and permanently stored in a national database. To protect the genetic
information of innocent arrestees, Congress should take a cue from our royal
forebears and adopt legislation similar to that which the U.K. adopted in May of
2012. In todays opinion in Maryland v. King, the Court authorized the collection of
DNA from anyone arrested for a serious crime. While the majority claimed to limit
its holding to serious crimes, there was no articulated Constitutional principle to
limit its judgment, suggesting to the dissenters (Scalia, Ginsburg, Sotomayor and
Kagan) that [w]hen there comes before us the taking of DNA from an arrestee for a
traffic violation, the Court will predictably (and quite rightly) say, We can find no
significant difference between this case and King. As a consequences of this
judgment, they continued, your DNA can be taken and entered into a national DNA
database if you are ever arrested, rightly or wrongly, and for whatever reason. The
opinion thus narrowed the difference between an innocent arrestee and convicted
criminal, with innocent arrestees bearing the brunt of the narrowing. Convicted
criminals can already have their DNA collected as a consequence of their conviction,
thus the Supreme Courts opinion extending the collection of DNA to arrestees will
have its biggest impact on those who have been acquitted of the crime for which
they were arrested. In the dissents words, this Act manages to burden uniquely
the sole group for whom the Fourth Amendments protections ought to be most
jealously guarded: people who are innocent of the States accusations. If youre
arrested by the police for a crime they may swab your mouth for DNA, and if it turns
out they made a mistake and arrested the wrong person, youll be released but your
DNA may (subject to local policies) sit indefinitely in a government database
somewhere. In the eyes of the dissent there is nothing to stop the police from
creating a policy that DNA will be collected for every arrest, or perhaps even
collected for every government interaction. As Noah Feldman has observed, the
possible future use of DNA might be one of bureaucratic identification. Is it
implausible to think that in a decade the government may ask for a drivers license,
registration and a DNA sample at a traffic stop? After all, the police need to ensure
that the person handing over their identification is the person depicted on the
drivers license, and DNA is far more accurate than an outdated drivers license
photograph. So what can Congress do to protect innocent people while still ensuring
DNA can be used to solve crimes? Why not take a cue from Europe and

automatically delete the DNA of innocent persons from government databases. In

2008, the European Court of Human Rights handed down its opinion in the Case of
S. and Marper v. UK. In the opinion the ECHR found that blanket and indiscriminate
retention of fingerprints, cellular samples and DNA profiles of persons suspected
but not convicted of offensesfails to strike a fair balance between the competing
public and private interests. Such indefinite retention of innocent persons data is in
the ECHRs words an interference with the applicants right to respect for private
life and cannot be regarded as necessary in a democratic society. Following the
decision the UK passed the Protection of Freedoms Act which required the removal
of innocent persons DNA from government databases, prohibited the storage of
DNA from people arrested and charged but not convicted of a minor offense, and
imposed a three-year limit on the storage of DNA for people charged, but not
convicted, of a serious offense. Thus, the opinion and the Protection of Freedoms
Act, shifted the U.K.s approach from one of automatic indefinite retention (with a
right to request deletion similar to the U.S. expungement policy) to one of automatic
deletion after a period of time. Congress should follow the U.K.s lead and pass
legislation to protect innocent people. Such legislation should should require that
the government delete DNA records of arrestees who are not charged with crimes or
who are acquitted of minor offenses. Second, for serious offenses (which Congress
will need to define), the legislation should require that the government delete the
DNA records of persons who are charged with but not convicted of serious offenses
(perhaps after 3-5 years). For those concerned about the impact of such a decision
on national security, Congress could implement procedures to allow for the
continued retention of DNA information about suspects in ongoing national security
investigations, subject to regular certification by the Secretary of Homeland Security
or Attorney General. Some people concerned about crime prevention may not be
troubled by the Supreme Courts opinion, likening it to fingerprints. But DNA is far
more revealing than a fingerprint, it gives the government ethnic and familial
information and as technology advances may enable far more intrusive tracking and
analytical capabilities. Collecting DNA in government databases will no doubt have
the beneficial effect of solving more crimes, but as the dissent notes so would the
taking of DNA samples from anyone who flies on an airplane, applies for a drivers
license, or attends a public school. Perhaps the construction of such a genetic
panopticon is wise. But I doubt that the proud men who wrote the charter of our
liberties would have been so eager to open their mouths for royal inspection.
Congress should act to protect innocent people from the collection and
storage of their genetic information.

Solvency Breach Notification

Breach notification as a legal oversight to surveillance is an
effective regulatory strategy- it deters future surveillance
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 11-13
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
In contrast, the FTC rule applicable to non-HIPAA PHR vendors relies on the
somewhat older approach to breach, whereby [u]nauthorized acquisition will
be presumed to include unauthorized access to unsecured PHR identifiable health
information absent reliable evidence showing that there has not been, or could
not reasonably have been, unauthorized acquisition of such information.63 Not
only do somewhat different rules apply to breach notification regarding essentially
similar EMR or PHR data, but security breaches regarding health data in the hands
of custodians who are neither HIPAA entities nor PHR vendors generally do not
require breach notification. Specifically, this regulatory gap works in favor of big
data custodians of non-HIPAA (medically inflected) health data or laundered HIPAA
data. A sufficiently serious breach in the face of poor security practices or
technology might trigger an FTC inquiry.64 Such eventuality aside the only
possible regulatory model would be state law breach notification. As
already noted few state laws include health information within their definitions of
protected data, though there are exceptions such as the Californian law. Breach
notification as a data protection model is deserving of some criticism. It is only
triggered when, necessarily, data protection has failed, and it is a somewhat
immature data protection model that likely will need additional calibration as we
analyze its underregulation or over-regulation tendencies. For example, to the
extent that more experience tells us that we may be over-regulating some types of
minor breaches it might be sensible to allow for an apologyplus-purchase of
insurance defense or safe harbor. Notwithstanding, HITECHs version seems to have
some value. First, as clearly intended by the statute, 68 the Wall of Shame
website acts as a strong deterrence system.69 As more data is collected about the
porousness of our health care providers systems, a simple web listing could evolve
into a more robust and useful ranking model across privacy and security
dimensions, as (for example) with the quality/safety-based Hospital Compare. 70
Second, the notification system has become an important part of OCR enforcement
as the agency relies on breach notifications to initiate privacy and security rule
enforcement. On balance, breach notification has strengthened its fellow
downstream protection models HIPAA confidentiality and security. First,
the HITECH Acts breach notification model includes a public shaming deterrent
designed to improve compliance with the HIPAA rules.72 Second, and obviously,
notifying HHS of a substantial breach invites investigation by OCR. Overall (and
likely this was an unintended consequence) breach notification is an endorsement
of health privacy exceptionalism with its regulatory model applying to very narrow
slices of health data custodians (HIPAA, PHR and others). However, the
narrowness of its definition and its quintessential downstream data protection

model confirm its irrelevance in any search for a federal privacy response to big
datas growing hold on medically inflected data.

Solvency - Courts/Scrutiny Key

Centralized federal action is key providing uniform guidance
is key to prevent policy fragmentation key to prevent overand under-reactions by the government
Azarchs 14 (Timothy Azarchs, Articles Editor, University of Pennsylvania Journal
of Constitutional Law, Volume 16. J.D. Candidate, 2014, University of Pennsylvania
Law School; B.A., 2011, Bard College.)(INFORMATIONAL PRIVACY: LESSONS FROM
ACROSS THE ATLANTIC, JOURNAL OF CONSTITUTIONAL LAW, Vol. 16:3, Feb.
2014)//ASMITH
Even if we accept that these holes should be filled, it would not necessarily be clear
that the federal judiciary should be the one to fill them. The most obvious problem
is one of democratic legitimacy: if there is no constitutional basis for the right, then
the federal courts have no authority to impose a remedy. This may be why the
Court has been so reluctant to make a definitive decision on the existence of a right.
To step forward and acknowledge a right would be to risk judicial overreach, yet, at
the same time, to step back would be to re-verse three decades of jurisprudence in
the lower courts and deny a right that may be desirable to protect.97 Another
problem with common law privacy protections is that, developing on a case-by-case
basis, they would be less transparent and coherent than a comprehensive
legislative effort.98 This is particularly true when there is no clear principle guiding
the decisions as to what should be protected and what should be sufficient
justification.99 Without guiding principles, judges are left to their own value judgments rather than uniform philosophical principles or democratically agreed-upon
consensus. Furthermore, there is little basis on which to predict what activity will be
deemed a violation until after a court has decided, leaving little guidance ex ante as
to when an action should not be taken, when a right needs vindicating, and when a
suit is frivo-lous.100 These critiques apply with equal force to the current state of
affairs, however, where the Supreme Court hypothesizes about a right to
informational privacy while the lower courts continue to feel their way in the dark
towards disparate ends.101 It is therefore not a reason for the Court to maintain its
current course. While the legislature may have more democratic legitimacy and
greater ex ante perspective from which to develop a cohesive frame- work, leaving
the decisions on privacy rights to the political process as opposed to the judiciary is
problematic from another perspective. One of the primary purposes of a constitution
is to prevent the will of the majority from oppressing the minoritywhy else
constrain the power of a democratically elected legislature?102 There is admittedly
no clear minority group disfavored by a lack of privacy protections. There are
undoubtedly some kinds of information each of us may consider worth protecting,
and the legislatures may eventually re-spond to that desire. However, legislative
action is not always effective at protecting dis-favored minority groups.103 The
majority may wish to oust these out-siders, or it may simply lack the motivation to
overcome the inertia of the legislative process. For instance, it might be easier to
pass a law that allowed the government to collect information about immi-grants
ostensibly because they are more likely to be terrorists or drug runnersthan to

pass a law that protects homosexuals from dis-closure of their sexual orientations.
The right to privacy is funda-mentally a minority protection, allowing a sphere of
autonomous de-cision-making and freedom from the fear of the majoritys ridicule
of ones personal choices. To lay the burden of protecting this right at the feet of the
majority suffers from the same problems as asking the majority to decide whether
one might engage in consensual homo-sexual relations or join the communist
party.104 Recognition by the courts that informational privacy is an important right
with constitu-tional dimensions could help ensure that the courts will scrutinize such
infringements, whether affirmatively enacted by the legislature or committed by the
executive in the absence of legislative protec-tions. The idea that so important a
right can exist on so shaky a groundor indeed not exist at allis fundamentally
problematic. In addition, these gaps in legislative protections for the right to privacy
have persisted for a very long time, and it is not altogether clear that the gears are
turning to close them now.105 Even if legisla-tive clarity is preferable to judicial
clarity, one clear answer from the Supreme Court is preferable to twelve vague ones
from the circuits. The current uncertainty has several detrimental effects. First, insofar as there is a correct answer to the question, a circuit split im-plies that one
side or the other is incorrect. Either constitutional rights are being underenforced
in jurisdictions that improperly nar-row the right, or nonexistent rights are being
enforced in jurisdic-tions that improperly broaden it. Second, this assumed, but
unconfirmed, right leaves the lower courts, government actors, and potential
claimants with little guid-ance. As Justice Scalia suggested in his concurrence in
NASA v. Nel-son, this encourages an endless stream of hopeful plaintiffs to flood the
courts with claims that are different on one or another dimension from decided
cases because they have no grounds on which to de-termine whether those
differences are relevant.106 A vague right may therefore result in even more
litigation than a broad but clear one. Another possibility is that, for fear of
prosecution, government agencies will be unwilling to cross a boundary whose
location is un-certain and will be deterred from beneficial policies that approach but
do not step over that boundary.107 The question should be set-tled, one way or the
other, and the Supreme Court may be the only institution that can settle it.

Government specification on justifications for patient

surveillance need to be reformed in order to protect privacy
Mariner 07 (WENDY K.MARINER, Professor of Health Law, Bioethics and Human
Rights, Boston University School of Public Health; Professor of Law, Boston
University School of Law; Professor of Socio- Medical Sciences, Boston University
School of Medicine. J.D., Columbia University School of Law; LL.M, New York
University School of Law; M.P.H., Harvard School of Public Health.)(MISSION CREEP:
PUBLIC HEALTH SURVEILLANCE AND MEDICAL PRIVACY, BOSTON UNIVERSITY LAW
REVIEW, Vol. 87:347, 2007)//ASMITH
In contrast to the broad, future-oriented ideas of public health they embrace, first
generation cases like Whalen sometimes treat patient privacy as narrow and
concrete. Under this approach, highly speculative benefits could be accepted as
legitimate reasons to override patient consent. At the same time, costs to the
patient must often be both probable and substantial, often in the form of financial

loss, in order to weigh in the balance. Even if public health goals are more
specifically identified, the definition of privacy in ones medical information may
also require more precision in order to achieve meaningful balance. Like public
health, the concept of privacy can be fraught with ambiguity and possibilities for
expansion. Privacy is often understood to mean an individuals right to control
access to information about herself.175 Yet the literature contains ample
acknowledgement that this is hardly sufficient to explain the many, sometimes
contradictory, facets of privacy, much less its exceptions.176 Certainly the Supreme
Court has yet to define the whole of its scope and limits. Even in the absence of
consensus on the overall concept, however, it is still both possible and defensible to
treat personal medical information privacy as a specific aspect of privacy for the
purpose of examining when that information is justifiably subject to involuntary
disclosure and re-disclosure to government. The analysis of the concept of
privacy for purposes of public health surveillance should be limited to information,
from whatever source, about an identifiable individuals health status, medical care,
genetic characteristics, personal behavior, or exposure to health risks. The Supreme
Court has referred to information privacy in part as the individual interest in
avoiding disclosure of personal matters.177 This disclosure can take several
forms. The first and most commonly thought of is disclosure to the public, in the
form of deliberate or negligent publication of personal facts to society at large. This
is the type of injury that impelled Warren and Brandeis to argue for a right to
privacy.178 However, it is probably the least likely harm to individuals whose
information is reported to a public health surveillance program. The second form of
disclosure, and the primary focus of this discussion, is the compulsory revelation or
transmission to a government agency. As emphasized by several judges in the
abortion cases discussed above, this form of disclosure is more accurately
characterized as a possible invasion of privacy, because, metaphorically at least,
the government forces its way into ones personal space to extract information that
a person wishes to keep secret. This form of disclosure/invasion takes place at each
level of surveillance. While concern for deliberate or negligent revelations to the
public at large may exist with respect to any collection of information, including
information voluntarily disclosed, it is likely that the core concern of information
privacy is with invasions of privacy in which the government obtains personal
information without consent.179 The concept of privacy attached to ones personal
information seems to include, at its essence, a sense of autonomy and selfdetermination not just physical control over papers or computer files. Unlike other
forms of property, the information has value because of what it reveals about a
person.180 Personal information is thus an aspect of the human being; it involves
ones identity and dignity.181 Loss of personal information can seem as much a
violation of a persons dignity as a physical invasion of the body. In this respect,
privacy protects ones sense of self. When government has the power to take that
personal knowledge, it invades that sense of self. This may be why the violation of
privacy often provokes feelings of outrage, even when the facts acquired are not
embarrassing. An invasion of privacy violates ones dignity, even if it fails to
produce economic injury. Yet courts have failed to frame this aspect of privacy as a
cognizable cause of action. Even though not everyone would agree on what types of
information would be embarrassing if revealed, the central issue is whether that

choice is theirs to make. If we conclude that the information should be revealed

because a majority of people dont care, we dispense with the principle that
everyone has prima facie control over the choice of revelation. That is not an
especially persuasive argument against requiring consent, and it fails to consider
whether revelation should be a matter of personal or social choice. Even where
there is a persuasive argument for social choice, the question remains whether that
choice should be made through legislation or by some other more stringent
mechanism, such as obtaining a warrant based on probable cause.

Court clarification on health and privacy laws are necessary in

order to protect privacy
Mariner 07 (WENDY K.MARINER, Professor of Health Law, Bioethics and Human
Rights, Boston University School of Public Health; Professor of Law, Boston
University School of Law; Professor of Socio- Medical Sciences, Boston University
School of Medicine. J.D., Columbia University School of Law; LL.M, New York
University School of Law; M.P.H., Harvard School of Public Health.)(MISSION CREEP:
PUBLIC HEALTH SURVEILLANCE AND MEDICAL PRIVACY, BOSTON UNIVERSITY LAW
REVIEW, Vol. 87:347, 2007)//ASMITH
The central question is whether there is a right of privacy that prevents the
government from obtaining medical information about an individual to be used for
various public health surveillance purposes without first obtaining the individuals
consent. States adopt reporting laws, of course, because most recognize common
law, if not statutory, rights of privacy and confidentiality in medical information,
which forbid physicians from disclosing patient information and records without
consent.127 Additionally, federal courts of appeal have recognized Fourteenth
Amendment protection for a persons privacy interest in personal medical
information and from involuntary disclosure to state and federal agencies.128
Unfortunately, this extensive body of case law provides little guidance for
determining the justifications for mandatory reporting laws. Such laws have rarely
received judicial review. The few U.S. Supreme Court decisions that have addressed
the subject have granted state legislatures substantial, but not unlimited,
deference. But the Court has yet to consider the constitutionality of modern public
health surveillance systems specifically those that compel disclosure of personally
identifiable medical information to allow deduplication and ensure that such data
are accurate enough to be used for research and budget analyses. Indeed, the
Courts decisions have rarely analyzed the actual use of the data to be collected,
referring to it generally as intended to prevent disease or promote public health. In
light of recent challenges to the use of personal medical information for other
purposes,129 however, it is unlikely that such surveillance programs will remain
under the radar forever. In Whalen v. Roe,130 the Supreme Court upheld a state law
requiring any physician who prescribed a Schedule II controlled substance to submit
a copy of the prescription to the New York State Department of Health.131 The
petitioners had challenged the laws requirement that patients names and
addresses be collected and retained by the state, arguing that it violated their right
to privacy as protected by the Fourteenth Amendment.132 The law was intended to
prevent the diversion of drugs into unlawful channels, specifically by preventing

individuals from obtaining controlled substances from more than one physician or
using stolen or altered prescriptions, preventing pharmacists from refilling
dangerous prescriptions, and preventing physicians from over-prescribing.133 If
prevention failed, the records would enable investigators to identify and possibly
prosecute those who were breaking the law. Not surprisingly, the Court found that
the goal was reasonable,134 and that the prescription system could reasonably be
expected to have a deterrent effect on potential violators as well as to aid in the
detection or investigation of specific instances of apparent abuse.135 The Court
noted that the reporting requirement was not meaningfully distinguishable from a
host of other unpleasant invasions of privacy that are associated with many facets
of health care,136 comparing it to reporting requirements relating to venereal
disease, child abuse, injuries caused by deadly weapons, and certifications of fetal
death.137

A stricter level scrutiny protects privacy rights and prevents

government inefficiencies due to excessive numbers of privacy
cases
Azarchs 14 (Timothy Azarchs, Articles Editor, University of Pennsylvania Journal
of Constitutional Law, Volume 16. J.D. Candidate, 2014, University of Pennsylvania
Law School; B.A., 2011, Bard College.)(INFORMATIONAL PRIVACY: LESSONS FROM
ACROSS THE ATLANTIC, JOURNAL OF CONSTITUTIONAL LAW, Vol. 16:3, Feb.
2014)//ASMITH
The urgency of this intuitive need for protection is reinforced by the fact that state
law remedies do not cover the full range of privacy issues, not even in the cases of
government executive action.86 Defamation claims may only be leveled when
disclosed information is false: not when the information is true, not when the
government collects private information without disclosing it, and not when the First
Amendment is implicated and no malice is shown.87 In most states, an action exists
for publication of a private fact, but only if there has been disclosure of highly
offensive matters to a wide audience: not when the disclosure is merely private but
not highly offensive, or when the audience is a small but important group such as a
persons spouse, parents, or employer.88 Nor does it exist in the fourteen states
that do not have this cause of action.89 Finally, there is a remedy for intentional
infliction of emotional distress, but this reaches only the most extreme and
outrageous disclosures, and even then, only when the disclosure is at least
reckless.90 Thus, a case in which a police officer needlessly discloses a persons HIV
status, causing that persons entire family to be ostracized, would likely not be
cognizable under any state law remedy because the information was true, disclosed
only to a small audiencewho later told the pressand likely not outrageous
enough to be intentional infliction of emotional distress.91 Similarly, a case in which
a boy commits suicide after the police threaten to tell his grandfather that he is a
homosexual would be unlikely to fall under any of these state law torts.92 There is
some question whether the gaps left by this patchwork of state law privacy
protections should be closed. Ingrid Schpbach Mar-tin argues that they should not

be closed because the law should favor free dissemination of information over
privacy.93 In other words, she believes that society would be a better place if
everyone came out of the closet and had a frank discussion about their lifestyle.
She worries that allowing someone to sue for disclosure of their sexual orientation
officially acknowledges that that status is shameful and embar-rassing.94 Martin
may be right that society would be a better place if everyone came out of the
closet. But to force individuals to disclose their sexual identity for our own
bettermentto force them to sacrifice their privacy and suffer the real if
unfortunate costs that might attend that sacrificemay ask too much. Martin
further argues that closing the gaps left by state tort law and allowing challenges to
potentially unconstitutional lawmaking could produce excessive litigation against
government agents that impede their efficiency.95 The thought that closing the
gaps would produce substantially more cases than have already been dealt with
over the last three decades hardly seems plausible, however. In the majority of
circuits, the courts have accepted some level of protection for informational privacy
rights already and must hear cases on these issues even where those protections
are limited to fundamental rights protected by the decisional line of privacy.96
There may even be less litigation when clear standards deter frivolous suits and a
recognized, defined right reduces the incidence of violation. While such a right may
cause a police officer to pause and consider whether dis-closure of a particular
piece of information collected in his or her investigation implicates a privacy right,
the potential harm to the fact-finding process can be minimized by an appropriately
deferential level of scrutiny, and the mitigating benefits to privacy rights may be
worthwhile.

Solvency Fed Key

Federal laws control state action
Gostin 2k (Lawrence O. Gostin, JD, LLD, Georgetown/Johns Hopkins University
Program in Law and Public Health, Washington, DC, and Baltimore)( Public Health
Law in a New Century, 2000 American Medical Association, JAMA, June 14, 2000
Vol 283, No. 22)//ASMITH
No inquiry is more important to public health law than understanding the role of
government in the constitutional design. If public health law principally addresses
governments assurance of the conditions for the populations health, then what
activities must government undertake? The question is complex, requiring an
assessment of duty, authority, and limits. In addition, this query raises a corollary
question: Which government is to act? Some of the most divisive disputes in public
health are among the federal government, the states, and localities about which
government has the power to intervene. The Constitution allocates power among
the federal government and the states (federalism) and limits that power (to protect
individual liberties). In the realm of public health, the Constitution acts as both a
fountain and a levee; it originates the flow of power to preserve the public health,
and it curbs that power to protect individual freedoms. Federalism functions as a
sorting device for determining which government (federal, state, or local) may
legitimately respond to a public health threat. Often, federal, state, and local
governments exercise public health powers concurrently. Where conflicts among the
levels of government arise, however, federal laws preempt or supercede state
actions, and state actions may preempt local laws.

States must conform to federal regulatory standards

Gostin 2k (Lawrence O. Gostin, JD, LLD, Georgetown/Johns Hopkins University
Program in Law and Public Health, Washington, DC, and Baltimore)( Public Health
Law in a New Century, 2000 American Medical Association, JAMA, June 14, 2000
Vol 283, No. 22)//ASMITH
In theory, the United States is a government of limited, defined powers. In reality,
political and judicial expansion of national powers allows the federal government
considerable authority to act in the interests of public health and safety. The federal
government has a number of powers at its disposal to prevent injury and disease
and promote the populations health. The most important public health powers are
the powers to tax, spend, and regulate interstate commerce. The powers to tax and
spend are important because they enable the government to raise revenue and to
allocate re- sources for the publics health. Resource allocation, of course, can be
highly contentious as evidenced by contemporary debates about spending money
from the tobacco settlement. The taxing power also provides a powerful means to
regulate, both directly and indirectly, private activities that endanger health. Tax
relief provides incentives for private activities that government views as
advantageous to public health (eg, employer-sponsored health care). Taxation also
regulates private behavior by economically penalizing risk-taking activities (eg,
taxes on tobacco and alcoholic beverages). Similarly, the spending power does not

merely provide Congress with independent authority to allocate resources for the
public good; it also allows Congress to set conditions on the receipt of funds.2 The
need for federal public health funds effectively induces state conformance with
federal regulatory standards. Congress uses conditional spending to induce states
to conform to federal standards in numerous public health contexts, including
Medicaid and Medicare, occupational health, and highway safety. Of all the
provisions bestowing federal public health power, none is more important than
Article 1, 8 of the Constitution, which grants Congress the power to regulate
Commerce . . . among the several States. Practically speaking, the power to
regulate commerce has enabled the national government to invade traditional
realms of state authority including environmental protection, occupational health,
food and drug purity, and safe drinking water. The Courts modern construction of
the power to regulate commerce has been described as plenary or all-embracing,
and has been exerted to affect virtually every aspect of social life.3

Constitutional protections and heightened scrutiny maintains

rights and dictate lower courts actions
Azarchs 14 (Timothy Azarchs, Articles Editor, University of Pennsylvania Journal
of Constitutional Law, Volume 16. J.D. Candidate, 2014, University of Pennsylvania
Law School; B.A., 2011, Bard College.)(INFORMATIONAL PRIVACY: LESSONS FROM
ACROSS THE ATLANTIC, JOURNAL OF CONSTITUTIONAL LAW, Vol. 16:3, Feb.
2014)//ASMITH
The Supreme Court has left many unanswered questions. It has not decided
whether a right to informational privacy exists; it has not decided what might
constitute an infringement upon such a right; and it has not decided what level of
scrutiny might be applied to such an infringement. Therefore, the lower courts have
each gone their separate ways. Some courts have followed Justice Potter Stewarts
concurrence in Whalen, Justice Antonin Scalias in NASA, and the ma-jority opinion
in Paul v. Davis, finding a restricted or nonexistent right.73 Others have created a
broader sphere of protection, from medical information to anything with a legitimate
expectation of pri-vacy, but nevertheless disagree on the level of scrutiny to be
applied when a right is infringed.74 The majority, however, have ruled in favor of a
relatively broad right and some form of heightened scrutiny.75 The courts that
refuse to find a constitutional right protecting in-formational privacy typically
express two lines of reasoning. The first is that no such right has any support in the
text of the Constitution, and it is inappropriate to create that right judicially.76 The
second is that an informational privacy right would be implicated in nearly eve- ry
action of the government. Forcing the government to justify intru-sions and asking
the courts to hear those justifications would be a burden too great to bear: the
courts can hear only so many cases, and every minute a government agent spends
defending his actions in court is a minute spent not performing his other duties.77
The perceived danger is that creating so broad a right would force courts to provide
limited protection against individual infringements.78 Greater scrutiny means that
statutes must be more narrowly tailored and government actions must have greater
countervailing interests before they are justified, potentially forcing the government
to use less efficient means to accomplish its goals. Demanding narrower tai-loring

and greater justifications may be particularly difficult when the judicial branch has
so little textual support for making such burden-some demands. Those courts that
have accepted a broad right have typically simp-ly cited Whalen and the Supreme
Courts other privacy decisions and announced tests.79 The tests may reflect what
Mary D. Fan refers to as the creepiness emotional meter.80 The gist of this
concept is that there is an intuitive sense that the government should not be able to
demand or divulge private information without good reason.81 Cer-tain actions
taken by government officials or legislatures can and do step beyond the pale, so
there must be some constitutional protec-tions when they do.82 The idea that a sex
tape taken as evidence of extortion could be passed around the precinct for the
viewing pleas-ure of the officers,83 or that humiliating details of a rapedetails that
the victim had not even told her husbandcould be released at a press conference
without public purpose,84 is so viscerally horrifying to the courts that it seems
intuitively impossible that no constitutional right exists to prevent such behavior.85

Although state and federal governments have authority over

health legislation, federal action is uniquely key- state action
is inconsistent and stalls legal process
Evans 13 (Barbara J. Evans. Professor of Law; Co-director, Health Law & Policy
Institute; Director, Center on Biotechnology & Law, University of Houston Law
Center, Yale Law School; M.S., Ph.D. Stanford University; Post-doctoral Fellow, The
University of Texas M.D. Anderson Cancer Center. Institutional Competence to
Balance Privacy and Competing Values: The Forgotten Third Prong of HIPAA
Preemption Analysis. P. 1185-1188.
http://lawreview.law.ucdavis.edu/issues/46/4/Articles/46-4_Evans.pdf)//EMerz
Congress and state legislatures throughout our nations history have
possessed the power to order actions to promote the publics health. In the
modern context, this includes the power to authorize programs that require the use
of peoples health data and biospecimens. Shortly after Platts data were reported to
the FDA and Institute of Medicine,40 Congress took such action in the Food and
Drug Administration Amendments Act of 2007,41 which authorizes
pharmacoepidemiological42 studies of postmarket drug safety using data for one
hundred million Americans.43 Congress also called for large-scale informational
studies in the comparative effectiveness provisions of the Patient Protection and
Affordable Care Act of 2010.44 Public health legislation (both state and federal)
authorizing studies of peoples health data and biospecimens is likely to be a
recurring feature of the twenty-first century legal landscape. There is great concern
that privacy laws may thwart the objectives of these types of public health statutes.
The HIPAA statute focused primarily on insurance and healthcare fraud issues, but it
also expanded federal regulation of medical privacy and data security. The
Administrative Simplification provisions in Subtitle F of Title II of HIPAA45 required
the Secretary of the U.S. Department of Health & Human Services (HHS) to develop
a group of interrelated regulations.46 Authority to develop Standards for the Privacy
of Individually Identifiable Health Information (the Privacy Rule47) appears in
section 264 of HIPAA, which is codified as a note to 42 U.S.C. 1320d-2. The main
text of 1320d-2 authorizes HHS to develop various other regulations such as the

Transactions Rule48 published in August 2000, the Security Rule49 promulgated in

2003, and standards for unique patient identifying numbers which proved
controversial and encountered delays.50 HIPAA deposited a new layer of federal
regulations onto a field already densely covered with state law.51 When healthcare
providers and insurers initially began to comply with the HIPAA Privacy Rule in 20032004, there already was a patch quilt of state privacy statutes as well as a large
body of common law, such as evidentiary privileges that protect medical
communications and tort causes of action for privacy violations. In an excellent
recent study, John W. Hill et al. explain how daunting this state-by-state
patchwork has become.56 They argue that it threatens to obstruct the
development of large, interoperable health data systems.57 Interoperable
data networks that muster data for tens or hundreds of millions of persons are, of
course, a critical infrastructure for the types of large-scale public health surveillance
and investigations58 described in recent legislation.59 Not all public health studies
require nationally-scaled data infrastructures, but a number of very promising
approaches do. Thus, maintaining state-by-state privacy requirements has
the potential to stall important public health initiatives by impeding access
to data and biospecimens.

State reforms can only ever be patchwork --- they dont apply
once the information leaves the physicians possession
Goldman, from the College of Physicians and Surgeons, Columbia University,
November 1998 (Janlori, Protecting Privacy To Improve Health Care, published in
HealthAffairs volume 17 number 6)//roetlin
In the absence of federal health privacy legislation, a number of states have moved to enact such legislation. In the

more than 250 bills with medical privacy provisions were introduced in
the states. More than thirty-two of these bills became law.22 However, there is little consistency to the state
laws in this area. Many states impose on physicians the duty to maintain the
confidentiality of medical records, but such protection may no longer apply after
the records leave the physicians possession (for example, to process a claim).23 State
laws also may only address specific medical conditions, instead of the medical
record as a whole. Virtually every state, for instance, has some form of special protection for communicable
past year alone

diseases.24 States have more recently enacted laws to protect the confidentiality of genetic test results.25 Other
state laws address a specific activity. A recent Minnesota law, for example, requires that a patients consent be

The end result is what many have

called a patch- work of protections at the state level.
obtained before his or her medical records are used in research.26

State law patchwork doesnt provide enough protection

Pritts 13 (Joy L. Pritts JD is a lawyer who practices in Washington DC and earned her degree at Georgetown
Univeristy. Altered States: State Health Privacy Laws and the Impact of the Federal Health Privacy Rule
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1047&context=yjhple)///CW
Medical records contain some of the most intimate details about an individual that can be found in a single place.
Health information privacy is based on the principle that individuals should be able to exercise control over this
intimate information, both by having full knowledge about what information is contained in the records and by

professional ethical requirements

do not adequately protect health information in today's complex health care
system, we have increasingly turned to the law as a source of protection. Until the recent
promulgation of the Federal Health Privacy Rule,' states have been the primary regulators of
health information through their constitutions, common law, and statutory
provisions. Although all three of these legal sources remain important, recent focus has been on the
enactment of detailed health privacy statutes that apply the fair information practice principles to
health information. However, for the most part states have adopted these principles in a fairly
haphazard fashion resulting in a patchwork of legal protections both within and
between states. The recently issued Federal Health Privacy Rule has effectively evened
out some of this discrepancy by establishing a federal floor of privacy protections based on fair
information practices. The Federal Rule, however, does not afford adequate protection of
health information because it has limited applicability and areas of lax protection. Because the Federal Rule
only preempts conflicting, less protective state laws, there is still room for states to protect their
own citizens by retaining or enacting health privacy protections that mirror and
improve upon those in the Federal Health Privacy Rule
being able to control who has access to the information. Because

Only federal standards can solve states fail

Andrea Wilson (Senior Business Practices Analyst at The Methodist Hospital
System, Houston, TX) 2009 MISSING THE MARK: THE PUBLIC HEALTH EXCEPTION
TO THE HIPAA PRIVACY RULE AND ITS IMPACT ON SURVEILLANCE ACTIVITY 9 HOUS.
J. HEALTH L & POLY 131-156, https://www.law.uh.edu/hjhlp/Issues/Vol_91/Wilson.pdf
State law, however, is so widely varied in terms of privacy protections currently in
place124 that some public health officials support federal preemption, claiming
that uniformity is necessary and that federal law should provide strong patient
protection.125 How much privacy an individual has depends largely on his state of
residence, and the legal protection of health privacy is uneven, not simply across
state lines, but within them.126 Though state control is an advantageous
approach, weak federal guidelines do a disservice to the nations population:
Independent evolution of state law has produced considerable variation and
inconsistency. Variability, of course, can be a strength in a federal system of
government, allowing state experimentation with complex issues. Variability in
surveillance and privacy protection, however, creates problems in an increasingly
mobile society in which disease outbreaks may erupt rapidly in several states,
requiring systematic and consistent collection of comparable data sets.127 Due to
this incongruent accumulation of legislation, the privacy an individual enjoys in one
state may be entirely altered if he moves to another state or simply crosses state
lines to seek medical treatment.128 Thus, there is an identifiable need for a raising
of the floor in the public health exception The exception in its current form
provides only ambiguous terms and no guidance as to the use of PHI once in the
possession of public health authorities. Model rules for privacy protection and the
suggestions for amendment discussed in this paper will have little to no impact if
not uniformly adopted and implemented in every jurisdiction. As one scholar noted,
When the law is comprehensive and well-considered, it can provide substantial
protections.129 However, when it fail[s] to provide clear criteria and useful
sanctions, it has the potential to hamper public health work in a variety of

ways.130 In order to ensure that basic privacy protections are uniform in every
state, regulations for justification, access, and disclosure must be added to the
HIPAA public health exception as standardized national criteria in the form of a
single, strong federal law.131 There has been some suggestion that HHS lacked
the authority needed to implement such regulations at the time of drafting the
original Rule.132 Accordingly, Congressional authorization may be necessary before
clearer guidelines for public health agencies could be promulgated. Despite the
virtues of state privacy laws, the public is calling for Congress to take action. The
patchwork system of state privacy laws does not afford comprehensive privacy
protection, and so Congress must provide additional protection through
comprehensive federal legislation.133 State law preemption for privacy regulations
should remain the standard for PHI disclosures. However, the only way to ensure the
privacy of personal medical records in the hands of public health authorities is to
strengthen the existing regulations. Without further standards at the national level,
the individual is left with incomplete and inadequate protections, and public health
officials will continue to encounter reluctance when soliciting PHI.

The plan is key to prevent privacy protective behavior while

still allowing for the flexibility to respond quickly to immediate
threats
Gostin and Hodge 2002 (Lawrence O. Gostin (Professor at Georgetown
University Law Center) and James G. Hodge Jr. (Professor at Arizona State
University). Personal Privacy and Common Goods: A Framework for Balancing
Under the National Health Information Privacy Rule. 2002.
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?
article=1086&context=facpub)//EMerz
National privacy safeguards are needed because of the proliferation of and access
to health records resulting from the ongoing shift from paper to electronic records
within the national health information infrastructure. The increasing potential to use
or reveal sensitive health data raises concerns about privacy violations. Health
information can include intimate details about the patient's mental and physical
health as well as social behaviors, personal relationships, and financial status.4
Polling data have consistently shown that Americans are concerned about the
privacy of their medical data.5 Over 80% of respondents in one survey suggested
they had "lost all control over their personal information."6 In another national
survey, 78% of respondents felt it is very important that medical records be kept
confidential. 7 Yet, there are multiple justifications for sharing health data to
accomplish various communal interests. Sharing data may be necessary to achieve
important health purposes (e.g., health research and public health) or for nonhealth-related purposes (e.g., the administration of justice and law enforcement).
We (and others) have previously suggested that health information privacy laws
should carefully balance the need for individual privacy with the benefits of using
health data for the common good.8 For many, protecting the rights of individuals to
control how their identifiable health data are accessed, used, or disclosed is the
ultimate goal of national health information privacy standards. Individual interests in
privacy, however, should not be regarded as absolute. Some disclosures of health

data without specific informed consent are ethically appropriate and legally
authorized, such as requirements to report infectious diseases to state health
departments and the duty to warn persons at significant risk of harm. The national
privacy standards set a "floor" for protections that, DHHS suggests, "balance[s] the
needs of the individual with the needs of the society."" Reaching this balance,
however, is precarious. In some cases, the common good to be achieved is not
worth the infringement of privacy. In other circumstances, the need for data may be
sufficiently strong to outweigh the individual's claim to autonomy and privacy.
Privacy laws at the federal, state, and local levels are fragmented and
inconsistent, and do not reflect any coherent formula for balancing. In
particular, the national privacy rule does not always achieve a fair and reasonable
allocation of benefits and burdens for patients and the community. We suggest rules
for balancing private and public interests that go beyond the traditional conception
of individual autonomy as a dominating factor. Rather than seeing autonomy as a
"trump card" that always prevails, our framework values both privacy and common
goods, without a priori favoring either. We instead seek to maximize privacy
interests where they matter most to the individual and maximize communal
interests where they are likely to achieve the greatest public good. Thus, where the
potential for public benefit is high and the risk of harm to individuals is low, we
suggest that public entities should have discretion to use data for important public
purposes. Individuals should not be permitted to veto the sharing of personal
information irrespective of the potential benefit to the public. Privacy rules should
not be so arduous and inflexible that they significantly impede, for example, health
services research or surveillance necessary to promote the public's health. Provided
that the data are used only for the public good (e.g., research or public health), and
the potential for harmful disclosures are negligible, there are good reasons for
permitting data sharing. If the data, however, are disclosed in ways that are unlikely
to achieve a strong public benefit, and the personal risks are high, individual
interests in autonomy should prevail. For example, if health care professionals
disclose personal health data to family, friends, neighbors, employers, or insurers,
the public benefits to be achieved may not be worth the cost in personal privacy.
Such disclosures can cause stigma and embarrassment. Disclosure to employers or
insurers (e.g., health, life, or disability) can result in discrimination. These kinds of
unauthorized disclosures can lead to a loss of patient trust in health care
professionals. Individuals may be reluctant to seek medical treatment for
some conditions (e.g., HIV/AIDS, other sexually transmitted conditions, or
genetic diseases) or to disclose important information to health
professionals. 12 Consequently, for these kinds of disclosures where the public
benefits are negligible and individual privacy risks are high, the law should strictly
prohibit the release of information without the patient's consent. The framework for
balancing we offer attempts to maximize individual and communal interests in the
handling of identifiable health data. Acquisition, use, or disclosure of health
information that can lead to harm would be subject to strict privacy protections.
Correspondingly, acquisition, use, or disclosure of health information for important
public purposes would be permitted provided that (1) uses are restricted to the
purposes for which the data are collected, and (2) subsequent disclosures for other
purposes are prohibited without individual authorization. This framework defends

autonomy when individual interests are high and public interests are low. We
recognize that adherence to this balancing test will entail a certain diminution of
autonomy. However, it will be worth the cost in terms of the benefits that everyone
will achieve in living in a society that values the communal goods offered by
research, public health, and other public enterprises.

***Advantages***

Privacy Protection Low - General

No expansive genetic privacy jurisprudence now
Scherr 13 (Albert E. Scherr. Professor of Law, University of New Hampshire.
Genetic Privacy & the Fourth Amendment: Unregulated Surreptitious DNA
Harvesting. 2013. P. 448. http://georgialawreview.org/wpcontent/uploads/2015/02/Download-PDF-V47-I2-Scherr.pdf)//EMerz
The nature and scope of the Fourth Amendments protection against an intrusion on
genetic privacy is not readily apparent from the text. It guarantees that [t]he right
of the people to be secure in their persons, houses, papers, and effects, against
unreasonable searches and seizures, shall not be violated . . . . The prohibition
reads like one against intrusions on an individuals physical privacy by the
governmentbe it real property, bodily integrity, other physical itemsand makes
no explicit mention of more intangible conceptions of privacy. The Fourth
Amendment also says nothing about security from intrusions into out-of-body DNA
left in a public place, just as it says nothing about intrusions involving a host of
other modern technologies like a GPS, public surveillance cameras, or various kinds
of technological eavesdropping. Each involves a type of technology that the Framers
had not contemplated. Each intrudes on more than purely property- or place-based
privacy. Historically, the Supreme Courts Fourth Amendment jurisprudence
reflected a relatively narrow and somewhat rigid, legalistic focus on property and
place in defining the extent of Fourth Amendment privacy.84 Without a physical
invasion, or a search of a person, papers, or tangible material effects, no Fourth
Amendment violation occurs.85 In this conception, privacy was tied very closely to
notions of property rights.

Current government surveillance is expanding rapidly without

patient knowledge
Brase 13 (Twila Brase. President Citizens Council for Health Freedom. Patient
Privacy and Public Trust: How Health Surveillance Systems Are Undermining Both.
August 2013. P. 1-2. http://www.cchfreedom.org/pr/50%20States%20Databases
%20Full%20Report.pdf)//EMerz
With funding primarily from Congress, state health departments have created a
multitude of government patient-tracking systems. Increasingly, these systems are
being linked together, creating individual health profiles and lifelong records. The
emergence of computerized medical recordsand the federal requirement that
physicians, hospitals and other health care professionals have interoperable
electronic medical records or be penalized in 2015has accelerated and facilitated
government access to private patient data.1 2 Often without consent, patient data
is collected from doctors, hospitals, and clinics in some cases annually for lifelong
monitoring. But while most assume that patient privacy rights are protected by
patient consent requirements, government health surveillance is characterized by a
surprising lack of patient consent and little to no public awareness or discussion of
the growing databases and registries. Even worse, the government seizure of data

often happens at a time and in a place when individuals are in a vulnerable state
at the clinic or in the hospital. Today, state government agencies collect illness,
injury, hospitalization, diagnostic, medication, genetic, birth and death data on
individual citizens. This collection and connection of private medical records data
occurs often without patient consent or knowledgeand sometimes without specific
authority in state law. These state collections of personal information include, but
are not limited to, the following conditions or test results, which may exist in
databases, registries or biobanks. States vary greatly in their collection of data.
Although all states have one or more of the following collections of data, not every
state maintains all of these collections. This private data is not only routinely
collected without patient consent, it is increasingly being linked together
for analysis, research and tracking. For example, as part of its application for a
federal Title V Maternal and Child Block Grant, Kansas reports: Kansas Maternal
and Child Health (MCH) is building data infrastructure, epidemiological capacity, and
products of analysis in order to carry out core public health assessment functions.
We continue to improve Kansas MCH data capacity by: 1) improving data linkages
between birth records and other data sets such as infant death certificates,
Medicaid eligibility and/ or paid claims files, WIC eligibility files, and new born [sic]
metabolic screening files; 2) improving access to hospital discharge data, Youth Risk
Behavior Survey (YRBS) data, Birth Defects Surveillance System (BDSS) data,
Pregnancy Risk Assessment Monitoring System (PRAM) data, and Children and Youth
with Special Health Care Needs (CYSHCN) program data6 Furthermore, the
amount of government health surveillance just keeps growing. The U.S.
Centers for Disease Control and Prevention (CDC) recently created the National
Public Health Surveillance/Biosurveillance Registry for Human Health (NPHSB
Registry), which they describe as, a comprehensive electronic catalog of over 280
CDC public health surveillance and biosurveillance assets related to human health.
Launched in December 2012, the Registry provides information to foster
collaboration among surveillance subject matter experts, and provides critical
information about CDCs surveillance capabilities to decision-makers as they
address a wide range of public health preparedness and response issues that
depend on effective coordination. ... The registry is currently located on CDCs
intranet and available only to members of the CDC community.

Physician-public trust has declined substantially; the US need

a solution now
Blendon, Benson, and Hero 14 (Robert J. Blendon, Sc.D., John M. Benson,
M.A., and Joachim O. Hero, M.P.H., Public Trust in Physicians U.S. Medicine in
International Perspective, from the Department of Health Policy and Management,
Harvard School of Public Health, Boston (R.J.B., J.M.B.); and the Program in Health
Policy, Harvard University, Cambridge, MA ( J.O.H.).The New England Journal of
Medicine, 371;17, nejm.org, October 23, 2014)//ASMITH
The U.S. health care reform process is entering a new phase, its emphasis shifting
from expanding health coverage to improving our systems for delivering patient

care. One emerging question is what role the medical profession and its leaders will
play in shaping future national health care policies that affect decision making
about patient care. Research suggests that for physicians to play a substantial role
in such decision making, there has to be a relatively high level of public trust in the
professions views and leadership. But an examination of U.S. public opinion data
over time and of recent comparative data on public trust in physicians as a group in
29 industrialized countries raises a note of caution about physicians potential role
and influence with the U.S. public. In a project supported by the Robert Wood
Johnson Foundation and the National Institute of Mental Health, we reviewed
historical polling data on public trust in U.S. physicians and medical leaders from
1966 through 2014, as well as a 29-country survey conducted from March 2011
through April 2013 as part of the International Social Survey Programme (ISSP), a
cross-national collaboration among universities and independent research
institutions (ISSP 2011 2013) (see box for poll information). We found that, as has
been previously reported, public trust in the leaders of the U.S. medical profession
has declined sharply over the past half century. In 1966, nearly three fourths (73%)
of Americans said they had great confidence in the leaders of the medical
profession. In 2012, only 34% expressed this view (Harris 19662012). But
simultaneously, trust in physicians integrity has remained high. More than two
thirds of the public (69%) rate the honesty and ethical standards of physicians as a
group as very high or high (Gallup 2013). Our review of numerous analyses of
public-opinion data about public trust in institutions and professions suggests that
the decline in trust is probably attributable to broad cultural changes in the United
States, as well as rising concerns about medical leaders responses to major
national problems affecting the U.S. health care system.1,2 Today, public
confidence in the U.S. health care system is low, with only 23% expressing
a great deal or quite a lot of confidence in the system (Gallup 2014). We
believe that the medical profession and its leaders are seen as a contributing factor.
This phenomenon does not affect physicians in many other countries. Indeed, the
level of public trust in physicians as a group in the United States ranks near the
bottom of trust levels in the 29 industrialized countries surveyed by the ISSP. Yet
closer examination of these comparisons reveals findings similar to those of
previous U.S. surveys: individual patients satisfaction with the medical care they
received during their most recent physician visit does not reflect the decline in
overall trust. Rather, the United States ranks high on this measure of satisfaction.
Indeed, the United States is unique among the surveyed countries in that it ranks
near the bottom in the publics trust in the countrys physicians but near the top in
patients satisfaction with their own medical treatment. The United States is tied for
24th place in terms of the proportion of adults who agree with the statement, All
things considered, doctors in [your country] can be trusted. About 6 in10 U.S.
adults (58%) agree with this statement, as compared with more than three fourths
in Switzerland (83%), Denmark (79%), the Netherlands (78%), and Britain (76%)
(ISSP 20112013) (see table). Part of the difference may be related to the lack of a
universal health care system in the United States. However, the countries near the
top of the international trust rankings and those near the bottom have varied
coverage systems, so the absence of a universal system seems unlikely to be the
dominant factor. By contrast, the United States ranks third in terms of the

proportion of adults who say they were completely or very satisfied with the medical
treatment they received at their last physician visit (56%). Of the 10 countries that
rank lowest in public trust in their countries physicians, all but the United States
also rank 19th or lower in patients satisfaction with their own medical care. The
United States also differs from most other countries in that U.S. adults from lowincome families (defined as families with incomes in the lowest third in each
country, which meant having an annual income of less than $30,000 in the United
States) are significantly less trusting of physicians and less satisfied with their own
medical care than adults not from low-income families. Less than half (47%) of lowincome Americans surveyed agreed that U.S. doctors can be trusted significantly
less than the 63% of nonlow-income Americans who expressed that view. Lowincome Americans were also less likely than nonlow income Americans (48% vs.
59%) to be completely or very satisfied with their treatment at their last physician
visit (ISSP 20112013) (see the Supplementary Appendix, available with the full text
of this article at NEJM.org). Although nonlow-income Americans expressed greater
trust in physicians than their low-income counterparts did, when responses were
analyzed by income group, the United States still ranked 22nd in trust among the
29 countries. On the flip side, although low-income Americans were less likely than
nonlow income Americans to report being completely or very satisfied with their
own care, the United States still ranked seventh in satisfaction among low-income
adults (ISSP 20112013). The same pattern is seen in subpopulations defined by
age or sex. Americans 65 years of age or older were significantly more likely than
younger Americans to agree that U.S. physicians can be trusted (69% vs. 55%), and
U.S. men were significantly more likely than U.S. women to think so (63% vs. 54%).
However, the United States ranked lower in terms of trust in the profession than
most other countries among both men (21st) and people 65 years of age or older
(22nd) (ISSP 20112013). In drawing lessons from these international comparisons,
its important to recognize that the structures in which physicians can influence
health policy vary among countries. We believe that the U.S. political process, with
its extensive media coverage, tends to make physician advocacy seem more
contentious than it seems in many other countries. Moreover, the U.S. medical
profession, unlike many of its counterparts, does not share in the management of
the health system with government officials but instead must exert its influence
from outside government through various private medical organizations. Some
other countries systems have more formal structures through which physician
leaders may bargain and negotiate with the government over such issues as
payment, professional autonomy, and quality of care.3 Moreover, in terms of health
policy recommendations, the U.S. medical profession is split among multiple
specialty organizations, which may endorse competing policies. Nevertheless,
because the United States is such an outlier, with high patient satisfaction and low
overall trust, we believe that the American publics trust in physicians as a group
can be increased if the medical profession and its leaders deliberately take visible
stands favoring policies that would improve the nations health and health care,
even if doing so might be disadvantageous to some physicians. 4,5 In particular,
polls show that Americans see high costs as the most important problem with the
U.S. health care system (RWJF/HSPH 2011), and nearly two thirds of the public
(65%) believes these costs are a very serious problem for the country

(NPR/RWJF/HSPH 2012). To regain public trust, we believe that physician groups will
have to take firm positions on the best way to solve this problem. In addition, to
improve trust among low-income Americans, physician leaders could become more
visibly associated with efforts to improve the health and financial and care
arrangements for low-income people. If the medical profession and its leaders
cannot raise the level of public trust, theyre likely to find that many policy decisions
affecting patient care will be made by others, without consideration of their
perspective.

Privacy Protection Low Judicial Guidance

Lack of clear court ruling on HIPAA surveillance limitations
results in confusion- that can justify more surveillance
Evans 13 (Barbara J. Evans. Professor of Law; Co-director, Health Law & Policy
Institute; Director, Center on Biotechnology & Law, University of Houston Law
Center, Yale Law School; M.S., Ph.D. Stanford University; Post-doctoral Fellow, The
University of Texas M.D. Anderson Cancer Center. Institutional Competence to
Balance Privacy and Competing Values: The Forgotten Third Prong of HIPAA
Preemption Analysis. P. 1180-1183.
http://lawreview.law.ucdavis.edu/issues/46/4/Articles/46-4_Evans.pdf)//EMerz
The HIPAA statute was enacted on August 21, 1996 and recently marked its
sixteenth anniversary. In those sixteen years, no court has ever decided a
case that posed a HIPAA preemption question in the context of public
health surveillance and investigations. In their fascinating survey of 113 HIPAA
preemption cases litigated through the fall of 2006, Sara Rosenbaum et al. did not
find any case in which the underlying controversy involved access to data or tissue
resources to use in such activities. A more recent search of all state and federal
cases decided between 1996 and July 2012 found only two HIPAA related cases that
ever cited 42 U.S.C. 1320d-7(b),17 the provision that defines the enumerated
public health activities and affords them special protection. The two cases that cited
1320d-7(b) had nothing to do with public health surveillance or investigations.
Those whom this provision aims to help members of the medical and public
health communities seeking access to data and tissue resources to improve the
publics health perhaps have a negative perception of lawyers and are reluctant
to turn to courts to clarify confusion about the law. As a consequence, rumor
rather than valid statutory interpretation has informed much of the
debate about HIPAA preemption and public health access to data. Discussions of
HIPAA preemption often rely heavily on secondary sources of literature and, less
frequently, on regulations, but almost never consult the relevant statutes. For
example, the Institute of Medicine, a highly respected advisory body that typically
produces rigorous, peer-reviewed analyses of policy issues affecting biomedical
research, discussed HIPAA preemption in a recent report without once citing the
preemption provisions of the HIPAA statute. Beliefs about HIPAA preemption are
circulated and recirculated in the secondary literature and eventually attain the
status of well-settled rumor. Even among law scholars, the HIPAA preemption
provisions have attracted little interest.

Whalen fails lack of guidance

Wilson 7 (Jessica, Juris Doctor at Duke University, Protecting Privacy
Absent a Constitutional Right: A Plausible Solution to Safeguarding
Medical Records, January 2007, Washingtion University in St. Louis)//JL
Whalen v. Roe provided little guidance for lower courts dealing with medical privacy
issues. Regarding the first of the Courts dual privacy interests, the individual interest in avoiding disclosure of
personal matters,

Whalen left unclear what constituted a violation of the right, and

failed to establish what type of constitutional treatment the courts were to use when
assessing it.58 Unlike the Courts second privacy interest in independence in making certain kinds of important
decisions, which had been fleshed out by several previous Supreme Court decisions59 including Roe v. Wade60

there was no clear legal precedent for a privacy interest in

nondisclosure of personal matters.62
and Paul v. Davis,61

Lower courts fail outdated and inconsistent

Hoppin 12 (Margaret, J.D. at New York University School of Law,
Overly Intimate Surveillance: Why Emergent Public Health
Surveillance Programs Deserve Strict Scrutiny Under The Fourteenth
Amendment, December 2012, NYU Law Review, Hein Online)//JL
Emergent
surveillance programs intrude upon a pri-vacy interest that courts
should recognize as fundamental for
the Fourteenth Amendment
emergent
programs should be reviewed under a strict scrutiny
The Supreme Court
recognized the Fourteenth
protects an interest in not disclosing private health
information
However, the Supreme Court has never explained the con-tours
of that right.
lower court opinions that address the constitutionality of
government public health surveillance programs are sparse, outdated, and
inconsistent
they have upheld public health surveillance programs against
privacy
public health

purposes of

. Accordingly,

standard.64

that

has

Amendment

to the govern-ment.65
66 Moreover,

. In general,

challenges, after applying rational basis review or a deferential balancing test.67

Precedents are outdated and too easily distinguishable

Hoppin 12 (Margaret, J.D. at New York University School of Law,
Overly Intimate Surveillance: Why Emergent Public Health
Surveillance Programs Deserve Strict Scrutiny Under The Fourteenth
Amendment, December 2012, NYU Law Review, Hein Online)//JL
existing Fourteenth Amendment privacy protections that apply to government public health
surveillance pro-grams. Those protections are widely understood to be limited , andto the extent the question has been addressed
scholars assume similarly limited protection would apply to emergent program s.68
That assumption is unwarranted: The relevant precedents are inconsistent,
outdated, and address readily distinguishable surveillance models . Moreover, several courts and judges
This Subpart describes

have suggested that develop-ments in public health surveillance could or should trigger more rig-orous scrutiny.

Genetic Surveillance Expanding Now

Local DNA databases are rapidly expanding now
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
I. THE EXPANSION OF LOCAL DNA DATABASES The expansion of local DNA
databases comes on the heels of a deep and sustained commitment from Congress
to build a national network of DNA databases overseen by the FBI. In a flurry of
legislation beginning in 1994, Congress authorized the creation and expansion of
that network, which is called the Combined DNA Index System (CODIS).39 Under
the CODIS umbrella, the FBI created a three-tiered hierarchy of databases made up
of the National DNA Index System (NDIS), the State DNA Index System (SDIS),
and the Local DNA Index System (LDIS).40 Congress designated the FBI to
regulate CODIS, and the FBI designed protocols to integrate the three levels into a
unified whole.41 In the decade after authorizing CODIS, Congress passed several
laws to expand the CODIS network.42 Yet, despite this expansion, local law
enforcement agencies have increasingly sought to create their own, non-CODIS DNA
databases. This Part analyzes what caused this shift. It then provides a description
of the local databases in Palm Bay, Florida; Bensalem Township, Pennsylvania; and
the state of Arizona. A. Fragmentation of Genetic Surveillance While the FBI
continues to exert significant control over law enforcements use of DNA databases,
its grip is weakening as a result of the expansion of local databases. This
fragmentation, which leaves local agencies increasingly in control of the use of
genetic surveillance, is the result of several factors. They include: 1) restrictions in
the CODIS regulations, which, according to many local law enforcement officials,
limit law enforcements ability to take full advantage of DNA databases to solve
crime;43 2) advances in DNA technologyallowing for quicker processing and the
analysis of extremely small biological samplesthat have coincided with reduced
costs; 3) federal funding that allows local law enforcement officials to bypass the
local budget process; and 4) private firms interested in expanding the use of
forensic DNA analysis. 1. CODIS Limitations Early adopters of local DNA databases
have pointed to two reasons why CODIS does not adequately meet their needs.
First, they argue that the CODIS authorizing statute and the FBIs regulations for its
use are too restrictive, preventing law enforcement from performing certain
searches and from including DNA profiles from certain individuals in CODIS.44
Second, they argue that because much of CODISs growth is the result of adding
DNA profiles from known violent offenders who are often serving lengthy prison
sentences, CODIS remains an ineffective crime-solving tool. The FBI has adopted an
extensive regulatory scheme for CODIS,45 and it regularly audits participating
public crime laboratories to ensure compliance.46 These regulations are designed to
ensure the database is reliable and secured.47 For example, the FBI will only allow
the inclusion and search of DNA profiles if the profiles were processed by public DNA
laboratories that are a part of the CODIS network.48 Second, federal regulations
prohibit inclusion in CODIS of many types of partial DNA profiles,49 and limit law
enforcements ability to compare a partial profile to the other profiles in CODIS.50

Third, the process of confirming a match in CODIS can take up to one month,51 and
this is in addition to the six to 12 months often needed for the actual DNA
processing at CODIS-participating laboratories.52 Fourth, federal regulations require
the removal of profiles from CODIS if a convicted offenders conviction is
overturned, or, in the case of an arrestee, if the charges are dismissed.53 Finally, as
a result of its emphasis on building a database of convicted offenders and arrestees,
the FBIs regulations prohibit the inclusion of DNA profiles from individuals, including
suspects, who provide law enforcement consensual DNA samples.54 Local DNA
databases are not required to comply with any of these federal regulations. For
example, they are free to include consensual DNA samples from people deemed
merely suspicious, victims, victims family members, and witnesses. These
consensual samples have driven the growth of local databases.55 Local DNA
databases are also built with DNA processing from private laboratories.56
Furthermore, local law enforcement is free to set its own protocols for including and
searching partial DNA profiles in their databases and for expunging DNA records.57

Genetic surveillance spills over into other areas of privacy

lack of privacy protections snowballs into acceptance of even
more intrusive pratices
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
The expansion of local DNA databases also brings into sharper focus the fears many
privacy advocates raised about CODIS. In short, they feared that once the FBIs DNA
database was created, it would be too tempting for law enforcement to limit its use,
causing the tool to evolve to reach deeper into our lives.216 CODISs growth
demonstrates the merit of these fears. CODIS expanded from an initial focus on
collecting profiles from offenders convicted of certain violent crimes, to all felony
offenders, and now to arrestees.217 Similarly, after first prohibiting familial
searches, CODIS now permits them in certain circumstances.218 These advocates
also fear what might come next when technology allows us to glean even more
information from an individuals DNA sample. They are particularly fearful of the
possibility that law enforcement might use genetic samples to attempt to identify a
genetic predisposition to crime.219 Finally, the expansion of local databases will
contribute further to the erosion of privacy protections to the extent that people
come to expect increased surveillance. Fourth Amendment privacy protection is
linked to societys reasonable expectations of privacy.220 As many have noted, this
standard is fluid, but it has historically moved in the direction of society accepting
lesser privacy protections. Law enforcements expansion of genetic surveillance has
contributed to this trend, and the trend will continue as it becomes routine for even
small agencies to build local databases.

FBI is increasing surveillancedisproportionately affects

minorities
Moore 9 (Soloman, reporter for the New York Times, F.B.I. and States Vastly
Expand DNA Databases http://www.nytimes.com/2009/04/19/us/19DNA.html?_r=0
4/18/09 JM)
Law enforcement officials are vastly expanding their collection of DNA to include
millions more people who have been arrested or detained but not yet convicted. The
move, intended to help solve more crimes, is raising concerns about the privacy of
petty offenders and people who are presumed innocent. Until now, the federal
government genetically tracked only convicts. But starting this month, the
Federal Bureau of Investigation will join 15 states that collect DNA samples from
those awaiting trial and will collect DNA from detained immigrants the vanguard
of a growing class of genetic registrants. The F.B.I., with a DNA database of 6.7
million profiles, expects to accelerate its growth rate from 80,000 new entries a year
to 1.2 million by 2012 a 15-fold increase. F.B.I. officials say they expect DNA
processing backlogs which now stand at more than 500,000 cases to increase.
Law enforcement officials say that expanding the DNA databanks to include legally
innocent people will help solve more violent crimes. They point out that DNA has
helped convict thousands of criminals and has exonerated more than 200
wrongfully convicted people. But criminal justice experts cite Fourth
Amendment privacy concerns and worry that the nation is becoming a
genetic surveillance society. DNA databases were built initially to deal with
violent sexual crimes and homicides a very limited number of crimes, said Harry
Levine, a professor of sociology at City University of New York who studies policing
trends. Over time more and more crimes of decreasing severity have been added
to the database. Cops and prosecutors like it because it gives everybody more
information and creates a new suspect pool. Courts have generally upheld laws
authorizing compulsory collection of DNA from convicts and ex-convicts under
supervised release, on the grounds that criminal acts diminish privacy rights. DNA
extraction upon arrest potentially erodes that argument, a recent Congressional
study found. Courts have not fully considered legal implications of recent
extensions of DNA-collection to people whom the government has arrested
but not tried or convicted, the report said. Minors are required to provide DNA
samples in 35 states upon conviction, and in some states upon arrest. Three
juvenile suspects in November filed the only current constitutional challenge against
taking DNA at the time of arrest. The judge temporarily stopped DNA collection from
the three youths, and the case is continuing. Sixteen states now take DNA from
some who have been found guilty of misdemeanors. As more police agencies take
DNA for a greater variety of lesser and suspected crimes, civil rights advocates say
the governments power is becoming too broadly applied. What we object to and
what the Constitution prohibits is the indiscriminate taking of DNA for things like
writing an insufficient funds check, shoplifting, drug convictions, said Michael
Risher, a lawyer for the American Civil Liberties Union. This year, California began
taking DNA upon arrest and expects to nearly double the growth rate of its
database, to 390,000 profiles a year from 200,000. One of those was Brian Roberts,

29, who was awaiting trial for methamphetamine possession. Inside the Twin Towers
Correctional Facility in Los Angeles last month, Mr. Roberts let a sheriffs deputy
swab the inside of his cheek. Mr. Robertss DNA will be translated into a numerical
sequence at the F.B.I.s DNA database, the largest in the world. The system will
search for matches between Mr. Robertss DNA and other profiles every Monday,
from now into the indeterminate future until one day, perhaps decades hence, Mr.
Roberts might leave a drop of blood or semen at some crime scene. Law
enforcement officials say that DNA extraction upon arrest is no different than
fingerprinting at routine bookings and that states purge profiles after people are
cleared of suspicion. In practice, defense lawyers say this is a laborious process that
often involves a court order. (The F.B.I. says it has never received a request to
purge a profile from its database.) When DNA is taken in error, expunging a
profile can be just as difficult. In Pennsylvania, Ellyn Sapper, a Philadelphia public
defender, has spent weeks trying to expunge the profile taken erroneously of a 14year-old boy guilty of assault and bicycle theft. Im going to have to get a judges
order to make sure that all references to his DNA are gone, she said. The police say
that the potential hazards of genetic surveillance are worth it because it solves
crimes and because DNA is more accurate than other physical evidence. Ive
watched women go from mug-book to mug-book looking for the man who raped
her, said Mitch Morrissey, the Denver district attorney and an advocate for more
expansive DNA sampling. It saves womens lives. Mr. Morrissey pointed to Britain,
which has fewer privacy protections than the United States and has been taking
DNA upon arrest for years. It has a population of 61 million and 4.5 million DNA
profiles. About 8 percent of the people commit about 70 percent of your crimes, so
if you can get the majority of that community, you dont have to do more than
that, he said. In the United States, 8 percent of the population would be roughly 24
million people. Britain may provide a window into Americas genetic surveillance
future: As of March 2008, 857,000 people in the British database, or about one-fifth,
have no current criminal record. In December, the European Court of Human Rights
ruled that Britain violated international law by collecting DNA profiles from innocent
people, including children as young as 10. Critics are also disturbed by the
demographics of DNA databases. Again Britain is instructive. According to a
House of Commons report, 27 percent of black people and 42 percent of
black males are genetically registered, compared with 6 percent of white
people. As in Britain, expanding genetic sampling in the United States could
exacerbate racial disparities in the criminal justice system, according to
Hank Greely, a Stanford University Law School professor who studies the
intersection of genetics, policing and race. Mr. Greely estimated that AfricanAmericans, who are about 12 percent of the national population, make up 40
percent of the DNA profiles in the federal database, reflective of their
prison population. He also expects Latinos, who are about 13 percent of the
population and committed 40 percent of last years federal offenses
nearly half of them immigration crimes to dominate DNA databases.
Enforcement officials contend that DNA is blind to race. Federal profiles include little
more information than the DNA sequence and the referring police agency. Subjects
names are usually kept by investigators. Rock Harmon, a former prosecutor for
Alameda County, Calif., and an adviser to crime laboratories, said DNA

demographics reflected the criminal population. Even if an innocent mans DNA was
included in a genetic database, he said, it would come to nothing without a crime
scene sample to match it. If you havent done anything wrong, you have nothing to
fear, he said.

Status quo federal courts and legislation allow for

exceptionalism
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 19-21
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
While the ethical basis (autonomy) for exceptional protection for health privacy is robust, a strong legal basis for

The US Constitution is silent on the issue

although the decisional privacy cases do recognize limited penumbral privacy
claims.169 Whalen v. Roe did articulate the duality of informational and decisional
privacy in a case that, broadly at least, concerned health privacy . Yet Justice Stevens
broadest pro-privacy statement in Whalen failed to articulate any exceptional
treatment of health information. Of course, in Jaffee v. Redmond, the same Justice did recognize a broad
federal common law psychotherapist privilege rooted in confidence and trust, yet it was hardly exceptional
as it was analogized to the spousal and attorney-client privileges . More recently, the
Supreme Court, while restraining some aspects of the surveillance state, generally has favored
data liquidity over data protection. Outside of the health-related HIPAA, the Genetic Information
health privacy exceptionalism is harder to articulate.

Nondiscrimination Act of 2008 (GINA)176 and a few other narrow sector-specific statutes like GLBA, most federal
privacy law is quite general in its reach. For example, the Privacy Act of 1974, while applicable to health care data

The same can be said of

federal scrutiny of the privacy standards of private, non-health care entities . In this
general space the FTC asserts two types of claims under Section 5(a) of the Federal Trade Commission Act:
unfair or deceptive acts or practices in or affecting commerce . Thus, with regard to
privacy, an unfair business practice case might be brought against a business for,
say, failing to have adequate security, while a deceptive or misleading claim might
apply to a business that, say, failed to comply with its own stated privacy policy . The
collected by the federal government, does not seem to apply exceptionally.177

FTC will leave most health care privacy cases to the HHS Office of Civil Rights although it has asserted its
jurisdiction in cases involving non-HIPAA entities. For example, In the Matter of CBR Systems, Inc., the FTC entered
into a settlement with a provider of umbilical cord blood and umbilical cord tissue-banking services. The proceeding
related to the theft of unencrypted computer drives exposing the health information of almost 300,000 of the

There has been little Congressional consideration of the implications

of health privacy exceptionalism or, for that matter, its absence . A rare exception was at the
banks customers.

1999 hearings on GLBA. When it became apparent that health insurers would be covered by the proposed
legislation a provision was added with the intent to protect health data. However, that provision would have had the
unintended consequence of opening up health data to broad opt-out sharing among financial institutions with

Organizations such as the American Medical Association and

the American Psychiatric Association (APA) strongly voiced their concerns , and the
attendant secondary use risks.

provision was dropped from the final bill. The APAs Dr. Richard Harding argued before the House of
Representatives, [i]t is critically important to recognize the difference between medical records privacy and
financial privacy, so making the case for health privacy exceptionalism: [T]he damages from breaches of medical

Medical records information can include information

on heart disease, terminal illness, domestic violence, and other women's health
issues, psychiatric treatment, alcoholism and drug abuse, sexually transmitted
diseases and even adultery . . . . These disclosures can jeopardize our careers, our
records privacy are of a different nature.

friendships, and even our marriages. And if such disclosures occur, there are truly few
meaningful remedies. Seeking redress will simply lead to further
dissemination of the highly private information that the patient wished to
keep secret . . . . Just a few months later this model of health privacy exceptionalism was confirmed when
President Clinton introduced the first version of the HIPAA privacy rule. 185 The rhetoric of exceptionalism was
clear. As the President noted, the purpose of the regulation was to protect the sanctity of medical records, and it
represented an unprecedented step toward putting Americans back in control of their own medical records.

Today the federal commitment to health privacy exceptionalism seems

strong. Of course there were a couple of bumps in the road as the Bush Administration replaced the original
Clinton Administration requirement of patient consent to disclosure for treatment, payment or health care
operations (TPO) purposes with the more permissive statement that [a] covered entity may obtain consent of the
individual to use or disclose protected health information to carry out treatment, payment or health care
operations.188 On the other hand the Bush Administration seemed to endorse health privacy exceptionalism when

Genetic Information Nondiscrimination Act. GINA, signed into law by

President Bush in May 2008, broadly prohibits discrimination by employers and
health insurers based upon genetic information. It does so primarily by using an
upstream data protection model whereby would-be data custodians are prohibited
from collecting genetic information. Two recent federal government reports
that have recommended the strengthening of data protection both
recognize health privacy exceptionalism. Unfortunately, in doing so they may drive
the unintended consequence of keeping strong, upstream protections out of the
health care space. First, the White House report Consumer Data Privacy in a
Networked World, while calling for Congress to enact legislation that includes an
impressive Consumer Privacy Bill of Rights rotating around Fair Information Practice
Principles (FIPPs), limits that request to commercial sectors that are not subject to
existing Federal data privacy laws.191 Second, the FTCs Protecting Consumer Privacy in an Era of
it championed the

Rapid Change, which calls for privacy by design and best privacy practices, expresses its sensitivity to burdens
introduced by overlapping or duplicative requirements on conduct that is already regulated but more positively
suggests the potential for the FIPPs framework to provide an important baseline for entities that are not subject to

neither report has led

to legislation. And with the political classes closing ranks over the Big Data-tainted
NSA spying controversy, a privacy law reform proposal does not seem likely to
emerge from either the White House or Congress.
sector-specific laws like HIPAA or GLBA. 193 Their considerable promise aside,

Genome surveillance is easier than ever now- low costs and

accessibility in recent years- this makes surveillance more
frequent
McEwen et al 13 (Jean E. McEwen, Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health,Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health. Joy T. Boyer, Senior Program Analyst,
and Kathie Y. Sun, Program Analyst. Evolving Approaches to the Ethical
Management of Genomic Data. February 28, 2013.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665610/)//EMerz
Plummeting sequencing costs, along with ongoing advances in
bioinformatics, now make it possible to generate an enormous volume of
genomic data about vast numbers of people. Depending on the cost

calculation method used, the cost of sequencing the first human genome was
somewhere around $300 million (see: http://www.genome.gov/10002192); today, it
is less than $8,000 (see: http://www.genome.gov/sequencingcosts), and prospects
for the $1,000 genome and even cheaper genomes are within sight [4]. Data from
genome-wide association studies (GWAS), from whole genome and whole exome
scans, and from other high-throughput technologies are proliferating [5, 6].
Although the ethical challenges associated with the management of information
have always been present in the field, the greater comprehensiveness and
informativeness of todays genomic data now makes these challenges even greater,
as was recently recognized in a report by the Presidential Commission for the Study
of Bioethical Issues [7]. First, unlike targeted genetic data of 2030 years ago, or
even the more comprehensive (but often not very informative) SNP data of 10 years
ago, the whole exome and whole genome sequence data now being generated
will eventually be able to reveal many of a persons specific health risks even if the data emerge from research or diagnosis related to a specific condition
[8]. The growing informational richness of genomic data not only facilitates the
range of questions it can be mined to help answer, but magnifies its potential for
misuse. Second, because of its comprehensiveness, genomic information even
when stripped of traditional identifiers has, at least in some sense, the potential to
re-identify the individual from whom it was obtained [8]. This characteristic, coupled
with the datas overall richness, amplifies concerns about who should be able to
have and control -access to it. Until recently, it was thought that re-identifying a
sample or data from which traditional identifiers had been removed required a
reference sample or data from the same person available for comparison [9],
However, we now know that it is possible, in some cases, to identify the source of a
sample or data by consulting genetic genealogy databases (readily available on the
Internet) that link Y chromosome short tandem repeat (STR) data to particular
surnames, and then combining that information with other publicly available data
(e.g., information about age, state of residence, or facts contained in obituaries)
[10]. Although the actual extent of this previously under-appreciated risk is still
unknown, the risk will almost certainly grow in the future, as more people are
sequenced and as the genetic genealogy industry grows. Indeed, the Advance
Notice of Proposed Rulemaking (ANPRN), a pending set of revisions to the Common
Rule (the regulations that apply to all U.S. federally funded research conducted with
human subjects) explicitly recognizes the potential for re-identification inherent in
all genomic data (see: http://www.gpo.gov/fdsys/pkg/FR-2011-07-26/html/201118792.htm). Finally, the complexity and frequently uncertain meaning of the
information being generated today through whole genome analyses, compared to
the more limited (and thus often more easily interpreted) information typically
derived through earlier, more targeted genetic tests, enhances the possibility that
the information, if shared, will be misunderstood [8]. This is creating new challenges
for researchers and clinicians, who must increasingly decide which, if any, individual
findings they should offer to return to those whose samples they have analyzed [11,
12]. Incidental findings (findings unrelated to the disorder that initially motivated
the research or testing) are inevitable not merely possible - in GWAS and in whole
genome and whole exome scans, and as will be discussed later, these present
particular challenges [8, 1316]. Although concerns about the ethical management

of research and clinical data are by no means new to the field, the transition over
the past 20 years from a narrowly genetic orientation to todays much more
comprehensive genomic one has been accompanied by shifts in the way the
information is being conceptualized and managed. It is thus useful to step back and
review systematically the events that have steered the course of these
developments and the new challenges emerging as a result.

Technology is lowering the cost of mass health data sharing

huge momentum for genomics coming
McEwen et al 13 (Jean E. McEwen, Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health,Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health. Joy T. Boyer, Senior Program Analyst,
and Kathie Y. Sun, Program Analyst. Evolving Approaches to the Ethical
Management of Genomic Data. February 28, 2013.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665610/)//EMerz
The field of genomics has long been distinguished by steadfast adherence to the
principle of broad data release. This commitment, first enshrined in the 1996
Bermuda Principles and subsequently reaffirmed, is aimed at maximizing the pace
of research and ultimately, its benefit to society [27]. As targeted genetic research
began to give way to research with a more genomic focus, the expectations
regarding broad data sharing - and rules to enforce them - were gradually extended
to apply not only to the data produced in large, community resource projects, but to
genomic data more generally. The introduction of SNP chips and the development of
improved statistical methods in the early 2000s, which suddenly made studies of
common, complex conditions more tractable, contributed to this trend [28]. GWAS
of common disease accelerated in the 2000s and quickly overshadowed the
previous focus on single gene disorders. To be adequately powered, however, such
studies typically required larger sample sizes (or datasets) than any single
researcher could amass. This circumstance, along with improvements in informatics
technology that made it cheaper and easier to share large amounts of data,
provided further momentum for sharing, and set the stage for the 2008 adoption of
the NIH GWAS Data Access Policy. That policy requires the deposition of summarylevel information and aggregate genotype data in the open access portion of the
NIH Database of Genotypes and Phenotypes (dbGaP), and the deposition of
individual-level data (genotypes and phenotypes) in the controlled access portion of
the database (see: http://grants.nih.gov/grants/guide/notice-files/NOT-OD-07088.html). Under the policy, controlled access data are made available to any
qualified researcher following review and approval by an NIH Data Access
Committee (DAC) [29]. Two other developments occurring in the late 2000s helped
further pave the way for expanded data sharing by (at least temporarily) helping
to quell lingering concerns of some institutional review board (IRB) members about
the associated risks. One development was the enactment of the Genetic
Information Nondiscrimination Act (GINA) (see:
http://www.eeoc.gov/laws/statutes/gina.cfm), which was initially greeted, at least by

some, with optimism that it would put to rest public worries about possible
misuses of genomic information, thus making protocols that relied on the use of
shared data or incorporated plans for broad data sharing more ethically acceptable
[30]. The second was the issuance by the Office of Human Research Protections
(OHRP) of guidance reaffirming a previously-stated position that research using only
de-identified materials falls outside the definition of human subjects research and
thus outside the protections outlined in the Common Rule (see
http://www.hhs.gov/ohrp/policy/cdebiol.html). This guidance provided some (again,
at least temporary) reassurance to IRBs that protocols involving the use of deidentified, archived samples or data, without re-consent, rested on firm ethical (or,
at least regulatory) footing. It also bolstered the confidence of institutional officials
charged with certifying the appropriateness of the data generated by investigators
at their institutions for deposition into dbGaP. The trend toward broader sharing of
data has been accompanied by a trend toward broader sharing of samples, often
through large biorepositories [31]. The new sequencing technologies make it
possible to conduct genomic studies with much smaller quantities of material,
increasing researchers willingness to share more of the valuable sample resources
they have acquired.

Genetic surveillance industrial complex entrenching itself now

constitutional and legislative protections are weak
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
II. IMPLICATIONS OF THE EXPANDED USE OF LOCAL DNA DATABASES The results
from Palm Bay and Bensalem demonstrate that local databases have the potential
to be a powerful law enforcement tool. Indeed, Director Harran concluded that local
databases are the best thing to come to law enforcement since fingerprints,150
and Palm Bay claims that its database prevented $6 million worth of property
crime.151 Given the reduction in property crime and the increased clearance rates
credited to local databases, it may appear difficult to question law enforcements
enthusiasm, particularly when the Supreme Court recently blessed the expansion of
DNA databases in Maryland v. King. 152 However, in addition to the promise of
more efficient crime-solving, local databases carry the potential for serious negative
implications that have not been fully considered by law enforcement. This Part
discusses the forces that will help to solidify local databases as an accepted
surveillance tool, categorizes and analyzes the potential negative effects of these
databases, and sets the stage for reforms proposed in Part III A. Entrenching Local
DNA Databases There are powerful external forces helping to ensure that once local
databases are adopted, they quickly become routine surveillance tools. This Section
focuses on three of these external forces: 1) current Fourth Amendment doctrine,
which allows law enforcement to tap into the everexpanding pool of personal
information collected and stored by private companies; 2) a nascent genetic
surveillance-industrial complex; and 3) growing public acceptance of law

enforcements use of genetic surveillance techniques Current Fourth Amendment

doctrinein particular the principles of the third-party doctrine153allows law
enforcement to benefit from the vast amount of information the public voluntarily
shares with private companies.154 This has led some scholars to conclude that law
enforcement will respond by altering their surveillance practices. Professor Paul
Ohm predicts that [a]s the surveillance society expands, the police will learn to rely
more on the products of private surveillance, and will shift their time, energy, and
money away from traditional self-help policing, becoming passive consumers rather
than active producers of surveillance.155 Professor Ohms instincts are correct
about certain types of surveillance activities. It seems likely that police will be
inclined to use information amassed by private sources, decreasing the need for law
enforcement to conduct duplicative surveillance. However, not all information
sought by law enforcement is captured in the private sector. Specifically, genetic
surveillance is one area where law enforcement will continue to be producers, as
opposed to consumers, of surveillance. Whereas Google, Facebook, and other
companies will feed law enforcements desire for digital surveillance, the expansion
of local databases demonstrates that law enforcement will be the driver of
collecting and analyzing genetic evidence. In addition, local law enforcements use
of genetic surveillance will be shaped by corporate interests.156 Corporate interests
have played a role in the development of local DNA databases since their
inception.157 The first local DNA database was designed jointly by a private DNA
lab and the Palm Bay Police Department.158 And private firms are integral to the
continued expansion of these databases. Large firms, such as Bode Technology and
Orchid Cellmark, view local law enforcement databases as potential revenue
streams, particularly because they promise to promote the use of DNA beyond
violent crimes (sexual assaults and homicides) to property crimes.159 These firms
see a business opportunity in processing the evidence swabs collected from
property crimes. Indeed, in marketing their products, they trumpet the studies that
have highlighted DNAs promise for solving these crimes.160 Similarly, smaller firms
have also sought to benefit from and to drive the expansion of local databases.
These include SmallPond and IntegenX.161 These companies have been consistent
participants in law enforcement conferences in the last several years,162 and they
have sought meetings with local agencies to pitch their products. Furthermore,
IntegenX offers to help potential buyers secure grants to purchase its products.163
The influence of private firms on policing techniques is not new and is certainly not
unique to genetic surveillance.164 However, it is important to recognize that these
private interests will influence the expansion, use, and long-term viability of this
surveillance tool. And because these private interests have evolved simultaneously
with local law enforcements push to enter the genetic surveillance space, the
prospect of a genetic surveillance industrial complex further entrenching the
practice of local databases seems likely. Finally, the very use of these databases will
also contribute to the publics acceptance of them. Even those with only a casual
understanding of surveillance techniques accept without question law
enforcements ability to collect personal informationincluding photographs,
fingerprints, addresses, etc.for investigative databases. Furthermore, because
CODIS has been around for 20 years, there is widespread understanding that law
enforcement collects DNA profiles from at least some segments of the population.

Thus, local databases are not a completely new surveillance tool. This incremental
evolution of law enforcement investigative databases in general, and DNA
databases in particular, will help to solidify local databases as a tolerated, if not
accepted, law enforcement tool.165

Doctor-Patient Trust - Uniqueness

Doctor trust is collapsing now
Harding 14 - Contributing Writer @LiveScience
(Anne, Americans' Trust in Doctors Is Falling, October,
http://www.livescience.com/48407-americans-trust-doctors-falling.html]
Americans' trust in the medical profession has plummeted in recent years, and
lags well behind public attitudes toward doctors in many other countries, according
to a new report. That lack of trust comes from how Americans' perceive doctors'
motivations, said
34 percent of
U.S. adults polled in 2012 said they had "great confidence in the leaders of the
medical profession," down from 76 percent in 1966

Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health in Boston and co-author of the new report. While physician leaders elsewhere

in the world often take public stands on key health and medical issues, Americans perceive the medical profession as looking out for itself, not advocating for public health, he said. Just

, according to the report. And a survey of people in 29 countries found the United States

ranked 24th in public trust of doctors. Just 58 percent of Americans surveyed said they "strongly agreed" or "agreed" with the statement that "doctors in your country can be trusted," versus 83 percent of people who said the same
in top-ranked Switzerland, and 79 percent in runner-up Denmark. Only Chileans, Bulgarians, Russians and Poles were less trusting of the medical profession, according to the report, which is published in the Oct. 23 issue of the New

the researchers analyzed dozens of opinion polls

looking at the public's trust in doctors. The findings indicate that, these days,
Americans see physicians as just another interest group among many, Blendon
said. "What's driving [trust levels] down is that physicians in the U.S., as groups and
leaders, are not seen as
advocates for health and health care
England Journal of Medicine. [7 Absolutely Evil Medical Experiments] For the study,

broad public

issues," Blendon told Live

Science. "In the U.S., they're seen more as a group concerned with their own professional problems and economic issues."

Robust survey of a broad range of indicators proves

Bynum & Porter, 13
W. F. Bynum, Roy Porter, British historian noted for his prolific work on the history of
medicine, former director of the Wellcome Institute for the History of Medicine at
University College, LondonRoutledge, Jun 20, 2013, Companion Encyclopedia of the
History of Medicine 794-795, accessed online via Google Books
One of the great ironies of the social history of medicine is that, at the supreme
moment of achieving this therapeutic power, the crown of glory was snatched from
the doctor's head. In the last quarter of the twentieth century, as an ever-broader
stream of antibacterial, anti-inflammatory and antineoplas- tic medications
became available, patients became increasingly alienated from the former
'demigods in white'. Recent statistics illustrate these changes. For example,
rising numbers Of malpractice suits point to growing alienation: one half of all
surgeons in Florida had been sued for malpractice within the period 197580, and
the better trained the surgeons were, the greater the number of suits.23 Between
and 1985, claims per 100 physicians in the United States as a whole more than
doubled. Some specialities were exceed- ingly vulnerable: over the five-year period
197681, claims against obste- u-icians tripled. The average claim itself climbed
from 98,000 in 1975 to almost $100,000 in 1988.2' Ch. 69 Medicine and the law; Ch.
History of ethics) Second, patients responded to their perception Of physicians'
coolness and lack of interest with a lack Of loyalty. Several different American polls
commissioned in the mid-1980s found that two-thirds of all patients would be
willing to 'change their provider in an attempt to find more satisfactory medical
care'.2S One contrasts this high volatility with patients in the days before the

Second World War who, with their families, would often develop lifelong
attachments to the same family doctor. The whole persona of the 'family doctor',
the elderly pipe-puffing figure present both at birth and death, is now
disappearing, both in fact and in the minds of patients. In the United States in
1988, only slightly more than one doctor in ten was in 'general family practice'.26
Nor were American patients particularly interested in the advice of their
physicians: the percentage of patients willing to use the family doctor as a source
of 'local health care information' declined from 46 per cent in 1984 to 21 per cent
in 1989.27 How did families select which hospital to attend? More than 50 per cent
of patients polled in 1989 said that 'they or their family have the most influence
in selection of a hospital' as opposed to listening to the doctor up from 40 per
cent in previous years." (Non-American readers will recall that private American
hospitals compete for patients.) This alienation from the doctorpatient
relationship has diminished the public's former hero-worship of the doctor.
According to a Gallup poll in 1989, 26 per cent of patients said they respected
doctors less now than ten years ago (14 per cent said more). And of those who
respected doctors less, 26 per cent said, 'they (the doctors) are in it for the
money'. Seventeen per cent claimed that doctors 'lack rapport and concern'.29

Best data proves trust is sinking

Blendon et. al, 10-23-14
Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero, M.P.H., The New England Journal of Medicine, October 23, 2014,
Public Trust in Physicians U.S. Medicine in International Perspective http://pnhp.org/blog/2014/10/24/improving-trust-in-theprofession/

Research suggests that for physicians to play a substantial role in such decision
making, there has to be a relatively high level of public trust in the professions
views and leadership. But an examination of U.S. public-opinion data over time and
of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a
note of caution about physicians potential role and influence with the U.S. public .
In a project supported by the Robert Wood Johnson Foundation and the National
Institute of Mental Health, we reviewed historical polling data on public trust in U.S.
physicians and medical leaders from 1966 through 2014, as well as a 29-country
survey conducted from March 2011 through April 2013 as part of the International Social Survey Programme (ISSP), a cross-national
collaboration among universities and independent research institutions . In 1966,
nearly three fourths (73%) of Americans said they had great confidence in the leaders of the
medical profession. In 2012, only 34% expressed this view. But simultaneously, trust in physicians
integrity has remained high. More than two thirds of the public (69%) rate the honesty and ethical standards of physicians as a group as very high or

public confidence in the U.S. health care system is low, with only
23% expressing a great deal or quite a lot of confidence in the system . We believe that the
medical profession and its leaders are seen as a contributing factor.
high (Gallup 2013). Today,

Longitudinal studies establish US doctor-patient relationships

are amongst the worst in the world
Collins, 10-23-14

Sam P.K. Collins is a health reporter for ThinkProgress, OCTOBER 23, 2014, Think
Progress, Americans Dont Trust The Medical Profession
http://thinkprogress.org/health/2014/10/23/3583625/americans-skeptical-doctors/
Americans count among the least trusting of the medical profession, according to an
international health care survey. The findings, which appeared in a recent issue of
the New England Journal of Medicine, show significant levels of suspicion of doctors,
especially among those who make less than $30,000 annually. Researchers
studied public health polls dating back four decades, including one
conducted by a consortium of universities between 2011 and 2013 during which
people in 29 countries answered survey questions. In that poll, 58 percent of
Americans said they trust the medical profession, placing the United States in
24th place with Croatia. It fits with decades of data on the American publics
trust in institutions, in general, Michael Gusmano, a scholar at the Hastings Center,
a Garrison, N.Y.-based research institute that focuses on health care, told WebMD.

Doctor-Patient Trust Privacy Key

Increased health care privacy is key to doctor-patient trust
Greenspun 15 (Harry Greenspun M.D. is the director of the Deloitte Center for Health Solutions, Earning
Patient Trust Crucial to Health Care Reform 4/27/15 http://deloitte.wsj.com/cio/2015/04/27/earning-patient-trustcrucial-to-healthcare-reform/)///CW

Maintaining privacy in health care used to be relatively straightforward . As a physician, I

was bound by doctor-patient confidentiality. This gave my patients the confidence that they
could share with me intensely personal information. Security focused on limiting access
to paper charts. Breaches typically involved only a handful of individuals. Now, in an era of electronic health
records (EHR) and clinical data shaken. From lapses in protocols to sophisticated cyber
attacks, the public is confronted with exposure on a massive scale warehouses,
consumers confidence in the security of their data continues to be . The value of health
care data on the black market is even beginning to exceed that of financial data, as
scammers and hackers can use information about individuals physical
characteristics to steal identities. The information that comes with a persons medical identity is also more
difficult to move back into the private realm once it leaks to the public. Some of this news could not come at a worse time. The
future of health care depends on secure flow of information. Nearly every major delivery reform, from value-based care and
population health to personalized medicine and use of real-world evidence, relies on data and the willingness of those who have it to
share it. The ability to better serve individuals depends on the health care industrys ability to view its data in aggregate.
Compounding the problem is the awareness that our overall privacynot just health privacyis slowly eroding. A casual glance at
online ads reveals how quickly your consumer data gets shared, but technology has taken us well beyond that. Last year, while
participating in a conference on privacy in Abu Dhabi, one of the speakers asked, Who knows youre here? The list grew rapidly:
my office, the airline, customs and immigration, the hotel, the taxi company, the coffee shop, my cellphone carrier, the conference
center, and the owners of the literally thousands of security cameras Id passed during my trip. Add notes to family and friends
along with followers on social media, and it was clear that the record of my trip had been broadly dispersed. As we sit on the cusp

Health data concerns are

different. While the loss of financial information can be distressing, the impact can usually be mitigated and consumer liability
is often limited. By contrast, disclosure of certain medical information can be devastating with
far-reaching consequences. In addition, breaches and misuse can introduce inaccuracies into a medical record,
potentially impacting patient safety. Privacy preferences fall along a continuum and vary even within individuals
of the era of big data in health care, there are several important things to consider:

depending on the topic. While many consumers may freely share certain health information for clinical research, on social media,
and with disease-specific websites, they fiercely protect other personal health data. As we strive to gather more data to advance

the tension between the need for individual privacy and knowledge for the
greater good is only going to increase. The industry has a communication challenge. Do your own survey and
health care,

ask some friends, What are the risks of having your medical information stored electronically? Once they have talked your ear off

What are the benefits? Having done this

many times myself, Ive found that few have a compelling answer . While we have invested
about identity theft, discrimination, and even extortion, ask them,

heavily in EHRs and health information exchange, we have done little to educate the public whose data may be at risk.

Perception of information collection crushes patient trust

Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
significant body of research has examined the perception of privacy concerns from
the viewpoint of a special class of patients, including mental health patients, seekers of
HIV testing and adolescents. In a recent survey of past research on healthcare confidentiality, Sankar et
al. (2003) make four overarching conclusions. First, patients strongly believe that their
information should be shared only with people involved in their care. Second,
patients do identify with the need of information sharing among physicians, though
A

HIV patients are less likely to approve sharing of their health information. Third,
many patients who agree to information sharing among physicians reject the notion
of releasing information to third parties, including employers and family members.
Lastly, the majority of patients who have undergone genetic testing believe that
patients should bear the responsibility of revealing test results to other at-risk
family members. This extensive body of research has primarily focused on the use of identifiable
or potentially identifiable information by others outside of immediate health providers, such as employers,
families and third parties (Sankar et al., 2003). However, very limited research has examined patients perceptions

more recent studies that examine

patients perceptions about consent for data use (Bansal et al., 2007; Campbell et al., 2007)). Bansal et al.
(2007) developed a set of constructs based on utility theory and prospect theory as antecedents of
trust formation and privacy concern that impact users personal disposition to
disclose their health information to online health websites . In particular, they reported that
users current health status, personality traits, culture, and prior experience with websites and online privacy
invasions play a major role in users trust in the health website and their degree of privacy
of sharing anonymised health records (perhaps with the exception of

concerns. On the other hand, in a mail-based survey with adult patients in England, Campbell et al. (2007) found
that about 2835% of patients are neutral to their health information such as age, gender, ethnicity, reason for
treatment, medical history, personal habits impacting health, type of treatment obtained, side effects of treatment
being used by physicians for other purpose. Only about 521% of patients, however, expected to be asked for
permission to use their information by their physicians. Similarly, only about 10% of the patients expected to be
asked for permission if their doctors used their health information for a wide variety of purposes, including
combining data with other patients data to provide better information to future patients, sharing treatment
outcomes with other physicians, teaching medical professionals and writing research articles about diseases and
treatments.

Patient-physician trust is critical to provide companies with

access to healthcare and information
Muller et al 14 (Evamaria Muller, Jordis M. Zill, Jorg Dirmaier, Martin Harter,
Isabelle Scholl, University Medical Center Hamburg-Eppendorf, Department of
Medical Psychology, Hamburg, Germany)(Assessment of Trust in Physician: A
Systematic Review of Measures, September 10, 2014, PLoS ONE 9(9): e106844.
doi:10. 1371/journal.pone.0106844)//ASMITH
Patient-centeredness has gained importance in research, health policy and clinical
practice. Trust is considered a central factor in determining a positive patientphysician relationship [13], which is an important dimension of patientcenteredness [4]. Trust in the context of healthcare has received increasing attention in the last two decades
[5]. This is partly due to the voice of concerns about the effects of organizational changes in the healthcare system
on patients trust in their healthcare professionals, healthcare institutions and the healthcare system itself [6,7 ].

Patients trust has a particularly delicate notion, as patients who are ill and may
have to face high risks regarding their health find themselves in an extremely
vulnerable situation. Reliance on patients individual physicians and the healthcare
system is often inevitable [6,8]. The patient-physician relationship is characterized by a knowledge and
power imbalance in which patients depend on the physicians expertise and execution of treatments to solve their
health problems [6,8,9]. Hence, trust in physician plays an important role and has been studied extensively. Trust in
physician can be defined as the patients optimistic acceptance of a vulnerable situation and the belief that the

Empirical studies have revealed that patients

trust in physician is associated with patient satisfaction [10], continuity of care [11]
and adherence to treatment [12]. Trust in physician facilitates access to healthcare,
disclosure of relevant information and thereby supports accurate and timely
diagnosis to be made [8]. Trust in physician is also associated with self-reported
physician will care for the patients interests [2].

health improvement [13] and patients self-reported ability to manage their chronic
disease [14]. As the body of work increases, the question of how to measure trust in physician gains importance.
The validity of empirical findings is fundamentally dependent on the quality of the measures in use. Therefore, the
selection of a measure should be carefully considered and based on the measures psychometric properties. Some
studies addressed the quality of trust in physician measures [5,7,15], but no systematic review on trust in physician
measures and their psychometric properties has been published to date. A thorough overview and comparison of
different validated measures is needed a) to facilitate the choice of an appropriate instrument in accordance with
the individual research purpose, b) to identify research gaps and needs for further psychometric testing of
instruments and c) to inspire new measurement developments, if necessary. Thus, the aims of this systematic
review of measures on trust in the physician are 1) to identify existing psychometrically tested measures of trust in
physician, 2) to determine the methodological quality of the studies that report on psychometric properties of
measures, and 3) to evaluate the quality of identified measures based on their psychometric properties.

Privacy and trust between doctors and pacients are critical to

successful medicine practices
Glen and Montieth 14 (Tasha Glenn, ChronoRecord Association, Inc.,
Fullerton, CA & Scott Monteith, Michigan State University College of Human
Medicine, Traverse City Campus)(Privacy in the Digital World: Medical and Health
Data Outside of HIPAA Protections, 14 September 2014, Curr Psychiatry Rep,16:494
DOI 10.1007/s11920-014-0494-4)//ASMITH
Trust between doctor and patient is fundamental to the practice of medicine. A
patientmust trust the physician sufficiently to share personal details that may be
stressful, embarrassing, or potentially damaging. A physician must trust that a
patient is sharing enough information to make an accurate diagnosis, and that a
patient is able to give informed consent about treatments that may pose significant
risks. Trust in psychiatrists may be more important to patients with mental disorders
than to patients with other serious illnesses [1]. An essential component of the trust
between doctor and patient is privacy. Over two thousand years ago, Hippocrates
emphasized the importance of privacy, and the practice of medicine has recognized
and valued the importance of privacy ever since. Privacy of medical data is
regulated by federal and state laws but primarily HIPAA. HIPAA regulates patient
data that is collected by providers and their business associates in relation to
treatment, payment or healthcare operations. Most privacy discussions relate to
concerns about HIPAA, such as the relative ease of re-identification of deidentified
data [2, 3]. This review will focus on the medical and health data that are
increasingly being collected outside of HIPAA protections. Medical and health data
outside of HIPAA can be volunteered by consumers directly, observed by
corporations recording consumer actions, and inferred by calculated models [4]. The
rapidly expanding stores of data collected outside of HIPAA are encroaching on the
traditional doctor patient relationship and eroding medical privacy

Patient-Doctor relations key to medical efficiency

Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
Privacy is viewed as a key governing principle of the patientphysician relationship.
Patients are required to share information with their physicians to facilitate correct
diagnosis and treatment, and to avoid adverse drug interactions. However, patients may refuse to

divulge important information in cases of health problems such as psychiatric

behaviour and HIV, as their disclosure may lead to social stigma and discrimination
(Applebaum, 2002). Over time, a patients medical record accumulates significant personal information including
identification, history of medical diagnosis, digital renderings of medical images, treatments, medication history,
dietary habits, sexual preference, genetic information, psychological profiles, employment history, income and
physicians subjective assessments of personality and mental state (Mercuri, 2004). Figure 1 shows a typical

Patient health records serve a range of purposes

apart from diagnosis and treatment provision. For example, information could be
used to improve efficiency within the healthcare system, drive public policy
development and administration, and in the conduct of medical research (Hodge, 2003).
information flow in the healthcare sector.

A patients medical records are also shared with payer organisations (e.g., private insurance or Medicare/Medicaid)
to justify payment of services rendered. Healthcare providers also use records to manage their operations and
improve service quality. Furthermore, providers may share health information through Regional Health Information
Organisations (RHIOs) to facilitate care services.

Public doesnt perceive gains from health surveillance

Andrea Wilson (Senior Business Practices Analyst at The Methodist Hospital
System, Houston, TX) 2009 MISSING THE MARK: THE PUBLIC HEALTH EXCEPTION
TO THE HIPAA PRIVACY RULE AND ITS IMPACT ON SURVEILLANCE ACTIVITY 9 HOUS.
J. HEALTH L & POLY 131-156, https://www.law.uh.edu/hjhlp/Issues/Vol_91/Wilson.pdf
Public health officials have always faced obstacles in the collection of data needed
for evaluating public health concerns and developing effective policy. 42 Agencies
frequently suffer from a lack of funding at the state level, resulting in a loss of
personnel for surveillance efforts. 43 Public health law aims to improve the health of
the population as a whole by implementing policies, which require the cooperation
of individual members of society. 44 However, citizens rarely see direct personal
benefits from public health efforts because these activities are designed for
aggregate well-being, as opposed to medical treatment which focuses on the
individual patient. 45 The public does not perceive substantia l gain from
surveillance, though it can clearly see that such activities require an inquiry into
personal medical histories. 46 As a result, patients and their health care providers
are reluctant to release private information. 47 Thus, there was cognizable difficulty
in gathering needed surveillance data before the promulgation of HIPAA, and
despite HHSs attempts to broaden the means by which public health authorities
could access this information, the terms of the regulations have exacerbated the
problem.

Doctor-Patient Trust Key to Medical Treatment

Doctor-patient trust is key to effective medical treatment
Leng 13 (Shirie Leng MD is an anesthesiologist, How can doctors and patients regain trust in each other?
8/3/13 http://www.kevinmd.com/blog/2013/08/doctors-patients-regain-trust.html)///CW
The Mayo Clinic Proceedings came out with a study that shows that many of the treatments that doctors once swore
by are useless or worse. The New York Times did a piece on it and the commentary contained a great deal of
doctor-bashing. So of course I opened my big mouth and pointed this doctor hatred out. The comment I got back

If people are starting to fear physicians then weve

got a real problem. Trust has always been the basis of the doctor-patient
relationship. If you cant trust us then we might as well go back to the days of charlatans
and quacks. I know, some people are going to say were all quacks anyway but those folks had shoddy
upbringing. If you cant trust us then were done . If you cant trust us then our relationship
becomes adversarial: you against me. If you cant trust us, you wont tell us things, you wont do what we
say, you will constantly be doubting our motives . And vice versa. Actually, now that I think of it,
the doctor-patient relationship becomes basically teenager-parent . The literature on
was this: Its not hatred, its fear. Wow.

doctor-patient trust suggests that a patients health or recovery depend in part on the doctor-patient relationship.
Judith Hall, a researcher at Northeastern University, wrote with colleague Debra Roter, Once the patient and
physician are brought together, they enter a relationship predicated on the expectations each olds for the conduct
of the other. The relationship thus formed has substantial implications for how the curing and caring process will be
accomplished and the extent to which needs and expectations will be met, satisfaction achieved, and health
restored. (Doctors Talking with Patients/Patients Talking with Doctors) Trust has many components. It is based
partly on compatible communication styles. The Journal of General Internal Medicine points to the patients
assessment of the physicians communication, level of interpersonal treatment, and knowledge of the patient. In
these times of short visits, short-tempered doctors and patients, and fragmented treatment, all those factors are in
jeopardy. Patient dissatisfaction implies poor trust. Race and gender of both patient and doctor has an impact.
Patients who genuinely like their doctors tend to trust them more. In the 1950s it was thought that the basis of
physician trust is the understanding that doctors treat everyone equally. The media has made sure we all know this
is not true, and this has to do with economics and geography as well as regional differences in standard of care.
That old-fashioned trust of the physician resulted in a paternalistic approach to medicine with the resulting backlash
by the autonomy movement. The basic function of the doctor, to diagnose and treat, has been called into question
by the Mayo Clinic article as well as a number of other stories such as over-prescribing, doctors taking money from
drug companies, the guy who performed illegal and unsanitary abortions, doctors turning down medicaid patients,

Doctors trust patients less too. Part of the reason doctors dont follow the latest
recommendations is fear of litigation, especially if they dont do something.
etc.

Lack of mandated privacy results in less overall information

and decreased trust in the medical system
Goldman, from the College of Physicians and Surgeons, Columbia University,
November 1998 (Janlori, Protecting Privacy To Improve Health Care, published in
HealthAffairs volume 17 number 6)//roetlin
Insufficient attention has been paid to date to the role that privacy and confidentiality
play in the health care setting. There is no comprehensive federal law to protect the
privacy of peoples health records, and state laws are scattered and inconsistent. Although the
American Medical Association (AMA) and other provider groups have long considered confidentiality a key
component of preserving the doctor/patient relationship, others view patient privacy as a barrier or a stumbling
block to achieving health carerelated goals.

There is a fear that protecting privacy will clog the

free flow of health information and make less information available for out- comes analysis, research,
and other public health activities.2 Ultimately, however, the converse is true: Without trust
that the personal, sensitive information that they share with their doctors will be

handled with some degree of confidentiality, patients will not fully participate in their
own health care. In the absence of such trust, patients will be reluctant to accurately
and honestly disclose personal information, or they may avoid seeking care
altogether for fear of suffering negative consequences, such as embarrassment,
stigma, and discrimination.

The plan is key to sustained participation in medical research

studies
Weir and Olick 4 (Robert, PhD and Professor Emeritus of Pediatrics at
the University of Iowa; Robert, Associate Professor of Bioethics and
Humanities at SUNY Upstate Medical University, The Stored Tissue
Issue: Biomedical Research, Ethics, and Law in the Era of Genomic
Medicine, 2004, Oxford university Press, p. 179)//JL
law governing genetic privacy and the risks of genetic discrimination are relevant
to biomedical research in at least three significant ways. First, though investigators are not obligated
to quote chapter and verse about existing law, fulfilling the duty of confidentiality and making accurate
representations about the bounds of this promise require a basic familiarity with the legal
terrain. Second, the legal landscape necessarily informs IRB judgments whether the
research protocol poses minimal risk and the shaping of informed consent requirements. Last, as observed
elsewhere, concerns about privacy and discrimination may play a pivotal role in a
potential participants willingness to enroll in a research study.
The state of the

Trust is essential to doctor-patient relationships and quality

health care
Russo 13 (Nicholas J. Russo is a 2012 honors graduate of the MBS program at
TCMC. Before attending TCMC, he received a Bachelor of Science degree in
technological systems management engineering and biology from Stony Brook
University in New York. He plans to continue his education in medicine.)(In
medicine, doctor-patient trust vital, February 18, 2013, The Scranton-Times
Tribune, http://thetimes-tribune.com/news/health-science/in-medicine-doctorpatient-trust-vital-1.1445937)//ASMITH
Amos was an Amish patient treated for pneumonia with penicillin injections by Dr.
Henry. On the final day of his regimen, Dr. Henry told Amos that he did not have a
bill prepared and asked him to return another day. Amos replied by writing a blank
check. Dr. Henry refused the blank check, explaining that he would be able to write
in any amount he wished. Amos replied without hesitation: "I trusted you with my
life. I do not see why I cannot trust you with my money." This story from the book
"Patients Are a Virtue," by Henry S. Wentz, demonstrates that trust is an essential
component of the doctor-patient relationship. The sanctity of this relationship is the
very essence of quality health care and is the basis for patient satisfaction and
positive outcomes. Studies show that patients feel strongly that trust should be the
No. 1 factor when it comes to choosing the "right" physician for you. A recent study
published in the Internal Journal of Medical Education demonstrated that better
patient outcomes and compliance with treatment increase when doctors are trusted

and more proactive in involving patients in their own health care. Patients agreed
they trusted their doctors more when extra time was spent explaining a procedure
and treatment. These patients were more likely to get regular checkups and medical
tests and take their medications properly. They were also more likely to follow a
healthy lifestyle, including diet and exercise, and control diseases such as blood
pressure and diabetes. Trusting your physician plays a much larger role than you
might imagine when making medically informed decisions. Dr. Janet Townsend,
founding chairwoman of the department of family, community and rural health at
the Commonwealth Medical College, believes that establishing a foundation of trust
with patients and their loved ones is the basis for delivering quality health care.
"People need to trust you as a doctor and know that you are truly here for them,"
she said. Dr. Townsend's experiences have taught her that there is no simple
equation for establishing trust, but it is a powerful tool for improving patient
outcomes. Dr. Mark White, an educator and community health researcher at TCMC,
takes great pride in his Physician and Society course for first-year medical students.
He believes that trust is an integral part of the doctor-patient relationship; it is the
root of passionate, patient-centered medicine, something he emphasizes in his
curriculum. In fact, doctor-patient relationships may be improving. A recent MSNBC
report presented a compelling argument that the traditional "authoritative attitude"
of some doctors with their patients is rapidly becoming a thing of the past. More and
more patients are taking responsibility for their health education, and trust may be
the key underlying factor that allows this open communication and better patient
treatment. Today's doctor-patient relationship is one in which both parties are more
equal than ever, which allows both to be rewarded for establishing lasting
relationships built on trust. New partnership In Northeast Pennsylvania, our
communities are grounded in trust. On a regular basis, senior citizens come to my
office for a consultation, and the first question they ask me is, "Who is your father,
Paul?" This is followed by, "Was Al your uncle?" "Are you related to Mike?" While I
was not sure of the importance of these questions early in my career, I have come
to realize that patients were just trying to make a connection with me. They wanted
to know if they could "trust" me. Nick Russo, a recent graduate of the
Commonwealth Medical College's Master of Biomedical Sciences program, presents
new research that supports their instincts: Patients who trust their health care
provider have better outcomes; the doctor-patient relationship matters.

Lack of doctor-patient trust causes lack of information

communication and prevents effective treatment
Goold and Lipkin 99 (Susan Dorr Goold, MD, MHSA, MA, Received from the
Division of General Medicine, University of Michigan Medical Center, Ann Arbor,
Mich. AND Mack Lipkin, Jr., MD, New York University Medical Center, New York)(The
DoctorPatient Relationship: Challenges, Opportunities, and Strategies, J Gen Intern
Med. 1999 Jan; 14(Suppl 1): S26S33. doi: 10.1046/j.15251497.1999.00267.x)//ASMITH
The relationship between doctors and their patients has received philosophical,
sociological, and literary attention since Hippocrates, and is the subject of some
8,000 articles, monographs, chapters, and books in the modern medical literature. A

robust science of the doctorpatient encounter and relationship can guide decision
making in health care plans. We know much about the average doctor's skills and
knowledge in this area, and how to teach doctors to relate more effectively and
efficiently.11, 12 We will first review data about the importance of the doctor
patient relationship and the medical encounter, then discuss moral features. We
describe problems that exist and are said to exist, we promulgate principles for
safeguarding what is good and improving that which requires remediation, and we
finish with a brief discussion of practical ways that the doctorpatient relationship
can be enhanced in managed care. The medical interview is the major medium of
health care. Most of the medical encounter is spent in discussion between
practitioner and patient. The interview has three functions and 14 structural
elements (Table 1).13 The three functions are gathering information, developing and
maintaining a therapeutic relationship, and communicating information.14 These
three functions inextricably interact. For example, a patient who does not trust or
like the practitioner will not disclose complete information efficiently. A patient who
is anxious will not comprehend information clearly. The relationship therefore
directly determines the quality and completeness of information elicited and
understood. It is the major influence on practitioner and patient satisfaction and
thereby contributes to practice maintenance and prevention of practitioner burnout
and turnover, and is the major determinant of compliance.15 Increasing data
suggest that patients activated in the medical encounter to ask questions and to
participate in their care do better biologically, in quality of life, and have higher
satisfaction.16 Effective use of the structural elements of the interview also affect
the therapeutic relationship and important outcomes such as biological and
psychosocial quality of life, compliance, and satisfaction. Effective use gives
patients a sense that they have been heard and allowed to express their major
concerns,17 as well as respect,18 caring,19 empathy, self-disclosure, positive
regard, congruence, and understanding,20 and allows patients to express and
reflect their feelings21 and relate their stories in their own words.22 Interestingly,
actual time spent together is less critical than the perception by patients that they
are the focus of the time and that they are accurately heard. Other aspects
important to the relationship include eliciting patients' own explanations of their
illness,23, 24 giving patients information,25, 26 and involving patients in developing
a treatment plan.27 (For an overview of this area of research, see Putnam and
Lipkin, 1995.28)

Doctor-Patient Trust Privacy Protection Behavior

Strong widespread support for public health information
privacy the aff is key to avoid action to avoid discrimination
Rubel 12 (Alan Rubel. Ph.D., Department of Philosophy, University of WisconsinMadison; J.D., magna cum laude, University of Wisconsin Law School Assistant
Professor. Justifying Public Health Surveillance: Basic Interests, Unreasonable
Exercise, and Privacy. 2012. P. 14-15.
https://kiej.georgetown.edu/home_files/22.1.rubel.pdf)//EMerz
There is, however, a question as to whether privacy is an important enough good
that it is a basic interest. In some contexts it may be. Privacy is best understood as
a three-part relation between a person, some domain of information, and some
other person, persons, or entity. Any discussion of interests in, claims regarding, or
rights to privacy should therefore specify who the privacy holder is, what
information is at issue, and who the other parties are that can learn that information
(Rubel 2011). Privacy in some information with respect to some entities would very
likely rise to the level of a basic interest. Consider privacy regarding how one votes
with respect to the state, privacy regarding ones intellectual habits with respect to
the state, and privacy regarding sexual orientation, genetic predispositions,
aspirations and fears, and ones naked body with respect to the general public. In
the public health context, the privacy at issue is generally privacy regarding ones
medical information with respect to certain government actors. If we assume that
no information conveyed will be disclosed to other agencies and to entities not
already involved in a persons health care, it is difficult to see a basic interest at
work. At least this is true in most cases; below I address some particular contexts in
which medical privacy may rise to the level of a basic interest. But the first premise
states that claims to privacy in health information are based on deep personal
interests. By this I mean that they are based on interests that are more weighty
than (mere) personal interests but not sufficiently weighty to be considered basic.
One reason is that health information privacy is important to many persons
conceptions of the good. As I have already noted, the desire for health information
privacy is strong, widespread, and resilient. Moreover, there is no reason to think
such a desire is based on a misplaced fear or a mistake about facts. Many people
are concerned about receiving ill treatment or being discriminated against on the
basis of health information. The possibility of having their health information
disclosed may lead people to avoid care, which is generally detrimental to
their health and hence interests regardless of their particular conceptions
of the good. Health privacy also implicates autonomy and dignitary interests,
regardless of whether there is a chance of ill treatment, discrimination, or care
avoidance (Bloustein 1964; Reiman 1976; Benn 1971; DeCew 1997). Some people
may wish not to have their identities shaped by information about their health and
so may want to control who views them in terms of their health conditions and who
views them without such information.12 A further reason that claims to health
privacy are based on deep interests has to do with a sense of fair terms of social

cooperation. Given the widespread desire for privacy generally and health
information privacy in particular, any mandatory diminution of that privacy by state
actors should be justifiable in terms that the subject of the information gathering
could agree to as fair in light of others reasonable conceptions of the good.
Certainly some information collection is justifiable in this way: keeping track of
motor vehicles and drivers licenses in order to assure only qualified drivers are on
the roads and that they are using nonstolen vehicles is surely justified in such a way.
But not all health information collection can be so justified. Where collection of
health information does not redound to the benefit of the subject of the information,
and where any health benefits to others are tenuous, small, or attainable in other
ways, it would be difficult to justify the collection as fair to the persons whose
conception of the good includes (or relies on) health information privacy.13 Finally,
there is an important liberty interest at stake in health information
privacy. Boudewijn de Bruin has recently made the case that privacy losses both
limit persons freedom to act in certain ways and decrease those same persons
knowledge about their freedom. If others have information about a person, they
may use that information in a way that affects that persons ability to act. So, a data
breach might give a bank officer information that would lead her to reject a persons
loan application on the ground that shes receiving, say, cancer treatment (2010).
Moreover, de Bruin points out that the value of freedom stems from knowing that
we possess it: uncertainty about the effects of information breaches undermines a
persons ability to act. Relatedly, there is an autonomy interest in understanding
such effects, since information collected for public health can often be used to
delimit a persons opportunities. Information about tuberculosis may be used to
quarantine or isolate people; information about HIV status is used to punish people
who have sex without disclosing their status; information about HIV affects persons
ability to travel and immigrate; information about vaccination affects whether
people can enroll in schools; information about body weight has been proposed as a
basis for an insurance surcharge for diabetics (Lacey 2011); and so forth. More
importantly, the effects of the information may not be known at the time it is
collected. We do not know how information will be used in the future. For these
reasons health privacy with respect to state actors is best understood as a deep,
personal (and nonbasic) interest. It is worth emphasizing that at this point I am
outlining a condition for justifying surveillance and arguing that it is justified to
restrict a claim based on a deep personal interest where exercising that claim
unreasonably threatens basic interests. A fortiori, it would be justified to restrict a
claim based on a nondeep personal interest. Now, in some cases privacy regarding
ones health with respect to state actors may implicate basic interests. As noted, TB
(especially TB that is multidrug resistant or extensively drug resistant) may be
grounds for quarantine or isolation (42 USC 264; 42 CFR 70, 71). Freedom of
movement would seem to be a basic interest. So, at least in some cases, privacy
with respect to state actors, in conjunction with laws enabling further actions based
on that surveillance, implicates basic interests. In such cases, we are not confronted
with conflicts between the basic interests of some individuals and the less weighty
personal interests of others but with conflicts between basic interests.
Subordinating some basic interests for the sake of other basic interests can be
justified by appeal to the number or magnitude of basic interests at stake, such that

if enough others interest in not contracting a disease that is likely to cause serious
illness or death is strongly enough implicated, it can be justified to surveil others
and to quarantine or isolate some. That does not entail that only aggregated
interests matter, just that some degree of aggregation of basic interests can provide
sufficient justification for subordinating of basic interests of others.1

Fears of privacy breaches causes withholding of patient data,

inconsistent care, and lack of care coordination
Glen and Montieth 14 (Tasha Glenn, ChronoRecord Association, Inc.,
Fullerton, CA & Scott Monteith, Michigan State University College of Human
Medicine, Traverse City Campus)(Privacy in the Digital World: Medical and Health
Data Outside of HIPAA Protections, 14 September 2014, Curr Psychiatry Rep,16:494
DOI 10.1007/s11920-014-0494-4)//ASMITH
Although the public routinely gives away most personal information, medical
privacy remains uniquely important to most, as underscored by the very existence
of HIPAA and HITECH. The use of technology in medicine is widely supported but
concern remains about the security of the medical information that is protected by
HIPAA, such as in EMR, as summarized in Table 2. In a study of psychiatric
outpatients almost 90 % had concerns about confidentiality with the use of EMR,
such as unauthorized access within a university healthcare system, inappropriate
use of information, and stigmatization [126]. There are serious consequences when
patients fear their privacy is at risk. Patients may become selective about the
information they provide, offering an incomplete or misleading description of their
condition. In recent surveys, a substantial number of people said they would
withhold data from their physician due to privacy concerns related to technology, as
shown in Table 3. Patients who are worried about privacy are also less likely to seek
care or return for follow-up treatment, or may seek care outside of their provider
network undermining the benefits of care coordination [126, 128]. Much of the
general public is unaware of the large amount of medical and health data being
amassed outside of HIPAA confidentiality protections. As the public becomes more
informed about the secondary market for health data, concern about privacy and
security of all medical data is likely to increase. This, in turn, may dissuade more
people from seeking help or revealing the information to physicians. This is of
particular concern to psychiatry, since patients with mental disorders are more
likely to withhold information from their doctors than patients with other serious
illnesses [1].

Electronic health records prevent effective data integration

and are subject to data errors
Hoffman and Podgurski 13 (Sharona Hoffman, the Edgar A. Hahn Professor
of Law and Professor of Bioethics and the Co-Director of the Law-Medicine Center at
Case Western Reserve University School of Law and Andy Podgurski, a Professor of
Electrical Engineering and Computer Science at Case Western Reserve University)
(Big Bad Data: Law, Public Health, and Biomedical Databases, Journal of law,

medicine & ethics, public health law conference: practical approaches to critical
challenges spring 2013, Case Western Reserve University)//ASMITH *EHR =
Electronic Health Record
The proliferation of available data is generating much excitement in the public
health community. However, this enthusiasm must be tempered by recognition of
the potential limitations of EHR data. EHRs often contain data entry errors, in part
because they can increase physicians documentation burden. Busy clinicians
sometimes type quickly and invert numbers, place information in the wrong
patients record, click on incorrect menu items, or copy and paste narrative from
prior visits without carefully editing and updating it.8 Much of the information in
EHRs is coded using not only the International Classification of Diseases (ICD- 9) but
also customized lists incorporated into EHR products, and coding can introduce
further errors. Codes may be confusing, misleading or too general to indicate the
specifics of patients conditions.9 Furthermore, EHRs may not accommodate
detailed and nuanced natural language notes about patients medical histories and
diagnostic findings.10 Commentators have noted that providers collect data for
clinical and billing purposes rather than for public health reasons. Thus, EHR content
is not always wellsuited for public health uses. Furthermore, clinicians may have
incentives to upcode in order to maximize charges, and this practice can
systematically compromise the accuracy of many records.11 The menus and lists
built into EHR systems may facilitate upcoding by suggesting items for which
physicians should bill and making it easy to click boxes for charge purposes. In
some instances, EHRs are incomplete, lacking essential information such as
treatment outcomes. Patients who receive medication from their doctors often do
not report whether the therapy was effective. The absence of return visits may
mean that the patients were cured, but it could also indicate that they failed to
improve or deteriorated and decided to visit different doctors or specialists.12 In
addition, patient records are often fragmented. A patient may see multiple doctors
in different facilities, and if these practices do not have interoperable EHR systems,
pieces of the individuals record will be scattered in different locations. Such
fragmentation can hinder surveillance and research efforts because the patients
medical history cannot easily be put together into a comprehensive whole.13 EHR
vendors are making slow progress towards achieving interoperability, the ability of
two or more systems to exchange information and to operate in a coordinated
fashion. In 2010 only 19% of hospitals exchanged patient data with providers
outside their own system.14 Vendors may have little incentive to produce
interoperable systems because interoperability might make it harder to market
products as distinctive and easier for clinicians to switch to different EHR products if
they are dissatisfied with the ones they purchased. The lack of interoperability in
EHR systems can also impede data harmonization. Different systems may use
different terminology to mean the same thing or the same terminology to mean
different things. For example, the abbreviation MS can mean mitral stenosis,
multiple sclerosis, morphine sulfate, or magnesium sulfate.15 If the terms
meaning is not clear from the context, then analysts may not be able to interpret it
correctly.

Health information privacy prevents privacy protective

behavior
Alan Rubel (University of Wisconsin Law School Assistant Professor , Ph.D.,
Department of Philosophy, University of Wisconsin-Madison; J.D., magna cum laude)
2014 Privacy, Surveillance, and Autonomy p. 312
One possibility is that privacy protections are justified by the potential negative
effects of information disclosure on persons' welfare. For example, a lack of privacy
may under- mine persons' healthcare: Where individuals worry about privacy
regarding their medical information, they are likely to engage in "privacy protective"
behaviors, such as lying to their care providers, seeing multiple providers, using
different pharmacies, not participat- ing in research, and paying in cash rather than
using insurance (Goldman 1998: 49; California Healthcare Foundation 2010: 20).
Likewise, privacy may increase or protect one's opportunities. Information about a
person's health status, medical history, or genetic attributes may undermine her
employment prospects, insurance eligibility, financial back- ing, promotion potential,
or opportunities for positions of responsibility. Privacy may also protect people from
stigma. Some may believe that aspects of a person's health and med- ical status
reflect negatively on that person (for example, sexually transmitted infections,
mental illnesses, some chronic diseases). Hence, where others learn that one has
such a condition, she may lose some degree of social esteem.

Doctor-Patient Trust Drug Resistance

Mis-diagnosis from lack of patient trust makes solving drug
resistance impossible
Stein et al. 6/25, (Uri Obolski, Gideon Y. Stein, Lilach Hadany, PLOS
Computational Biology, University of New South Wales, Antibiotic Restriction Might
Facilitate the Emergence of Multi-drug Resistance, June 25, 2015,
http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1004340)//IB
the most pressing public health issues challenging
medicine [1]. Resistance frequency is continually rising i n abundant pathogenic bacteria
[2,3], entailing higher risk for patients and increased economic costs [4,5]. Especially perilous
are infections of multi-drug resistant (MDR) bacteria, which can lead to higher rates of
inadequate treatment and mortality [68], and at times are resistant to almost all available antibiotics
[9,10]. Even drugs of last resort , with relatively low prescription rate, are revealed to have
increasing resistance frequencies [11,12]. The increase in antibiotic resistance frequencies is a
consequence of microbial evolution and adaptation, induced by vast anthropogenic antibiotic
consumption and dissemination [13]. This arms-race hinges on two main forces, acting at opposite directions:
resistance acquisition and spread in bacterial populations , and new antibiotic production [14].
Seeing that rates of new antibiotics' production are steadily decreasing [15] (although efforts are
Antibiotic resistance management is one of
modern

made to motivate the development of new antibiotics [16,17]), we are left to consider measures to impede the

Reducing superfluous antibiotic usage,

both in human consumption and veterinary usage, is currently considered the
prominent course of action [18,19]. Albeit the benefit of reducing overall superfluous antibiotic usage is
emergence of new resistant, and particularly MDR, bacteria.

easy to justify and seems to have almost no drawbacks; restricting specific antimicrobial agents involves a

increasing
the probability of correct treatment. The rationale of restricting specific drugs is an
evolutionary one. The use of a certain antibiotic exerts selective pressure on microbes to
acquire resistance to that antibiotic. However, restricting an antibiotic does not amount to complete
compromise between increasing resistance to a drug saved for the most acute scenarios, versus

avoidance of its usage, as it will still be used against infections resistant to all other antibiotics [20]. Thus an
increase in the frequency of bacteria resistant to the common antibiotics might result in increased usage of the
restricted antibiotic as well.

Medical efficiency is key to solving drug-resistance

Cobey el al. 15, (Gabriel G. Perron, R. Fredrik Inglis, Pleuni S. Pennings and
Sarah Cobey, Evolutionary Applications, Fighting microbial drug resistance: a
primer on the role of evolutionary biology in public health, 23 MAR 2015,
http://onlinelibrary.wiley.com/doi/10.1111/eva.12254/full)//IB
biologists have a large role
to play in microbial resistance management. A better understanding of resistance evolution
could not only help extend the use of antibiotics but could also help identify future antibiotics and
strategies that may be more successful (Bush et al. 2011). For example, models based on
community ecology could uncover how resistance is influenced by competition, migration, and
environmental conditions. This direction is especially important given the accumulating
evidences for the contribution of resistance genes already present in nature to the
evolution of novel traits (Martinez 2012; Wellington et al. 2013). Evolutionary biologists can further
understanding of fitness costs of resistance in many ways. This issue contains several articles on
Given the seemingly unavoidable nature of antibiotic resistance, evolutionary

this topic, from the distributions of fitness costs in experimental populations (Melnyk et al. 2015) and the costs

associations with their genetic basis (Vogwill and MacLean 2015), to the relationship between costs of resistance
and strain backgrounds in different environments (Hall et al. 2015) and the pleiotropic effect of resistance mutation

is crucial to predict the

distribution and persistence of antibiotic-resistant bacteria. More generally,
understanding the evolutionary and community ecology of drug resistance is
essential for successful long-term management of antibiotic-resistant infections . The
in the presence of multiple antibiotics (Schenk et al. 2015). This information

introduction of penicillin helped cure infections caused by Streptococcus but potentially enabled other bacteria,

multiple-antibioticresistant bacteria such as Clostridium difficile have spread in hospitals around the world, most
often infecting patients treated with antibiotics. Other opportunistic pathogens that can evolve
multidrug resistance, such as Pseudomonas aeruginosa and Acinetobacter baumannii, have increased
in frequency in hospitals (Chen et al. 2008; Giske et al. 2008). Future treatment strategies should
consider how host microbial communities affect patients resistance to infections (Lemon et
such as S. aureus, to fill the vacant niche (Levy and Marshall 2004). More recently,

al. 2012). The study of social interactions in microbes also shows great promises. Excreted proteins can act as
public goods (Griffin et al. 2004), meaning that extracellular resistance mechanisms can contribute to the
protection of whole communities (Dugatkin et al. 2005).

Such effects can maintain resistance

plasmids in experimental populations of bacteria (Yurtsev et al. 2013) and confer protection to unrelated
bacteria species (Perlin et al. 2009). Applying principles of social evolution could lead to new treatments
(Boyle et al. 2013). For example, antivirulence drugs are an especially promising method to
control bacterial infections. Rather than trying to kill bacteria, these drugs modulate social
interactions between microbes, selecting for less virulent variants (Brown et al. 2009; Ross-Gillespie et
al. 2014). For more discussion of the role of evolutionary biology in managing antibiotic resistance in human
medicine and agriculture, refer to Baquero et al. (2015) and Chang et al. (2015), respectively.

Bacteria resistance increasing, its only a matter of time before

Omni-resistant bacteria are here
Cobey el al. 15, (Gabriel G. Perron, R. Fredrik Inglis, Pleuni S. Pennings and
Sarah Cobey, Evolutionary Applications, Fighting microbial drug resistance: a
primer on the role of evolutionary biology in public health, 23 MAR 2015,
http://onlinelibrary.wiley.com/doi/10.1111/eva.12254/full)//IB
Shortly after the discovery of penicillin, Abraham et al. (1941) demonstrated that
cultures of Staphylococcus aureus could be made resistant by continuous subculture in the
presence of the antibiotic in vitro. Because of the large mutation supply rate in some bacterial
populations, the evolution of microbial resistance via random mutations is often seen
experimentally or during clinical treatment (MacLean et al. 2010a). The first signs of de novo antibiotic resistance of
clinical relevance were observed in Mycobacterium tuberculosis soon after the introduction of streptomycin in
infected patients (Crofton and Mitchison 1948; Youmans and Williston 1948). It was later found that resistance most
often arose from mutations in the ribosomal proteins, the cellular target of the antibiotics (Gillespie 2002). De novo
evolution of resistance is often caused by either a modification of the antibiotic's cellular target (Spratt 1994) or by
increased expression of certain genes, such as those coding for efflux pumps. Expression may change due to
mutations in expression pathways (Ahmetagic and Pemberton 2011; Suzuki et al. 2014) or gene amplification

Modification of cellular targets is especially

common when the genes encoding the targets are large, increasing the likelihood of
spontaneous beneficial mutations affecting the target (MacLean et al. 2010a). Resistance
mutations due to increased expression of cellular machinery tend to confer resistance to multiple
antibiotics, especially for efflux pumps, and can be difficult to identify (Suzuki et al. 2014). High-throughput
(Sandegren and Andersson 2009; Sun et al. 2009a).

sequencing now makes it possible to track the evolution of resistance during single infections and to identify
possible interactions between resistance mutations and other traits (Lieberman et al. 2011). Because the

evolution of resistance depends greatly on the mutation supply rate (i.e., the combined

effect of population size and mutation rate), mechanisms that increase the mutation rate are likely to increase the

Many mutations, especially those affecting the fidelity of DNA replication

can cause hypermutability (Denamur and Matic 2006). Even though deleterious mutations
usually outnumber beneficial mutations, an increased rate of mutation may promote adaptation in
stressful environments, where fluctuating selective pressures favor phenotypic change (Taddei et al. 1997;
Tanaka et al. 2003). For this reason , mutator populations of bacteria are often associated with
antibiotic resistance (Bjrkman et al. 2000; Chopra et al. 2003; Oliver et al. 2004; Maca et al. 2005; Daurel
et al. 2007; Henrichfreise et al. 2007). Interestingly, some antibiotics have mutagenic properties and
therefore increase the mutation rate of bacteria (Iyer and Szybalski 1958, 1959; Kohanski et al. 2010;
rate of resistance evolution as well.
and repair,

Gutierrez et al. 2013). The mutagenic effect of different antibiotics is mainly associated with the induction of the
SOS response, which is caused by oxidative stress and DNA damage (Radman 1975; Friedberg et al. 2002).

Rapid

adaptation to new environments In many infections,

the emergence of antibiotic resistance

involves the action of specialized traits that were already present in the environmental populations of bacteria.
Soon after the discovery of penicillin, Abraham and Chain (1940) described an instance of such rapid adaptation

Following the introduction

of penicillin in London's hospitals, resistant strains of S. aureus repeatedly appeared and caused treatment
failure (Barber 1947). The penicillin-resistant strains, most often harboring penicillinase activity, quickly
outnumbered penicillin-sensitive strains in most hospitals, and penicillin ceased being the drug of
when they observed an enzyme capable of inhibiting the activity of penicillin.

choice to treat the bacterium (Barber and Rozwadowska-Dowzenko 1948; Nichols and Needham 1949; Rountree and
Thomson 1949). The story repeated itself countless times with resistance emerging in hospitals
following the introduction of each new antibiotic. For example, aminoglycoside kinases, a large group of enzymes
modifying the structure of aminoglycoside antibiotics, were discovered after the introduction of streptomycin, the
first antibiotic discovered through a directed search for an antimicrobial (Davies 1994). Efflux pumps, one of the last
major groups of resistance genes to be discovered, were first associated with tetracycline resistance in the 1970s
(Ball et al. 1980; McMurry et al. 1980). Soon after, other efflux mechanisms in a variety of organisms were found
that conferred resistance to different antibiotics. Efflux pumps remain one of the most common forms of
antimicrobial resistance (Poole 2005). Over the past sixty years of research, multiple variants of each resistance
mechanism group have been described.

Multidrug-resistant bacteria first emerged in European

hospitals. As early as 1952, it was reported that most infectious staphylococcal strains were resistant to
penicillin and tetracycline (Rountree and Thomson 1949; Clarke et al. 1952; Lowbury et al. 1952; Kirby and Ahern

Today, it is estimated that between 20% and 80% of healthcare-associated infections

worldwide result from multiple drug-resistant bacterial infections (Levy and Marshall 2004).
Horizontal gene transfer The rapid evolution of drug resistance , and multidrug resistance in particular,
highlights the important role of horizontal gene transfer in microbial evolution
1953).

(Ochman et al. 2000). Unlike meiotic sex in eukaryotes, genetic exchange of DNA fragments in bacteria is

drugresistant genes, can spread from one bacterium to another through plasmids, bacteriophages,
unidirectional and independent of reproduction (Redfield 2001; Vos 2009). Genetic material, including

and transposons [for a comprehensive review, see Thomas and Nielsen (2005)]. Although many of these mobile
genetic elements can in theory evolve somewhat independently from other genes (e.g., as selfish genetic

many of the most common

resistance genes found in hospitals today are encoded on small plasmids that can be
exchanged among different bacterial strains and species (Bennett 2008). In bacteria, chromosomal genes can
elements), many carry traits that benefit their hosts (Rankin et al. 2011). In fact,

also be transferred via homologous recombination or transformation, the uptake of naked DNA in the environment
(Vos 2009). Transformation is believed to have enabled the evolution of penicillin-resistant Streptococcus
pneumoniae, an important pathogenic bacterium, through the acquisition of genes from Streptococcus viridans, a

Transformation can also promote

multidrug resistance, especially in the presence of standing genetic diversity (Perron et al. 2012). The
capacity of microbes to acquire resistance genes from their surroundings highlights the potentially
important role of environmental reservoirs in the spread of resistance across ecological
niches (Perron et al. 2008a; Forsberg et al. 2012; Finley et al. 2013).
naturally occurring penicillin-resistant bacterium (Spratt 1994).

Global disease resistance is increasing rapidly the ability to

treat diseases is close to collapsing ending modern medicine
Fukuda 14 - Assistant Director-General Health Security, World Health
Organization
(Keiji, Antimicrobial resistance: global report on surveillance 2014 April,
http://www.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1)
Antimicrobial resistance (AMR) within a wide range of infectious agents is a growing
public health
threat of broad concern to countries and multiple sectors. Increasingly,
governments around the world are beginning to pay attention to a problem so
serious that it threatens the achievements of modern medicine. A post-antibiotic
erain which common infections and minor injuries can killfar from being an
apocalyptic fantasy, is instead a very real possibility for the 21st century.
Determining the scope of the problem is essential for formulating and monitoring an
effective response to AMR. This WHO report, produced in collaboration with Member
States and other partners, provides as accurate a picture as is presently possible of
the magnitude of AMR and the current state of surveillance globally. The report
focuses on antibacterial resistance (ABR) in common bacterial pathogens. Why?
There is a major gap in knowledge about the magnitude of this problem and such
information is needed to guide urgent public health actions. ABR is complex and
multidimensional. It involves a range of resistance mechanisms affecting an everwidening range of bacteria, most of which can cause a wide spectrum of diseases in
humans and animals. One important finding of the report, which will serve as a
baseline to measure future progress, is that there are many gaps in information on
pathogens of major public health importance. In addition, surveillance of ABR
generally is neither coordinated nor harmonized, compromising the ability to assess
and monitor the situation. Nonetheless, the report makes a clear case that
resistance to common bacteria has reached alarming levels in many parts of the
world indicating that many of the available treatment options for common infections
in some settings are becoming ineffective. Furthermore, systematic reviews of the
scientific evidence show that ABR has a negative impact on outcomes for patients
and health-care expenditures.

Doctor-Patient Trust Bioterror

Trust solves bioterror response compliance and disease
Glass 2 - Dept. of Epidemiology, Johns Hopkins University Bloomberg School of
Public Health
(Thomas, Bioterrorism and the People: How to Vaccinate a City against Panic Clin
Infect Dis. (2002) 34 (2): 217-223)
The public will not take the pill if it does not trust the doctor. Stopping a
disease outbreak will require that public health professionals and government
leaders carefully nurture the general population's trust and confidence in the
institutions of public health and government and their actions, especially if largescale disease containment measures are necessary. After a bioterrorist attack,
public trust could be a fragile asset, yet it is essential. The issue of trust bears
significantly on 2 critical aspects of the medical and public health response to
bioterrorism: (1) the choice of strategies for effective communication with the
public, and (2) the processes for debating, as a society, some of the more ethically
complex dimensions of disease containment. Although there is a tendency to view
the media as an impediment to emergency response, a bioterrorist attack would
necessitate a close working relationship between the media, decision-makers, and
those involved in response operations. Given the speed with which news reports
circulate today, and given the importance of the media in shaping public responses,
health departments and hospitals would need to be responsive to media requests
for information [28, 44]. An important step toward maintaining an effective,
nonadversarial relationship with the press is to have more routine interactions with
reporters, producers, and editorial boards before periods of crisis. During an
emergency, health professionals could then build on their relationship with the
media to effectively disseminate an accurate account of events, provide vital
disease control information, and communicate the rationale and justification for the
necessary medical and public health responses. Mass media outlets can get vital
information to the largest numbers of people the most quickly. However, the mass
media and the Internet are not sufficient. Additional communication strategies
would be critical to enlisting the public as partners in implementing epidemic
controls. Multilingual materials and culturally relevant messages that are endorsed
and delivered by persons who have local respect and authority can help ensure that
control measures are successfully disseminated to all sectors of a diverse
community [6, 45]. Direct personal contact has the most significant effect on a
person's willingness to trust and act on health-related information [17, 45]. Public
outreach strategies of health departments and emergency services should include
interpersonal exchanges of informationfor example, town meetings and public
workshops. On the other hand, the realities of an outbreak of a disease that is
propagated by person-to-person transmission would require alternatives to such
public meetings. Under those circumstances, means of remote communication (e.g.,
telephone trees, Internet-based communications, and newsletters) would be
important alternatives.

Continual research solves and deters bioterror

Chyba 4 - Co-Director of the Center for International Security and Cooperation
(CISAC), Stanford Institute for International Studies, and an Associate Professor at
Stanford University
[Christopher & Alex Greninger, Biotechnology and Bioterrorism: An Unprecedented
World Survival, 46:2, Summer 2004, http://iisdb.stanford.edu/pubs/20722/Chyba_2004.pdf]
In the absence of a comprehensive and effective system of global review of
potential high-consequence research, we are instead trapped in a kind of
offencedefence arms race. Even as legitimate biomedical researchers develop
defences against biological pathogens, bad actors could in turn engineer
countermeasures in a kind of directed version of the way natural pathogens
evolve resistance to anti-microbial drugs. The mousepox case provides a
harbinger of what is to come: just as the United States was stockpiling 300m
doses of smallpox vaccine as a defence against a terrorist smallpox attack,
experimental modification of the mousepox virus showed how the vaccine could
possibly be circumvented. The United States is now funding research on
antiviral drugs and other ways of combating smallpox that might be effective
against the engineered organism. Yet there are indications that smallpox can be
made resistant to one of the few known antiviral drugs. The future has the
appearance of an eternal arms race of measures and countermeasures. The
arms race metaphor should be used with caution; it too is in danger of calling
up misleading analogies to the nuclear arms race of the Cold War. First, the
biological arms race is an offencedefence race , rather than a competition
between offensive means. Under the BWC, only defensive research is legitimate.
But more fundamentally, the driver of de facto offensive capabilities in this arms
race is not primarily a particular adversary, but rather the ongoing global
advance of microbiological and biomedical research. Defensive measures are in
a race with nefarious applicationsof basic research, much of which is itself
undertaken for protection against natural disease. In a sense, we are in an arms
race with ourselves. It is hard to see how this arms race is stable an offence
granted comparable resources would seem to be necessarily favoured. As with
ballistic missile defence, particular defensive measures may be defeated by
offensive countermeasures. In the biological case, implementing defensive
measures will require not only research but drug development and
distribution plans. Offensive measures need not exercise this care, although
fortunately they will likely face comparative resource constraints (especially if
not associated with a state programme), and may find that some approaches
(for example, to confer antibiotic resistance) have the simultaneous effect of
inadvertently reducing a pathogens virulence. The defence must always guard
against committing the fallacy of the last move, whereas the offence may
embrace the view of the Irish Republican Army after it failed to assassinate the
British cabinet in the 1984 Brighton bombing: Today we were unlucky, but
remember we have only to be lucky once you will have to be lucky always.40

At the very least, the defence will have to be vigilant and collectively smarter
than the offence. The only way for the defence to win convincingly in the
biological arms race would seem to be to succeed in discovering and
implementing certain de facto last-move defences, at least on an organism-byorganism basis. Perhaps there are defences, or a web of defences, that will
prove too difficult for any plausible non-state actor to engineer around. Whether
such defences exist is unclear at this time, but their exploration should be a
long-term research goal of US biodefence efforts. Progress might also have an
important impact on international public health. One of the Grand Challenges
identified by the Bill and Melinda Gates Foundation in its $200m initiative to
improve global health calls for the discovery of drugs that minimise the
emergence of drug resistance a kind of last move defence against the
evolutionary countermeasures of natural microbes.41 Should a collection of
such defensive moves prove possible, bioterrorism might ultimately succumb
to a kind of globalised dissuasion by denial :42 non-state groups would
calculate that they could not hope to achieve dramatic results through
biological programmes and would choose to direct their efforts elsewhere.

Doctor-Patient Trust Medical Research

Doctor-patient trust is key to human participation in medical
research
Miller, 1
Frances H. Miller*, * Professor of Law, Boston University School of Law; Professor of
Public Health, Boston University School of Public Health; Professor of Health Care
Management, Boston University School of Management, Boston University Law
Review, April, 2001, 81 B.U.L. Rev. 423, SYMPOSIUM TRUST RELATIONSHIPS PART 1
OF 2: TRUSTING DOCTORS: TRICKY BUSINESS WHEN IT COMES TO CLINICAL
RESEARCH Lexis
Trust is the sine qua non for public support of medical research. Clinical
investigations inevitably subject human participants to the risk of harm in order to
produce scientific results designed to advance the social good. n92 Research
subjects must trust that those risks have been limited to an irreducible minimum,
and that the potential consequences of their participation have been completely
explained to them, before they assume the status of experimental animals. n93
Without that trust, societal support for human participation in clinical trials will
simply vanish - or ought to. Civilized society's deeply-rooted ethical and legal
traditions of respect for the autonomy of human beings demands [*440] no less.
n94

Human participation is the bedrock of life-science innovation--trust is key

NCEHR 13 - National Council on Ethics in Human Research, national organization
mandated to advance the protection and well-being of human participants in
research and to foster high ethical standards for the conduct of research involving
humans.
(http://www.ncehr-cnerh.org/)
Innovation in many areas of science depends on the use of human volunteers as
research subjects.The involvement of human participants is not confined to bio
medical science, but extends to many areas of social sciences and humanities. In
Canada and elsewhere, research on humans fulfils many functions the creation of
new knowledge, the formation of new social and economic policy, and the
development of innovative new products and processes for human health,
education and social development. The research enterprise is viewed by many in
the public and private sectors as a driver of economic and social development,
innovation, and national prosperity. A sub-sector of this research enterprise,
research with humans, depends on the willingness of individuals, organizations,
collectivities and communities to become engaged in research in the social,
behavioural, natural, and medical and health sciences. It is essential that the

public trust on which the participation of volunteer subjects depends be

maintained and increased.

Doctor Patient Trust Medical Innovation

Trust solves frivolous lawsuits
Roter 6 Professor @ JHU
(Debra, The Patient-Physician Relationship and its Implications for Malpractice
Litigation, J. Health Care L. & Pol'y 304)
The current review does not bring forward any new ideas; the link between
malpractice litigation and the power of communication to support or undermine the
doctor-patient relationship is widely recognized by patients and physicians alike. As
noted in a New York Times essay on medical malpractice: [P]atients who like their
doctors don't sue, no matter what their lawyer says. Our efforts in medical schools
to turn out skilled yet empathetic physicians who communicate clearly and who can
put themselves in their patients' shoes is critical to stemming the malpractice
crisis. Patients sue when their feelings are ignored or when they are angered by lack
of genuine concern for their welfare. . . . Though it provides no guarantee, a sound
physician-patient relationship is a powerful antidote to frivolous lawsuits."
Relationships matter to both patients and physicians and the relationship itself may
be the most powerful antidote to the malpractice crisis that medicine can provide.

Frivolous litigation collapses medical innovation

Curley 14 member of the Healthcare Fraud and Abuse practice group of Bass,
Berry & Sims PLC and a former assistant U.S. attorney and civil chief at the U.S.
Attorneys Office for the Middle District of Tennessee in Nashville.
(Matthew, Balance needed in fighting health-care fraud, The Tennessean,
http://www.tennessean.com/story/opinion/contributors/2014/11/15/balance-neededfighting-health-care-fraud/18988193/)
It is important for government regulators to understand that even the most frivolous
whistleblower lawsuits can result in lengthy and expensive investigations and
business disruptions. Dollars and time devoted to responding to such lawsuits and
investigations are diverted from patient care and innovation at a time when
health-care providers are facing historic changes from health-care reform and
tremendous downward pressure on the payments they receive.

High litigation costs collapse medical innovation

Robert 14 Headaches & Migraines Expert, citing Connell, MD, OB/GYN and
former FDA advisory panel chairperson
(Teri, Are Frivolous Lawsuits Driving Up Healthcare Costs?,
http://headaches.about.com/cs/advocacy/a/lamus_cala.htm)
Dr. Elizabeth Connell is an OB/GYN and former FDA advisory panel chairperson. She
has joined the Sick of Lawsuits Campaign as Senior Counselor. Dr. Connell has been
involved in lawsuit abuse issues for years and wants Americans to know how
frivolous lawsuits threaten our healthcare system by driving up costs, jeopardizing
medical innovation, limiting access to healthcare and making doctors afraid to

practice medicine. "I am fed-up with the shameless tactics of some personal injury
lawyers and the out-of-control litigation that endangers our access to healthcare,"
Dr. Connell said. "I am very pleased to be part of the Sick of Lawsuits campaign and
to help to inform Americans about how lawsuit abuse threatens our entire
healthcare system." In a recent press release, stated the following "Lawsuit Abuse
Facts: " According to a recent Towers Perrin study, the U.S. tort liability system cost
each U.S. citizen $721 in 2001 ($205 billion total). More than 40 percent of doctors
reported avoiding prescribing appropriate medication because they knew the drug
might be involved in litigation. Personal injury lawyers walk away with 30-50 percent
of any jury award to the plaintiff, plus an additional percentage of the award to
cover expenses. Since its widely used cholesterol-lowering drug Baycol was
withdrawn from the market, Bayer is facing more than 8,000 lawsuits. The New York
Times notes that at least 6,000 of those lawsuits, however, are being filed by people
who did not suffer any side effects whatsoever. Their web site state these "Fast Facts
- Symptoms of Lawsuit Abuse:" Lawsuit abuse affects all Americans on different
levels. 80% of Americans say personal injury attorneys take too much of their
clients' winnings. 76% of Americans believe medical liability lawsuits threaten
access to quality healthcare for families. 74% of Americans describe medical liability
issue as crisis or major problem. By 61% to 22% margin, Americans say lawsuits
against doctors result in wealthy lawyers rather than improved quality of care for
patients. Lawsuit costs passed on to consumers add up to nearly $721 per year for
every person in America today. Because of litigation fears, 79% of doctors said they
had ordered more tests than they would based only on professional judgment of
what is medically needed. It takes at least a year to resolve most lawsuits, and
delays of three to five years are not uncommon. Unfortunately, injured people with
legitimate claims can wait years before their cases go to trial. An estimated $50
billion per year is spent on unnecessary test procedures designed only to guard
doctors and hospitals against malpractice claims. Almost half of the money spent by
physician insurers goes towards defending cases that ultimately are closed without
compensation paid to the claimant.

Doctor-patient trust is key to medical research---applies even

to research projects not done by the doctor
NIH 7
(Ethical Obligation Towards Research Subjects, Mens Sana Monogr. 2007 Jan-Dec;
5(1): 107112, doi: 10.4103/0973-1229.32153)
An issue of major concern is protection of the interests of research subjects. The
reason why patients agree to become research subjects is not only for personal
medical benefit but, as an extension, to benefit the rest of the patient population
and also advance medical research. These areas are hardly served if research data
is doctored or concealed, as can happen to protect industry interests or if industry
solely decides the terms and conditions of research contracts. The ethical
obligations of investigators to protect the rights and interests of research
participants have been articulated repeatedly (National Commission for the
Protection of Human Subjects of Biomedical and Behavioral Research, 1979;

Declaration of Helsinki, 1964, updated 2004). Moreover, although informing subjects

about risks and benefits empowers them to protect their interests and their rights
as decision makers, it is equally the case that patients expect and trust guidance
given by their doctors on whether or not to participate in research, which
therefore puts added responsibility on researchers to ensure protection of the rights
and interests of their research subjects: It is widely assumed that informing
prospective subjects about the risks and possible benefits of research not only
protects their rights as autonomous decision makers, but also empowers them to
protect their own interests. Yet interviews with patient-subjects conducted under the
auspices of the Advisory Committee on Human Radiation Experiments suggest this
is not always the case. Patient-subjects often trust their physician to guide them
through decisions on research participation. Clinicians, investigators and IRBs must
assure that such trust is not misplaced (Kass et al., 1996). The case of trust is often
much more so in countries like India where patient trust may land them in various
exploitative situations. Trust is the fragile foundation of contemporary
research (Kass et al, 1996). Since it is fragile, it needs careful handling. Scientific
research is especially prone to manipulation as the temptation to utilise one's power
over trusting subjects has a great opportunity to get misused. Science, we know,
offers great powers, without the necessary obligation to utilise it responsibly. This is
its greatest drawback. Scientific research involving human subjects can be the most
tragic example of this truism. Processes inbuilt into research protocols that protect
against exploitation need faithful implementation.

Doctor-Patient Trust - A2 Data Breaches Inevitable

HHS final rule regulation implementing HITECH/HIPAA reform
ushers in a new era of compliance cleans up data breaches
and solves private sector data breaches
Daniel Solove (the John Marshall Harlan Research Professor of Law at George
Washington University Law School, the founder of TeachPrivacy, a privacy/data
security training company, and a senior policy advisor at Hogan Lovells) 2013
HIPAA Turns 10: Analyzing the Past, Present, and Future Impact
file:///C:/Users/Jordan%20Foley/Downloads/HIPAA%20Turns%2010-%20Analyzing
%20the%20Past%20Present%20and%20Future%20Impact.pdf
In January 2013, after years of industry anticipation, HHS issued the final regulation
implementing the HITECH Acts HIPAA modifications. According to OCR Director Leon
Rodriguez, the rule marks the most sweeping changes to the HIPAA Privacy and
Security Rules since they were first implemented. One of the most notable changes
was expanding HIPAA to be directly applicable to business associates.
Subcontractors of business associates receiving or processing PHI were also
deemed to be business associates. Previously, business associates were governed
by their contract with a covered entity, but after HITECHs HIPAA modification, they
are now subject to HIPAA sanctions and enforcement. Moving to hold business
associates to the same high standard as covered entities is a huge step in the
direction to protect patient privacy, Lucci says. This is because more than 20
percent of all the breaches reported on the HHS website known as the wall of
shame are caused by business associates, she says. This equates to over 12
million patients who have had their information at risk due to an organization
outside of the healthcare organization itself, Lucci says. The changes made by the
HITECH Act to HIPAA will usher in a new level of compliance, according to Rebecca
Herold, a longtime information security and privacy expert and CEO of The Privacy
Professor. Herold notes that when many covered entities saw no sanctions were
being applied for non-compliance by OCR, many became much less concerned with
implementing the Security Rule requirements and have not updated any of their
privacy polices since they were first established back in 2002 or 2003. Business
associates were generally not concerned with HIPAA beyond simply having the
business associate agreement in place, she says. However, today many in the
healthcare industry are beginning to realize the importance and seriousness of
HIPAA compliance.

Doctor-Patient Trust - A2 Research Turn

Privacy key to trust the aff wont hinder research
Deborah Peel (M.D. psychiatrist and president of the Patient Privacy Rights
Foundation) April 2006 Privacy and health research can co-exist
http://www.govhealthit.com/news/peel-privacy-and-health-research-can-co-exist
Some health care professionals are concerned that medical privacy is hindering
health care research. Nothing could be further from the truth. As a practicing
psychiatrist, I would like nothing more than research that looks longitudinally at
thousands of people with depression to learn what medications are best for treating
someone after 10 to 15 years. Studies that track thousands of people over many
years will be one of the greatest benefits of having a national electronic medical
record system. But that kind of research does not require knowledge of patients'
names. The vast majority of legitimate research can be conducted using aggregated
data that doesn't include patients' names, addresses or Social Security numbers. To
protect our medical privacy, technology now provides the tools to segment our most
sensitive medical information. It also allows the sharing of aggregated health
information for research to improve health care. Privacy and research can benefit
from technology. It's not an either/or proposition. If we are smart and we care about
sound scientific medical practices, we will build patient-controlled access to medical
records into the network. That will ensure that information in the electronic medical
record is accurate and reliable. Why? If people believe they do not have medical
privacy, they will lie about their medical illnesses or omit mentioning critical tests
and details rather than have the information flow to any number of health-related
businesses. Such firms are allowed under the Health Insurance Portability and
Accountability Act (HIPAA) to receive medical information about patients without
their knowledge and consent. How can that be? Our existing federal privacy law is
toothless. The federal government amended HIPAA in 2003, allowing more than
600,000 types of businesses and millions of their business associates to access
medical records without patient consent for the "treatment, payment and
operations of health-care related activities." To argue that medical privacy will result
in higher costs and obstruct research is simply wrong. How can anything possibly be
private with this type of loophole? Americans need and want the benefits that can
come from lifelong, electronic medical records that allow the gathering and sharing
of anonymous medical data to improve health care for all. But Americans must have
medical privacy protections to trust a high-tech national health system. There's no
reason we can't have both.

Anton Vedder, Colette Cuijpers, Petroula

Security of databases and communications is a quintessential precondition for trust

in electronic services, including e-health services. While user trust is already

considered
essential for online commercial transactions,31 building user trust in e-health
services
is deemed extra important as users may fear unwarranted access to sensitive
personal
information or vulnerability to identity theft or online fraudrisks that do not arise
as
easily in comparable traditional offline practices, at least not to the same degree.32
The factors mentioned so far have been shown to be important for users trust in
online services in general, and can therefore be expected to be important for
patients
trust in e-health as well. In addition, for caregivers, trust in the reliability of data,
data
exchange and communication is reported to be of high importance.33 Means for
establishing
reliability are of course to be found in the creation of possibilities for checking
correctness and correction of information, for example through transparency and
simplicity, and security safeguards in databases and communications. For health
professionals,
reliable authentication methods are also extremely important in order to
guarantee that a patient is who she suggests she is and that the data introduced
are really
hers.
This brings us to data protection regulation as a precondition for user trust.
According
to the WHO report cited in the introduction, privacy and trust in a healthcare
context
are intrinsically linked. The relationship between the patient and the healthcare
provider

Medical Research Antibiotic Resistance

Antibiotic resistance threatens extinctionUK National Threat list
Sample 1/23/13, PhD in biomedical materials from Queen Mary's, University of
London, worked at the Institute of Physics as a journal editor (Ian, Antibioticresistant diseases pose 'apocalyptic' threat, top expert says, The Guardian,
http://www.theguardian.com/society/2013/jan/23/antibiotic-resistant-diseasesapocalyptic-threat)AM
Britain's most senior medical adviser has warned MPs that the rise in drug-resistant
diseases could trigger a national emergency comparable to a catastrophic terrorist
attack, pandemic flu or major coastal flooding. Dame Sally Davies, the chief medical
officer, said the threat from infections that are resistant to frontline antibiotics was
so serious that the issue should be added to the government's national risk register
of civil emergencies. She described what she called an "apocalyptic scenario" where
people going for simple operations in 20 years' time die of routine infections
"because we have run out of antibiotics". The register was established in 2008 to
advise the public and businesses on national emergencies that Britain could face in
the next five years. The highest priority risks on the latest register include a deadly
flu outbreak, catastrophic terrorist attacks, and major flooding on the scale of 1953,
the last occasion on which a national emergency was declared in the UK. Speaking
to MPs on the Commons science and technology committee, Davies said she would
ask the Cabinet Office to add antibiotic resistance to the national risk register in the
light of an annual report on infectious disease she will publish in March. Davies
declined to elaborate on the report, but said its publication would coincide with a
government strategy to promote more responsible use of antibiotics among doctors
and the clinical professions. "We need to get our act together in this country," she
told the committee. She told the Guardian: ""There are few public health issues of
potentially greater importance for society than antibiotic resistance. It means we
are at increasing risk of developing infections that cannot be treated but
resistance can be managed. "That is why we will be publishing a new crossgovernment strategy and action plan to tackle this issue in early spring."

Antibiotic development cannot keep pace with superbugs

Sample 1/23/13, PhD in biomedical materials from Queen Mary's, University of
London, worked at the Institute of Physics as a journal editor (Ian, Antibioticresistant diseases pose 'apocalyptic' threat, top expert says, The Guardian,
http://www.theguardian.com/society/2013/jan/23/antibiotic-resistant-diseasesapocalyptic-threat)AM
The issue of drug resistance is as old as antibiotics themselves, and arises when
drugs knock out susceptible infections, leaving hardier, resilient strains behind. The
survivors then multiply, and over time can become unstoppable with frontline
medicines. Some of the best known are so-called hospital superbugs such as MRSA
that are at the root of outbreaks among patients. "In the past, most people haven't
worried because we've always had new antibiotics to turn to," said Alan Johnson,
consultant clinical scientist at the Health Protection Agency. "What has changed is

that the development pipeline is running dry. We don't have new antibiotics that we
can rely on in the immediate future or in the longer term." Changes in modern
medicine have exacerbated the problem by making patients more susceptible to
infections. For example, cancer treatments weaken the immune system, and the
use of catheters increases the chances of bugs entering the bloodstream. "We are
becoming increasingly reliant on antibiotics in a whole range of areas of medicine. If
we don't have new antibiotics to deal with the problems of resistance we see, we
are going to be in serious trouble," Johnson added. The supply of new antibiotics has
dried up for several reasons, but a major one is that drugs companies see greater
profits in medicines that treat chronic conditions, such as heart disease, which
patients must take for years or even decades. "There is a broken market model for
making new antibiotics," Davies told the MPs. Davies has met senior officials at the
World Health Organisation and her counterparts in other countries to develop a
strategy to tackle antibiotic resistance globally.

Antibiotic resistance bacteria is rapidly proliferating

Sample 1/23/13, PhD in biomedical materials from Queen Mary's, University of
London, worked at the Institute of Physics as a journal editor (Ian, Antibioticresistant diseases pose 'apocalyptic' threat, top expert says, The Guardian,
http://www.theguardian.com/society/2013/jan/23/antibiotic-resistant-diseasesapocalyptic-threat)AM
Drug resistance is emerging in diseases across the board. Davies said 80% of
gonorrhea was now resistant to the frontline antibiotic tetracycline, and infections
were rising in young and middle-aged people. Multi-drug resistant TB was also a
major threat, she said. Another worrying trend is the rise in infections that are
resistant to powerful antibiotics called carbapenems, which doctors rely on to tackle
the most serious infections. Resistant bugs carry a gene variant that allows them to
destroy the drug. What concerns some scientists is that the gene variant can spread
freely between different kinds of bacteria, said Johnson. Bacteria resistant to
carbapenems were first detected in the UK in 2003, when three cases were
reported. The numbers remained low until 2007, but have since leapt to 333 in
2010, with 217 cases in the first six months of 2011, according to the latest figures
from the HPA.

Antimicrobial resistance mounting in the squo

Alford 5/1/14, PhD in life sciences from the University of Warwick and science
communicator with a focus on infectious diseases and HIV (Justine, Antibiotic
Resistance Now A Global Threat According To Latest WHO Report, IFL Science,
http://www.iflscience.com/health-and-medicine/antibiotic-resistance-now-globalthreat-according-latest-who-report)AM
The World Health Organization (WHO) has issued a report that serves as a stark
wake-up call to the growing worldwide problem of antimicrobial resistance. The
report highlights the need for a concerted effort from both governments and society
as a whole to tackle this ongoing issue which poses a global health security
threat. Antimicrobial resistance (AMR) occurs when organisms such as bacteria and
viruses evolve mechanisms to evade therapeutic agents, for example antibiotics,

rendering them ineffective. Were all familiar with the hospital superbug MRSA
(methicillin-resistant Staphylococcus aureus), but that just scratches the surface on
this now incredibly widespread problem. Not only does AMR make infections more
difficult to treat, it also means that relatively minor injuries and common infections
have the potential to become life threatening. If we dont step up our game, the
achievements of modern medicine are seriously at stake. In order to compile this
report, the WHO gathered and analyzed surveillance data from 114 countries which
detailed resistance rates amongst common disease causing pathogens. Amongst
the findings was the worrying fact that the bacterial species K. pneumoniae, which
commonly causes infections in hospitals and the community, is becoming
increasingly resistant to last resort antibiotics, and drug resistance was found in
every region surveyed. Other bacterial species demonstrating both widespread and
high levels of drug resistance were E. coli and S. aureus, which can cause urinary
tract infections and blood stream infections. Around 20% of tuberculosis cases were
also found to have multidrug-resistant TB. The report also highlighted increasing
resistance to antiviral drugs by both influenza viruses and HIV. In particular, they
found that drug resistant HIV strains were being increasingly transmitted since
between 10-17% of HIV infected patients in certain countries that had never
received treatment were already resistant to at least one antiretroviral drug.
Antibiotic resistance is on the rise because of overuse and misuse of antibiotics both
in medicine and agriculture. Not finishing the course of antibiotics and prescribing
antibiotics when they are not needed both encourage the emergence of resistance.
There is therefore a dire need for the development of novel antibiotics before the
current ones become useless, meaning that common infections risk becoming fatal.
Hopefully this report will spur countries to come together to formulate a global plan
to prevent this ominous situation from worsening, and may also serve to monitor
future progress.

Medical Research Life Sciences Leadership

Medical innovation is key to life-sciences leadership
Atkinson 12 PhD in City and Regional Planning, The Information Technology
and Innovation Foundation and United for Medical Research
(Robert, Leadership in Decline, http://www2.itif.org/2012-leadership-in-decline.pdf)
Advances in life sciencesincluding pharmaceuticals, biotechnology, and
medical deviceswere a major driver of global economic growth in the second
half of the twentieth century. Since World War II, the United States has stood firmly
at the forefront of the life sciences revolution, with this leadership built upon a
solid commitment to robust and sustained federal investment in biomedical research
and development (R&D), channeled primarily through the National Institutes of
Health (NIH). This public investment laid the foundation for the development of
scores of breakthrough pharmaceutical drugs and therapiesfrom personalized
gene therapies to synthetic skin to cures for certain types of cancerand has
catalyzed the development of a globally competitive, high-wage life sciences
industry in the United States. Today, the U.S. life sciences industry supports more
than 7 million jobs and contributes $69 billion annually to U.S. gross domestic
product (GDP).1 But U.S. leadership in the global life sciences industry is today
under threat on two fronts. First, federal investment in biomedical research through
NIH has decreased, both in inflation-adjusted dollars and as a share of GDP, nearly
every year since 2003. Put simply, the United States is not sustaining the historically
strong investment in biomedical research that once propelled it to global life
sciences leadership. At the same time, global competition has intensified, as a
growing number of countries, including China, Germany, India, Singapore, Sweden,
the United Kingdom, and others have recognized that life sciences represents a highwage, highgrowth industry and have taken measures seeking to wrest life sciences
leadership from the United States. These nations have not only significantly
expanded their financial support for biomedical research, they have also
implemented a range of policies designed to enhance their biomedical innovation
ecosystems, such as tax incentives through patent boxes, regulatory reforms to
speed drug approvals, and immigration and education policies designed to attract
and to educate the best life sciences talent. As this report demonstrates, in an
increasing number of indicatorsfrom trade balances in pharmaceuticals to shares
of global pharmaceutical-industry outputsuch policies and investments have
enabled several countries life sciences industries to become competitive with that
of the United States. China, for example, has identified biotechnology as one of
seven key strategic and emerging (SEI) pillar industries and has pledged to invest
$308.5 billion in biotechnology over the next five years. This means that, if current
trends in biomedical research investment continue, the U.S. governments
investment in life sciences research over the ensuing half-decade is likely to be
barely half that of Chinas in current dollars, and roughly one-quarter of Chinas level
as a share of GDP. And China already has more gene sequencing capacity than the
entire United States and about one-third of total global capacity. Other countries are
also investing more in biomedical research relative to the sizes of their economies.

When it comes to government funding for pharmaceutical industry-performed

research, Koreas government provides seven times more funding as a share of GDP
than does the United States, while Singapore and Taiwan provide five and three
times as much, respectively. France and the United Kingdom also provide more, as
shares of their economies.2

Life-sciences leadership is key to tacit diplomacy---solves

multiple existential risks
Benson 14 - professor of microbiology in the Department of Molecular and Cell
Biology at the University of Connecticut and a Jefferson Science Fellow.
(David, Tacit Diplomacy in Life Sciences, Science and Diplomacy,
http://www.sciencediplomacy.org/perspective/2014/tacit-diplomacy-in-life-sciences)
Although some life science advances have generated worry in diplomatic circles,
scientists using the technologies and conducting the research are far more likely to
embrace new advances as they emerge, usually, but not always, without
controversy. So what accounts for the different attitudes, and what might be done to
reconcile the positive progression of science with diplomatic and security concerns?
This article highlights the roles played by the unprecedented rise of international
collaborations in scientific communities, the internationalization of science
education, and the attendant slow but steady adoption of norms of behavior. These
roles together knit a kind of tacit diplomacy that helps to mitigate concerns
about advances in the life sciences. Diplomacy can involve scientific issues in
diverse ways. For example, scientific cooperation can help to change a diplomatic
relationship, or enhance the economic trade and/or security of the United States (or
another country).1 Science also informs the diplomatic processes related to, for
example, securing arms control, mitigating climate change, improving food security,
or reducing illegal trade in endangered species.2, 3 Tacit diplomacy in science
governs how the global community of scientists interacts via understood, but
generally unstated, behavioral norms. Absent this foundation, science diplomacy
cannot work optimally or sustainably. Tacit diplomacy in science governs how the
global community of scientists interacts via understood, but generally unstated,
behavioral norms. Most scientists recognize the set of norms that are tacitly
assumed to operate in collaborative science and in the communication of scientific
knowledge. The InterAcademy Council, an organization of national academies from
countries around the world, lists seven values or norms that characterize successful
scientific interactions: honesty, fairness, objectivity, reliability, skepticism,
accountability, and openness.4 Tacit diplomacy among scientists assumes that
these norms are at least nominally in place, unless proven otherwise, with the result
being the evolution of that elusive, bilateral human behavior of mutual trust. The
outcome of tacit diplomacy is that scientists interacting with colleagues from very
different countries and cultures can achieve common goals. The power of tacit
diplomacy derives from its implementation in international scientific interactions
that globally number in the millions each year. Such interactions range from formal
collaborations to less formal points of contact via email, video conference, or
telephone, at international and national conferences and meetings and invited

seminars. In the aggregate these contacts strengthen norms at an interpersonal

level, for example in faculty-advisorstudent or colleaguecolleague relationships
rather than government-to-government relationships. Importantly, such behavioral
norms spread along with the migration of technology and scientific understandings.
Tacit diplomacy cannot be imposed by international and national organizations or by
governments that often desire to manage or do something about the risks of
misuse or the spread of scientific advances that are of concern. Such management
is often expressed in top-down notions of oversight (regulations), education (e.g.,
research integrity or biosecurity training), awareness-raising exercises, and written
codes of conduct. While each of these notions has local utility, they are of
questionable effect in dealing with broader underlying issues that are primarily
ethical in nature.5 A number of global trends have promoted the spread of tacit
diplomacy and are of considerably broader significance than management tools
when it comes to garnering adherence to norms. Some trends can also erode tacit
diplomacy in science. Both need to be understood to increase awareness and
consideration in diplomatic arenas. Global Trends that Promote Tacit Diplomacy
Trends that promote tacit diplomacy in the life sciences generally coincide with
those in all of science and technology (S&T). Some are well-known contributors to
globalization in general: the Internet lubricating collaborations, expanding
information access, and facilitating research investment globally; greater ease of air
travel allowing scientists to develop collaborations at meetings, use large shared
facilities, and study overseas; and the expanding use of English, in particular the
near universal acceptance of English as the common language of science.6 A more
specific trend that reflects and promotes the internationalization of science is the
steady increase in global research and development funding. From 1996 to 2011,
global funding, life sciences included, increased nearly two and one-half times
worldwide in real dollars, with the recognition that S&T is key to innovation and
economic growth.7 Increased funding has allowed developing countries with
emerging economies to aggressively seek international partners for developing
science while building their own infrastructure and programs. For these countries to
succeed, adherence to norms and development of trust are essential. There has
been a dramatic increase in collaboration reflected by internationally coauthored
articles. For example, the proportion of S&T publications from the United States
having international coauthors rose from 7 percent in 1986 to 29 percent in 2010.8
Open-access scientific journals and still-evolving policies in the large publishing
houses lower barriers to collaborative publication between scientists in developing
and developed countries, creating a more integrated global science community.9 An
increasing number of undergraduate and graduate students are seeking higher
quality training outside their home country.10 For example, Brazils Science without
Borders program has the goal of sending one hundred thousand students to study
abroad by 2015. In 2012, foreign students received about 34 percent of all science
and engineering doctorates awarded in the United States,11 an increase from about
15 percent in 1977.12 PhD programs have also proliferated in Asian countries, such
as China, Singapore, and Australia, catering to students from less-developed
countries. Returning students bring new technologies, fresh scientific perspectives
and patterns of normative scientific behaviors that facilitate science diplomacy.
Returning students bring new technologies, fresh scientific perspectives and

patterns of normative scientific behaviors that facilitate science diplomacy. Finally,

solutions to global challenges increasingly require pollination across disciplinary
borders of basic and applied life sciences, social science, and engineering.13, 14, 15
Issues involving emerging infectious diseases, climate change, food security,
fisheries management, for example, touch multiple countries and scientific
disciplines. Diplomatic efforts aimed at their resolution proceed more effectively
from a foundation of trust built by tacit diplomacy developed among scientists
across appropriate disciplines.

Medical Research Hegemony Impact

Medical research is key to hegemony
Martinez-Lopez 4 MPH, MD, commander of the U.S. Army Medical Research
and Materiel Command
(Lester, Biotechnology Enablers for the Soldier System of Systems, Biotechnology
Revolution)
The Army has historically recognized that the individual soldier, the critical element
of operational success, is an integral component of weapons, transportation, and
other hardware systems and that military hardware (and software) must be
designed with human factors in mind. Today, we think of the soldier as a system;
taken together with his or her equipment, the soldier is a system of systems. This
more holistic approach encompasses not only the human-system interface, but also
the full range of biological, environmental, and occupational factors that can affect
a soldiers health and performance. Soldiers today face more environments and
threats than the soldiers of yesteryear, and we anticipate that the challenges will
continue to increase. To maximize a soldiers performance and prevent disease and
injury in this changing operational setting, the U.S. Army is pursuing research,
development, and engineering to transform the individual soldier into a fully
protected and integrated Soldier System of Systems. Biotechnology-based
strategies are key to achieving this goal. Challenges Soldiering remains a
dangerous business, involving a wide variety of threats to health and performance.
To protect the soldier, we must counter traditional threats from ballistics weapons,
as well as from chemical and biological weapons. However, we often overlook the
fact that the majority of casualties have historically resulted not from enemy
weapons, but from diseases (especially infectious diseases), non-battle-related
injuries, and stress. For example, in the Vietnam War, 83 percent of all hospital
admissions were for disease and non-battle injuries. A traditional rule of thumb is
that there is one combat-stress casualty for every three physical casualties. It is
also important to recognize the unique features of the military environment that
adversely affect human performance without directly causing casualties. If
performance degradation is severe enough, however, missions can be
compromised, which can lead to serious consequences, including casualties. The
soldiers occupational environment is extremely stressful, both physically and
mentally. Work is conducted outdoors in all types of weather and at all altitudes. The
workload continues around the clock and is subject to sudden, rapid changes in
intensity. Soldiers are required to remain attentive and vigilant and process
increasing amounts of information very quickly. In the future, even greater
demands will be made upon soldiers. Future operational concepts call for
highly mobile forces enabled by increasingly sophisticated weapon and
information systems. Currently, the military must be able to deploy one division
(10,000 to 18,000 troops) into an operational theater on 120 hours notice and five
divisions within 30 days. The soldier of the future must be physically ready to
deploy on a moments notice; upon arrival, he or she must be ready to fight,
anywhere in the world. Soldiers may also be required to change rapidly from

humanitarian to peacekeeping to warfighting roles (as in Iraq). These requirements

will make substantial cognitive, perceptual, and emotional demands on soldiers.
Highly mobile operations will also increase the dispersion and isolation of small
units and individual soldiers, changing the way support services, such as medical
support, are delivered and making it imperative that soldiers remain fit and healthy.
Future soldiers will have to be capable of going without sleep or resupply for
extended periods of time and more reliant on self- or buddy-aid in the event of
illness or injury. The Soldier System of Systems The Soldier System of Systems is
a multi-tiered strategy in which the soldier and his or her weapon and support
systems are considered as a unified system that encompasses the full range of
medical and nonmedical systems for protecting and enhancing the soldiers
health and performance. This strategy consists of three levels of defense: Protection; Surveillance; and
Intervention. Protection is subdivided into the three categories: Individual Force Health Protection; Individual Force Protection; and Force Protection. Role of Biotechnology The key to
realizing the Soldier System of Systems is biotechnology. In 2001, the U.S. Army commissioned a National Research Council (NRC) committee, the Committee on Opportunities in
Biotechnology for Future Army Applications, chaired by NAE member Michael R. Ladisch of Purdue University, to accomplish the following goals: Examine trends in the bioscience and
engineering industries, including small business involvement and university and other institutional research activities in biology, biomimetics, and related areas. Determine whether
trends in research, technology transfer, and commercialization could be used to predict advances likely to be useful for the Army through 2025. Identify the bioscience and engineering
technologies with the most potential for Army applications, based on affordability and the likelihood of leveraging commercial research and development. Identify critical barriers to the
development of biotechnologies with strong potential for Army applications, especially barriers that could be surmounted by appropriate investments in science and technology.
Recommend research initiatives that could help the Army exploit promising developments in biotechnologies and engineering. The results of the NRC study published in 2003 identified
20 prospective applications for Army investment over the short term, midterm, and long term. Biotechnology in the Army Based on the recommendations of the NRC Committee and
internal assessments of technology readiness and soldiers needs, the Army is currently investing in several broad areas that cut across multiple technology applications. The Armys
intramural biotechnology effort is being conducted at facilities that fall under the U.S. Army Medical Research and Materiel Command (USAMRMC) and the U.S. Army Research,
Development and Engineering Command (RDECOM). USAMRMC focuses on medical and human performance applications; RDECOM focuses on nonmedical systems applications.
Extramural basic research is being coordinated by the Army Research Office (ARO), based in Research Triangle Park, North Carolina. ARO oversees two major collaborative ventures with
academia that are focused on biotechnology enablers: the Institute of Collaborative Biotechnologies, which includes the University of California at Santa Barbara, California Institute of
Technology, and Massachusetts Institute of Technology (MIT), to provide the Army with core competencies and expertise; and the Institute of Nanotechnologies, a $50-million research
collaboration between the Army and MIT. The remainder of this article highlights examples of biotechnology-based systems being developed for the Soldier System of Systems. VaccineBased Protection against Endemic Diseases and Biological Agents Current efforts to develop improved vaccines for Individual Force Health Protection are focused on molecular
recognition and vaccine design and construction. In addition to potentially protecting against diseases for which little or no protection is currently available, molecular biology-based
vaccines are expected to avoid causing some of the side effects commonly associated with traditional vaccines, which are based on whole killed or attenuated live organisms. DNA-based
vaccines are being developed by the U.S. Army for several diseases, including dengue fever, malaria, and Hantaan virus, and for biowarfare agents, including anthrax, botulinum
neurotoxins C through G, and staphylococcal enterotoxins A and B. Genetic and genomic technologies have shifted research and development efforts away from whole pathogens to
specific viral or bacterial components that confer long-term immunity in those who survive infection. Army-sponsored vaccine research is currently being conducted at the U.S. Army
Medical Research Institute of Infectious Diseases (USAMRIID), the Walter Reed Army Institute of Research (WRAIR), and the U.S. Naval Medical Research Center (USNMRC). As an
example of the current state of the art, DNA vaccines are being developed at USAMRIID to protect against hantaviruses, which cause hemorrhagic fever with renal syndrome (HFRS) or
hantavirus pulmonary syndrome (HPS). Both HFRS and HPS are acute febrile illnesses that are lethal in 5 to 15 percent and 40 to 50 percent of victims, respectively. DNA sequences that
code for specific hantavirus genes have been inserted into nonpathogenic viral vectors, precipitated onto gold microbeads, and injected into the skin of test animals with a needleless
gene gun (Hooper et al., 2001). Hamsters injected with the vaccine were protected against challenge infection, and rhesus monkeys produced antibodies that neutralized virus particles.
Hamsters injected with monkey serum as much as five days after viral challenge were protected from developing HPS (Custer et al., 2003). Existing methodologies are continually being
refined for more rapid identification of the immune-response-producing components of pathogens, the isolation of genes that code for these components, and large-quantity production
of component-coding genes. Rapidly formulated DNA vaccines that are effective against multiple strains of the same organism or combinations of multiple organisms can render the
soldier of the future resilient against threats posed by emerging diseases and genetically engineered biowarfare agents. Drug-Based Protection against Endemic Diseases and Biological
Threat Agents Non-vaccine-based efforts in Individual Force Health Protection are based on molecular recognition and drug design and testing. The Army is currently focusing on
preventive and therapeutic drugs for malaria, a disease for which vaccine-based approaches have not been effective. To ensure that the Soldier System of Systems includes protection
against this common tropical disease, the Army is pursuing both vaccine-based and non-vaccine-based strategies. The recent completion of the malaria parasite genome sequence
(Gardner et al., 2002) has opened the search to the full spectrum of gene-based drug discovery, coupled with more conventional biotechnological, pharmacological, and medicinal
methods of drug optimization. Drugs could also be potentially tailored to specific subpopulations to improve safety and increase effectiveness. When a large number of individuals
receive identical doses of the same drug, their responses and side effects vary greatly. These differences are attributed to presumed variabilities in drug-metabolizing enzymes, receptor
subtypes, and other genetic factors. Pharmacogenomic and toxicogenomic profiling can facilitate the identification of subpopulations of individuals for whom a given drug is less effective
or more toxic. In some cases, differences may be correctable by introducing minor changes into the chemical structure of the drug. Monitoring of Physiological Status To further
Surveillance and Intervention through the identification of impending degradations in physical or cognitive performance and improved casualty assessment, the Army is investing in
molecular recognition technologies. Current prototypes of monitoring systems of physiological status are based on electrical or mechanical sensing of measures of physical activity, heart
rate, temperature, and other parameters. A goal for the future is the detection of biomolecules in perspiration or other accessible body fluids that correlate with a soldiers potential to
execute a mission. This could be accomplished through biosensors for physiological surveillance or casualty diagnosis integrated into soldier ensembles. At present, little is known
about which, if any, secreted biomolecules are appropriate for sensing. The molecules being investigated include proteins, such as growth factors, metabolites, such as glucose or
lactate, and stress hormones, such as cortisol. With proteomics, researchers can profile the expression of all proteins in a tissue and identify patterns and relationships among them
under specific performance environments. Investigators at the Natick Soldier Center are attempting to identify performance-relevant markers and develop additional types of
biosensors. An example of the latter is a project at Georgetown University, cosponsored by the Army and the Defense Advanced Research Projects Agency, that has resulted in the
development of a biofluidic chip that extracts molecules, such as glucose, that do not usually diffuse across skin, from subepidermal interstitial fluid. Protection against Environmental
Injury As part of Individual Force Health Protection and Intervention, genomic detection and drug design and testing technologies are being pursued for protection against
environmental injuries. Genomic methodologies are being used to identify molecular regulators that enhance a soldiers adaptation to environmental stressors, such as extreme heat,
cold, and altitude, and biomarkers that predict increased or decreased susceptibility to environmental injuries. Investigators at the U.S. Army Research Institute of Environmental
Medicine have characterized gene-expression patterns in peripheral blood mononuclear cells (PBMCs) isolated from soldiers who exhibit signs and symptoms of exertional heat injury
(Sonna et al., 2004), as well as PBMCs isolated from health volunteers and then exposed to heat or cold under controlled conditions in the laboratory (Sonna et al., 2002a,b). They have
also characterized changes in cultured human liver cells exposed to low oxygen tensions to mimick high altitude (Sonna et al., 2003). More than 50 proteins are affected by heat stress;
fewer than 20 are affected by cold; and more than 380 are affected by hypoxia. Novel approaches being considered for preventing environmental injuries include nutritional supplements
and smart suits with sensing capabilities. Host-Based Detection and Diagnosis of Exposure to Chemical and Biological Hazards Army investment in genomic detection, molecular
recognition, and molecular toxicology is funding the development of host-based detection systems in support of Individual Force Health Protection and Surveillance. A fundamental
concept in toxicology is the dose-toxicity relationship, in which the adverse effects elicited by a toxic substance are dependent on the level of exposure to the toxic substance. Exposure
levels too low to cause outwardly observable changes in health often cause changes at the molecular level. By detecting molecular changes in the soldier before observable signs and
symptoms of toxicity appear, it becomes possible to prevent further exposure and initiate a protective or intervention-based strategy to avert or ameliorate adverse events. DNA
microarray technology is being used at the U.S. Army Center for Environmental Health Research, the Edgewood Chemical and Biological Center (ECBC), and WRAIR to identify genetic
markers of response to different classes of toxic hazards and long-term changes in gene expression following asymptomatic, low-level exposures to chemical warfare agents. An
interesting finding is that male and female rats show different alterations in gene expression following whole-body inhalational exposures to low doses of sarin vapor (Sekowski et al.,
2002). DNA microarray technology is also being used at USAMRIID and WRAIR to assess immune system responses to a variety of biological agents. The expression patterns of isolated
PBMCs exposed to biological agents in the laboratory setting support discrimination of agents that include bacteria (e.g., anthrax, plague, and brucella), toxins (e.g., staphylococcal
enterotoxin B, cholera toxin, and botulinum neurotoxin A), and viruses (e.g., Venezuelan equine encephalitis and dengue fever) (Das et al., 2002). Furthermore, PBMCs isolated from
nonhuman primates exposed to anthrax in vivo reveal patterns of gene expression that correlate with the impending onset of symptoms. The latter approach could be beneficial for
detecting exposures to genetically modified organisms that cannot be detected by pathogen-based methods. Hazard-Based Detection and Diagnosis of Exposure to Biological Hazards
Another element of Individual Force Health Protection and Surveillance is the combination of molecular recognition and bioderived electronic and photonic materials to detect pathogenic
organisms in the environment. Investigators at the Natick Soldier Center are leveraging the electrical conduction and optical properties of polymers that have been complexed with
single-stranded DNA or RNA to form sensitive gene chip biosensors. When the nucleic acid of a pathogenic organism hybridizes to a complexed nucleic acid probe, the properties of the

polymers change. Investigators are also developing peptide-based receptors that bind selectively to pathogenic bacteria. Investigators at ECBC are working on peptide-based receptors
that bind toxins, such as ricin and staphylococcal enterotoxin B, and on designing and fabricating a DNA/RNA microarray capable of detecting and identifying pathogens down to the
level of different strains. These technologies can also be used for monitoring food and water for contamination. Catalytic Inactivation of Toxic Agents Individual Force Health
Protection, Individual Force Protection, and Force Protection are being addressed through investment in catalytic enzymes and drug design and testing to protect against toxic chemical
and biological agents. At the U.S. Army Medical Research Institute of Chemical Defense, bioengineered recombinant butyrylcholinesterase is being investigated for use as prophylaxis
against the adverse effects of exposure to nerve agents, such as sarin, soman, tabun, and VX. This enzyme mimics acetylcholinesterase and competes with it for binding nerve agents,
thus reducing the level of acetylcholinesterase inactivation. It is anticipated that a single dose of this enzyme will be capable of scavenging nerve agent through stoichiometric binding
for up to eight hours. Current efforts are directed at engineering the enzyme so that it has catalytic activity in vivo and exploring the use of a transgenic goat model for generating
sufficient quantities of engineered enzyme to conduct clinical trials. At ECBC, recombinant enzymes are being incorporated into fabrics and polyurethane foams for nonmedical
protection and into sprays, detergents, degreasers, and other matrices for decontamination following exposure. Enzymes for hydrolyzing G-type and V-type nerve agents have been
identified, cloned, and optimized. Organophosphorus acid anhydrolase, which works against the G agents sarin, soman, and tabun, is in large-scale process development. Random and
site-directed mutagenesis has resulted in variants of organophosphorus hydrolase enzyme with increased activity against the V-type agent VX. Organophosphorus hydrolase is also
currently in process development. In addition, a bacterial enzyme has been identified that hydrolyzes sulfur mustard, and a collaborative project is under way with Rockefeller University
to assess the effectiveness of using bacteriophage lysins to destroy anthrax spores (Schuch et al., 2002). Biomembrane and Fiber Generation The Army is investing in bioderived
materials and molecular recognition as part of Individual Force Protection, Force Protection, and Intervention. A process called electrospinning is being used at the Natick Soldier Center
to produce high-surface-area nanofiber membranes with unique reactive sites for selective immobilization of biological recognition elements. The current focus is on including
immobilized antibodies and antimicrobial peptides on electrospun nanofibrous poly(epsilon-caprolactone) (PCL) for selective binding to pathogens. These materials can be used in the
development of clothing-based biosensors and in filtration of pathogens from food, water, and clothing. Other electrospun polymeric materials include polyurethanes and polyvinyl
chloride. Biomembranes and fibers are also being investigated at the Institute for Soldier Nanotechnologies. There, electrospun polymers are being used as extracellular matrixmimicking scaffolds to support tissue regeneration and as vehicles for delivering drugs and biologics that promote tissue healing after injury. Protection against Ballistics Hard and
lightweight ceramic materials, such as boron carbide, are incorporated into body armor and other forms of protective shielding. Research is now focusing on bioderived nanoceramics in
support of Individual Force Protection and Force Protection. In nature, organisms can form ceramics under mild conditions using protein-directed templated crystallization mechanisms.
Identifying novel peptides that control inorganic ceramic architecture is a technical challenge being addressed at the Natick Soldier Center. Based on our current understanding of how
nature nucleates inorganic nanocrystallization, researchers are attempting to use biomimetic approaches to create novel materials not found in nature. For example, the proteins that
direct crystallization for generation of sea urchin spicules are being genetically modified to favor ions, such as boron and aluminum, rather than the naturally incorporated ions of
calcium and silica. Systems Engineering Issues A key challenge to realizing the Soldier System of Systems is to provide a comprehensive range of capabilities while simultaneously
meeting stringent military requirements to minimize weight and power consumption. Todays soldiers may carry as much as 100 pounds of equipment. In keeping with requirements for
increased mobility, the objective is to reduce the effective load to less than 40 pounds by developing efficient multifunctional systems for the Soldier System of Systems. Examples
include a single system for detecting exposures to chemical warfare agents, toxic environmental chemicals, biowarfare agents, and/or infectious pathogens and a single vaccine system
for protecting against multiple pathogenic organisms. The problem is complicated because of potential interactions among drugs and vaccines that can decrease their effectiveness or
increase their toxicity. Another concern about biologically based systems is their stability and durability. Many biological molecules are susceptible to degradation, and it remains to be
seen whether bio-based materials and sensors will be able to perform well under rugged field conditions in which they are exposed to extremes of temperature and humidity, the

could be logistically
insupportable or unaffordable if stockpiles must be frequently refreshed.. Other
major challenges to realizing the Soldier System of Systems are gaps in our
knowledge. Despite substantial progress in the enabling technologies for
engineering sensors and DNA vaccines, questions remain about which
biomolecules are appropriate for sensing and why some vaccines fail to elicit a
protective response. We will certainly need more basic research on enabling
technologies and their applications. By continually monitoring progress in basic
and applied research in the academic, governmental, and industrial
communities, the Army can hope to fill these knowledge gaps, identify the
most promising enabling technologies, and promote their development by carefully
directing its investments.
possibility of oxidation, and other stresses. Biomaterials must also have a reasonably long shelf-life, because perishable materials

Medical Research Economy Impact

Medical innovation is key to the economy
Paranicas 14 President and Chief Executive Officer @ HINJ
(Dean, THE VALUE OF MEDICAL INNOVATION: SAVING LIVES, SAVING MONEY,
HealthCare Institute of New Jersey (HINJ), http://hinj.org/the-value-of-medicalinnovation-saving-lives-saving-money/)
Medical innovations produced by American life sciences companies have vastly
improved the human condition. Our pharmaceutical, biotech, medical technology,
device and diagnostics companies have helped people live longer, with less pain
and greater quality of life. Over the past century, the life sciences has eradicated
some of the worlds most dreaded diseases such as polio and smallpox. More
recently, the industry has made other diseases such as breast cancer, HIV/AIDS,
heart disease and lung cancer no longer the death sentences that they once were.
Collectively, new therapies are the greatest contributors to increased life
expectancy. According to the National Bureau of Economic Research (NBER),
between 1960 and 1997, new therapies accounted for 45 percent of the increase in
life expectancy in 30 developing and high-income countries. Between 2000 and
2009, new therapies accounted for 73 percent of the increased life expectancy for
these countries. Despite the dramatic life-saving advancements that the life
sciences sector has made, our work is far from done. Diabetes, Alzheimers, Ebola,
different types of cancers, and other formidable medical conditions demonstrate the
compelling need for Americas medical innovation community to build upon its
tremendous achievements to continue saving lives around the world. Toward that
goal, every day, teams of scientists from New Jersey companies go to work to
research and discover the next generation of medicines, therapies, devices,
technologies and diagnostic tools that will alleviate even more of these lifethreatening and life-altering diseases. Medical Innovations Overlooked Benefit With
these medical innovations, past and future, comes an often-overlooked benefit: the
incalculable billions of dollars in savings to patients, their families, insurers,
employers, governments and hospitals in avoided medical expenses associated with
keeping people healthy or curing them of a life-long, chronic condition. Certainly,
these medicines, therapies, medical technologies, devices and diagnostic tools keep
people healthier. They limit the need for frequent visits to the doctor. They help to
avoid costly hospital stays. They help patients avoid expensive surgeries.
Unfortunately, these tremendous cost savings often go unrecognized. Instead, we
hear frequent reports about the high cost of medicine or about new technologies or
diagnostic tools being deemed too expensive or unnecessary. We hear that
medical innovation is a cost-driver, not a cost-saver. The reality is quite to the
contrary. Medications, therapies and medical technologies and devices not only
save lives they save money. By eradicating a disease, people no longer need to
seek or spend money on treatment. By better managing and preventing more
serious complications from an existing disease, people avoid more costly medical
care. By discovering a new treatment or cure, the costs that would have been
incurred in addressing a patients ongoing medical issues can be avoided entirely.

Therefore, developing new treatments, cures and health technologies is one of the
most important steps we can take not only to save lives and improve the quality
of life, but also to avoid the expenditure of enormous amounts of health care
dollars. How much savings does medical innovation produce? There is not one,
simple answer to that question. However, there are numerous academic and
government statistics that point to the economic benefits of innovation in the
health-care marketplace. In a paper published by the Journal of Political Economy in
2006, it was estimated that over the preceding 50 years, medical innovation had
been the source of nearly half of all economic growth in the United States.
Impressively, for every dollar spent on innovative medicines, total healthcare
spending is reduced by $7.20, according to an NBER paper. As for the price of
medicine in America, only 9 cents of every health care dollar spent in America goes
to medicines, according to the Centers for Medicare & Medicaid Services (CMS) in
2013. The other 91 cents goes to hospitals, physicians, clinics, long-term care
facilities, and government administration and net cost of health insurance. Imagine
if we could use that 9 cents to reduce the remaining 91 cents or even avoid
significant portions of it in the first place. The result would be saved lives and even
greater health-care savings. Medication Adherences Important Role Medication
adherence also plays an important role in health-care savings, as medical
innovations can provide no benefit if they are not accessed by patients. Of the
approximately 187 million Americans who take one or more prescription drugs, it is
estimated that up to one-half do not take their medications as prescribed. Poor
medication adherence results in 33 to 69 percent of medication-related hospital
admissions in the U.S., at a cost of roughly $100 billion per year. In total, nonadherence to prescribed medicines results in approximately $290 billion in
unnecessary spending annually. Americans with chronic conditions account for 84
percent of health care spending. In 2011, this totaled more than $2 trillion. By using
medical innovations to prevent or better manage the most common chronic
diseases, the U.S. could decrease treatment costs by $218 billion per year and
reduce the economic impact of disease by $1.1 trillion annually. For diabetes, the
total costs of this chronic disease rose to $245 billion in 2012 from $174 billion in
2007. Without a cure, in the next 25 years, annual spending on diabetes is forecast
to increase steeply to approximately $336 billion annually. For Alzheimers disease,
in the absence of disease-modifying treatments, the cumulative costs of care for
people suffering with Alzheimers from 2010 to 2050 are expected to exceed $20
trillion. A treatment breakthrough that only postpones the onset of Alzheimers by
as few as five years could result in annual Medicare savings of $33 billion in 2020
and climb to $283 billion by mid-century, while annual Medicaid savings could
increase from $9 billion in 2020 to $79 billion in 2050. A 2007 Milken Institute paper
reported that cancer treatment results in a tenfold increase in productivity
specifically, $37 billion in cancer treatments resulted in an estimated $373 billion in
increased productivity. While the monetary cost savings of medical innovation are
extraordinary, the value to patients is nothing short of priceless. For example,
according to the American Cancer Society, U.S. cancer survivorship alone has more
than tripled since 1970, with nearly 14.5 million cancer survivors alive in the
country this year. Also, as of 2014, the U.S. five-year survival rate for all cancers
diagnosed between 2003 and 2008 is 68 percent. With HIV/AIDS, medical innovation

has delivered an astounding 3 million life years, which has produced an economic
value of $1.3 trillion, according to a 2006 published paper. Medical Innovation: A Key
Part of the Solution Medical innovation is complex, high-risk, time-consuming and
extremely expensive. But it is clear that medical innovation is a key part of the
solution not only to alleviating human suffering, but also to reducing significantly
the incalculable costs associated with treating that suffering. As a society, we need
to recognize the enormous multifaceted return on the investment in medical
innovation, and nurture rather than stifle the virtuous cycle of better health,
longer life and economic benefit resulting from life sciences innovation.

Medical innovation is key to growth

Hugin 13 Chairman, Pharmaceutical Research and Manufacturers of America
(Robert, Medical Innovation Benefits Patient Health, Economic Growth,
http://www.phrma.org/robert-hugin-remarks-japan-media-roundtable)
But Celgene is by no means unique among PhRMA member companies. Our
companies are vibrant and changing rapidly. All have impressive, committed, and
dynamic leaders. We all have a common mission, to make a meaningful difference
in the lives of patients around the world. PhRMA members have a common business
proposition, that value can't be created if patients dont benefit first. And the best
way for us to deliver a transformational future of medicine that is in the best longterm interest of for patients is to invent it ourselves. We have a major responsibility
to discover and develop new innovative therapies, and we are doing so, investing
more, as a percentage of our revenues into R&D, than any other industry in the
world. This came to almost $50 billion last year globally. But government policies
also have a significant impact on investment and innovation and our ability to
deliver transformational outcomes to patients. In the US, over the past 60 years,
medical innovation has been the source of more than half of our economic
prosperity and growth. In the US, since 1988, as a result of medical innovation, 42
million life years for cancer patients have been saved contributing nearly $3.5
trillion to our economy. Decades of health economic evidence reinforce that
pro-innovation and pro-patient policies do make a difference for patients,
healthcare and the economy.

Medical innovation is key to the economy---increased lifeexpectancy positively correlates with growth
---answers the life-expectancy turn

Wright 13 - editor-in-chief for Life Science Leader Magazine

(Rob, How Important Is Medical Innovation To The U.S. Economy?,
http://www.lifescienceleader.com/doc/how-important-is-medical-innovationeconomy-0001)
Living Longer, Better, Wealthier?
From 1900 2010, the United States has witnessed a 96% decrease in deaths, and
a 62% increase in life expectancy. By the year 2040, average U.S. life expectancy is

anticipated at being 85 years of age, while the rest of the world is estimated to be
at 72 years of age. According to Frank Lichtenberg, Ph.D., new therapies are the
greatest contributor to increased life expectancy. A business professor at Columbia
University, Lichtenberg assessed the contribution of pharmaceutical R&D to
longevity and the economic growth which results. You may find some of his insights
startling. First, the pharmaceutical industry is the most R&D-intensive sector of the
economy, not technology. Second, the rate of return on investment in
pharmaceutical R&D is 18%. Third, using newer drugs actually decreases overall
healthcare costs, with much of the savings being due to reduced hospital stays and
physician office visits. For $1 spent on innovative medicines, healthcare spending is
reduced by approximately $7.20. So let me ask you what type of financial impact
does living longer have economically? According to University of Chicago
economists Kevin Murphy, Ph.D., and Robert Topel, Ph.D., who calculated cumulative
gains in life expectancy after 1900 to be worth over $1.2 million to the
representative American in the year 2000. Further, in the 30 years between 1970 to
the year 2000, life expectancy gains added approximately $3.2 trillion per year to
the national wealth of the United States. But medical innovation contributes more
than just living longer and accumulation of wealth. Medical Innovation Economics
101 Over the past 50 years, medical innovation has been the source of more than
50% of all economic growth in the United States. It is estimated that there are more
than 650,000 jobs in the U.S. biopharmaceutical sector, with each of these jobs
supporting an additional five jobs in other sectors. In a report by Battelle, a
nonprofit R&D organization, the overall economic impact of the biopharmaceutical
sector on the U.S. economy in 2009 (as measured by output) was estimated to be
more than $917 billion on an annual basis. Further, the biopharmaceutical sector
generated nearly $85 billion in state, local, and federal tax revenues for 2009. The
annual average personal income of a biopharmaceutical worker in 2009 was nearly
twice the average across all private sector industries ($118,690 vs. $64,278). When
you compare export numbers among industries, you may be surprised to learn that
in 2010 the U.S. biopharmaceutical industry exported $46.7 billion, which is more
than automobiles ($38.4 billion), plastics and rubber products ($25.9 billion),
communications equipment ($27 billion), and computers ($12.5 billion). With all of
these positive U.S. economic attributes, why then does it seem everyone is intent
on killing the golden goose that medical innovation represents? The Obama
administration is pushing for policy changes to Medicare Part D, which if enacted
will most likely result in decreased pharmaceutical R&D spending, as well as the
loss of possibly 250,000 high wage jobs. So Paul, to answer your question, the
pharmaceutical industry is BIG. How important is medical innovation to the
U.S. economy VERY!

Medical Research Quality

Robust clinical trials are key without them the medical
knowledge gained causes long-term damage
Sean Tunis (Centers for Medicare & Medicaid Services, Baltimore, Md) Daniel
Stryer (Agency for Healthcare Research and Quality, Rockville, Md) and Carolyn
Clancy (Agency for Healthcare Research and Quality, Rockville, Md) 2003
Practical Clinical Trials http://umassmed.edu/uploadedFiles/QHS/Content/Tunis
%20article1.pdf
The prevalence and significance of gaps in knowledge about clinical effectiveness
are most readily appreciated by reviewing the results of most systematic literature
reviews, technology assessments, and clinical practice guidelines. These reports are
generally produced to provide comprehensive reliable information for decision
makers and usually address common conditions with large aggregate cost,
morbidity, and public health importance. A consistent finding of these reviews is
that the quality of evidence available to answer the critical questions identified by
experts is suboptimal. For example, a systematic review of newer pharmacologic
agents for depression concludes that few studies provided data on the long-term
effectiveness of treatment, the functional status of patients, or the outcomes of
patients treated in typical practice settings.11 Furthermore, few studies compared
the older inexpensive agents with newer agents in terms of adverse effects and
clinical efficacy. Most well-done systematic reviews and clinical guidelines reach
similar conclusions about the quality of evidence associated with common clinical
problems. These gaps in evidence undermine efforts to improve the scientific basis
of health care decisions in several ways. Organizations that develop evidencebased
clinical practice guidelines may not be able to develop clear, specific
recommendations.12 For example, the background report for clinical guidelines on
outpatient management of exacerbations of chronic obstructive pulmonary disease
found that although numerousindustry-sponsored clinical trials reported minor
differences in the antimicrobial activity of alternative broadspectrum antibiotics, no
trials had been performed to determine whether any of the newer broad-spectrum
antibiotics were better than older generic antibiotics or even placebo (for mild
exacerbation).13,14As a result, the guideline could not provide definitive
recommendations on the appropriate choice of antibiotics for chronic obstructive
pulmonary disease exacerbations. The limited quantity and quality of available
scientific information also impede the efforts of public and private health insurers in
developing evidencebased coverage policies for many new and existing
technologies.7,15 Poor-quality studies of new technologies can lead to millions of
dollars being allocated for new technologies for which the long-term benefits and
risks have not been determined.4 Minimally invasive technologies for treatment of
benign prostatic hyperplasia (BPH) are in widespread use, yet no clinical trials have
been performed to compare the risks and benefits of these treatments with
standard surgical interventions.16 The Medicare program has spent millions of
dollars per year for home use of special beds for patients with pressure ulcers,
despite the fact that no well-designed study demonstrates that they improve

healing of these ulcers.17 The limited production of this body of research becomes
increasingly problematic as major increases in public funding for basic research
generate an expanding range of potentially valuable technologies in need of careful
objective evaluation.

Disease - Turns Economy

Disease spread goes global- easy transmission of todays
viruses make it possible- that causes economic and healthcare
collapse worldwide
Nguyen-Van-Tama and Hampson 3 [Jonathan S. Nguyen-Van-Tama
(Aventis Pasteur MSD,) and Alan W. Hampson (WHO Collaborating Centre for
Reference and Research on Influenza). The epidemiology and clinical impact of
pandemic influenza. 2003. P. 5.
http://www.birdflubook.org/resources/tam1772.pdf]//EMerz
The three influenza pandemics of the 20th century indicate what can be expected
when the first pandemic of the 21st century makes its appearance. The pandemic
virus may emerge in China or a nearby country and could include surface antigens
or virulence factors derived from animal influenza viruses, much like the avian
A/H5N1 virus that emerged in Hong Kong in 1997. Once the new virus acquires
the ability to be transmitted efficiently from person to person, it will
spread rapidly throughout the world. Several waves of infection will occur.
Morbidity will be extensive in all age groups, and there will be widespread
disruption of social and economic activity in all countries. Excess mortality
will be evident in most if not all age groups. It is unlikely that health care systems in
even the most economically developed countries will be able to adequately cope
with the demand for health care services. Although modern medical care will offer
life-saving treatment to some individuals who in earlier pandemics would not have
survived, the principle determinants of the severity of the next pandemic will be the
virulence and transmissibility of the virus and the susceptibility of human
populations to infection. There is little that people can do to change or control these
variables. What they can do, however, is prepare their societies for managing the
consequences of the pandemic and ensure that there are adequate supplies of
vaccines and antiviral agents to lessen if not control its impact.

Disease turns free trade- any global spread of disease could

collapse international trade- ensuring health is a prerequisite
to the global economy
Kerr et al 6 [William Kerr. Van Vliet Professor Senior Associate, Estey Centre for
Law and Economics in International Trade. A Trade Regime for Sub-National Exports
Under the Agreement on the Application of Sanitary and Phytosanitary Measures.
2006. P. 2. http://www.uoguelph.ca/catprn/PDF-CP/Commissioned_Paper_20063_Kerr.pdf]//EMerz
International trade can be a significant factor in the spread of diseases from one
region of the world to another. As such, efficacious international movement controls
on potential disease spreading entities such as people, animals, plants or products
from plants and animals is a critical component of good disease management.
Collectively, in international trade law these policies are known as sanitary and
phytosanitary (SPS) measures. Many of these controls are implemented based on
national borders as they are convenient separators of government responsibility.

While governments have a legitimate obligation to prevent disease entry,

spread and establishment in their country, they are also frequently pressured
to utilize health regulations as disguised trade barriers to provide protection to their
national producers from international competition (Kerr, 2004). To prevent this,
international efforts were undertaken to promote measures being applied only when
there is a scientific justification. One of the first steps taken was to create
international expert bodies that could bring together technical expertise from
around the world to form recommendations regarding what would constitute good
scientific disease management practices. These included, but were not limited to,
disease-related trade restrictions. Effective enforcement, however, was difficult as
the international institutions involved lacked a binding dispute settlement
mechanism (Kerr, 2004). As governments increasingly agreed to constrain their
ability to utilize traditional protectionist measures, such as tariffs and quotas,
through consecutive negotiating rounds at the General Agreement for Tariffs and
Trade (GATT), illegitimate barriers to trade, such as SPS measures being applied
when not scientifically warranted, were seen as a rising problem in international
trade relations. Members decided to negotiate an agreement within the GATT, the
precursor to the World Trade Organization (WTO), which would govern the use of
SPS measures, allowing Members to enact them but only to the extent necessary to
protect human, animal or plant health. The significance of having an agreement on
the application of SPS measures in the newly created WTO was that it would now be
subject to the WTOs binding dispute settlement procedures, forcing governments to
abide by the rules agreed upon or face retaliation instead.

Disease A2 Burnout
Disease causes extinction -- Burnout is wrong
Karl-Heinz Kerscher 14, Professor, Space Education, Wissenschaftliche Studie,
2014, 92 Seiten
The death toll for a pandemic is equal to the virulence, the deadliness of the
pathogen or pathogens, multiplied by the number of people eventually infected. It
has been hypothesized that there is an upper limit to the virulence of naturally
evolved pathogens. This is because a pathogen that quickly kills its hosts might not
have enough time to spread to new ones, while one that kills its hosts more slowly
or not at all will allow carriers more time to spread the infection, and thus likely outcompete a more lethal species or strain. This simple model predicts that if virulence
and transmission are not linked in any way, pathogens will evolve towards low
virulence and rapid transmission. However, this assumption is not always valid and
in more complex models, where the level of virulence and the rate of transmission
are related, high levels of virulence can evolve. The level of virulence that is
possible is instead limited by the existence of complex populations of hosts, with
different susceptibilities to infection, or by some hosts being geographically
isolated. The size of the host population and competition between different strains
of pathogens can also alter virulence. There are numerous historical examples of
pandemics that have had a devastating effect on a large number of people, which
makes the possibility of global pandemic a realistic threat to human civilization.

Modeling/Leadership
Global disease surveillance is modeled after the United Stateseven if they win there is no precedent, its empirically proven.
Additionally, member nations wont comply if federal
surveillance overwhelms local authority.
Calain 07 (Philippe Calain, Senior Researcher at the Research Unit on
Humanitarian Stakes and Practices, based in the Swiss section of Medecins sans
Frontie`res. Trained as a medical doctor and a specialist in infectious diseases and
tropical medicine, he has over ten years of experience in international public
health Exploring the International Arena of Global Health Surveillance,
Published in Health Policy and Planning
http://heapol.oxfordjournals.org/content/22/1/2.full)

In May 2005, the 58th World Health Assembly adopted a much overdue revision of the
IHR, referred to as the IHR(2005) (WHO 2005a). Compared with the 1969, 1973 and 1981 versions of the IHR , the
revised regulations expand considerably the scope of internationally notifiable
epidemic diseases, they accommodate criteria for novel epidemic events and they set out conditions for
involvement of the international community in outbreak response. In May 1995, the 48th World Health Assembly
had already adopted two resolutions calling, respectively, for a revision of the IHR and for the establishment of a
comprehensive programme to tackle new, emerging and re-emerging infectious diseases (WHO 1995a).

Accordingly, in October 1995, a new unit was established at WHO as the Division of Emerging Viral
and Bacterial Diseases Surveillance and Control (EMC) (WHO 1995b), to be later renamed successively as the

Department of Communicable Diseases Surveillance and Response (CSR) and the

Department of Epidemic and Pandemic Alert and Response (EPR). In 2000, under the

operational support of CSR team members, a Global Outbreak Alert and Response Network (GOARN) was created to
coordinate technical resources involved worldwide in combating outbreak-prone diseases (Enserink 2004). The
apparent success of GOARN and collaborating technical partners in limiting the international spread of SARS in 2003
(Heymann and Rodier 2004) has vindicated efforts led by WHO to put the control of emerging or re-emerging
diseases high on the global health agenda. Next to giving itself the necessary legal instruments (through the
revised IHR) and putting itself in a position to coordinate international response to outbreaks (through the GOARN),

the WHO Secretariat has crystallized around the CSR/EPR Department a

considerable amount of expertise in capacity building , in preparation for deliberate epidemics
and in promoting public health surveillance at all levels. Inspired by a model developed from
the early ages of the United States Centers for Disease Control and Prevention
(US-CDC), WHO has become the flagship of the concept of global
surveillance of communicable diseases (Heymann and Rodier 1998). Since 2003, a limited
pandemic of SARS first, soon followed by the fearsome expansion of epizootic avian H5N1 influenza from South-East

Asia to the entire Old World, have been putting this concept to the test. The SARS and avian influenza epidemics have certainly
helped in facilitating the acceptance of the new IHR, through their combined health and economic impacts. Avian influenza H5N1 is
now in the limelight of international health concerns by being seen as a possible precursor of an upcoming human pandemic (WHO
2005b). Since the end of 2005, several high profile meetings in Geneva, Ottawa, Tokyo and Beijing have tried to mobilize the
international community to shift health priorities and financial resources toward preparedness against the anticipated influenza
pandemic (Health Canada 2005; World Bank 2005; WHO 2005c; WHO Regional Office for the Western Pacific 2005). In May 2006, the
59th World Health Assembly called upon Member States to speed up the implementation of the IHR(2005), or at least of the
provisions that are deemed relevant to the hazards posed by avian influenza and pandemic influenza (WHO 2006). Historical
landmarks of public health surveillance Public health surveillance applied to outbreak detection and monitoring is not a new idea.
During the plague of London in 1665, parish clerks compiled weekly bills of mortality detailing about 40 different causes of death
(Naphy and Spicer 2001). In a recent era, the most influential character was Alexander Langmuir who established and popularized
the modern concepts of disease surveillance, following the footsteps of the 19th century statistician William Farr (Thacker and Gregg
1996).2 A public health epidemiologist by training, Langmuir pursued an academic career in parallel with holding high-level positions
in committees of the US Department of Defense overseeing THE INTERNATIONAL ARENA OF GLOBAL PUBLIC HEALTH SURVEILLANCE
3 by guest on July 23, 2015 http://heapol.oxfordjournals.org/ Downloaded from biological warfare programmes during the World War
II and the Cold War periods (Fee and Brown 2001). In 1949, he was recruited to the US-CDC, to become its chief epidemiologist.
Building upon the US experience of malaria and poliomyelitis eradication programmes, he designed a remarkably successful national
system of disease reporting and created the Epidemic Intelligence Service. The 1990s saw the rise of the emerging diseases
worldview, a post-colonial concept rooted in new biomedical concerns as much as in perceived threats from a de-territorialized
world.3 A landmark 1992 report of the US National Academy of Science (Institute of Medicine 1992) formalized the definitions of
emerging and re-emerging diseases and explicitly discussed their global implications. The social, humanitarian, economic and

political fallout of (re)-emerging diseases became obvious, first in 1991 when cholera reappeared in South America (Sanchez and
Taylor 1997) and next in April 1994 when plague broke out in Surat, India (Garrett 2001). The latter circumstance showed how panic
and lack of leadership can lead to unnecessary impacts on national economies and on local communities (Cash and Narasimhan
2000). In April 1995, an outbreak of highly fatal cases of haemorrhagic fever in Kikwit in the Bandundu Province of DRC (former
Zaire) came to the attention of the international health community through a network of informal and rather delayed channels,
before it could be confirmed as the re-emergence of an Ebola virus. It attracted an unusual amount of press coverage and scientific
attention worldwide, partly justified by concerns over international spread. Lessons from the outbreak in Kikwit (Heymann et al.
1999) led to surveillance being put at the core of CSR activities, and to the revival of interest in the International Health
Regulations.4 Precursor regimes of international governance on communicable diseases actually date back to the first International
Sanitary Conference of 1851. Under their successive formats, they already incorporated mixed concerns over public health as well
as related trade and political issues (Fidler 2003). Their impact seems, however, to have been rather limited. In contrast, the
widespread interest in international health regulations seen at the present time reveals new dimensions to the global public health
debate, as well as far-reaching implications of global surveillance. Semantic ambiguities When Alexander Langmuir (1963, 1971)
redefined surveillance to fit his own public health purposes, he departed from a former meaning which restricted the term to
individuals, i.e. typically contacts who had to be followed up for signs of disease without restricting their movements by isolation or
quarantine.5 Instead of individuals, Langmuirs (1963) modern view of surveillance applies to diseases, as defined by: the continued
watchfulness over the distribution and trends of incidence through the systematic collection, consolidation and evaluation of
morbidity and mortality reports and other relevant data. Intrinsic in the concept is the regular dissemination of the basic data and
interpretations to all who have contributed and to all others who need to know. With some prophecy, Langmuir anticipated future
problems and cautioned that: the actual performance of the research study should be recognized as a function separate from
surveillance. The blurred boundary between research and surveillance is a critical issue that was later emphasized by

Stephen Thacker, a succeeding senior epidemiologist at the US-CDC .6 Thacker noted the
ambiguities carried under disease surveillance and epidemiologic surveillance, and he advocated the
term public health surveillance to avoid confusion with epidemiologic research
(Thacker and Gregg 1996). Directly inspired by Thackers definition, the WHO definition of
public health surveillance proposed under resolution WHA58.3 (WHO 2005a) is clear enough to avoid

confusion with research activities: Surveillance means the systematic ongoing collection, collation and analysis of
data for public health purposes and the timely dissemination of public health information for assessment and public

carries two sources of

ambiguity, which were further reflected during the international consultation process and in the drafting of
advanced versions of the revised IHR(2005). These ambiguities relate to (1) the scope of health events
targeted by surveillance, and (2) the sort of public health action in which the
international community through WHO experts will find itself involved by virtue
of the IHR(2005) mandate. Shared concerns by some experts and policy makers over the scope of the new
health response as necessary. Despite its clear merits, however, the latter definition

IHR appear in successive versions of a decision instrument annexed to the IHR(2005) (WHO 2004a). Initially
designed exclusively as a criteria-based algorithm, the final version of the annex ultimately includes as well a
number of specific diseases, leaving it open to frequent updates as new pathogenic agents become identified. In
the same line, it is not explicit whether the IHR(2005) have regulatory authority over programme evaluation as well
as detection of epidemics, both being classical components of communicable diseases surveillance.7 In a
conceptual framework endorsed by members of the CSR team (McNabb et al. 2002), the two related components of
public health action (acute epidemic-type response and planned management-type response) are explicitly
considered as complementary outputs of public health surveillance. What will be missing in some cases of new
epidemic threats, especially when the risk assessment is inconclusive, is a gauge of the degree of urgency from
which international action is legitimate. These issues have some relevance obviously in terms of national
sovereignty. More recently, WHO has been promoting, developing and implementing in several countries the
relatively new concept of Early Warning Systems (EWARS) for outbreak surveillance (WHO 2005d). Direct reference
to EWARS would perhaps have lifted some ambiguities carried by too loose a definition of surveillance and would
have better clarified the scope of the IHR(2005) and their derived requirements for Member States. Of equal
relevance to the scope of the IHR(2005) is the lack of conceptual clarity over the term global health security
(Aginam 2005; McInnes and Lee 2006). Global health security features prominently in WHO policy documents (for
an example see WHO 2001) to summarize the overall strategy 4 HEALTH POLICY AND PLANNING by guest on July
23, 2015 http://heapol.oxfordjournals.org/ Downloaded from covered by epidemic alert and response activities.
Other international alliances (Global Health Security Initiative 2006) use the term with a clear orientation toward the
public health response to the specific threats of international biological, chemical and radio-nuclear terrorism.

How and if Member States of WHO will abide by the IHR

depend on a delicate balance
between perception of threats from specific health events (public health effects per se, or
political or economical consequences), incentives set up by interested parties and any consideration of
national sovereignty. Sovereignty has been one of the main matters of discussion during
Sovereignty and ethical standards

(2005) (which are to become legally binding in June 2007) will obviously

successive consultations leading to resolution WHA58.3 (WHO 2004a). The issue has an additional level of

for countries with federal governments, where authority over public health
is generally devolved to regional jurisdictions (Wilson et al. 2006). The IHR(2005) do not include a
complexity

sanctions regime for States that fail to comply with their provisions (WHO 2005e). Several jurists (Plotkin and
Kimball 1997; Fidler 2003) have stressed the marginal role of former versions of the IHR compared with other
international regimes, notably the World Trade Organization8 and its related multilateral agreements dealing in a

more direct way with factors causing the emergence of communicable diseases. It is, however, likely that the new
IHR will become more influential than their precursor versions of 1969, 1973 and 1981, for several reasons: (1) the
broader scope of health events under consideration, (2) a more active and better defined role for WHO in the
response phase, and (3) more flexible mechanisms for WHO to circulate information critical to control public health
threats (including information from non-official sources or about non-compliant state parties). Despite the latter
opportunity embedded in the new IHR, it will remain as difficult as ever for WHO to exercise its handling of sensitive
information, especially in a world where the press and the public are the driving forces behind increased
transparency.

Courts model each other- constitution globalization

Kersch 05, (Ken I, 4 Wash. U. Global Stud. L. Rev. 345, New Legal
Transnationalism, the Globalized Judiciary, and the Rule of Law, 2005,
http://heinonline.org/HOL/Page?
handle=hein.journals/wasglo4&div=19&g_sent=1&collection=journals)//IB
In recent years in the United States, constitutional reasoning and practice has been
going global. For many, this trend became apparent for the first time when, in the course of its
analysis in the recent affirmative action and gay rights cases, the U.S. Supreme
Court made frank references to foreign practices , public opinion, and court decisions, as well as
international agreements-those ratified by the United States and those not.' While, strictly speaking, not
unprecedented, the Court's transnational references in these cases were notable for a
number of reasons. First, because they took place in decisions not involving international affairs, as traditionally

in cases involving domestic policy issues that are at the heart of partisan political
were unusually prominent. Second, rather than amounting to casual allusions, they
represent a calculated step by key justices on the Court --led by Justice Breyer, but also joined
defined, but rather
contention, they

by Justices Ginsburg, Kennedy, and O'Connor-to bring the Court's approach toward constitutional interpretation into
line with new approaches being taken by justices in the courts of other countries.2 And third,

these efforts in

the American judiciary are taking place in a distinctive reformist intellectual context in which many
scholars and activists, both in the United States and around the world, are coming to
understand legal transnationalism as an imperative .' As is evident from even the most casual
perusal of the increasingly high profile journals of international law, scholars are now hard at work trying out
alternative doctrines, seeking those that will be least politically vulnerable. Debates involving the applicability of
the law of nations, customary international law, treaties, international agreements and pronouncements, and
foreign practices, precedents, judicial reasoning (under the guise of "constitutional borrowing"), and public opinion
to the decisionmaking processes of American judges deciding domestic constitutional cases, more and more are
filling pages of these law journals. These calculated efforts to transform the way in which the Court considers
domestic constitutional issues may very well mark the beginning of a major departure in the direction of American
constitutional law.

US is losing healthcare leadership

Szarfenberg 10, (Ryszard, Culture and Education, QUALITY OF SOCIAL
WELFARE SERVICES, 2010, http://janinewedel.info/KiE-nr-5-2010.pdf#page=61)//IB
the
concepts of new public management, pro-quality reforms of general interest
services have been and still are undertaken . Services of general interest include social welfare
services and hence they are also concerned. Th e leading role in the adoption of this philosophy
is played by health services sector, and in this connection also by social services similar to those
provided by care homes or nursing and medical institutions that are closest to the health services sector. One of
the presently dominant sources of ideas aimed to improve quality are the strategies
In recapitulation, despite ambiguity and multidimensionality of the notion of quality and discrepancies in

and instruments recommended and applied in the private sector. However, quality assurance models in the sector
of manufacturing and commercial services not necessarily work well in social services. Th erefore, approaches
intended to take due account of their specifi cs are being developed. However, it is not certain whether even those
service models and standards that are well adjusted to specifi cs of the social sector will have a signifi cant impact

on improvement of the clients quality of life, in particular in social care institutions. Presently,

Poland

implements a systemic project Operational Programme Human Capital Creating and Developing
Standards for Social Welfare and Integration Institutions, whose name originally contained the words quality
standards, but quality was dropped from a successive version46. It is not known why this change was made
(perhaps due to the conviction that ISO quality management standards are not adequate for social welfare

creation and development of standards with exclusion of

such an extremely important premise for this process as the intention to improve
services quality, seems at least puzzling.
organisation and services), but

Disparate Impact
Health surveillance disproportionately targets minorities and is
ignored by activist the plan is key
Hoppin 12 (Margaret, J.D. at New York University School of Law,
Overly Intimate Surveillance: Why Emergent Public Health
Surveillance Programs Deserve Strict Scrutiny Under The Fourteenth
Amendment, December 2012, NYU Law Review, Hein Online)//JL
Security surveillance programs that target politically vulnerable domestic
communities for dragnet surveillance have prompted wide-spread concern in the last decade,
although legal challenges to national security programs generally have not reached a decision on the merits.141

advocacy groups responded promptly to the revelation that

New York City Police Department sur-veillance programs targeted Arab and Muslim
communities in the Northeast.142 Some politicians publicly declared that the programs were disturbing and
For example, politicians and

said they would not have allowed such a program if they had known about it.143 Academics and academic institutions expressed similar concern and criticism.144 Community leaders petitioned the New Jersey Attorney General
to investigate a New Jerseybased surveillance program and give a full accounting of ongoing surveillance.145 In

one commentator advo-cates robust constitutional

privacy protections because legislative efforts to regulate surveillance may . . .
insufficiently protect the pri-vacy of certain politically unpopular minorities, like
Muslim-Americans.146 Like Arab and Muslim Americans in the security sur-veillance
context,147 people with diabetes, obesity, and certain other chronic conditions are
politically vulnerable in the health surveillance context. Diabetes
disproportionately affects black and Latino New Yorkers, [and] . . . those
living in low-income households and neigh-borhoods, both with respect to its prevalence
the context of security surveillance,

and the rates and severity of related complications.148 The same is true of obesity and obesity-related health

many chronic condi-tions, including diabetes, are often perceived as a

self-inflicted problem among the elderly who are sedentary and obese.150 The argument that
governments have a legitimate interest in controlling medical and social costs of
individuals unhealthy behaviors that are borne by society at large151 may be used to justify
inappropriate pri-vacy invasions, especially given that public discourse about obesity is infused with
moral condemnation.152 Judicial recognition that emer-gent programs infringe upon
constitutionally protected privacy rights would require governments to develop
substantive (instead of rhetor-ical) justifications for deploying the most invasive types of public
health surveillance against vulnerable populations or, alternatively, to modify those surveillance
programs. One indication that diabetics may be a politically vulnerable group is that , in
stark contrast to security surveillance programs, the launch of the A1C registry provoked virtually
no response. On July 13, 2005, the Department published in the City Record a notice of its intention to create
problems.149 In addition,

the A1C registry and to hold a public comment period.153 On August 16, 2005, the Department held a public
hearing on its proposal.154 In response, the Department received only thirty-one written comments;155 at the
hearing, six health care practitioners and one member of the health care technology industry testified in support,

No civil liberties organization commented

on the proposal.157 Despite its involvement in privacy debates relating to AIDS and bioterrorism sur-veillance,
the ACLU was not even aware of the proposal .158 With a few notable exceptions,159 the public
health community has responded to the A1C registry with approval , and the legal comand three private individuals testified in opposition.156

munity has not responded much at all. Of the handful of commenta-tors on the program, most emphasize its

no one has challenged the program in court. In addition, despite similarities between the A1C Registry and an HIV
surveillance program proposed by the Department at the same time,161 the objections of the
better-organized HIV community held more traction . . . [and] effectively thwarted more
potential as a public health tool.160 Perhaps even more surprising,

aggressive surveillance.162 The HIV proposal prompted both the medical community and a wider public [to take]
notice and . . . grapple with the meaning of expanded surveillance.163

Diseases can be used as a front to impose on minority privacy

Bayer and Fairchild 10, (Ronald and Amy, Social Research, When Worlds
Collide: Health Surveillance, Privacy, and Public Policy, September 1, 2010,
http://web.b.ebscohost.com.proxy.lib.umich.edu/ehost/pdfviewer/pdfviewer?
sid=e3a9c3e1-758e-455d-8d55bdb218570cd9%40sessionmgr111&vid=9&hid=125)//IB
In June 1981 the Centers for Disease Control (CDC) reported the appearance in previously healthy
gay men of conditions that usually occurred 908 social research only in individuals with compromised
immune systems. One month later the CDC reported that in the prior two and a half years Kaposi's
sarcoma, a malignancy rare in the United States, especially in young people, had been diagnosed in 26 gay
men in New York and California. These were sentinel cases of an epidemic that would have a
profound impact on gay men, intravenous drug users and their sexual partners, and African
American and Latino communities in the last two decades of the twentieth century (Bayer 1989).
Early on there would be some calls for rigid separation of the sick, though it soon became clear that the
new disease could only be spread through sexual contact, from the sharing of drug injection equipment, by

the disease arrived at the

very moment when American politics had taken a sharp conservative turn with the
election of President Ronald Reagan heightened the concern of those who feared that AIDS
would provide the occasion for the wide-scale abrogation of the privacy rights that
had gained recognition in the prior decade. Such fears would have a deep and
lingering impact on the surveillance activities undertaken in response to the new
epidemic threat.
contaminated blood, and from infected pregnant women to their fetuses. That

Health surveillance violates privacy and disproportionately

affects minorities
Hoppin 12 (Margaret, J.D. at New York University School of Law,
Overly Intimate Surveillance: Why Emergent Public Health
Surveillance Programs Deserve Strict Scrutiny Under The Fourteenth
Amendment, December 2012, NYU Law Review, Hein Online)//JL
Courts have not considered the implications for Fourteenth Amendment privacy
protections
important questions
remain unan-swered: Does
modern technology
alter the
scope or nature of constitutional privacy protections
politically underrepresented populations disproportionately experience chronic
diseases and obesity, and are therefore more likely to be targets of
surveillance
commentators
have identified three features
that
of the last thirty-five years of devel-opments in public health surveillance programs, technology, or data mining capabilities. As a result,
the fact that

permits ongoing and intimate surveillance of personal behaviors

in the context of public health surveillance?103 What about the fact that

?104 and are therefore more likely to be targets of surveillance?104 B.Similarities in Security Surveillance and Public Health Surveillance Courts and

addressed similar questions in the context of security surveillance programs. In particular, they

of government security surveillance

have

make the privacy invasions especially troubling: the surveillance is increasingly

comprehensive and intimate, it involves
unprecedented size
it
targets politically underrepresented domestic communities
all three features have provoked significant privacy concerns
The
nature of government surveil-lance is
changing the analysis under the Fourth Amendment
the targeting of
politically underrepresented com-munities has not explicitly done so
registries of

and data mining potential, and

. In the context of security surveillance

programs,

courts have incorporated each concern into Fourth Amendment anal-ysis:

. However, there is variation in the extent to which

intimate and comprehensive

and its state counterparts,

, and the use of registries and data mining

falls in the middle.

Genetic information collection is being manipulated to

reinforce racial order
Roberts 11 (Dorothy E. Roberts, Kirkland & Ellis Professor, Northwestern
University School of Law; faculty fellow, Institute for Policy Research)(Collateral
Consequences, Genetic Surveillance, and the New Biopolitics of Race, Howard Law
Journal, Vol. 54 No. 3, 2011)//ASMITH
This Article considers state and federal government expansion of genetic
surveillance as a collateral consequence of a criminal record in the context of a new
biopolitics of race in America. As I discuss more fully in my book Fatal Invention:
How Science, Politics, and Big Business Re-create Race in the Twenty-First Century,
the emerging biopolitics of race has three main components.1 First, some scientists
are resuscitating biological theories of race by modernizing old racial typologies that
were based on observations of physical differences with cutting-edge genomic
research.2 These scientists are redefining race as a biological category written in
our genes.3 Second, the biotechnology and pharmaceutical industries are
converting the new racial science into products that are developed and marketed
according to race and that incorporate assumptions of racial difference at the
genetic level.4 Finally, government policies that appear to be colorblind are
stripping poor minority communities of basic services, social programs, and
economic resources in favor of corporate interests, while simultaneously imposing
on these communities harsh forms of punitive regulation.5 Mass incarceration and
its collateral consequences are the chief examples of the punitive regulation of
African American communities. This Article contends that these dehumanizing
policies of surveillance and control are obscured by the emerging genetic
understanding of race, which focuses attention on molecular differences while
ignoring the impact of racism in our society.6 Only a decade ago, the biological
concept of race seemed to have finally met its end.7 The Human Genome Project,
which mapped the entire human genetic code, proved that race could not be
identified in our genes.8 Yet, there has been an explosion of race-based science and
biotechnologies. For example in 2005, the United States Food and Drug
Administration (FDA) approved the first race-specific drug, BiDil, to treat heart
failure in black patients.9 In addition, fertility clinics solicit egg donations based on
race and use race in genetic tests to determine which embryos to implant and
which to discard.10 Consumers can send cheek swabs to dozens of online
companies to find out not only their genetic ancestry, but also their racial
identity.11 Furthermore, one of these companies used the same forensic tools to
help law enforcement agencies identify the race of suspects.12 Most relevant to the
subject of this Symposium, in the last decade, federal and state governments have

been rapidly expanding the collection of genetic information for law-enforcement

purposes.13 With eight million offender samples, the U.S. federal government has
stockpiled the largest database of DNA seized from its citizens of any country in the
world.14 Because of rampant racial bias in arrests and convictions, the
governments DNA databases, which are being amassed nationwide, effectively
constitute a race-based biotechnology emerging from genetic science.15 Unlike
voluntary genetic testing technologies that claim to help people cure their diseases,
improve the genetic composition of their children, and find their identities, forensic
DNA repositories are gathered by the state without consent and maintained for the
purpose of implicating people in crimes.16 Theses repositories signal the potential
use of genetic technologies to reinforce the racial order not only by incorporating a
biological definition of race, but also by imposing genetic regulation on the basis of
race.

Discriminatory arrests causes lifetime genetic surveillance of

blacks; government DNA collection is a means to create a
universal database for black men
Roberts 11 (Dorothy E. Roberts, Kirkland & Ellis Professor, Northwestern
University School of Law; faculty fellow, Institute for Policy Research)(Collateral
Consequences, Genetic Surveillance, and the New Biopolitics of Race, Howard Law
Journal, Vol. 54 No. 3, 2011)//ASMITH
These privacy violations are exacerbated by the racial inequities that plague every
part of the U.S. criminal justice system. The most stunning aspect of this injustice is
the mass incarceration of African American men.77 Radical changes in crime
control, drug, and sentencing policies over the last thirty years produced an
explosion in the U.S. prison population from three hundred thousand to two million
inmates.78 Additionally, the United States has the highest rate of incarceration in
the world at a magnitude unprecedented in the history of Western democracies.79
The gap between black and white incarceration rates has increased along with
rising inmate numbers.80 Black men are eight times as likely as white men to be
behind bars.81 One in nine black men aged twenty to thirty-four is in prison or in
jail.82 In fact, most people sentenced to prison today are black.83 In her 2010 book,
The New Jim Crow, legal scholar Michelle Alexander demonstrates that black
incarceration functions like a modern-day Jim Crow caste system because it
permanently locks a huge percentage of the African American community out of
the mainstream society and economy, replicating the subjugated status of blacks
that prevailed before the civil rights revolution.84 The targeted imprisonment of
black men is translated into the disproportionate storage of their genetic profiles in
state and federal databases. We can look to the United Kingdom to gauge the likely
racial impact of our own federal database now that it has surpassed theirs in size.
Their database reveals that 40% of all black men and 77% of black men aged fifteen
to thirty-five, compared with only 6% of white men, were estimated to have genetic
profiles in the UK national DNA database in 2006.85 Also in 2006, Stanford
bioethicist Hank Greely estimated that at least 40% of the genetic profiles in the
U.S. federal database were from African Americans, although they make up only
13% of the national population.86 Sheldon Krimsky and Tania Simoncelli arrive at a

similar estimate in which 41% to 49% of CODIS profiles are from African
Americans.87 The extension of DNA collection by the federal government and a
number of states to people who are only arrestedas opposed to charged or
convictedbrings many more whites into the system, but it is also on its way to
creating a nearly universal database for urban black men.88 These men are
arrested so routinely that upwards of 90% would be included in databases if the
collection policy is strictly enforced.89 In April 2010, Arizona Governor Jan Brewer
signed a controversial law giving police broad authority to detain anyone suspected
of being in the country illegally.90 This law is held up as a model for immigration
enforcement policy in other states.91 When combined with congressional
authorization of DNA sampling from all federal detainees,92 these immigration laws
will cause the number of Latino profiles in CODIS and state databases to skyrocket.
Police routinely consider race in their decision to stop and detain an individual.93 A
New York Times/CBS News Poll conducted in July 2008 asked: Have you ever felt
you were stopped by the police just because of your race or ethnic background?94
Sixty-six percent of black men said yes, compared to only 9% of white men.95 The
United States Supreme Court has authorized police to use race in determining
whether there is reasonable cause to suspect someone is involved in crime.96
Michelle Alexander calls the Courts license to discriminate the dirty little secret of
policing.97 In recent decades, a conservative Supreme Court has eroded the
Warren Courts protections against police abuse in ways that promote the arrest of
blacks and Latinosrelaxing, for example, the standard for reasonable suspicion
and has blocked legal channels for challenging racial bias on the part of law
enforcement.98 There is overwhelming evidence that police officers stop motorists
on the basis of race for minor traffic violations, such as failure to signal a lane
change, often as a pretext to search the vehicle for drugs.99 One of the first
confirmations of this was a 1992 Orlando Sentinel study of police videotapes that
discovered that, while blacks and Latinos represented only 5% of drivers on the
Florida interstate highway, they comprised nearly 70% of drivers pulled over by
police and more than 80% of those drivers whose cars were searched.100 A study
of police stops on the New Jersey Turnpike similarly found that, although only 15%
of all motorists were minorities, 42% of all stops and 73% of all arrests were of black
drivers.101 In Maryland, only 21% of drivers along a stretch of I-95 outside of
Baltimore were African Americans, Asians, or Latinos, but these groups made up
nearly 80% of those who were stopped and searched.102 Likewise, an Illinois state
police drug interdiction program, known as Operation Valkyrie, targeted a
disproportionate number of Latinos, who comprised less than 8% of the Illinois
population but 30% of the drivers stopped by drug interdiction officers for petty
traffic offenses.103 Police officers also make drug arrests in a racially biased
manner. Although whites use drugs in greater numbers than blacks, blacks are far
more likely to be arrested for drug offensesand, therefore, far more likely to end
up in genetic databases.104 The latest National Survey on Drug Use and Health,
released in February 2010, confirms that young blacks aged eighteen to twenty-five
years old are less likely to use illegal drugs than the national average.105 Yet, black
men are twelve times more likely than white men to be sent to prison on drug
charges.106 This staggering racial disparity results in part from the deliberate
decision of police departments to target their drug enforcement efforts on urban

and inner-city neighborhoods where people of color live. Indeed, the increase in
both the prison population and its racial disparity in recent decades are largely
attributable to aggressive street-level enforcement of the drug laws and harsh
sentencing of drug offenders.107 A crusade of marijuana arrests in New York City in
the last decade provides a shocking illustration.108 Since 1997, the New York Police
Department (NYPD) has arrested 430,000 people for possessing tiny amounts of
marijuana, usually carried in their pockets. 109 In 2008 alone, the NYPD arrested
and jailed 40,300 people for the infraction.110 Even more alarming is the extreme
racial bias shown in whom the police target for arrest. Although U.S. government
studies consistently show that young whites smoke marijuana at the highest rates,
white New Yorkers are the least likely of any group to be arrested.111 In 2008,
whites made up over 35% of the citys population but less than 10% of the people
arrested for marijuana possession. 112 Instead, the NYPD has concentrated arrests
on young blacks and Latinos. Police arrested blacks and Latinos for marijuana
possession at seven and four times the rate of whites, respectively.113 The racist
marijuana policing strategy is based on the routine police practice of stopping,
frisking, and intimidating young blacks and Latinos. According to Harry Levine, the
City University of New York sociologist who exposed the arrest campaign, In 2008,
the NYPD made more than half a million recorded stop and frisks and an unknown
number of unrecorded stops, disproportionately in black, Latino and low-income
neighborhoods.114 Although New York City is the marijuana arrest capital of the
world, other cities like Atlanta, Baltimore, Denver, Houston, Los Angeles,
Philadelphia, and Phoenix are also arresting and jailing huge numbers of blacks and
Latinos for marijuana possession.115 The widespread arrests of young blacks and
Latinos for marijuana possession and other petty offenses, such as truancy,
skateboarding, and playing loud music, have devastating consequences. A first-time
offender who pleads guilty to felony marijuana possession has a permanent criminal
record that can block him or her from getting a student loan, a job, a professional
license, food stamps, welfare benefits, or public housing.116 Even if they avoid
prison on a first offense, those who are arrested a second time risk a harsh
sentence for being a repeat offender.117 In addition to harsh sentencing, a lifetime
of genetic surveillance can now be added to the long list of collateral consequences
created by discriminatory arrests.

DNA databanks magnify stereotypes and intensifies racial

injustices and disparities
Roberts 11 (Dorothy E. Roberts, Kirkland & Ellis Professor, Northwestern
University School of Law; faculty fellow, Institute for Policy Research)(Collateral
Consequences, Genetic Surveillance, and the New Biopolitics of Race, Howard Law
Journal, Vol. 54 No. 3, 2011)//ASMITH
Racial disparities in DNA databanks make communities of color the most vulnerable
to state surveillance and suspicion.118 The disproportionate odds faced by blacks
and Latinos of having their DNA extracted and stored will, in turn, intensify the
racial disparities that already exist in the criminal justice system. People whose DNA
is in criminal databases have a greater chance of being matched to crime scene
evidence. While a guilty person may have no right to complain, that is no excuse for

unfairly placing certain racial groups at greater risk of detection. Blacks and Latinos
have greater odds of being genetically profiled largely because of discriminatory
police practices.119 Moreover, people whose profiles are entered in DNA databases
become subject to a host of errors that can lead to being falsely accused of a crime.
As the federal government and a growing number of states extend the scope of DNA
collection to innocent people, they are imposing this unmerited risk primarily on
minorities. The problem is not only that all of these harms are placed
disproportionately on people of color, but also that the dangers of state databanks
are multiplied when applied to blacks and Latinos because these groups are already
at a disadvantage when they encounter the criminal justice system. Blacks and
Latinos have fewer resources than whites to challenge abuses and mistakes by law
enforcement officers and forensic analysts.120 They are stereotyped as criminals
before any DNA evidence is produced, making them more vulnerable to the myth of
DNA infallibility.121 The experience of being mistaken for a criminal is almost a rite
of passage for African-American men, writes journalist Brent Staples.122 One of
the main tests applied by a disturbing number of Americans to distinguish lawabiding from lawless people is their race. Many, if not most, Americans believe that
black people are prone to violence and make race-based assessments of the danger
posed by strangers they encounter.123 One of the most telling reflections of the
presumption of black criminality is biased reporting of crime by white victims and
eyewitnesses.124 Psychological studies show a substantially greater rate of error in
cross-racial identifications when the witness is white and the suspect is black.125
White witnesses disproportionately misidentify blacks because they expect to see
black criminals.126 According to Cornell legal scholar Sheri Lynn Johnson, This
expectation is so strong that whites may observe an interracial scene in which a
white person is the aggressor, yet remember the black person as the
aggressor.127 In numerous carefully staged experiments, social psychologists have
documented how peoples quick judgments about the criminal acts of others are
influenced by implicit biaspositive or negative preferences for a social category,
such as race or gender, based on unconscious stereotypes and attitudes that people
do not even realize they hold.128 Whites who are trying to figure out a blurred
object on a computer screen can identify it as a weapon faster after they are
exposed to a black face.129 Exposure to a white face has the opposite effect.130
Research participants playing a video game that simulates encounters with armed
and unarmed targets react faster and are more likely to shoot when the target is
black.131 The implicit association between blacks and crime is so powerful that it
supersedes reality; it predisposes whites to see black people as criminals. Most
wrongful convictions occurred after witnesses misidentified the defendant.132
Databanks filled with DNA extracted from guilty and innocent black men alike will
enforce and magnify the very stereotypes of black criminality that lead to so many
wrongful convictions in the first place. Collecting DNA from huge numbers of African
Americans who are merely arrested, with no proof of wrongdoing, embeds the
sordid myth of black criminality into state policy. As databanks swell with DNA from
black people who are arrested or convicted on petty offenses and as their relatives
also come under suspicion in states with familial searching, the government
effectively treats every black person in many communities as a criminal suspect. It
seemingly also legitimizes the myth that blacks have a genetic propensity to

commit crime. In 2010, Florida State University criminologist Kevin Beaver

published a widely reported study claiming to show that young men with the lowactivity form of the monoamine oxidase A (MAOA) genedubbed by the press as
the warrior genewere more likely to join gangs than those who had the highactivity version of the MAOA gene.133 He concluded that male carriers of low
MAOA activity alleles are at risk for becoming a gang member and, once a gang
member, are at risk for using weapons in a fight.134 The public, who already
implicitly associates blacks with violence, may link research claiming that genes
cause gangbanging and aggression to the disproportionate incarceration of African
Americans along with the disproportionate banking of African Americans genetic
profiles, to reach the false conclusion that blacks are more likely to possess these
crime producing traitsor even that most blacks actually possess them. Americans
will become even more indifferent to racial injustice in law enforcement if they are
convinced that black people belong behind bars because of their genetic
predilection to crime.

DNA databases target minorities- eliminating the

governments ability to conduct this form of surveillance
minimizes racial targeting
Grimm 7 (Daniel J. Grimm. Lawyer in Cape Girardeau, Missouri. The
Demographics of Genetic Surveillance: Familial DNA Testing and the Hispanic
Community. May 2007. P. 1165-1166.
http://projects.nfstc.org/fse/pdfs/Grimm.pdf)//EMerz
While familial testing potentially affects the privacy rights of every person whose
relative is a suspect, perhaps an even greater concern is that these threats to
privacy will not be distributed equally throughout the population.7 The databank
system, representing the convergence of DNA profiles collected over the course of
many years, is not racially neutral.8 Instead, years of disproportionately high arrest
and conviction rates have created a data field in which African Americans are
overrepresented.9 While troubling, a related concern that has yet to receive
sufficient attention is the degree to which demographics, which also drive databank
system configurations, may produce similarly disproportionate outcomes for the
Hispanic community.10 As the demographic group with the highest rate of natural
population growth, each profile input from a Hispanic defendant is likely, on
average, to lead investigators relying on familial testing to a higher number of
genetic relatives than if the profile had been obtained from a non-Hispanic
person.11 Disproportionate distribution of privacy violations is nearly inevitable in
such a system. The Hispanic community, like the African American community, is
subject to disproportionate arrest and conviction rates, such that familial DNA
testing will have an especially significant impact on Hispanic people. Under familial
testing, Hispanics will be more likely than other demographic groups to be added to
the databank system, more likely to partially match a sample once it is added to the
database, and, therefore, will be more likely to be targeted by law enforcement for
DNA sample collection. Nonetheless, familial DNA testing will likely survive a

constitutional challenge under the Equal Protection Clause, but is likely to be

rejected under the probable cause requirement of the Fourth Amendment.
Allowing DNA databanks like CODIS magnifies racial disparities across all
aspects of the justice system --- because people of color are
disproportionately arrested, the databanks will have disproportionate
amounts of their DNA in them --- this leads to unjust conviction and masks
racialized violence --- ruling on the 14th amendment alone is impossible
and has been tried --- the plans use of multiple grounds is key
Risher, attorney with the American Civil Liberties Union (ACLU), July-August 2009
(Michael, Racial Disparities in Databanking of DNA Profiles, published in
Genewatch Volume 22 Issue 3-4, p. 22-24)//roetlin
Of the hundreds of thousands of arrests every year in California on suspicion of a felony, nearly 320,000 in 2006,

A disproportionate number of these innocent

arrestees are people of color. In the U.S. justice system, people who are arrested but never
convicted are presumed innocent; yet, as of January 1, 2009, all arrestees have been
forced to let the State of California take a DNA sample, analyze it and include the
resulting profile in a criminal database, to be compared evermore with crime-scene
evidence. There are procedures for some of these people to try to get the samples and profiles expunged;
approximately 30% never lead to any conviction.[1]

however, these procedures often require arrestees to wait three or more years before even requesting
expungement and necessitate the help of a lawyer. As a result, the overwhelming majority of people arrested but
not convicted of any crime are unlikely even to try to get their samples destroyed. Tens of thousands of profiles

The consequence will be a

magnification of the current racial disparities in our criminal justice system as
more and more people of color's DNA profiles are included in databases that make
them potential suspects whenever DNA is recovered from a crime scene. The effects of this
taken from innocent people will thus remain in these criminal databases.

disproportionate inclusion of people of color in the databanks are made clear by the other papers in this series on
genetics and race. What is perhaps less clear is how our criminal justice system, which promises equal justice under
the law, can tolerate this injustice. This paper, after outlining the legal growth and transformation of DNA
databanks, examines how various steps in our criminal justice system create and magnify racial disparities, and

taking DNA
samples at various stages in this process may affect these disparities and the factors
that cause them. I use as my primary example California's system because it is one of the world's largest
how the law makes it nearly impossible to effectively address the problem. It also looks at how

criminal justice systems in one of the nation's most diverse states. It is also the system in which I have practiced
law for the last decade, and is representative of where DNA databanks throughout the country will likely be in the
next few years as more and more states and the federal government collect DNA from arrestees.[2] DNA databanks
comprise two distinct components: the actual biological samples and the computerized database of the profiles

biological samples are

collected from crime scenes (forensic samples) and from known individuals (known samples).
generated by analyzing these samples. In criminal-justice databanks, the

Until recently, known samples were usually obtained by drawing blood, although now most states and the federal

The
government analyzes both forensic samples and known samples to create DNA profiles, which are
essentially a digitized description of 26 parts of the DNA molecule . The profiles are then
uploaded to the Combined DNA Index System ("CODIS"), a centralized, searchable law
enforcement database accessible to state, federal, and international law
enforcement agencies. CODIS was created by the FBI in 1994 after Congress authorized it to establish a
government primarily obtain samples by swabbing the inside of the person's cheek to collect skin cells.[3]

national DNA database to link existing state and local databanks. The biological samples themselves are retained

Once an arrestee's profile is uploaded into

CODIS, it is immediately compared to the thousands of crime-scene samples in the
CODIS forensic database. As long as the arrestee's profile remains in CODIS, any new crimeby the local police or crime lab for later testing.

scene samples will be searched against it. When an arrestee profile exactly matches a crime-scene
profile, CODIS automatically notifies agencies that provided the sample. Then that agency will usually provide the

DNA databanks
have expanded the range of people
subject to having their DNA forcibly seized, analyzed, and the resulting profile
databanked. California's databank is a good example of this. It was originally conceived as a way to connect
identity of the arrestee to the agency with jurisdiction over the crime so that it can follow up.
have grown exponentially in the last decade as new laws

people convicted of serious violent crimes with other such crimes in which DNA evidence is most useful. The
original 1989 DNA-collection law established a databank and required people convicted of murder or a felony sex
offense to provide DNA samples before they were released from custody.[4] The state department of justice had the
authority to analyze these samples and include the resulting analysis in the new statewide databank.[5] From
today's perspective, this program seems quite limited: the only people subject to having their DNA databanked had
been convicted of very serious crimes, either by pleading guilty or after the charges had been proved beyond all
reasonable doubt to a jury. But the law soon began to expand to include more people. The first steps were modest:
in the late 1990s, new crimes were added to the list of qualifying offenses, and the law was amended to require that
samples be taken immediately after conviction, rather than just before release. The latter change was enacted as
the focus shifted from preventing new crimes to solving old crimes. In 2004, California

voters enacted

Proposition 69, drastically expanding the database . The two biggest changes were that, as of
November 2004, every person convicted of any felony - which can include simple drug
possession, shoplifting, or even intentionally writing a check without sufficient
funds to cover it - has had to provide DNA samples. And, as of January 1, 2009, every person
arrested for a felony in California must give a DNA sample. Prop. 69 thus radically changed the database from one
comprising profiles of individuals convicted of violent felonies to one that includes profiles from suspected

This huge increase is not distributed equitably among all people. AfricanAmericans comprise 6.7% of California's population, but 21.5% of those arrested for
felonies in the state.[6] Although, as discussed below, the possibility of race-based decision-making at all levels
shoplifters.

of the criminal justice system makes it impossible to know whether changing from a database of people convicted
of felonies to one including everybody arrested for felonies will result in an increase in the proportion of people of
color in the database it will clearly result in a significant increase in the absolute number of minorities included.
Racial disparities fluctuate depending on the stage of the criminal proceeding from the high-level initial decision to
make certain acts criminal, to a police officer's decision to contact or arrest an individual, to the decisions made by
prosecutors, judges, jurors, and defense lawyers. Thus, the stage at which DNA samples are taken will affect the
racial disparities in the databank, albeit in unpredictable ways. The first and broadest stage at which racial
disparities are introduced into the criminal justice system is at the legislative level, where crimes are defined and
classified. The basic question is, of course what conduct is considered criminal: why is a person who possesses
drugs subject to criminal sanctions while a business that puts its workers or consumers at risk with dangerous or
unsanitary facilities subject only to civil sanctions? Even beyond that basic issue, our criminal justice system treats
very similar conduct differently in ways that create racial disparities. The most notorious example of this is the
crack versus powder forms of cocaine disparity in the federal system, which for years punished people convicted of
crack cocaine offenses (well over 80% of whom are African- American) much more severely than powder cocaine
offenders (72% of whom are white or Hispanic).[7] The legislative establishment of "drug-free zones," often around
schools, parks, or public-housing projects, can also have racially disparate effects.[8] These laws mean that people
who live and commit drug crimes in dense urban areas, where few locations are not close to a school or park, will
be punished more harshly for the same conduct than are their suburban or rural counterparts. Because urban areas
usually have higher proportions of people of color, these harsher punishments will reinforce racial disparities.

Laws like these interact with seemingly race-neutral DNA collection laws to produce
great disparities in the databank. A databank that includes all persons convicted of
felonies will include every person - primarily people of color - convicted of
possessing cocaine or heroin, no matter how small the amount; but it will not
contain samples from people - primarily white - convicted of minor
methamphetamine offenses that were prosecuted as misdemeanors . Conversely, a
databank that includes only violent crimes or sex crimes - as many originally did - should result in fewer disparities
than an all-felony database for the reasons just described. Excluding non-violent crimes is reasonable since DNA

DNA databanks themselves create a

feedback loop that further magnifies these disparities. Well over half of all serious crimes
evidence is almost never involved in non-violent offenses.

go completely unsolved, with the police never even identifying a suspect. If DNA databanks work as they are
intended, they will identify suspects for at least some - perhaps many - of these crimes. But

a racially skewed

databank will produce racially skewed results; because racial disparities in the
criminal-justice system have led to the inclusion of a disproportionate number of
profiles of African-Americans in CODIS, the databank will return a disproportionate
number of matches to African-American suspects . In contrast, crimes committed by members of
groups that are underrepresented in CODIS will escape detection, particularly as the police spend an increasing
amount of their limited time and resources focusing on cases where they have found a DNA match. The U.S.
Constitution, as interpreted by the courts, does not prohibit this shift, regardless of the racial disparities it

the Fourteenth Amendment's promise of equal

protection of the law prohibits only intentional discrimination, which means that
challenges to criminal laws that result in racially disparate impacts are extremely
difficult. In the words of the U.S. Supreme Court, discriminatory intent means "more than intent as volition or
introduces. The courts have held that

intent as awareness of consequences. It implies that the decision-maker, in this case a state legislature, selected or
reaffirmed a particular course of action at least in part because of, not merely in spite of, its adverse effects upon
an identifiable group." If the governmental body would have acted the same way even without the discriminatory
intent, the law stands. The United States Court of Appeals has applied these same principles to reject an argument
that the racial disparities in the federal DNA database made it unconstitutional.[9] No matter how disparate the
impact of the database, without indications that Congress enacted it in order to adversely affect African-Americans,
the challenge failed. A second policy-level set of decisions also creates racial disparities: the allocation of lawenforcement resources. The clearest big-picture example of this is the so-called "war on drugs," which is largely
responsible for filling our prisons with men and women of color over the last 30 years.[10] A war on securities fraud
or tax evasion would result in the arrest and prosecution of a very different demographic. Yet resources for
combating white-collar crimes have been cut, despite evidence that violations are common and devastating to our
society, as evidenced by the current global impacts of finance fraud. On a smaller scale, police decisions to conduct
buy-bust operations in specific neighborhoods - where undercover officers attempt to buy drugs from people on the
street and then arrest anybody who sells them the drugs - mean that the police choose who will be targeted based
on what neighborhood is chosen for the operation. These operations usually occur in poor, urban neighborhoods
with large minority populations. Racial disparities also enter through racial profiling by individual officers. Studies
have shown that some mixture of unconscious racism, conscious racism, and the middle-ground use of criminal
profiles often leads law enforcement to focus its attention and authority on people of color. This can include
everything from discriminatory enforcement of traffic laws to detainment and arrests of people of color without
sufficient individualized suspicion. As with challenges to legislative actions, challenges to racial profiling under the
Constitution are extremely difficult because of the need to show discriminatory intent. The difficulty is magnified
because the law gives police officers substantial discretion as to who they approach, stop, question, or search. The
Supreme Court has held that the police may lawfully make pretextual stops - for example, singling out one speeding
driver among many because the officer has a hunch that they may be carrying drugs. This means that, although the
police may not stop a person based solely on race, there are many explanations an officer can give if called upon to
explain a stop: the driver or passenger's nervous glance, reduced speed upon seeing the officer, a pedestrian
wearing a heavy coat on a warm day, and so on. None of this behavior alone would justify the stop of a car, but
such seemingly innocent actions are enough to justify the officer's decision to stop this particular car for driving a
few miles per hour over the speed limit while ignoring all the others that did the same, or to stop a particular
individual for jaywalking while ignoring similar violations. Even if a court determines that an officer did make a stop
based on nothing more than the driver's race, the only remedy is the possibility of a civil suit against the officer.
Unless serious harm was done, this is highly unlikely to occur, so it is not a significant deterrent to such police
abuse of power. Arrestee sampling adds another incentive for police officers to make questionable or outright illegal
arrests. Whether or not the arrest leads directly to charges being filed, the arrestee's DNA profile will automatically

Because of the
barriers to having DNA samples removed, few arrestees will be able to have their
samples and profiles expunged, thus allowing a single law enforcement officer the
power to place people under lifetime genetic surveillance. The low level of proof required
be included in the database and run against all crime-scene evidence, now and in the future.

to make an arrest, combined with the difficulties of preventing arrests that are illegal for lack of proof or for

DNA collection immediately after arrest will lead

to large databases full of innocent people. Furthermore, given the ubiquity of racial
profiling, people of color will largely populate the databases . The bottom line is that police
end up with enormous discretion to determine who is in a database, with absolutely
no review of many of their arrests. The consequence of the arrest of a plainly and indisputably
innocent person will be not only a short stint in jail, but a lifetime of genetic surveillance.
discriminatory enforcement of laws, means that allowing

Genetic discrimination results in workplace discriminationincentivizes companies to test potential employees

Broome 2 (Zachary Broome. University of Alabama. MBA. The Legal Issues of
Genetic Discrimination. P. 40-41.
http://www.bama.ua.edu/~joshua/archive/aug06/Zach%20Broome.pdf)//EMerz
In contrast to the positive benefit genetics presents in homosexual discrimination, a
second area of legal debate stemming from genetic research is that of workplace
discrimination. A watchword of many companies when considering employees is
liability, or the potential responsibility a company might have for any employee who
causes damage while at work. Presently, liability for things like violent behavior can
only be determined based on prior offenses, such as a criminal record. With the
advancement of genetic research, there have been 41 claims that some people
contain predispositions towards violence and anger. Mark Rothstein, in an article for
the American Judicature Society, questioned if employers in the future have a duty
to review medical records or conduct their own medical testing to determine
whether applicants had genetic indicators of an increased risk for violent behavior
If behavioral genetic tests were on the market and their use by employers was not
unlawful, it is possible that a jury might impose liability for failure to use them.
(Rothstein) For many companies, being liable for a single lawsuit could cost them
millions of dollars. Testing would not be limited to violent characteristics, but could
also be applied to any sort of negative predisposition, such as drug and
alcohol abuse. Therefore, it is not only conceivable but also likely that many
businesses would require testing of all potential employees and only hire those that
possessed no threat of litigation or deviant behavior. Some critics of legislating
against genetic discrimination argue that discrimination in the workplace is purely
hypothetical and does not warrant creating new laws. They contend that critics like
Rothstein are too focused on possibilities. The problem with that belief is it is simply
not true. In a statement released by the ACLU, it was noted, Genetic testing in the
workplace is on the rise. In 1982, a federal government survey found that 1.6% of
companies who responded were using genetic testing for employment purposes. 1
In a similar survey conducted by the American Management Association in 1997, 610% of employers were found to be conducting genetic testing. 2 Moreover, there
have been many documented cases of genetic discrimination. 3 In a survey of
nearly 1,000 individuals who were at risk for genetic conditions, over 22% reported
that they had experienced some form of discrimination based on their risk status. 4
The U.S. Department of Labor has found genetic information to be a very serious
workplace issue. 5 (ACLU; all numerical citations reflect citations of ACLU
columnist as noted in subsection of sources) As this release contends, genetic
discrimination is rising, and rising unabated because it is legal. There is little
opposition in contemporary legislation to employers enjoying a hiring bias based on
genetic predispositions, primarily because the research of the Humane Genome
Project is the first time such a possibility has existed. Realizing the high potential
for, and beginnings of, discrimination by employers, the Humane Genome Project
created a research department called Ethical, Legal, and Social Issues (ELSI) in 2003
to determine ways to prevent such problematic consequences of sequencing the

genome. ELSI noted that the Americans with Disabilities Act of 1990 is the best
source of protection against genetic discrimination, but is still weakened by the
simple flaw that it never explicitly provides for discrimination based on genetic
testing. The problem with the ADA is it only specifically prevents discrimination
against expressed genetic conditions, not those merely represented in a persons
DNA. This makes the law almost useless in combating employer discrimination,
which focuses on sifting out workers with the potential for problems.

Genetic discrimination promotes eugenics- that treats disabled

people as a lower class
Broome 2 (Zachary Broome. University of Alabama. MBA. The Legal Issues of
Genetic Discrimination. P. 40-41.
http://www.bama.ua.edu/~joshua/archive/aug06/Zach%20Broome.pdf)//EMerz
While the issue of discrimination is generally considered only in terms of limiting the
rights of current members of society, one emerging branch of genetic discrimination
being contested is eugenics. Eugenics carries a certain social connotation of radical
ideals of racial purity, but actually refers to any sort of manipulation of the gene
pool to produce desired offspring. The issue proposed by critics of new research is
that advanced genetic testing allows potential parents to select which children they
want to consider rearing based solely on genetic discrimination of potential flaws.
While this seems an honest enough process, some groups, such as fundamentalist
Catholics and radical disability activists, view this as a medical version of negative
eugenics. Negative eugenics is defined by one group as preventing the births of
children, with characteristics (genotypes/phenotypes) viewed as unhealthy or
undesirable or preventing child bearing by "undesirable" individuals. (Wolbring)
Many people who argue against discrimination of genetically flawed embryos and
fetuses say that doing so not only reinforces the social stigma attached to those
born with disabilities, but also implies that some forms of life are better. The law, by
contrast, is in favor of those who do wish to be selectively pregnant and avoid
genetic disorders. The most basic, and famous, ruling in the matter is Roe v. Wade,
which contends that women have the right to abortion regardless of reason. In
addition, there is no legal stipulation on in vitro fertilization clinics as to what
embryos can or cannot be implanted into the mother. Unlike previous discussions of
genetic discrimination, in the situation of pregnancy there is nothing legal the
dissenting group can do. Selective pregnancy, through whatever means, is a
constitutionally guaranteed right and precludes any arguments against
discriminatory practices. The issue of genetic discrimination, especially in the
workforce, is something that must be decided by changes in legal issues. As noted,
when there is no legal recourse for those with unfavorable genetic conditions, both
employers and insurance companies will take advantage of the unfortunate. In
addition, both the government and scientific community have a responsibility to
protect those who might be harmed by the decision to pursue knowledge of
genetics. The advances in science allow for a better understanding of the genome,
but also provide another potential outlet for social division on physical premises. In
essence, measures must be enforced to ensure that the civil rights of those with

genetic predispositions will be secure, or the country will create a potential for
tragedy.

Genetic discrimination otherizes people with diseases and

disabilities
Lemke 13 (Thomas Lemke. Heisenberg Professor of Sociology with focus on
Biotechnologies, Nature and Society at the Faculty of Social Sciences of the GoetheUniversity Frankfurt. Perspectives on Genetic Discrimination. 2013. P. 2-3.
http://samples.sainsburysebooks.co.uk/9781134056910_sample_508168.pdf)//EMer
z
One may wonder whether today we have reached the age of the gene police
predicted by Canguilhem in an almost visionary fashion.2 A series of empirical
studies conducted in different countries in the last twenty years has pointed to new
forms of exclusion, disadvantage, and stigmatization caused by the increase of
genetic knowledge (Billings et al. 1992; Geller et al. 1996; Low, Kind, and Wilkie
1998; Otlowski et al. 2007; Taylor et al. 2008). The spectrum of this genetic
discrimination ranges from labor market exclusion and problems with insurance
policies to difficulties involving adoption agencies. Thus, applicants job
qualifications have been rejected, and they have been denied employment on the
grounds of a possible future disease. Similarly, health and life insurance companies
have cancelled or refused to issue policies when genetic risks were suspected
among their (potential) customers. In other cases, couples were denied child
adoption when one spouse had a disposition for a genetic disease. Experiences of
genetic discrimination have also been documented with regard to the health sector,
the education system, and the military. The hopes of a molecular medicine, able
to identify and prevent disease before concrete symptoms manifest themselves, are
overshadowed by the nightmare of a society in which career prospects, insurance
options, educational pathways, and family planning are determined by genetic
characteristics. The academic discourse surrounding the negative consequences of
growing genetic knowledge is dominated by the fear of a genetic underclass
(Nelkin and Tancredi 1994: 176; Nelkin 1992: 190; Keays 2000: 8485; Kutter and
Ruess 2001) or new pariahs (Kitcher 1996: 127)individuals stigmatized,
pathologized, and discriminated against on the basis Introduction 3 of their genetic
properties. The main concern is that innovations relating to genetic
knowledge will produce new types of class formation not based on socioeconomic status, but on genetic criteria. A danger is seen in a genetocracy
with individuals, ethnic groups, and races increasingly categorized and stereotyped
by their genotype, making way for the emergence of an informal biological caste
system in countries around the world (Rifkin 1998: 3; cf. also Dickens 2001: 105
106). Apart from academic discourse, the problem of genetic discrimination has now
prompted regulatory initiatives at the juridical and political level to determine the
conditions and limitations concerning the use of genetic information. Many countries
have introduced laws designed to prevent the discriminatory treatment of
individuals due to their genetic properties. These legislation projects guarantee the
right to self-determination and genetic privacy, and protect personal data against
misuse.

Surveillance Bad - Privacy

Medical privacy is a bulwark against violent totalitarianism and
fascism
Faria 98 (Miguel A. Faria Jr. MD is a consultant neurosurgeon and author of Vandals at the Gates of Medicine
(1995) and the newly released Medical Warrior: Fighting Corporate Socialized Medicine (Macon, Georgia, Hacienda
Publishing, Inc., 1997). He is also the Editor-in-Chief of the Medical Sentinel.
, Patient Privacy and Confidentiality --- Time to Draw the Line
http://www.haciendapub.com/medicalsentinel/patient-privacy-and-confidentiality-time-draw-line)///CW
The dismemberment of the medical profession continues unabated in the age of managed care, HMOs, and
corporate socialized medicine. The patient-doctor relationship, erstwhile based on trust and beneficence, has been
eroded by the corporatist ethics imposed on the practice of medicine. The situation worsens daily as the excesses
of HMOs are brought to light and patients realize many of their physicians are no longer their advocates but
adversarial gatekeepers, enticed by the managed care organizations (MCOs) to ration medical care - for the

this dismemberment is most

pronounced, aimed like a dagger at the heart of Hippocratic medicine, is the relentless
violation of patient privacy and medical record confidentiality. Privacy and trust in
the patient-doctor relationship have been essential elements in medical ethics and
the practice of medicine. Thus, it's worth examining what the Oath of Hippocrates states regarding this
network's (and the doctor's) economic benefit. One area where

issue: Whatever, in connection with my professional practice, or not in connection with it, I may see or hear in the
lives of men which ought not to be spoken abroad I will not divulge, as reckoning that all such should be kept
secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the
art, respected by all men at all times, but should I trespass and violate this oath, may the reverse be my lot.
Patient confidentiality, then, is not only a time-honored principle of medical practice, but indeed, a strong covenant

Clinton was asked to

invoked the privacy of

of the ethics of Hippocrates, inherent to the honorable medical profession. When President
release his medical records to the public during the 1996 re-election campaign, he

the patient-doctor relationship

and his lawyers refused to do so (recently it has taken subpoenas and a

grave criminal investigation by the Office of the Independent Counsel before the president surrendered certain

Americans should be entitled

to, and afforded, this same right of privacy, and should be concerned about confidentiality for ultimately,
biologic samples and medical information to government investigators).

as patients, we will all have sensitive medical information compiled. Yes, we will all have medical charts compiled
documenting details of our medical history, which should only be inspected by medical personnel to whom explicit
written consent has been given for continuity of medical care, or made accessible to third parties (including the
government) upon written authorization from the patient - each time information is requested, and delineating the
specific need for the disclosure, as well as outlining the manner in which the information will be used.(1) This may

at the time of the Nazi

Third Reich in Germany, where records of those whose life were deemed "not worth
living" were compiled, inspected, and selected by government officials before the intended victims were
sent to the extermination camps. Nevertheless, no one knows what the future will bring. The
holocaust of Nazi Germany, after all, was preceded by the openness, permissiveness, and
seemingly beneficent social and welfare policies of the Weimar Republic . Confidentiality
of medical records is, perhaps, particularly important in the case of psychiatric patient-doctor consultations. In
the Soviet Union, "psychiatric" records of dissidents were kept and used to
document the "illnesses" prior to sending the "patients" for "rehabilitation" in the
gulags of Siberia. In America, only a few years after the stumble of the Soviet bear - and at the height of the
not seem as important in our open and permissive society of the 1990s, as it was

1993-1994 health care debate - Hillary Clinton wanted to establish a Health Security Card with an encoded
computer chip capable of containing 60 pages of potentially prejudicial information (i.e., sexually transmitted
diseases, drug and alcohol abuse, depression, etc.) and sensitive personal data (i.e., living arrangements,
impotence, sexual practices, etc.) on every American - a federal dossier - from personal medical records to
tabulations of individual health care costs (i.e., charges incurred by the government as a result of the individual
acting as a "consumer of finite and scarce health care resources"). As U.S. Supreme Court Justice William O. Douglas
stated in 1996: "Once electronic surveillance...is added to the techniques of snooping that this sophisticated age
has developed, we face the stark reality that the walls of privacy have broken down and all the tools of the police

all three branches of

government are making a mockery of patient record confidentiality and the privacy
(and trust) of the patient-doctor relationship . In fact, patient medical records are being viewed
state are handed over to our bureaucracy."(2) Towards a National ID Card Today,

increasingly as public property and considered "within the public domain" by many government bureaucrats! The
administrative simplification provisions of the Kassebaum-Kennedy law (1996) and the various administrative edicts
from the offices of the Department of Health and Human Services (HHS) and the Health Care Financing
Administration (HCFA) militate, ever more insidiously, for the collection and the electronic transfer of records
(including mental health records), and medical data generated by every patient-doctor encounter. Ironically, the
Kassebaum-Kennedy law* requires HHS Secretary Donna Shalala to make recommendations for preserving patient
confidentiality in medical records. Instead, Sec. Shalala contends that "individuals' claims to privacy must be
balanced by their public responsibility to contribute to the common good, through use of their information for

the government in other communications

paid lip service, in Orwellian Newspeak fashion, to preserving personal privacy ,
the assignment of unique health identification requirements makes a mockery of patient
confidentiality and personal privacy.
important, socially useful purposes..."(3) Although Sec. Shalala and
have

DNA testing violates privacyFirst and Fourth Amendment

Nelkin and Andrews 1(Dorothy and Lori, Department of Sociology and School
of Law, New York University 2 Chicago-Kent College of Law, Illinois Institute of
Technology, DNA identification and surveillance creep Sociology of Health & Illness
Vol. 21 No.5 1999 ISSN 01419889, pp. 689706
http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.00179/pdf 2001 JM)
To the marines, prisoners, and immigrants who challenged mandatory testing, body
tissue holds religious, social and political meanings, and privacy concerns were
critical. For Native American Donald Power, the militarys taking of DNA violated his
religious beliefs. Mayfield and Vlacovsky defined their DNA in terms of personal
identity. And even prisoners, whose privacy rights are compromised, defined the
taking of DNA as different from the searching of prison cells or body cavities. While
convicted felons would have lesser rights than other individuals, the potential uses
of forensic DNA banks affect more than just criminals. Those tested in a DNA
dragnet because they happen to be in an area will then have their DNA samples on
file. Victims also have their DNA tested at forensic labs and their samples may be
banked. Family members related to the offenders are also affected because health
information about the offender (say, a genetic predisposition to cancer) indicates
genetic risks to relatives as well. Collecting tissue samples from an individual who
has not been charged or convicted of a crimeas in a DNA dragnetcould violate
the persons Fourth Amendment right to be free from unreasonable searches and
seizures. However, persuaded by the scientific nature of profiling, courts have
allowed the random stopping of individuals thought to fit criminal profiles of
hijackers or drug smugglers. One judge, referring to a hijacker profiles as elegant
and objective was convinced that hijackers had characteristics markedly
distinguishing them from the general traveling public (US v. Lopez 1971 As a
controlling tool for modern institutions and complex organisations, the use of DNA is
appealing. But in light of problems of privacy and potentials for abuse,
testing should be closely regulated. The Fourth Amendment could be used to
prohibit non-consensual tissue collection so as to limit the taking of DNA samples
(Krent 1992). Informed consent doctrines could be more widely enforced to limit
possibilities of abuse. Or the property interests in the body could be recognised,

giving people greater control over what is done with their tissue (Andrews 1986).
There could be greater limits on access to DNA information: Vermont legislation, for
example, includes language in a databanking bill to prohibit the use of genetic
information as a basis for employment and insurance decisions. Though the practice
of testing and banking DNA is extending to a widening range of peoplefrom
soldiers who go to battle to chaplains assistants, from violent to nonviolent felons,
from immigrant families to foreign adopteesthere has been little public concern
about the practice. The possibilities of error are deflected by faith in science and,
especially, the promise of genetics. Potential abuses of DNA data are deflected by
perceptions that surveillance pertains to othersthe soldier, the criminal or the
illegal immigrantand a belief that DNA identification is an efficient means to
maintain social order. Moreover, Americans these days have few expectations
of privacy, accepting surveillance in many spheres. Shoppers accept television
surveillance in department stores, strollers accept camera surveillance in public
parks (Nelkin 1995). The dossier society that Laudon and Rule predicted years ago
has crept up on us; facilitated by the ability to gather, store, and access information
not just about finances, credit rating, or consumer preferences, but about the
body, identity, and health. In 1972, a legal scholar wrote that the social security
numbers assigned to us at birth have become a leash around our necks, subjecting
us to constant monitoring and making credible the fear of the fabled womb-to-tomb
dossier (Miller 1972). Could DNA identifiers eventually replace social security
numbers, requiring every person to have DNA on file? Today, according to Janet
Hoeffel (1990), It is not merely paranoia to imagine the incremental steps the
current government would take that would lead from a data bank with DNA profiles
on criminals to a data bank with profiles on each of us. Indeed, molecular biologist
Leroy Hood has predicted that within 20 years all Americans will carry a credit card
type plastic stripe that contains computer readouts of their personal genomes: Your
entire genome and medical history will be on a credit card (Hood 1996)

Genetic surveillance is a serious intrusion of privacy and

contradicts democratic principlesthe result is totalitarianism
Roberts 11 (Dorothy E. Roberts, Kirkland & Ellis Professor, Northwestern
University School of Law; faculty fellow, Institute for Policy Research)(Collateral
Consequences, Genetic Surveillance, and the New Biopolitics of Race, Howard Law
Journal, Vol. 54 No. 3, 2011)//ASMITH
Government DNA data banking began as a targeted procedure to assist law
enforcement in identifying perpetrators of a narrow set of crimes.59 It has
expanded into a form of state surveillance that ensnares innocent people or petty
offenders who have done little or nothing to warrant the collateral intrusion into
their private lives. Databanks no longer detect suspectsthey create suspects from
an ever-growing list of categories. Even so, the public shows little alarm about the
massive retention of genetic information because the balance between protecting
individual privacy and keeping the streets safe seems to fall in favor of more law
enforcement. DNA profiling is a far more precise and objective method of identifying

suspects compared to less sophisticated law enforcement techniques, such as

eyewitness identification or smudge fingerprints found at a crime scene.60 Far from
feeling threatened by this gigantic storehouse of genetic data, many Americans see
it as a surefire way of catching criminals and ensuring that only guilty people are
convicted of crimes.61 Storing an innocent persons DNA seems a small price for
such a great public good. The countless cases where DNA data banking either
yielded no benefit or produced erroneous identifications received little attention
from the media. Moreover, the public does not hear from the thousands of innocent
people whose DNA was seized and stored against their will. Although DNA testing
has shed light on the injustice of false convictions, it cannot solve the underlying
problems that lead innocent people to be convicted in the first place. Most wrongful
convictions result from deep biases in the criminal justice system that make poor,
minority defendants vulnerable to police abuse, misidentification, and inadequate
representation.62 False confessions coerced by the police are one of the main
causes of wrongful convictions.63 According to the Innocence Project, In about
[twenty-five] percent of DNA exoneration cases, innocent defendants made
incriminating statements, delivered outright confessions or pled guilty.64 Coerced
false confessions were a factor in fifteen of thirty-three exonerations won by the
Center on Wrongful Convictions.65 It makes no sense to correct a problem created
by law enforcements abuse of power by handing over even more authority to law
enforcement in the form of DNA collection. The way to reduce wrongful convictions
is to remove the biases based on race and class that corrupt our criminal justice
system. Extending the reach of state surveillance does just the opposite. Besides,
contrary to the publics belief that DNA evidence is infallible, there have been
numerous cases of errors in the handling and analysis of DNA that have led to false
accusations and convictions of innocent people.66 These weaknesses in the states
use of DNA data banking as a tool for reducing crime make it harder to justify the
resulting breach of individual privacy. Society recognizes that the government
violates its civil liberties if it taps our telephones or secretly searches our homes
without court permission.67 Collecting and storing our DNA is also a serious
intrusion into our private lives because DNA is a part of the body; taking it without
consent violates our bodily integrity. In addition to this material aspect, DNA
contains sensitive personal information that can be used to identify our family
members and us, can be matched with other private records, including medical
files.68 Society tolerates the state forcibly extracting highly personal data from
people convicted of serious crimes because these offenders have a diminished right
to privacy as a result of their antisocial conduct.69 But as the categories of people
who are compelled to submit DNA broaden, it becomes less clear why the state
should have so much power over them. Once compelled DNA collection goes
beyond murderers, rapists, and armed robbers, law enforcements need for a suspects DNA lessens and the right to retain control over their private information
strengthens.70 Although people convicted of heinous crimes may forfeit their claim
to privacy, there is no such justification for seizing genetic samples from someone
who has, say, forged a check. State agents should be required to obtain informed
consent to take or test DNA from anyone who has not been convicted of a serious
crime. Although U.S. courts have been slow to recognize this threat to civil
liberties,71 in 2008, the European Court of Human Rights unanimously held that the

United Kingdoms storage of DNA for purposes of criminal investigation infringed

privacy rights protected by Article 8 of the European Convention.72 The European
Court was especially troubled by the indefinite retention of genetic information
taken from children and adults who were never convicted of a crime,73 stigmatizing
them as if they were convicted criminals. This equation of the innocent and the
guilty disregards the presumption of innocence accorded to citizens in a democracy.
Massive government collection of DNA transforms the relationship between citizens
and their government in ways that contradict basic democratic principles.74
Government becomes the watchdog of citizens instead of the other way around.
Although they are guilty of no wrongdoing, huge segments of the population are
perpetually under suspicion. Citizens can no longer rely on the state to safeguard
their privacy by forgetting their past behavior because evidence about them is
stored forever.75 The state has the authority to take citizens private propertyin
this case, their genetic informationwithout due process.76 Those are features of a
totalitarian state, not a liberal democracy.

Public health surveillance risks invasions of privacy and

previous cases fail to addresses status quo conditions
Mariner 07 (WENDY K.MARINER, Professor of Health Law, Bioethics and Human
Rights, Boston University School of Public Health; Professor of Law, Boston
University School of Law; Professor of Socio- Medical Sciences, Boston University
School of Medicine. J.D., Columbia University School of Law; LL.M, New York
University School of Law; M.P.H., Harvard School of Public Health.)(MISSION CREEP:
PUBLIC HEALTH SURVEILLANCE AND MEDICAL PRIVACY, BOSTON UNIVERSITY LAW
REVIEW, Vol. 87:347, 2007)//ASMITH
Today, almost everyone, regardless of station, could be subject to public health
surveillance. The scope of public health surveillance has grown significantly beyond
its contagious disease origins. Public health organizations now recommend
compulsory reporting of more than sixty infectious diseases, twenty-nine genetic
conditions (for newborns), almost all types of cancer, and other chronic diseases like
asthma and lupus.14 The Bush administrations National Strategy for Pandemic
Influenza has given the Department of Homeland Security the task of developing a
National Biosurveillance Integration System (NBIS) to integrate surveillance data
about agriculture, food, environment, and human diseases.15 In January 2006, the
New York City Department of Health and Mental Hygiene began requiring
laboratories to submit electronic reports of the blood sugar test results of all
patients with diabetes, by name and without patient consent.16 The Health
Department intends to contact patients who are not controlling their blood sugar to
encourage taking medications, better diet, and more exercise.17 Although there will
always be a need to investigate disease outbreaks in order to prevent epidemics,
the more prevalent use of disease surveillance data today is for statistical analysis,
planning, budgeting, and general research.18 This new generation of reporting laws
reflects a goal of many people in public health: to collect data about chronic
diseases outside the context of a research study and without the need to obtain any

individual patients informed consent. The question is whether these new

surveillance programs should be able to compel the collection of personally
identifiable data. Is it possible to reconcile individual interests in personal privacy
with modern forms of public health surveillance? Are mandatory public health
surveillance programs that focus on statistical analysis, research, or monitoring
personal health status a reasonable exercise of the states police power, or are they
vulnerable to challenge as an invasion of privacy? Do they offer the promise of
medical advances, or the threat of general searches, which the authors of the Bill
of Rights were so concerned to protect against?19 This Article begins to answer
these questions. Part I summarizes the evolution of public health surveillance
programs. Part II describes three major functions of surveillance programs: outbreak
investigation, identifying newborns who need essential medical care, and research.
It also highlights how the aim of those who collect medical information has shifted
from preventing the spread of contagious diseases to the more general purposes of
research, budget analysis, and policy planning.20 This shift poses a challenge to the
principles of liberty and privacy that underpin ones individual autonomy to decide
whether to participate in research or to accept medical care. Part III argues that the
sparse case law on constitutional challenges to compulsory reporting laws offers
only a fragile conceptual framework for modern public health statutes that compel
the disclosure of personally identifiable information. The cases themselves offer
little guidance, often ignoring how surveillance information is used and how
valuable the right of privacy is to individuals. Modern health surveillance programs,
with their focus on obtaining data accurate enough to use for statistical analysis and
research, do not easily fit the legal constructs guiding earlier laws designed to
prevent epidemics. At the same time, the general goal of improving public health
fails to provide any principle for limiting government intrusions into medical privacy.
The Article concludes that modern public health surveillance needs defensible
principles that define the scope and limits of state power to collect personally
identifiable medical information. Part IV outlines a more robust approach to
balancing the states interest in public health and the individuals interest in the
privacy of medical information. This approach weighs the present value of the
actual use of the information (instead of speculative longrange goals) against the
dignitary value of privacy. Although space precludes a fully developed argument, I
hope this Article will inspire thoughtful efforts to retain the value of modern public
health surveillance without sacrificing the value of patient privacy.

State data collection without consent invades subject rights

Mariner 07 (WENDY K.MARINER, Professor of Health Law, Bioethics and Human
Rights, Boston University School of Public Health; Professor of Law, Boston
University School of Law; Professor of Socio- Medical Sciences, Boston University
School of Medicine. J.D., Columbia University School of Law; LL.M, New York
University School of Law; M.P.H., Harvard School of Public Health.)(MISSION CREEP:

PUBLIC HEALTH SURVEILLANCE AND MEDICAL PRIVACY, BOSTON UNIVERSITY LAW

REVIEW, Vol. 87:347, 2007)//ASMITH
Several states have gone beyond authorizing the creation of cancer registries, and
have enacted laws or adopted regulations that either permit or require medical
providers to report cancer cases to a registry without their patients consent.106 In
some states, advocacy groups lobbied state legislatures and health departments for
a centralized source of information, either in an attempt to explain unusually high
rates of cancer in their communities or in response to fears of exposure to hazards
from local manufacturing plants.107 The more important factor appears to be the
availability of federal grant funds to create or expand a registry.108 CDC prefers
that registries be located in states that require the reporting of cancer cases by law.
Although the National Cancer Act does not require states to enact any particular
laws, undoubtedly because such a federal requirement would violate state
sovereignty,109 grants are unlikely without a mandatory reporting law. The Act
requires that statewide cancer registries be legally authorized to obtain all medical
records of cancer patients from any individual or organization providing cancer
services in order to be eligible for funding.110 It would be difficult to assure access
to all records without dispensing with consent.111 Arguably, any use of personally
identifiable surveillance data apart from outbreak investigation and epidemic
containment could qualify as research with human subjects. Cancer registries
squarely present the question of whether the state can demand access to an
individuals personally identifiable information for use in research without consent.
Since the Nuremberg Code was issued in 1947, research with human subjects has
been deemed unethical and unlawful unless the subject gives voluntary, informed
consent.112 The consent requirement is intended to protect the individuals right of
selfdetermination and the dignity of human beings recognized in all international
declarations and covenants on human rights.113 Without informed consent,
humans are being treated only as a means to an end.114 These foundational
principles have been embodied in the common law,115 and in regulations
governing federally funded research known as the Common Rule,116 and may
have constitutional protection.117 All of these sources support the conclusion that
the use of personally identifiable information for research purposes without the
subjects consent violates the subjects rights.118

A2 Politics

Link Turn
The plan is popular tech companies will push for the plan and
it has widespread support
Young 14 (Kerry Young, Roll Call Staff, graduate of Tulane University)(Tech Firms
Ask Congress to Redefine Medical Privacy Rules, Sept. 8, 2014, Roll Call,
http://www.rollcall.com/news/tech_firms_ask_congress_to_redefine_medical_privacy_
rules-236069-1.html?pg=3&dczone=policy)//ASMITH
Tech firms, including Amazon.com Inc., are asking Congress to redefine the rules on medical
privacy, saying the risks of potential disclosure should be weighed again against the
anticipated benefits of wider sharing and easier access to crucial health data.
Executives of tech companies and health organizations have told the House Energy and Commerce Committee in

conservative stance on health data privacy

is hindering development of new medical technologies and approaches to
treatment, and also adding costs to already burdened state and federal budgets. We, in our effort to protect
recent months that what they consider an excessively

the patients, are constructing a health care system that they and we cannot afford, and were putting the balance in
the wrong spot, Joseph M. Smith, a former Johnson & Johnson medical technology executive who has been involved
with venture capital projects, told the committee in June. In Congress view of trying to protect everyone from that
information, we may be protecting them to death. Much of what health researchers and executives seek involves
more clear guidance on what are known as HIPAA privacy regulations. The name reflects their genesis as an add-on
provision to the Health Insurance Portability and Accountability Act of 1996 (PL 104-191). Yet, these calls for a new
look at HIPAA are coming at a time of marked concern about the sanctity of consumers online accounts health

House Republicans responded with great concern when the Department

of Health and Human Services this month announced that common malware had
been detected on the website for the federal medical insurance exchange. No
personal information was comprised as a result of this intrusion on a healthcare.gov
test server, HHS has said. June brought a furor over the revelation of an experiment seeking to alter the
and otherwise.

emotional state of about 690,000 of Facebook users. Thats likely to heighten peoples concern about how data in
general is shared online, especially medical records, said Justin Brookman, director for consumer privacy at the
Center for Democracy & Technology. By and large, they dont expect that they are going to be guinea pigs, he

In May, HHS
reported a record HIPAA settlement of $4.8 million in a case involving New York
Presbyterian Hospital and Columbia University and medical records for about 6,800
people, including laboratory results . The hospital and Columbia learned of the security lapse when the
said. When we are talking about health information, people feel even more strongly about it.

partner of a deceased patient found that persons health information on the Internet. New York Presbyterian and the
university notified HHS of the security lapse, and theres been no indication any of that information was ever

Still, HHS found their approach to guarding data lacking

and levied the record fine. The complexity of HIPAA regulations and the threat of
inadvertently triggering fines keep many small companies from venturing into
projects that would involve using medical data, Smith said at the Energy and
Commerce meeting in June. Once they understand the HIPAA penalties and the machinery involved and
accessed or used inappropriately.

the limitations that imposes on the value that they could create, they demure, said Smith, now the chief medical
and science officer at the nonprofit West Health Institute, noting this has an effect on the United States health
system at large. The innovative spirit falters when it encounters that immovable object that we currently call

Large companies also are looking for changes in HIPAA. Paul Misener,
Amazons vice president for global public policy, in July told Energy and Commerce
that current rules make it difficult to negotiate contracts for cloud computing
services. Congress should direct HHS to provide more clear guidance on the HIPAA requirements for cloud
HIPAA, he said.

computing when the host firm has no way of accessing the encrypted data that would be stored, he said. The
current interpretation impedes health-care delivery entities from leveraging cloud services by causing the parties
to negotiate a business associate agreement in which virtually all of the terms are inapplicable because the cloud

said These complaints about

HIPAA have caught the attention of a powerful lawmaker who is intent on putting
forth broad bipartisan health legislation in the next session of Congress. We have
heard on numerous occasions that there is a wealth of health data available, but
there are barriers to using it, House Energy and Commerce Chairman Fred Upton,
R-Mich., told CQ Roll Call in an email last week. We are exploring opportunities to break down
services provider does not have access to health information, Misener

those barriers, allowing for greater innovation and advancement, all the while protecting the privacy of our patients.
A look at HIPAA has been part of what Upton calls his 21st Century Cures Initiative, which has drawn federal
officials, including top Food and Drug Administration regulators, to sit and publicly hash out ideas with company
executives and patient advocates. Uptons lead partner in the project is Diana DeGette, D-Colo., and the backers so
far include two Democrats competing for their partys top spot on Energy and Commerce, Frank Pallone Jr. of New
Jersey and Anna G. Eshoo of California. In May, HHS reported a record HIPAA settlement of $4.8 million in a case
involving New York Presbyterian Hospital and Columbia University and medical records for about 6,800 people,
including laboratory results. The hospital and Columbia learned of the security lapse when the partner of a
deceased patient found that persons health information on the Internet. New York Presbyterian and the university
notified HHS of the security lapse, and theres been no indication any of that information was ever accessed or used

The
complexity of HIPAA regulations and the threat of inadvertently triggering fines keep
many small companies from venturing into projects that would involve using
medical data, Smith said at the Energy and Commerce meeting in June. Once they understand the HIPAA
inappropriately. Still, HHS found their approach to guarding data lacking and levied the record fine.

penalties and the machinery involved and the limitations that imposes on the value that they could create, they
demure, said Smith, now the chief medical and science officer at the nonprofit West Health Institute, noting this
has an effect on the United States health system at large. The innovative spirit falters when it encounters that
immovable object that we currently call HIPAA, he said. Large companies also are looking for changes in HIPAA.
Paul Misener, Amazons vice president for global public policy, in July told Energy and Commerce that current rules
make it difficult to negotiate contracts for cloud computing services. Congress should direct HHS to provide more
clear guidance on the HIPAA requirements for cloud computing when the host firm has no way of accessing the
encrypted data that would be stored, he said. The current interpretation impedes health-care delivery entities from
leveraging cloud services by causing the parties to negotiate a business associate agreement in which virtually all
of the terms are inapplicable because the cloud services provider does not have access to health information,
Misener said These complaints about HIPAA have caught the attention of a powerful lawmaker who is intent on
putting forth broad bipartisan health legislation in the next session of Congress. We have heard on numerous
occasions that there is a wealth of health data available, but there are barriers to using it, House Energy and
Commerce Chairman Fred Upton, R-Mich., told CQ Roll Call in an email last week.

We are exploring
opportunities to break down those barriers, allowing for greater innovation and
advancement, all the while protecting the privacy of our patients. A look at
HIPAA has been part of what Upton calls his 21st Century Cures Initiative, which has
drawn federal officials, including top Food and Drug Administration regulators, to sit
and publicly hash out ideas with company executives and patient advocates. Uptons
lead partner in the project is Diana DeGette, D-Colo., and the backers so far include two Democrats competing for
their partys top spot on Energy and Commerce, Frank Pallone Jr. of New Jersey and Anna G. Eshoo of California.

A2 Bioterrorism DA

No Link
Changing health policies keycurrent policies are more
ineffective
Mauroni 11 (Al, Director of the U.S. Air Force Counterproliferation Center, GAUGING THE RISK
FROM BIOTERRORISM http://warontherocks.com/2014/01/gauging-the-risk-from-bioterrorism/3/ 1/6/15 JM)

The focus of the federal government has been on coordinating a medical response
to biological incidents, given that in the event of certain contagious diseases, the
impact may be global and fast moving. As a result of policy that addresses both
natural disease outbreaks and bioterrorism, there are numerous government
agencies involved. Others have talked about the need to work public health with
national security to address shared health security concerns. However, any focus on
bioterrorism is lost in the greater concern about natural disease outbreaks. The
challenge is one of resources and priorities between public health threats and
deliberate biological threats. The public health community has a prioritized list of
global infectious diseases. Diarrhea, malaria, dengue fever, and seasonal influenza
top the list, followed by strains of hepatitis, HIV/AIDS, typhoid, and meningitis.
Anthrax and smallpox are not listed in the top 30 infectious diseases because there
are not regular outbreaks of those diseases and vaccines exist for both. Among the
60-70 infectious diseases that are tracked by the public health community, about
ten constitute military biological warfare (BW) or bioterrorism threats. If
the public health community is leading the medical response to bioterrorism, we
need to understand that it isnt focused on deliberately released BW threats.
A 2011 CRS report on federal efforts to address the threat of bioterrorism makes
this point. Although there is clear presidential and congressional attention on
bioterrorism, the report notes criticism on the lack of metrics and unclear goals
across the interagency, leading to ineffective efforts. The risk assessment
process does not adequately address the intent and capabilities of deliberate actors.
National bio-surveillance is challenged by expensive environmental sensors. The
investment of billions of dollars into medical countermeasures for BW threats has
been slow to produce results, and has been criticized by those who would rather see
funds invested against public health threats. The CRS report fails to address the
public health community issues overshadowing bioterrorism concerns, but one
should be able to read this between the lines. It may be correct that a response to a
biological incident should not be determined by the threat source (Mother Nature
versus a deliberate actor), but certainly it makes a difference to those federal
agencies responsible to prevent those threat sources from acting and to protect
specific populations (military service members versus the general population).
Defending fit military troops against BW agents on the battlefield (bio-defense) is
very different from protecting young and old civilians from biological hazards
dispersed by extremists (bio-security), which is distinct from protecting the general
public from natural disease outbreaks (bio-safety). Currently, there is no clarity in
national policy to reflect these distinct roles. It is clear that the federal government
has been tasked to defend the public against the threat of bioterrorism. Numerous
government agencies are involved, and given the breadth and depth of this subject,
it is difficult (but not impossible) to address all aspects and programs associated

with the subject. Public health threats are more probable and affect more people
than bioterrorism threats do. But, attempts to get a two for one by tasking
the public health system to address bioterrorism in a holistic all-hazards
approach will fail, resulting in a loss of focus on bioterrorism. The future
challenges of infectious diseases and new biotechnology will continue to require a
hard focus on how we conduct bio-defense, bio-safety, and bio-security. As DoD and
the interagency comes together to develop policies and strategies for countering
biological threats, we need to ensure we are asking the right questions and not
shortcutting the system in favor of quick fixes that may fail to produce viable
results. Above all, we need to abandon rhetorical statements about how the threat
is real and how a terrorist WMD incident will happen within the next five years.
These statements arent resulting in increased resources or attention. Its not 2001
anymore. Its time for relevant analysis against tomorrows challenges.

No Impact
No risk of a bioterror attackits too technically difficult
PressTV 15 (PressTV, reporting source from the UK, Ebola can be weaponized for bioterrorism
in UK: Study page 3 http://www.presstv.com/Detail/2015/02/01/395598/Weaponized-Ebola-could-be-used-in-UK
2/1/15 JM)

The Ebola virus could be weaponized to kill thousands of people in Britain, UK germ
warfare experts have warned. According to an investigation carried out at the
Defense Science and Technology Laboratory at Porton Down in Wiltshire, there are
three scenarios in which the virus could be weaponized for use in the UK, British
media reports. The study was conducted following a request by the government for
guidance on the feasibility and potential impact of a non-state actor exploiting the
Ebola outbreak in West Africa for bioterrorism, The Mirror reported on Saturday.
Following the assessment which was carried out last October, the British
government called for the screening of passengers at Heathrow airport. The results
of the study have emerged in a redacted version edited by the Ministry of Defense
(MoD) and show it would difficult for Ebola to be weaponized by terrorists without
the backing of a government, implying the possibility of the bioterrorist act. This
scenario would be logistically and technically challenging for a nonstate group, read part of the redacted document about the first scenario. There
are practical issues with such a scenario that of themselves are often not
insurmountable but taken together add enormously to the complexity of
successfully undertaking this attack, The Mirror excerpted in relation to the second
scenario. Regarding the third scenario the report said it would be very technically
challenging. The report was redacted by the MoD because it contains details whose
disclosure would prejudice the capability and effectiveness of our forces and safety
of UK citizens. Ebola is a form of hemorrhagic fever, whose symptoms are diarrhea,
vomiting, and bleeding. The virus spreads through direct contact with infected
blood, feces, or sweat. It can be also spread through sexual contact or the
unprotected handling of contaminated corpses.

Checks in place to ensure no impact

MNT 15 (Medical News Today, Leading reporting news source for medical and health news,
Genetic safety switches could help curb potential bioterror risks
http://www.medicalnewstoday.com/releases/288584.php 1/28/15 JM)

The potential threat of bioterrorism using man-made biological organisms could be

reduced, thanks to a new method developed by scientists. Synthetic biologists - who
can design and modify the DNA of living organisms to give them novel, useful
functions - have devised a way of containing their products to help ensure that they
work only as intended. Researchers have developed a set of genetic switches that
can be built into engineered organisms, to control the function of genes they need
to survive. The genetic switches are controlled by the addition of a mixture of
naturally occurring chemicals, which can be customised for a variety of products.

These could prevent potential harm from either the theft or misuse of
these substances, which are used in biofuels, food, and medicines.
Researchers at the Universities of Edinburgh and NYU Langone Medical Center have
developed two types of molecular switch that work in yeast, a commonly used
model organism. The team inserted a second set of on and off switches to target
another vital gene, to mitigate the risk that changes in the live yeast might enable it
to circumvent chemical control. The study, published in Proceedings of the National
Academy of Sciences, was funded by the US Defense Advanced Research Projects
Agency and the Biotechnology and Biological Sciences Research Council. Dr Yihzi
Patrick Cai of the University of Edinburgh's School of Biological Sciences, who jointly
led the research, said: "Synthetic biology is a fast-developing field with huge
potential to benefit society, but we need to be mindful about its potential risks and
take active steps to limit them in our biological designs. With these genetic safety
switches, we can contain engineered organisms with a special combination of small
molecules."

Bioterrorism unlikelytime, resources, danger, dissemination

techniques all check
Ivanov 14 (Sandra, postgraduate education in Peace and Conflict Studies. She is currently an
editor of the blog Conflict and Security, and primarily works in the non-government sector, HOW TO
MAKE THE EBOLA BOMB': WHY YOU SHOULD STOP WORRYING ABOUT BIOTERRORISM
http://cimsec.org/make-ebola-bomb-stop-worrying-bioterrorism/13069 9/23/14 JM)

Many studies from a health, as well as a humanities perspective, assume that

terrorists could successfully generate biological or chemical agents and weaponise
them. Taking this initial premise, a lot of literature has been based around this
looming threat, subsequently offering policy advice, public health
recommendations, and technological investment to avoid such catastrophes.
However it would be useful to deconstruct this claim entirely. So Ill begin by
offering a baking recipe, to explore at the very core, what a group would need to do
to successfully create a biological weapon, in this case, utilising the Ebola virus.
Ingredients Firstly, any terrorist group wanting to create and weaponise a biological
or chemical agent will need to have an appropriate kitchen. In the case of the Ebola
virus, a standard biosafety level 4 (BSL-4) scene will be required (Adeline M.
Nyamathi et al., Ebola Virus: Immune Mechanisms of Protection and Vaccine
Development, Biological Research For Nursing 4, No. 4, April 2003: 276-281). Some
features of these laboratories include decontamination mechanisms, pest
management systems, air filters, and special suits. Sometimes the kitchen will have
to be in a separate building, or in an isolated area within a building to meet the
safety requirements. Not only will the kitchen be under strict conditions, the baking
process will need to be kept in total secrecy. The constant threat of law
enforcements raiding facilities, and intelligence and secret services detecting
activities will have to be avoided. Also, there are only some fifty of these
laboratories successfully maintained worldwide. Before starting, make sure there is
a baking dish of uncertainty readily available to just throw all of the following
ingredients into: 1 Tablespoon of Proper Agent Initially, a terrorist group must decide

what kind of agent they would like to use in a bioterror attack. This is one part of
the recipe which can be modified, but the other ingredients will be standard for all
types of attacks. The recent spread of the deadly Ebola virus will be the agent of
choice for this bomb. Ebola is a virus which is passed to humans through contact
with infected animals. The spread of the virus from person-to-person is brought
about through blood and bodily fluids, as well as exposure to a contaminated
environment. An infected live host with Ebola would need to be maintained in a
human or animal only a few animals are able to be used as hosts, such as
primates, bats, and forest antelope. Although Ebola infection of animals through
aerosol particles can be effective, it has not successfully been transferred with this
method to humans (Manoj Karwa, Brian Currie and Vladimir Kvetan, Bioterrorism:
Preparing for the impossible or the improbable, Critical Care Medicine 33, No. 1,
January 2005: 75-95). 1 Bucket of Resources and Money In order to develop a
biological weapon, a substantial amount of material and money is required.
Investment is needed from the very outset taking into account membership size
and capabilities of a terrorist group, financial assets of a group, and making sure
territory and proper infrastructure is available for the biological agent. For a
successful bomb to be created, a group must think about the resources they will
need for each stage of the baking process, such as weapons production, potential
testing phases, and logistics, such as transportation and communications
technologies (Victor H. Asal, Gary A. Ackerman and R. Karl Rethemeyer,
Connections Can Be Toxic: Terrorist Organizational Factors and the Pursuit of CBRN
Terrorism, National Consortium for the Study of Terrorism and Responses to
Terrorism, 2006). Resources needed for an Ebola Bomb will most likely need to be
imported from the outside, and a group must determine the feasibility of acquiring
the materials and technologies needed for the bomb (Jean Pascal Zanders,
Assessing the risk of chemical and biological weapons proliferation to terrorists,
The Nonproliferation Review, Fall 1999: 17-34). A surplus of money would also be a
smart idea in case technical difficulties arise. 5 Cups of Expertise With all the correct
resources and necessary amount of monetary support, the recipe will require the
right kind of know-how. For an operation like this, a terrorist group should have
members with high levels of education and training in science, engineering, and
technological development, to deal with highly virulent agents, and for successful
weaponisation (Zanders). A group may need to be integrated into knowledge flows
and institutions, or be able to recruit members to their cause with this specific
expertise (Asal, Ackerman and Rethemeyer). Knowledge and expertise is required to
create the correct strain, handling the agent, growing the agent with the desired
characteristics, and maintaining the agent. Taking Ebola specifically requires
synthesising proteins which make it infectious, and becomes a task that is difficult
and unlikely to succeed (Amanda M. Teckma, The Bioterrorist Threat of Ebola in
East Africa and Implications for Global Health and Security, Global Policy Essay,
May 2013). If Ebola is successfully created in the kitchen, it is not itself a biological
weapon an expert will be required to transform the virus into a workable
mechanism for dissemination. A Teaspoon of Risk The decision to use biological
weapons for an attack is in itself extremely risky. There is a risk that
bioterrorism could cause dissenting views among followers, and that
public approval and opinion may channel the way a group operates. After

all, terrorists are political communicators, wanting to bring attention to their

grievances. If a group becomes polarised or resented by their actions, they will not
see the benefits of pursuing certain methods. Terrorists want to send powerful
messages, gain more members, in which these members assist to bring about
certain plans and demands. Therefore, public opinion and political opportunism will
be risked in a quest to create a bioweapon such as an Ebola Bomb (Zanders).
Secondly, a terrorist group may be subject to more scrutiny or attention. This is why
keeping activities covert will be a key to success. States will be more vigilant
towards groups that are known to be seeking and acquiring biological and chemical
capabilities (Asal, Ackerman and Rethemeyer). And finally, risk will always cling on
to funding requirements, and potential technical difficulties in all stages of the
bioweapon making process. A Fist of Time Now this recipe is going to take a while to
prepare and bake in the oven, and there is no particular moment to determine when
it should be removed from the baking dish. So, whatever group wants to make this
bomb, will need to realise this is a long-term and complex effort. It will not work like
most conventional weapons, which produce a high number of casualties with a
single explosion, and that could be a reason why bioterrorism is not the most
popular means for a violent attack demanding time, effort, and resources
without guarantees of a concrete result. A fist full of time may be needed so
that knowledge, both tacit and explicit, can be acquired, as well as accounting for
the various mistakes and learning curves to overcome (Asal, Ackerman and
Rethemeyer). It can also refer to how long it will take to cook up, maintain and
prepare a virus for an attack. It will take time to create a successful weapon with
prior testing, and wait for the correct environmental conditions when it comes to
dissemination. Time will have to be a group investment it is not the kind of bomb
that will detonate immediately. A Pinch of Curiosity of the Unknown The teaspoon of
risk coincides with uncertainty, and there will need to be a commitment to potential
unknown factors. It is unknown what will happen once a virus is disseminated. Will
the weapon even work in the first place? Weather conditions are unpredictable and
Ebola will not have a prominent effect in certain environments. What happens to the
terrorist group if the attack fails? What happens to the reputation of the group and
its membership, or will the group cease to exist? If the recipe is a success, it is
impossible to control the biological agent which is released not only can it affect
the targeted population, but it may annihilate the terrorist group itself. There will be
an unknown into potentially losing local and international support, and donors if this
causes widespread catastrophe. Method: Weaponisation and Dissemination Mix that
up good in your baking dish of what is now deep uncertainty and pop it in the
oven to bake. But as time passes, it seems as though the ingredients are not rising.
The process of turning a biological agent into a weapon for attack is the phase with
the most hurdles for terrorist groups. In order for a virus to inflict a lot of harm, it
has to be disseminated through an effective delivery mechanism. As mentioned
previously, the Ebola virus needs a live host. Weaponising a live host is more
difficult than other agents which can be cultured on dishes of nutrients. The process
has many stages which involve testing, refining, upgrading, and toughening. The
methods to disseminate an agent are only known to few people, and rarely
published it is not a basement project (Teckman). Lets take Aum Shinrikyo as an
example of conducting a bioterrorist attack (even it was only a chemical attack).

This apocalyptic religious organisation in Japan managed to release sarin gas inside
a Tokyo subway, killing a dozen people, and injuring 50. However, even with money
and resources, they failed to effectively weaponise the chemical. Factors which led
to their failure included internal secrecy and breakdown in communication; selecting
members only solely dedicated to their cause to work on the weapons, ultimately
employing unskilled people to operate and maintain the project, causing accidents
and leaks (Zanders). Aum Shinrikyos attempt to disseminate botulinum toxin into
Tokyo using a truck with a compressor and vents, did not work because they had not
acquired an infectious strain (Sharon Begley, Unmasking Bioterror, Newsweek,
13.03.2010; Chronology of Aum Shinrikyos CBW Activities, Monterey Institute of
International Studies, 2001). Finally, a major obstacle to successfully disseminating
Ebola, is because this virus requires a specific environment in order to thrive.
Weather conditions can be unpredictable, and Ebola particularly needs high
temperatures and humidity to remain effective. Obviously, this Ebola Bomb has
not come close to containing the right requirements needed to explode. Looking
back historically, pathogens, and all kinds of toxins have been used as tools in
sabotage and assassinations since the beginning of time. Now, it would be silly to
say this recipe will never work there will always be a possibility that Ebola or other
viruses may be used as biological weapons in the future. However, the likelihood of
its development and use by a terrorist group is quite improbable. Mentioning Aum
Shinrikyo again, they are an organisation which at the time, had a war chest of more
than $300 million, with six laboratories and a handful of biologists, in the end
having insurmountable difficulties with the weaponisation and dissemination
processes, and killing a dozen people (Begley). There is a greater amount of
knowledge and technology available in our day and age than in 1995 with the Aum
Shinrikyo attacks, but it is still unlikely that this will be the weapon of choice.
Examining state biological weapons programmes, Soviet Russia had almost 60,000
personnel employed in their weapons development, with only about 100 people that
actually knew how to take an agent through the full production process. In the
United States, at Fort Detrick, there were 250 buildings with 3,000 personnel, and it
took them a while to weaponise a single agent, such as botulinum (Manoj Karwa,
Brian Currie and Vladimir Kvetan). Nowadays, the narrative has assumed a
worst case scenario analysis, and subsequently narrowed down bioterrorism to a
single threat prognosis. There is little distinction made between what is
conceivable and possible, and what is likely in terms of bioterrorism.
Anything can be conceived as a terrorist threat, but what is the reality? The Ebola
Bomb is not a danger. The likelihood of a bioterrorist attack remains highly
unlikely (Teckman). The focus should be on preventing natural pandemics of human
disease, such as tuberculosis, SARS, AIDS and influenza emphasis placed on how
we can cure diseases, and how medical training could be improved to contain, and
avoid viruses such as Ebola altogether. Resources are being pumped into
biodefence in the security as well as the medical sector, but preparedness and
investment in bioterrorism needs to be in proportion to actual threats, otherwise,
funds are diverted away from much needed public health programmes: Diversion of
resources from public health in the United States include diversion of funds needed
for protection against other chemical risks spills, leaks and explosives and
infectious diseases. Each year in the United States there are 60,000 chemical spills,

leaks and explosions, of which 8,000 are classified as serious, with over 300
deaths. There are 76 million episodes of food-borne illness, leading to 325,000
hospitalisations and 5,000 deaths, most of which could be prevented. There are
110,000 hospitalisations and 20,000 deaths from influenza, a largely preventable
illness, and there are 40,000 new cases and 10,000 deaths from HIV/AIDS. Diversion
of resources for public health outside the US reduce the resources that can help
provide protection against diseases rooted in poverty, ignorance and absence of
services. Victor W Sidel, Bioterrorism in the United States: A balanced
assessment of risk and response, Medicine, Conflict and Survival 19, No. 4, 2003:
318-325. The effectiveness of biological weapons has never been clearly shown, the
numbers of casualties have been small and it is likely that hoaxes and false alarms
in the future will continue to outnumber real events and create disruptive hysteria
(Manoj Karwa, Brian Currie and Vladimir Kvetan). Emphasis needs to be back on
medical research, as well as social science investigations into the roots of why
terrorist groups would even want to pursue biological weapons, and the lengths
they would go to use them. Let this be an avenue for further pondering and
exploring, the realities of bioterrorism.

Bioterrorism wont happentoo many resources are put into

defense
Goonzer 12 (Merrill, reporter for The Fiscal Times, Billions to Stem an Unlikely Bioterror
Attack http://www.thefiscaltimes.com/Articles/2012/03/30/Billions-to-Stem-an-Unlikely-Bioterror-Attack 3/30/12
JM)

Republicans and Democrats agreeing on industrial policy to save the auto industry?
Unthinkable. Republicans and Democrats agreeing on industrial policy to promote
clean energy companies? Absurd. But Republicans and Democrats agreeing on
industrial policy for the pharmaceutical industry to develop drugs and vaccines to
combat bioterror agents? It not only passed by unanimous consent in the Senate
earlier this month, it will likely be approved by the conference committee that will
soon consider the $4.5 billion Pandemic and All-Hazards Preparedness Act (PAHPA),
the reauthorization of the 2006 law coordinating the nations decade-long effort to
prepare for a terrorist biological warfare attack. Despite the reality that the only
bioterrorist attack that has ever taken place on U.S. soil (one week after 9/11) was
launched by a rogue U.S. scientist who had worked in the Cold War biological
weapons program and was one of the worlds few experts in weaponizing anthrax,
the nation has spent an estimated $66 billion in the past decade preparing for the
next assault. Tens of billions of dollars have been poured into basic science and
applied research to develop vaccines and drugs to combat diseases like anthrax,
smallpox (a disease that no longer occurs naturally on earth), botulism and
plague. Billions more has gone into beefing up the public health systems ability to
respond to emergency health crises. Hospitals have been paid to expand their
capacity to respond to surges of patients stricken by a pandemic or a terrorist
attack. These nationwide grant programs have helped build a broad base of political
support for the programs. And now, in the reauthorization bill sponsored by Sen.

Richard Burr, R-N.C., Congress has earmarked $50 million for a strategic investor
venture capital fund to invest in start-up biotechnology companies that are
developing drugs and vaccines that combat bioterror pathogens. Structured as a
public-private partnership outside the government, the goal is to bring more private
funding into the hunt for new countermeasure products. It will be added to the
$450 million a year the government already doles out in grants to companies
through the Biomedical Advanced Research and Development Authority (BARDA)
and the $2.9 billion earmarked over the next five years for procurement of new
drugs and vaccines for government stockpiles. As the votes in Congress attest (the
House version of the bill also passed on a voice vote), the massive commitment to
biodefense spending in the 2000s has won broad support from the nations research
and scientific establishment. The National Institute for Allergies and Infectious
Diseases (NIAID), headed since the 1980s by Anthony Fauci, receives over $1 billion
a year for bioterror-oriented scientific research. The National Cancer Institute, by
comparison, receives about $5 billion to look for cures for the tumors that kill over a
half million Americans annually. Officials at NIAID and legislators on Capitol Hill say
the massive investment in preventing and curing diseases that rarely if ever occur
naturally is providing a huge boost to the moribund U.S. effort to develop new
antibiotics to fight the drug resistant bacterial strains that are causing tens of
thousands of deaths annually in U.S. hospitals. The goal of this basic research is to
lay the groundwork for developing broad-spectrum antibiotics and antiviralsdrugs
that can prevent or treat diseases caused by multiple types of bacteria or viruses
and multi-platform technologies that potentially could be used to more efficiently
develop vaccines against a variety of infectious agents, the agency says on its
website. But some scientists complain that the anti-bioterror research agenda has
detracted from research that specifically targets infectious diseases that are already
killing people, both in the U.S. and in the developing world. Im sure other
programs are reduced because of the money weve put into this, said Peter Agre,
director of the Johns Hopkins Malaria Research Institute and winner of the 2003
Nobel Prize in chemistry for his work on cell membrane channels. Were seeing
scientists who have to prematurely end their careers because they cant get grants.
Is this bioterror the most important and cost-effective research being done on
infectious diseases? I dont think it is. However, the leaders of the Infectious
Diseases Society of America, which represents the medical specialists and
researchers in the field, back the program because it creates a stream of funding
that otherwise wouldnt exist. While we understand the nations current fiscal
pressures, we believe that greater investment in key areas is crucial to protect the
American people and others from biothreats, pandemics and emerging infections,
Thomas Slama, the groups president, wrote in a letter to House and Senate leaders
last month. Beefed up biodefense spending also gets championed by the movement
to broaden the pipeline of new antibiotics being developed by the pharmaceutical
industry. Their argument is the same as NIAIDs: a new drug that fights an anthrax
infection could also be used to treat the drug-resistant hospital-acquired infections
that kill tens of thousands of Americans a year. BARDA has pumped $200 million
into critical developmental molecules that would either be dead or much less
further along if BARDA wasnt around, said Brad Spellberg, a professor of medicine
at the Los Angeles Biomedical Research Institute. He also consults for numerous

drug companies working on new antibiotics. The government has become a

resource for companies that are not well capitalized.

Topicality

A2 Surveillance
We meet- health surveillance has intent and uses technology
Rubel 12 (Alan Rubel. Ph.D., Department of Philosophy, University of WisconsinMadison; J.D., magna cum laude, University of Wisconsin Law School Assistant
Professor. Justifying Public Health Surveillance: Basic Interests, Unreasonable
Exercise, and Privacy. 2012. P. 2-3.
https://kiej.georgetown.edu/home_files/22.1.rubel.pdf)//EMerz
Public health surveillance is the ongoing systematic collection, analysis, and
dissemination of health data to those who need to know (Thacker, Stroup, and
Dicker 2003, p. 224). Its scope is wide, both in its purposes and its methods.
Information gathered in public health surveillance is used to assess public health
status, to define public health priorities, to evaluate programs, and to conduct
research (Thacker 1994, p. 8). Surveillance is used in detecting epidemics,
understanding the natural history of diseases, determining the magnitude and
geographic distribution of problems, evaluating control and prevention efforts,
planning and priority setting, detecting changes to health practices, and stimulating
research (Thacker, Stroup, and Dicker 2003, pp. 814; Thacker 1994, pp. 824; CDC
2011a). Surveillance systems collect information in numerous ways. They may use
mundane sources such as vital statistics (e.g., birth and death records), surveys,
and environmental data regarding risk factors (e.g., air-monitoring data gathered
under the Clean Air Act and hazardous materials spills reported to the federal
Department of Transportation) (Thacker, Stroup, and Dicker 2003, p. 231). There are
also sentinel surveillance programs, which monitor key health events. For example,
occupational health conditions are monitored in the United States by key health
care providers participating in the Sentinel Event Notification System for
Occupational Risks (SENSOR) (Stroup, Zack, and Wharton 1994, pp. 4546). The
recognition that behavior is a crucial aspect of health has led public health agencies
to gather information regarding the use of alcohol, cigarettes, and drugs, the use of
safety devices such as seatbelts and bicycle helmets, and persons eating, exercise,
and sexual habits (Gostin 2008, p. 292). A relatively novel approach, which may
prove useful for early detection of outbreaks or bioterrorism, is syndromic
surveillance. This involves collecting and analyzing statistical data on health trends
such as symptoms reported by people seeking care in emergency rooms or other
health care settingsor even sales of flu medicines (Stoto, Schonlau, and Mariano
2004).

Medical privacy is at the heart of the topic of surveillance and

privacy expert consensus is unanimous
Goldman, from the College of Physicians and Surgeons, Columbia University,
November 1998 (Janlori, Protecting Privacy To Improve Health Care, published in
HealthAffairs volume 17 number 6)//roetlin
a comprehensive national health
privacy law is critical to ensuring both the integrity of the doctor / patient
Reports over the past twenty years unanimously conclude that

relationship and the continued development of this nations health care system . 17 As
an editorial in the Washington Post concluded: Of all the threats posed to personal privacy by
new information technologies, the threat to the privacy of medical records is by far
the most urgent. 18 In the past few years nearly every witness who has testified before
Congress on this issue has stated that a comprehensive federal privacy law is
critical to preserving peoples trust in their doctors and in the health care system.
Every report on health privacy issued recently concludes that a federal health
privacy law is necessary to plug existing gaps in law, policy, and practice. There
also is strong public support for a comprehensive federal health privacy law.

The aff deals with public health surveillance

Lee et al, American Journal of Public Health, 12 (Lisa M. Lee, PhD,
MS, Charles M. Heilig, PhD, and Angela White, MA, Lisa M. Lee is with the Office of
Surveillance, Epidemiology, and Laboratory Services at the Centers for Disease
Control and Prevention (CDC), Atlanta, GA. Charles M. Heilig is with the Tuberculosis
Trials Consortium, Division of Tuberculosis Elimination, CDC. Angela White is with the
J. L. Rotman Institute of Philosophy, University of Western Ontario, London, ON,
Canada.) Health Policy and Ethics | Peer Reviewed | AMERICAN JOURNAL OF PUBLIC
HEALTH, January 2012, Vol 102, No. 1)//ASMITH
PUBLIC HEALTH Surveillance is defined as the ongoing, systematic collection,
analysis, and interpretation of health-related data with the a priori purpose of
preventing or controlling disease or injury, or of identifying unusual events of public
health importance, followed by the dissemination and use of information for public
health action.1 It is distinct from other types of surveillance (e.g., security or
intelligence) in that the purpose of public health surveillance is to prevent or control
disease or injury and to improve the publics health.2 Surveillance is a foundational
tool of public health, serving as the finger on the pulse of the health of a
community. Public health surveillance is used, in some cases uniquely, to quantify
the magnitude of health problems, describe the natural history of disease, detect
outbreaks and epidemics of known or new pathogens, document the distribution
and spread of health events, facilitate epidemiological and laboratory research,
generate and test hypotheses, evaluate control and prevention measures, monitor
isolation activities and changes in infectious agents, detect changes in health
practices, plan public health actions and use of resources, and appropriate and
allocate prevention and care funds.3 Public health surveillance consists of 7
ongoing, systematic activities in 3 basic stepssystem development, data
collection and analysis, and data usethat provide continuous feedback for system
improvement. The first step, system development, involves (1) planning and design.
The second step, data collection and analysis, involves (2) data collection, (3)
collation, (4) analysis, and (5) interpretation. The third step, data use, involves (6)
dissemination and (7) application to public health program. These 7 activities create
the infrastructure of a coherent and state-of-the-art system.4 Findings from such
systems are fed directly to public health programs that benefit the populations and
communities from which the data are collected2; this feedback into programmatic
action distinguishes public health surveillance from other ways of knowing about
health.5 Public health surveillance systems vary according to their purpose, the

condition monitored, and the planned uses of the data. Some systems use non--name-based reporting mechanisms; others require names and other personal
identifiers for case reporting. We examine the conditions under which it is ethically
justifiable to create and maintain a public health surveillance system that, in
addition to the disease or health outcome, risk factors, and demographic
characteristics, requires that a name or other identifying information be reported to
the local or state health official for storage and future use.

A2 Its
Multi-jurisdictional law enforcement task forces transfer
jurisdictional power to state authorities
Brenda Grantland (private attorney in Mill Valley California, with 30 years'
experience primarily in asset forfeiture defense, as well as federal criminal appeals
and victims rights and restitution. Brenda handles federal cases throughout the
country, and frequently works with other attorneys or legal teams as a consultant or
co-counsel) February 2015 The truth about federal multi-jurisdictional task forces:
resources for reporters writing about Holders policy change
http://brendagrantland.com/truthjustice/the-truth-about-federal-multi-jurisdictionaltask-forces/
My final rant (for tonight) about multi-jurisdictional drug task forces: The Holder
policy order is partially a clever ploy to appease those clamoring for forfeiture
reform but also a Trojan horse. It is a Trojan horse because it will force state and
local police agencies to form multi-jurisdictional task forces with the federal
government if they want to preserve their previously abundant Equitable Sharing
revenue streams. Task forces are governed by contract between participating police
agencies. State and local police agencies are created and regulated by statutes
and/or ordinances, and answer directly to the local or state government which
created them, and the agencys chain of command answers to the top official of the
agency, with internal checks and balances to ensure that they enforce the law they
were hired to enforce. The state or local legislature controls their purse strings and
that is a big motivator to get them to obey the applicable state or local law. The fact
that the federal government could override that statutorily established chain of
command, substituting federal law for the law of the state, county or city that hired
them is questionable in itself. That state and local officers chain of command could
be supplanted by a board of directors created by private contract between law
enforcement agencies is a topic of grave concern that warrants discussion. Once
agents are detailed to task forces, the chain of command is no longer the usual
government hierarchy of the county sheriffs department, city police, or state police
even though those local agencies continue to pay their salaries. Who do the task
force agents ultimately answer to? They owe their allegiance not to the chain of
command of the agencies that pay their salaries, but to a board of directors chosen
by their individual participating government agencies, governed by the task force
coordination agreement. The Holder policy change will only cut off Equitable Sharing
revenue to state and local police agencies that remain under the chain of command
of their local agencies. This policy change will force the local agencies to form
federal task forces to preserve their revenue streams. From what I conclude from
reading the DEAs website, forming a federal task force is an easy thing to do. They
just negotiate a contract with surrounding local law enforcement agencies to create
a multi-juridictional task force and apply to have the DEA sponsor it. The local
agents get cross-deputized as federal agents (probably a brief ceremony with no
entrance test or prerequisites except maybe a criminal background check). This
empowers all of them to enforce federal law while they are on the payroll of state

and local law enforcement agencies. The state and local agencies are rewarded by a
kickback from the Equitable Sharing program of a percentage of the forfeiture
revenue generated each time their agents on the task force help generate federal
forfeiture revenue. The Equitable Sharing program promises law enforcement
agencies up to 80% of the proceeds of the forfeiture case they work on, with the
profits being split up according to how much each agency contributed, with the U.S.
Department of Justice being the sole arbiter on who gets what percentage of the
loot, with unreviewable discretion to decide as it pleases. Nation wide, police
agencies are showing serious lacks of control already violations of civil rights, use
of excessive force, falsification of evidence and other misconduct. Stricter oversight
is needed to regain control over the forces that are supposed to be maintaining law
and order. They dont need more autonomy.

***NEG***

***Doctor-Patient Trust CP***

1NC
Text: The United States Federal Government should track
healthcare companies quality of care by mandating that
Department of Health and Human Services evaluate health
care companies for privacy protections. The United States
Federal Government should mandate that health institutions
use high security cloud computing to store sensitive data
about patients by enforcing encryption and redaction
measures.
Cloud computing has potential to secure patient data if health
care providers implement encryption and redaction measures
Filkins 14 (Barbara Filkins. Senior SANS Analyst and Healthcare Specialist. New
Threats Drive Improved Practices: State of Cybersecurity in Health Care
Organizations. December 2014. P. 19. https://www.sans.org/readingroom/whitepapers/analyst/threats-drive-improved-practices-state-cybersecurityhealth-care-organizations-35652)//EMerz
This emphasis indicates that the cloud-computing industry has matured.
Respondents are now looking toward secure access and data-centric controls and
are less concerned with operational considerations such as monitoring of cloud
applications for vulnerabilities and threats. Cloud computing may be an area where
secure, multifactor authentication, which combines two or more independent
credentialssuch as what the user knows (password), what the user has (security
token) and what the user is (biometric verification)also takes off. This year, 60% of
respondents said they are using multifactor authentication as their top control to
address the risk to data and applications in the cloud. This represents a shift from
2013, where APIs for data reporting, auditing and providing alerts were cited by
respondents as the top security control for addressing cloud security concerns.
Cloud computing is also driving a more data-centric method of security, which
focuses on protecting data rather than just protecting the network or application in
which the data lives. Starting a data-centric security plan involves learning and
understanding where sensitive data resides, as well as how that information will be
used, accessed, managed, retained or retired across its life cycle. The next step is to
assess the risks and determine the policies and resources needed and available to
monitor and control risk in cloud-based computing models. For example, storing
data in the cloud demands encryption for the data at rest. Is that provided through
the internal application or the cloud services provider? Sharing that same data
among individuals with different roles and levels of access might demand further
modification of data to protect it, such as redaction, masking or a combination of
both.

Data breaches are likely with current cloud computing

technologynew security measures and technology can
prevent them
Filkins 14 (Barbara Filkins. Senior SANS Analyst and Healthcare Specialist. New
Threats Drive Improved Practices: State of Cybersecurity in Health Care
Organizations. December 2014. P. 19. https://www.sans.org/readingroom/whitepapers/analyst/threats-drive-improved-practices-state-cybersecurityhealth-care-organizations-35652)//EMerz
Trends such as mobile and cloud computing are game changers for the way
individuals and organizations must approach the security of their systems, the
privacy of protected sensitive data, and compliance. Health care organizations must
complement traditional, infrastructure-driven controls such as network perimeter
security with protections for the newer and evolving threat vectors where their data
and applications are outside of the protected network. Providers, payment plans,
insurers and other related industries now allow patients unprecedented access to
helpful, sophisticated health information and digital tools. Patients have online
access to their doctors, and immense social support is also provided online. The fact
is that the attack surfaces are many, and the movement to detect, protect and
defend in the health care industry, as shown by the small improvements in this
survey, is still not enough to keep up the pace. Investment in understanding the
new threat landscape and designing solutions to protect against these attacks,
including leveraging newer tools for protecting data and responding to new forms of
attacks, become critical to staying ahead of attackers.

This institutional trust is key to solve

Rowe and Calnan 6 (Rosemary Rowe and Michael Calnan. Professor of Medical
Sociology, School of Social Policy, Sociology and Social Research at the University of
Kent. Trust Relations in Health Care- the New Agenda. 2006.
http://eurpub.oxfordjournals.org/content/eurpub/16/1/4.full.pdf)//EMerz
There is
considerable evidence as to what factors encourage patient trust in clinicians: the
clinicians technical competence, respect for patient views, information sharing, and
their confidence in patients ability to manage their illness .8 Patient participation per se does
Given that trust remains important, how can new forms of trust relations be developed and sustained?

not necessarily result in higher trust, rather it is associated with value congruence regarding participation, patient
involvement produced higher trust where patients wanted to participate.9 In contrast, evidence as to what builds
institutional trust is sparse, with trust relations between providers and between providers and managers a

Hall et al US survey of HMO members found that system trust

could help the development of interpersonal trust, where there was no prior
knowledge of the clinician, but it is not known how interpersonal trust affects
institutional trust. Medical errors and cost containment are associated with distrust
of health care systems, whereas relationship building with the local community is
regarded as an important trust building mechanism. However, little research has been
particularly neglected area.

conducted to identify how different modes of governance affect institutional trust. The focus of trust relationships

in market based systems such

as the US patient trust may be more important to secure loyalty to
particular providers whereas in tax-financed systems which are organized by national or regional
may of course differ according to the model of health care delivery;

health systems converge and increasingly share

common challenges including: providing adequate patient choice; managing a mixed
economy of provision; and more explicit rationing, then both interpersonal and
institutional trust will continue to be important for all health systems. In conclusion, we
would argue that clinicians and managers need to address and respond to the changing
nature of trust relations in health care. The benefits of trust demonstrate the value to be Trust and
agencies public trust may be more necessary. However, as

the sociology of the professions 5 gained from ensuring that both interpersonal and institutional trust are
developed, sustained, and where necessary rebuilt. Trust is still fundamental to the clinicianpatient relationship but
as that relationship has changed so has the nature of trust. Trust is now conditional and has to be negotiated but,
whilst clinicians may have to earn patients trust, there is good evidence as to what is required to build and sustain
such interpersonal trust. The lack of knowledge about how institutional trust can be developed indicates the need
for research, ideally through inter-country comparisons to identify whether such trust varies by health system and
how it can be generated. The cost of failing to recognize the importance of trust and to address the changing nature
of trust relations could be substantial: economically, politically, and most important of all, in terms of health
outcomes.

2NC Extensions
Government monitoring of healthcare quality ensures trust in
patients
CQHCA 1 (Committee on the Quality of Health Care in America. Crossing the
Quality Chasm: A New Health System for the 21st Century. March 1, 2001.
http://www.ncbi.nlm.nih.gov/books/NBK222265/)//EMerz
Recommendation 2: All health care organizations, professional groups, and private and public purchasers should
pursue six major aims; specifically, health care should be safe, effective, patient-centered, timely, efficient, and

safety, effectiveness, patientcenteredness, timeliness, efficiency, and equity are achievable throughout the
health care sector. This opportunity for improvement is not confined to any sector, form of payment, type of
organization, or clinical discipline. Problems in health care quality affect all Americans today,
and all can benefit from a rededication to improving quality, regardless of where they receive
equitable. The committee believes substantial improvements in

their care. The committee applauds the Administration and Congress for their current efforts to establish a
mechanism for tracking the quality of care. Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.; Agency
for Healthcare Research and Quality Part A) provides support for the development of a National Quality Report,
which is currently ongoing. Section 913(a)(2) of the act states: Beginning in fiscal year 2003, the Secretary, acting
through the Director, shall submit to Congress an annual report on national trends in the quality of health care
provided to the American people. Recommendation 3:

Congress should continue to authorize

and appropriate funds for, and the Department of Health and Human
Services should move forward expeditiously with the establishment of,
monitoring and tracking processes for use in evaluating the progress of
the health system in pursuit of the above-cited aims of safety,
effectiveness, patient-centeredness, timeliness, efficiency, and equity. The
Secretary of the Department of Health and Human Services should report annually
to Congress and the President on the quality of care provided to the American
people. Without ongoing tracking of quality to assess the country's progress in meeting the aims set
forth in this chapter, interested partiesincluding patients, health care practitioners, policy
makers, educators, and purchaserscannot identify progress or understand where
improvement efforts are most needed. Continued funding for this activity should be ensured.

Health institutions use weak cloud services to transmit

sensitive patient data
Filkins 14 (Barbara Filkins. Senior SANS Analyst and
Healthcare Specialist. New Threats Drive Improved Practices: State of
Cybersecurity in Health Care Organizations. December 2014. P. 10-11.
https://www.sans.org/reading-room/whitepapers/analyst/threats-drive-improvedpractices-state-cybersecurity-health-care-organizations-35652)//EMerz
Health care organizations rely on cloud services for applications processing
sensitive information, including protected health care patient records as well as PCIprotected financial information. Respondents plan to expand these services in the
next 12 months. Open-ended responses by several respondents reflect the bias
against cloud services, most often prompted by concerns over loss of control or
oversight over sensitive data, but more than 60% are either using or planning to
use the cloud for multiple applications containing sensitive data, as shown in Figure

4. Mobile devices are also a source of additional risk, according to respondents. Not
surprisingly, 92% of respondent organizations allow access to calendar and email
via mobile devices. However, 52% also allow respondents to access health record
information from their mobile devices, and nearly as many access data from cloudbased applications, through which they may be processing highly sensitive data, as
discussed previously (see Figure 5).

Secure cloud computing increases patient trust in health care

institutions
CSCC 12 (Cloud Standards Customer Council. Advocacy group dedicated
surrounding the transition to the cloud. Impact of Cloud Computing on Healthcare.
November 2012. P. 12. http://www.cloudcouncil.org/cscchealthcare110512.pdf)//EMerz
Patient centricity has become the key trend in healthcare provisioning and is
leading to the steady growth in adoption of electronic medical records (EMR),
electronic health records (EHR), personal health records (PHR), and technologies
related to integrated care, patient safety, pointof-care access to demographic and
clinical information, and clinical decision support. Availability of data, irrespective
of the location of the patient and the clinician, has become the key to both
patient satisfaction and improved clinical outcomes. Cloud technologies
can significantly facilitate this trend. Cloud computing offers significant
benefits to the healthcare sector: doctors clinics, hospitals, and health clinics
require quick access to computing and large storage facilities which are not
provided in the traditional settings. Moreover, healthcare data needs to be shared
across various settings and geographies which further burden the healthcare
provider and the patient causing significant delay in treatment and loss of time.
Cloud caters to all these requirements thus providing the healthcare
organizations an incredible opportunity to improve services to their
customers, the patients, to share information more easily than ever before,
and improve operational efficiency at the same time.

Doesnt link to the net benefit- health businesses that use

cloud computing still adhere to status quo HIPAA procedures
CSCC 12 (Cloud Standards Customer Council. Advocacy group dedicated
surrounding the transition to the cloud. Impact of Cloud Computing on Healthcare.
November 2012. P.7. http://www.cloudcouncil.org/cscchealthcare110512.pdf)//EMerz
In the United States, every healthcare entity (e.g., hospital, university research
facility, physicians office) that deals with Protected Health Information (PHI) must
adhere to the guidelines stipulated under the Health Information Portability and
Accountability Act (HIPAA). HIPAA is a U.S. Federal law that was designed to protect
patient privacy, and does so by mandating and enforcing strict privacy and security
rules over how medical information is collected, handled, used, disclosed and
protected. While the HIPAA Privacy rule pertains to patients privacy and rights for
their personal health information, the HIPAA Security rule, focuses on assuring the

availability, confidentiality, and integrity, of electronic protected health information

through a series of administrative, physical and technical safeguards. Under Title II
of HIPAA, most of a patients medical record and payment history are considered
PHI, and is protected under the law. PHI may only be disclosed to other medical
entities on a need to know basis, only upon the permission of the individual
patient and only the minimum data fields required for the purpose involved. As a
result, one of the challenges is Patient Consent Management and managing PHI in
a way that is sufficiently simple to enable use by the general public. The owner of
the data must require the cloud service provider (aka the business associate) to
contractually agree to maintain all PHI in adherence with HIPAA standards. The
HIPAA Privacy rule defines a business associate as a person or entity that performs
certain functions or activities that involve the use or disclosure of protected health
information on behalf of, or provides services to, a covered entity. Covered entities
are institutions, organizations or persons who electronically transmit any health
information in connection with transactions for the United States Health and Human
Services (HHS) adopted standards. While ultimate responsibility for compliance
always resides at the covered entity, the actual implementation of certain
operational and control aspects of securing the data occurs at the business
associate cloud provider.

***States CP***

1NC
Text: The 50 states and relevant US territories should apply
strict scrutiny to public health surveillance programs.
State privacy protections are extremely effective
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 19-21
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
Health privacy and HIPAA frequently are viewed as indistinguishable. However,

health privacy

exceptionalism is not restricted to federal law. In the decade and a half since the appearance of
the HIPAA regulations and notwithstanding the Privacy Rules limitation on preemption, state law regarding
health privacy appears to have receded into the background. The Bush Administrations
health information technology narrative included the characterization of divergent state laws as impeding EHR
implementation. 144 Furthermore, in the intervening years several states have normalized their laws with HIPAA.

There are explicit protections of privacy in a handful of State constitutions .146 And
some state supreme courts have implied such a right147 that subsequently has been applied in cases involving

state
legislatures embraced strong, exceptional health privacy models (particularly in the preHIPAA years). 149 Indeed many state privacy statutes continue to escape preemption due
to HIPAAs more stringent provision. Any generalized account fails to credit
the resilience of health privacy exceptionalism in some states . Of course, there
medical information.148 Yet there is nothing that could be as described as exceptional. In contrast, many

should be little surprise that California has built on its enviable consumer protective reputation with additional

Confidentiality of Medical Information

Act dates from 1981. It is notable for possessing a broader reach than HIPAA, applying, for
example, to health data custodians who are not health care providers.151 California passed one of the
first health information breach notification laws.152 More recently the state established the Office
substantive and enforcement provisions. The states original

of Health Information Integrity to ensure the enforcement of state law mandating the confidentiality of medical
information and to impose administrative fines for the unauthorized use of medical information153 which requires:
Every provider of health care shall establish and implement appropriate administrative, technical, and physical
safeguards to protect the privacy of a patient's medical information. Every provider of health care shall reasonably
safeguard confidential medical information from any unauthorized access or unlawful access, use, or disclosure.

Texas enacted similarly broad protection for health information . In

sharp contrast to the narrow HIPAA conception of a covered entity, the Texas law applies to any person
who . . . engages . . . in the practice of assembling, collecting, analyzing, using,
evaluating, storing, or transmitting protected health information . 155 Texas also requires
Perhaps more surprisingly

clear and unambiguous permission before using health information for marketing 156 and broadly prohibits the
sale of an individual's protected health information.157 As discussed above, HITECH (together with a change in
administration) provided the enforcement focus that HIPAA had lacked.158 However, the 2009 legislation did not
alter the longstanding HIPAA position of not permitting private rights of action.159 Of course a small number of
states permit such actions under their health privacy statutes.160 However, almost all jurisdictions allow some
species of the breach of confidence action in such cases,161 and some even allow HIPAA in through the back door
establishing a standard of care in negligence per se cases.162 For example, Resnick v. AvMed, Inc., concerned two
unencrypted laptops that were stolen from the defendant managed care company. The compromised data
concerned 1.2 million persons, some of whom subsequently became victims of identity theft. Dealing with Florida
law allegations of breach of contract, breach of implied contract, breach of the implied covenant of good faith and
fair dealing, and breach of fiduciary duty, the Eleventh Circuit addressed the question whether plaintiffs had alleged
a sufficient nexus between the data theft and the identity theft. The court concluded that the plaintiffs had pled a
cognizable injury and . . . sufficient facts to allow for a plausible inference that AvMeds failures in securing their
data resulted in their identities being stolen. They have shown a sufficient nexus between the data breach and the

identity theft beyond allegations of time and sequence.164

Overall there seems to be a

proliferation of data breach cases being filed in state courts . State privacy case law
and legislation are continually evolving both in and out of the health care space.
However, there is reason to believe that health privacy exceptionalism remains an
accepted tenet among state courts and legislatures.

The states are sufficient

Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
While a federal law would be most effective, there are other options to achieve
some of the benefits of the reforms outlined in Part III.C. For example, each state
could be encouraged to adopt a model statute that includes these reforms. The
prospect of quick action by each state seems considerably less likely to occur
without the stick of being excluded from CODIS that could be a part of federal
regulation. However, Alaska, Vermont, and Washington have demonstrated that
some states are capable of regulating local databases. In addition, there are options
aside from legislation. Existing regulatory bodies could promote these reforms as
best practices for local DNA databases. For example, the recently created National
Commission on Forensic Science (NCFS), a joint project of the Department of
Justice and the National Institute of Standards and Technology (NIST), describes
part of its mission as reduc[ing] fragmentation and improve[ing] federal
coordination of forensic science.323 Similarly, NISTs newly-formed Organization of
Scientific Area Committees (OSACs) represents another potential source for
external regulation.324 Whereas the NCSF will outline broad policies, the OSACs are
designed to adopt specific standards and guidelines for each forensic
discipline.325 These organizations, which include national leaders from law
enforcement, practice, and academia, are limited to adopting non-binding
recommendations. However, even recommended procedures could be powerful
forces to alter current practices. Finally, while this Article argues that external
regulation is optimal and necessary,326 it is at least possible that the early
adopters of local databases could organize a working group to develop uniform
standards. Director Harran of Bensalem has considered holding a meeting with the
agencies that use local databases to explore the adoption of standard
procedures.327 A working group offers at least three potential incremental benefits.
First, simply starting the dialogue would force some agencies to articulate their
practices and procedures. Second, a discussion about what regulations are needed
could encourage law enforcement to consider some of the external costs of local
databases. Finally, even if the working group did not possess the power to adopt
binding regulations, it is possible that some agenciesmotivated by the selfinterested desire to continue using their own local databasescould pressure others
to act more cautiously so as not to generate interest from external regulators.
CONCLUSION Given the pressure on police to solve crimes and reduce criminal
activity, it is not surprising that law enforcement aggressively adapts surveillance
technology to its benefit. Such actions are often commendable and encouraged.
Indeed, the very manner in which law enforcement agencies measure their absolute

and comparative successthrough crime rates and clearance ratesincentivizes

local agencies to push the boundaries of crimesolving tools. Early adopters of local
databases are doing just that, trying to maximize the ability of forensic DNA
analysis to fight and deter crime. Palm Bay, Bensalem, and others have shown that
local databases offer great promise when measured on that scale. But a narrow
focus on crime rates and clearance rates is not the only relevant metric when
allocating policing resources in general, and public surveillance in particular. Rather,
policing has the potential to generate positive and negative externalities unrelated
to crime rates and clearance rates, and these externalities are often difficult to
measure reliably. Furthermore, there is little incentive for law enforcement to
identify or measure these externalities, particularly negative ones. This Article is the
first attempt to identify the full implications of local databases. While it is beyond its
scope to measure these externalities, identifying their existence and recognizing
law enforcements failure to consider them calls for some level of external
regulation of local databases. Because the empirical work needed to measure the
external costs of local databases has not been developed, the reforms proposed in
this Article are modest. It is possible, although, in the opinion of the author, unlikely
that the external costs of local databases will outweigh their benefits. If that proves
true, states should follow Vermonts lead and ban local databases. More than likely,
the result of a full-scale empirical study of local databases will call for something in
the middle, rejecting the total prohibition in Vermont and rejecting the current
landscape, where local agencies are free to develop and use local databases
without external regulation.

Solvency Flexibility
States solve better
Duffy et al 11(Effective State-Based Surveillance for Multidrug-Resistant
Organisms Related to Health Care-Associated Infections,Jonathan Duffy, MD,
MPH,a,b Dawn Sievert, PhD, MS,a Catherine Rebmann, MPH,a Marion Kainer, MD,
MPH,c,d Ruth Lynfield, MD,c,e Perry Smith, MD,c,f and Scott Fridkin, MDa Division of
Healthcare Quality Promotion, Centers for Disease Control and Prevention, Epidemic
Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA 2011
Mar-Apr; http://www-ncbi-nlm-nihgov.proxy.lib.umich.edu/pmc/articles/PMC3056030/?tool=pmcentrez)
A primary aim of public health surveillance is to direct prevention and control
activities and monitor their effectiveness. Collection of surveillance data by itself
does not control disease or constitute public health action. As public health
agencies operate with finite resources, implementation of surveillance tools should
occur in conjunction with a plan to interpret and act on the data collected.
Resources should be devoted to MDRO surveillance activities only when resources
are also available for specific MDRO infection- or transmission-prevention activities
or to build capacity to respond with public health action to the MDRO surveillance
data. Moreover, integrating input from local partners and key opinion
leaders in infection control and prevention to ensure that any surveillance
and response strategy is consistent with regional priorities or concerns is
critical. A state is more likely to develop a surveillance system that meets
its particular needs and functions well within the constraints of its
available resources if the state health department takes an active role in
deciding what MDRO surveillance activities are appropriate for its
circumstances. Surveillance activities developed in response to mandates
created without health department input could lack these characteristics.

Solvency - Speed
Stats solve quicker public health responses
Galva et al 5 (Jorge, JD MHA, Christopher Atchison, MPA, Samuel Levy, PhD SM, analysts for
Public Health Reports, Public Health Strategy and the Police Powers of the State
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569983/ 2005 JM)

The preparedness of the U.S. public health system to respond to acts of terrorism
has received a great deal of attention since September 11, 2001, and especially
subsequent to the anthrax attacks later that year. The use of biologic agents as a
weapon has served as a catalyst to better aligning public safety and health
strategies through public health law reforms. Associated with this work is the
renewal of the debate over the most appropriate means to both protect the public
and asssure the rights of individuals when implementing readiness strategies. A key
element of the debate focuses on what is a reasonable application of state-based
police powers to ensure community public health standards. The doctrine of state
police power was adopted in early colonial America from firmly established
English common law principles mandating the limitation of private rights when
needed for the preservation of the common good. It was one of the powers
reserved by the states with the adoption of the federal Constitution and was
limited only by the Constitution's Supremacy Clausewhich mandates preeminence
of federal law in matters delegated to the federal governmentand the individual
rights protected in the subsequent Amendments.1,2 The application of police power
has traditionally implied a capacity to (1) promote the public health, morals, or
safety, and the general well-being of the community; (2) enact and enforce laws for
the promotion of the general welfare; (3) regulate private rights in the public
interest; and (4) extend measures to all great public needs.3 The application of
police powers is not synonymous with criminal enforcement procedures; rather,
this authority establishes the means by which communities may enforce civil selfprotection rules. More specifically, public health police power allows the states to
pass and enforce isolation and quarantine, health, and inspection laws to interrupt
or prevent the spread of disease. Historically, the exercise of public health police
power was enforced with strong support of the courts and restraint of police power
occurred only when there was open disregard for individual rights. The abilities of
states to exercise their police powers has been constrained since the 1960s by the
legal and social reexamination of the balance of power between the individual, the
states, and the federal government, which affects contemporary efforts to reform
public health law in the face of terrorism. Given the development of the criminally
based threats to health marked by bioterrorism, the relatively recent emphasis
on the personal rights side of the equation should be reassessed.4 A
reexamination of the legal, ideological, and social limits of police power is
appropriate since increased state capacity can be crucial for first responses
to terrorist threats or actions. Effective first responses may be hampered in the
absence of pragmatically designed realignments of the state-individual relationship
and the redesign of state public health infrastructures.5 This article begins with an
historical overview of the doctrine of state police power, addresses recent
limitations imposed on the implementation of public health police powers, then uses

the example of the imposition of quarantine orders to illustrate the state's capability
to impose such orders in exercise of its police power. Finally, it suggests changes in
state public health agency governance, focus, and regulation to rebalance public
and private interests.

Solvency General
States solve besthave a balance of privacy and effectiveness
Galva et al 5 (Jorge, JD MHA, Christopher Atchison, MPA, Samuel Levy, PhD SM, analysts for Public Health
Reports, Public Health Strategy and the Police Powers of the State
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569983/ 2005 JM)

Population-based measures in response to increased public health threats assume

diverse forms. These are essentially clustered in two distinct groups: prevention
(detection, data-basing, and tracking), and remediation (containment of actual
damage). Preventive measures entail mechanisms to control and track the
movement of persons and things. This type of activity may involve the enactment
and enforcement of unsympathetic laws and regulations affecting real or perceived
spheres of rights. Effective enforcement will depend on the public health authorities'
ability to safely overcome resistance to these measures. The control of the flow of
information may also result in restrictions to the access and publication of public
health information. Remediation demands even greater degrees of control over
persons and property. Remediation measures could include: (1) quarantine and
involuntary holds when and where necessary for an indefinite period limited only by
the cessation of the state of emergency; (2) suspension of habeas corpus in case of
quarantine with very limited post-detention remedies for the individuals affected;
and (3) property rights (establishment of public interest easements on private
property in anticipation of an emergency and deputization/commandeering privatesector resources for public use during an emergency). Remediation measures must
be rapidly implemented in the event of biological attack or new infectious
disease.65 Significant normative measures in this respect have been proposed at
both the federal and state levels.66 The Model State Emergency Health Powers Act
(MSEHPA) illustrates this effort. The MSEHPA contains projected measures based on
potential terrorist threats and proposed preventive and remedial measures as well
as a detailed description of the protection of individual and business rights
during an emergency.67 The State Emergency Powers Act's purpose is to create a
unified response system whereby the states put into effect standardized
measures.68 The driving principle behind this uniform legislation is twofold: on the
one hand, standardization and modernization of obsolete or inapplicable state laws
regulating public health responses, and on the other, creation of balance between
states' ability to control individual activity and constitutional rights.4 The goals of
the MSEHPA are, inarguably, meritorious.69 Nevertheless, there are valid concerns
regarding the effects of the attempted balance of public and private interests on the
states' ability to carry out an effective public health response. There is foundation
for these concerns. The MSEHPA's balancing act may sidestep the needed
mechanics of infectious disease control by unduly incorporating post-Warren Court
legal restraintspre-intervention notices, hearings, heightened burden of proof, and
access to witnessesinto the law.70 The MSEHPA fails to restore the historic
deference to public health activities or enhance the crucial scientific and
administrative underpinnings of public health enforcement actions. Stringent
preventive and remedial public health measures are necessary to face contagion.

The recent experience with quarantine measures as the principal method used
against SARS validates this conclusion.44 Taiwan successfully implemented a broad
quarantine program: 131,132 persons were placed under strict quarantine orders
that required them to stay where they were quarantined, submit to periodic
temperature checks, and sharply restrict transportation or visits to public places.
These measures were needed because of the unknown transmissibility of SARS;
they are associated with the rapid control of the epidemic in that country.71
Although the Canadian government attempted to use voluntary isolation, ultimately
orders were issued for mandatory quarantine when the use of voluntary isolation
became difficult.72 The Canadian government's response was later characterized as
deficient, while the limited spread of SARS in Canada has been attributed to
chance.73 It is hard to envision the application of the MSEHPA in a manner
congruent with stringent quarantine measures. The procedural guarantees in the
MSEHPA may well be impossible to implement due to the risk of exposing judges,
witnesses, and the public to possible contagion. In addition, the judiciary and public
authorities are not prepared to implement quarantine orders due to lack of
familiarity with public health doctrines or logistical shortcomings.74,75 The effects
of one successful injunction resulting from these shortcomingsvery likely under
the MSEHPAallowing, for example, a single SARS super-spreader to avoid
quarantine, could be devastating.76 A perfect balance between private and public
rights in the face of a highly infectious disease may not be attainable, or even
desirable. Emergency activities will be effective if the states' exercise of
public health police power is strengthened by good scientific practices and
rigorous application of justified means of control. Expiration of any
extraordinary powers once the emergency is controlled remains an obligatory
feature unless there is reauthorization on the basis of solid scientific evidence. The
ultimate goal of public health law should be the reinforcement of public health on
the basis of historic principles of police power allowing broad but temporary
administrative activities that are needed to face an impending emergency when the
situation warrants.77 This necessitates a return to the traditional historic bases of
public health police power. Recommended steps in this direction should include: (1)
reinforcing the administrative capability for the issuance of robustly evidence-based
public health orders properly issued under authority of law; (2) removing all judicial
pre-intervention review measures of such orders while limiting review of public
health orders to the post-execution phase; (3) subjecting all public health orders to
automatic expiration terms and making renewal of the orders contingent on the
same robust degree of evidence allowing the original order.

The issue of health information is the jurisdiction for the state

Oconnor et al 11(Informational Privacy, Public Health, and State Laws, 2011
October Jean O'Connor, JD, DrPHcorresponding author and Gene Matthews, JD with
the Centers for Disease Control and Prevention, Atlanta, GA. Gene Matthews is with
the North Carolina Institute of Public Health, Chapel Hill. http://www-ncbi-nlm-nihgov.proxy.lib.umich.edu/pmc/articles/PMC3222345/?tool=pmcentrez)

The US Constitution does not impart a broad right to the privacy of individual health
information.7 At the federal level, statutes place boundaries around the collection,
use, and disclosure of certain types of health-related information. These statutes
include the Freedom of Information Act,8 the Privacy Act of 1974,9 the Department
of Health and Human Services (HHS) Human Subject Protection Regulations,10 the
E-Government Act of 2002, 11 the Family Educational Rights and Privacy Act,12 the
Federal Drug and Alcohol Confidentiality provisions,13 and the Genetic Information
Nondiscrimination Act.14 These statutes restrict the use of information for different
purposes. For example, the HHS Human Subjects Protection Regulations focus on
protecting information in the research context. However, the most frequently cited
law in discussions of the privacy of public health information is the Health Insurance
Portability and Accountability Act (HIPAA) and its associated regulations. The HIPAA
Privacy Rule protects most health records from disclosure but permits health care
providers to make disclosures to public health officials and for certain other
purposes.15 The rule does not protect information possessed by public health
officials from disclosure, except in limited circumstances. HIPAA also does not
preempt state laws on the use or disclosure of data by public health authorities.16
Because there is no national standard for safeguarding all data held by public health
agencies, state laws remain central to discussions of the privacy, confidentiality,
security, use, and disclosure of information within the public health system.17
These state laws have been reported to be fragmented and antiquated, and to fail
to effectively balance competing individual interests in privacy with the need to
share public health data and information for the common good.18(p1389) For
more than a decade, both public health advocates and privacy advocates have
responded to this need by calling for clearer protections for state public health
information and developing model state policies.17,19,20 To disseminate ideas to
update state public health privacy laws, Gostin et al. developed the Model State
Health Privacy Act (MSHPA), a model statute for states to use as a guide in
developing new laws, in 1999.18 The MSHPA contains detailed language about the
appropriate acquisition and use of public health information, terms for when it is
appropriate for state health departments to disclose that information, and penalties
for noncompliance. After the events in the fall of 2001, the Model State Emergency
Health Powers Act (MSEHPA) was drafted to promote the adoption of state public
health emergency statutes that contained, among other things, language related to
the disclosure of public health information.21 Despite these efforts, anecdotal
information suggests that few states have adopted public health privacy and
disclosure provisions recommended in the MSHPA and MSEHPA. To address the lack
of adoption of provisions by states and the continuing development of new
approaches to data exchange, Lee and Gostin recently recommended a set of
national principles for protecting public health data.17 The principles included
discussion of use of data for legitimate public health purposes, collection or use of
the minimum information necessary, data use agreements and security measures,
and stewardship and trust. The need to develop a common approach to the use and
disclosure of public health information has also been recognized as more than solely
a domestic problem; various professional organizations (e.g., the International
Epidemiological Association22) have developed guidelines for the use of data by
their members, and an international collaborative is seeking to develop a collective

code of conduct for the use of public health data.23 An analysis of current public
health privacy laws can inform these efforts. The success of a national or
international set of principles for the use and disclosure of personally identifiable
health information under the control of the public health system depends, in part,
on acknowledging the specific political and historical factors that have resulted in
existing laws. In the United States, understanding current state laws may assist in
identifying approaches to bridging the gap between the reality that state and local
public health agencies face and ideal policies, frameworks, or practices for the use
and disclosure of public health information. Identifying approaches and patterns in
existing state laws is also an essential first step in further analyses of what laws are
effective.

States solve best only way to avoid circumvention

Pritts 13 (Joy L. Pritts JD is a lawyer who practices in Washington DC and earned her degree at Georgetown
Univeristy. Altered States: State Health Privacy Laws and the Impact of the Federal Health Privacy Rule
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1047&context=yjhple)///CW

States have traditionally been the primary regulators of health care information. While
the promulgation of the Federal Health Privacy Rule changes the regulatory landscape, it need not supplant the
importance of state health privacy laws. In fact, states have often become more active after the enactment of federal privacy laws,
enacting statutes that either mirror or build upon the federal protections. This approach, endorsed by the Privacy Protection Study Commission in the 1970s,
ensures that the states will be able to enforce the law and protect their
citizens.8 4 Because the Federal Health Privacy Rule does not preempt current or future
stronger state health privacy laws, the states have ample opportunity to fill the gaps
and strengthen the weaknesses of the federal regulation . States therefore should not rely
solely on the Federal Health Privacy Rule to protect the privacy rights of their citizens. Rather, states should
take advantage of the need to evaluate their health privacy laws in light of the Federal Health Privacy Rule and take appropriate action. States with little statutory protection of health
information in place may want to use Federal Health Privacy Rule as a roadmap for enacting comprehensive state health privacy laws. At a bare minimum, states can mirror the

to afford truly comprehensive protection,

states should directly regulate not only the entities governed by the Fed eral Health Privacy Rule,
but also the other major generators and holders of health information (such as employers and life
insurers). Additionally, states should directly regulate the recipients of health information from
these core record keepers. Furthermore, states should strengthen some of the weak
provisions of the Federal Health Privacy Rule, such as the use of health information for marketing
purposes. States with fairly well developed health privacy rules should also reevaluate their laws in light of the Federal Health Privacy Rule. Some state and federal rules
federal protections, thereby allowing enforcement to occur at the state level. However,

may accomplish the same goals through slightly different requirements (e.g., different content requirements for a notice advising the patient of information practices). In this

States
should also use this as an opportunity to fill in gaps in state law that may exist (such as having statutory access rights to hospital
situation, a state may want to harmonize its provisions with the Federal Rule in order to avoid confusion and to afford some degree of uniformity between states.

records but not doctor's records).

CP solves more stringent state laws take precedence over

federal regs
Holloway 3 (Jennifer Daw Holloway is a communications manager at Ipas, an organization
dedicated to safe abortions. What takes precedence: HIPAA or state law? January 03,
http://www.apa.org/monitor/jan03/hipaa.aspx)///CW
With the Health Insurance Portability and Accountability Act (HIPAA) privacy rule compliance date--April 14--fast
approaching, psychologists must explore how the new federal rules interact with their current state laws.

HIPAA's privacy rule governs how health-care providers handle the use or disclosure
of protected health information (PHI). In effect, PHI is defined as individually identifiable health
information relating to the condition of a patient, the provision of health care or payment for care. All states

already have privacy laws that apply to such information . Areas such as patient consent,
access to records and subpoena rights, to name a few, are included under HIPAA as well as state laws. So, will
HIPAA's rules preempt state laws? "The

general standard is that if a state law is more

protective of the patient, then it takes precedence over HIPAA ," says Doug
Walter, legislative and regulatory counsel in APA's Practice Directorate. Conversely, if a state law is less
stringent than HIPAA, then HIPAA takes over , he says. The following examples illustrate the
interplay between state laws and HIPAA and how that will affect psychologists: Consent for payment, treatment
and health-care operations. Dr. Smith, a psychologist in Utah, has scheduled a new patient. When the patient comes
for her general appointment, Dr. Smith's office must be sure she signs a consent form for the disclosure of her

Utah law requires that psychologists obtain signed consent, while the HIPAA
privacy rule does not require consent. So, Utah law applies instead of HIPAA in this case
records.

because the state law gives patients greater privacy protection. Other states may have similar laws that would take
precedence over HIPAA. Patient access to psychotherapy notes. Under HIPAA, patients are granted access to their
records, with the exception of "psychotherapy notes," better known as what psychologists traditionally call "process
notes." But in some states, such as Vermont, patients can access their psychotherapy notes under state law. So,
when a patient of Vermont practitioner Dr. Jones asks to see his notes, Dr. Jones must permit the patient to see the

Because Vermont law provides greater rights from the patient's standpoint for
it takes precedence over the HIPAA
requirements. Again, several other states may have such protective laws. Subpoena of patient records. Dr.
notes.

the patient to access his or her psychotherapy notes,

Milton, a psychologist in New Hampshire, receives a subpoena requesting one of his patient's records. Attached to
the subpoena is a notice from the requesting party's attorney stating that her office has made diligent but
unsuccessful efforts to reach the patient to serve notice that his records are being requested. This is an adequate
attempt to notify the patient under HIPAA and, therefore, the psychologist would not be barred from producing the
patient's records if HIPAA took precedence. However, under New Hampshire law, psychologists are precluded from
producing their patients' records for a third party absent a court order or patient consent. New Hampshire law is
more protective than HIPAA with respect to records subpoena. Therefore, state law preempts HIPAA in this case.

There are myriad examples--aside from the three above--of how state laws may
take precedence over HIPAA. The simple rule of thumb is that any provision--in state laws or HIPAA--that
gives greater protection to patients' privacy or right to access their own health information takes precedence. The

HIPAA privacy rule "won't impair the effectiveness of state laws that are more
protective of privacy," says Russ Newman, PhD, JD, APA's executive director for practice. And, he notes,
in states where protective laws haven't been enacted, HIPAA will not prevent states from enacting laws that provide
greater patient privacy protection. HIPAA assumes that practitioners know the ins and outs of their state laws, but
figuring out which law will take precedence involves a complicated analysis of state statutes, regulations and
common law decisions. The APA Practice Organization and the APA Insurance Trust are developing comprehensive
resources for psychologists that will facilitate compliance with the HIPAA privacy rule. Along with several offerings, a
new product, "HIPAA for Psychologists"--which will include the necessary state-specific forms that comply with both
the HIPAA privacy rule and relevant state law--will be available for purchase online at the Practice Organization's
new practitioner portal.

Health Data is important for state use

Oconnor et al 11(Informational Privacy, Public Health, and State Laws, 2011
October Jean O'Connor, JD, DrPHcorresponding author and Gene Matthews, JD with
the Centers for Disease Control and Prevention, Atlanta, GA. Gene Matthews is with
the North Carolina Institute of Public Health, Chapel Hill. http://www-ncbi-nlm-nihgov.proxy.lib.umich.edu/pmc/articles/PMC3222345/?tool=pmcentrez)
Developments in information technology that make it possible to rapidly transmit
health information also raise questions about the possible inappropriate use and
protection of identifiable (or potentially identifiable) personal health information.
Despite efforts to improve state laws, adoption of provisions has lagged. We found
that half of states have no statutes addressing nondisclosure of personally

identifiable health information generally held by public health agencies. Exceptional

treatment of HIV, sexually transmitted infections, or tuberculosis-related information
was common. Where other provisions were found, there was little consistency in the
laws across states. The variation in state laws supports the need to build consensus
on the appropriate use and disclosure of public health information among public
health practitioners. Surveillance, epidemiological, and laboratory data are
essential to the practice of public health, particularly at the state and
local level.1 Public health practitioners within government agencies use data to
identify new cases of disease and to make decisions about when to apply public
health interventions. The exchange of information between health officials in
different jurisdictions has been demonstrated to be essential to managing outbreaks
of well-understood diseases, such as measles, and identifying and responding to
new and emerging threats, such as severe acute respiratory syndrome and
pandemic influenza A (H1N1). However, the very developments in information
technology and health care policy that make it increasingly possible to rapidly
transmit health information, such as electronic medical records and health
information exchanges, continue to raise questions about the possible inappropriate
use and lack of protection of personally identifiable health information.24 In highly
charged situations, such as the recent influenza A (H1N1) pandemic, variations in
state laws and incomplete understanding among jurisdictions can easily lead to
inconsistent public health disclosure practices, resulting in media questions about
the integrity of information access policies.5,6 Clearly, consideration should now be
given to a more cohesive approach to public health information sharing.

State prohibition of re-identification of patient information is

crucial in preventing widespread sharing of personal patient
files
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 16-19
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
There has always been something lopsided about the HIPAA regulatory model.
Rather than concentrating on securing health data, most of the Privacy Rule
provisions detail wide-ranging exceptions (public health, judicial and regulatory) to
data protection or outline the process by which patients can consent to disclosure.
Just recently, for example, a pharmacy chain made the headlines by conditioning its
loyalty rewards program on a broad HIPAA authorization.86 It is no surprise,
therefore, to learn that there has been leakage of health data through the
very system set up to protect it. Such leakage has been exacerbated by the
mission creep exhibited by the recipients of data under HIPAA, particularly public
health agencies. As Wendy Mariner notes: Today, almost everyone, regardless of
station, could be subject to public health surveillance. The scope of public health
surveillance has grown significantly beyond its contagious disease origins.
. . . [A] new generation of reporting laws reflects a goal of many people in public
health: to collect data about chronic diseases outside the context of a research
study and without the need to obtain any individual patient's informed consent. . . .

Do they offer the promise of medical advances, or the threat of general searches,
which the authors of the Bill of Rights were so concerned to protect against?87 For
example, a 2013 report from the Citizens Council for Health Freedom alleges broad
state health surveillance based on individual and often identifiable records.88
However, public health authorities are not only voraciously consuming patient data
but also abetting the acquisition of the same by big data companies. Researchers at
Harvards Data Privacy Lab have found that thirty-three states re-release patient
hospital discharge data that they have acquired as HIPAA-permitted recipients of
patient data. 89 Generally states release this data (that is no longer in the HIPAA
protected zone) in somewhat de-identified or anonymized form but with little
restriction on future use of the data. The nave thought that such data was only
being released to academic researchers was upended by the Data Privacy Labs
discovery that many of the major buyers of such state health databases were big
data companies.90 Most states only charge small fees that are not a major source
of revenue for them, and many are oblivious to this practice.91 The obvious
solution is for the state public health agencies to contractually prohibit reidentification. For example, the National Practitioner Data Bank (NPDB) collects
information about physician malpractice awards, adverse licensure reports and
Medicare/Medicaid exclusions. Although it is not a public resource the NPDB does
release de-identified data. Following a re-identification episode NPDB now contains
a prohibition on re-identification, specifically against using its dataset alone or in
combination with other data to identify any individual or entity or otherwise link
information from this file with information in another dataset in a manner that
includes the identity of an individual or entity. Clearly, state health departments
and any similarly placed recipients of HIPAA data should require similar restrictions.
Indeed, the proposed FTC privacy framework would mandate such: . . . [I]f a
company makes such de-identified data available to other companies whether
service providers or other third parties it should contractually prohibit such entities
from attempting to re-identify the data. The company that transfers or otherwise
makes the data available should exercise reasonable oversight to monitor
compliance with these contractual provisions and take appropriate steps to address
contractual violations.95 Until such prohibitions are instituted HIPAAs public
health exception unpardonably will continue to facilitate the laundering
of protected patient data as it is transferred from a data protected domain
to unprotected space.

***Disad Links***

Politics Link
Congress has no interest in changing health surveillance
standards
Evans 13 (Barbara J. Evans. Professor of Law; Co-director, Health Law & Policy
Institute; Director, Center on Biotechnology & Law, University of Houston Law
Center, Yale Law School; M.S., Ph.D. Stanford University; Post-doctoral Fellow, The
University of Texas M.D. Anderson Cancer Center. Institutional Competence to
Balance Privacy and Competing Values: The Forgotten Third Prong of HIPAA
Preemption Analysis. P.1189-1190.
http://lawreview.law.ucdavis.edu/issues/46/4/Articles/46-4_Evans.pdf)//EMerz
The problem, however, is that Congress appears to lack this desire. An
excellent opportunity to address this problem came and went when Congress
introduced major amendments to the HIPAA statute in the 2009 Health Information
Technology for Economic and Clinical Health (HITECH) Act.74 Congress declined to
expand HIPAAs preemption of state privacy law. Pragmatism counsels that HIPAAs
preemption provisions are not likely to change. Those who favor a more
uniform legal framework to support large, interoperable public health data networks
and public health uses of data must find a way to achieve these goals within the
existing preemption framework. To paraphrase Donald Rumsfeld, You go to war
with the [HIPAA preemption provisions] you have, not the [provisions] you might
want or wish to have at a later time.75 Accordingly, this Article takes a fresh look
at HIPAAs existing preemption provisions to check for tactical opportunities that
earlier scouts may have overlooked.

Privacy rulings are extremely unpopular and take up the entire

floor- HIPAA empirics proves
Evans 13 (Barbara J. Evans. Professor of Law; Co-director, Health Law & Policy
Institute; Director, Center on Biotechnology & Law, University of Houston Law
Center, Yale Law School; M.S., Ph.D. Stanford University; Post-doctoral Fellow, The
University of Texas M.D. Anderson Cancer Center. Institutional Competence to
Balance Privacy and Competing Values: The Forgotten Third Prong of HIPAA
Preemption Analysis. P. 1212-1213.
http://lawreview.law.ucdavis.edu/issues/46/4/Articles/46-4_Evans.pdf)//EMerz
The HIPAA Privacy Rule had a famously contentious rulemaking history. The
proposed regulation drew more than 52,000 public comments and the final rule of
December 2000 subsequently was reopened for a second round of comments and
amendments. Consensus was hard to achieve and, in fact, was not fully
achieved. The Privacy Rule continues to be disliked by all sides. For example, it is
simultaneously criticized for allowing too much and not enough access to data and
biospecimens. Modestly positioning the Privacy Rule as a floor of privacy protections
may have had a calming effect during the fractious rulemaking process. By its own
terms, the Privacy Rule is merely a floor, and that was all that needed to be
discussed during the rulemaking. The Privacy Rule only becomes a ceiling in one

narrow context public health uses of data and biospecimens and then only
when read in conjunction with the HIPAA statute. The rulemaking carefully set the
stronger statutory preemption provision at 42 U.S.C. 1320d-7(b) to one side and
avoided making it a topic of rulemaking discussions.

No political constituency for the plan politicians will defer to

law enforcement
Jason Kreag (Visiting Assistant Professor, University of Arizona James E. Rogers
College of Law) 2015 GOING LOCAL: THE FRAGMENTATION OF GENETIC
SURVEILLANCE http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2583957
The lack of legislative interest in regulating local DNA databases is not
surprising.287 Absent a public outcry, there is normally little political upside for
politicians to initiate legislation to curb police use of a tool that law enforcement has
identified as effective.288 And the possibility of a public outcry resulting from
surveillance techniques like local databases, which disproportionately impact people
with comparatively little socioeconomic standing and political power, seems unlikely
because citizens tend not to see themselves as the subjects of future police
investigations.289 Furthermore, even if policy makers would be interested in
regulating a particular surveillance method, they are often not notified of new
techniques in advance, leaving the new methods to gain a foothold absent external
oversight.290

The debate over the plan get dragged into the ObamaCare
debate
Katherine Gasztonyi (associate in the firms Washington, DC office and a member
of the Privacy & Data Security and Intellectual Property Rights practice groups)
2014 House Republicans Signal Push for Data Breach Legislation
http://www.insideprivacy.com/united-states/congress/house-republicans-signal-pushfor-data-breach-legislation/
In the wake of the recent Target Corp. credit card data breach, Congress is once
again turning its attention to data breach legislation. In a memorandum to
Republican lawmakers on January 2, House Majority Leader Eric Cantor (R-Va.)
stated that he intends to schedule legislation on security and breach notification
requirements for federally facilitated healthcare exchanges when Congress resumes
session next week. Democratic leaders characterized the news as yet another
effort by Republican lawmakers to undermine the Affordable Care Act rather than a
serious effort to deal with data security issues.

***Case***

1NC Link Turn

Despite privacy concerns - substantial numbers of patients are
still engaging the medical system now
Erin McCann (Managing Editor of Healthcare IT News) November 2014 Trust
issues over health privacy persist http://www.healthcareitnews.com/news/trustissues-over-health-privacy-persist
Healthcare industry, listen up: You've got a consumer distrust issue on your hands.
The majority of American consumers continue to have serious doubts over the
privacy and security of their medical records so much so that a sizable number of
them actually withheld information from care providers over those concerns. This
according to a new Office of the National Coordinator for Health IT survey, which
took a pulse of consumer perceptions toward healthcare privacy and security. The
numbers are telling. After surveying more than 2,000 consumers, ONC officials
found that about three-quarters of them were either very or somewhat concerned
over the privacy and security of their medical records. What's more, 10 percent of
respondents withheld information from their healthcare provider who used an
electronic health record. (This compared to the 6 percent who withheld data from
providers who used paper medical records.) The differences between the two were
not statistically different, ONC pointed out. The lion's share of Americans are also
not keen on their medical records being sent electronically or through fax, with
about 60 percent of consumers indicating concern over unauthorized access of their
medical records when they're sent in these two forms. These numbers appear to
align with a similar study conducted by Harvard researchers just last year. The
study, which assessed the privacy perceptions of U.S. adults, found similarly that
more than 12 percent of the 1,500 respondents withheld information from care
providers over medical security concerns. Findings supported "the need for
enhanced and sustained measures to ensure the confidentiality, integrity and
availability of PHI," Harvard School of Public Health researchers wrote in the study.
Despite all these concerns, as ONC officials highlighted in Tuesday's HIT Policy
Committee meeting, most respondents still "wanted healthcare providers to use an
EHR despite any potential privacy and security concerns," with some 76 percent
indicating this. "In spite of the fact that a majority of Americans expressed concerns
regarding the privacy and security of both their medical records and with sharing of
their medical records, support for EHRs and electronic health information exchange
remained consistently strong," said Vaishali Patel, senior advisor at the Office of the
National Coordinator for Health IT.

Restrictions on health surveillance destroys medical research

and disease prevention anonymization and consent are too
burdensome turns the entire aff
Chris Verity et al. (Child Development Centre, Addenbrooke's Hospital, past
chairman, British Paediatric Surveilance Unit Executive Committee, Agnus Nicoll,
PHLS Communicable Disease Surveillance Centre, and Donal Manning, Child
Development Centre, Addenbrooke's Hospital) 2002 Consent, confidentiality, and

the threat to public health surveillance / Commentary British Medical Journal,

International edition324.7347 (May 18, 2002): 1210-3
Why is surveillance important? Since the 1980s the public has become increasingly
concerned about health protection against real and perceived hazards, including
HIV, bovine spongiform encephalopathy/variant Creutzfeldt-Jakob disease, food
poisoning, possible adverse effects of medicines and vaccines, etc.16 People expect
that health surveillance will be undertaken efficiently and effectively. When
outbreaks of infectious disease occur, local public health doctors, regional
epidemiologists, or, centrally, the Communicable Disease Surveillance Centre,
mount rapid investigations to enable them to provide protective measures, identify
hazards, and reduce the risk of further infections and disease. Is surveillance
acceptable? When the rationale for surveillance is explained to colleagues in
primary care and in hospitals, they are almost always cooperative, as are affected
patients and healthy "controls," sometimes providing personal information over the
phone. Similarly, feedback from parents of children with rare but important
disorders indicates that they support surveillance and would not welcome changes
that threaten its completeness or accuracy. No major effort, however, has been
made to explain surveillance mechanisms or their importance to the public. Threats
to health surveillance The present arrangements for health surveillance are
threatened by the proposal that either explicit consent should be sought from
patients for use of their personal data, or data must be completely anonymised.
Obtaining explicit consent before sharing identifiable patient data Simple but
unrealistic suggestions have been made to solve the complex problems surrounding
surveillance, consent, and confidentiality One is that consent for reporting can
readily be obtained from patients or parents. Almost all reporting and referral of
clinical specimens relies on the cooperation of busy people such as clinicians and
microbiologists who are providing patient care with growing workloads in an
increasingly bureaucratic environment For example, over 90% of paediatricians
return the British Paediatric Surveillance Unit's monthly surveillance card, but the
data the card requests are purposely kept to a minimum in order to sustain good
response rates.17 It is our considered opinion, and that of our colleagues, that if
explicit consent for sharing data had to be obtained the completeness and
timeliness of reporting would be dangerously disrupted. Obtaining explicit consent
would be most difficult for single consultations-for example for an acute
infectionwhen the need for a report is often only appreciated some time after
collection of the specimen or after initial diagnosis. It is usually impossible to
determine at the time of a consultation which specimen will reveal a significant
pathogen. For laboratory reporting, clinicians would have to ask for consent for
sharing of data or specimens for every proposed investigation, or else pathologists
would later be ringing up clinicians to ask them to trace and contact patients for
consent. Neither system could be expected to work well. When approached, families
almost always wish to cooperate,4 but reporting doctors do not readily want to add
the task of obtaining consent to their other work commitments,4 18 as a sequential
surveillance and research investigation undertaken by the Royal Colleges of
Ophthalmologists and Paediatrics and Child Health on retinopathy of prematurity
illustrates. In this study, 235 cases were initially reported through conventional

surveillance (without seeking explicit consent from parents). Later, reporting

doctors were asked to obtain consent because an additional research study involved
seeking parental views. In some cases repeated reminders to clinicians were
needed although there were only three parental refusals. Eventually consent was
obtained for 188 of 221 eligible cases (85%), and each consent took on average 3
months to obtain (L Haines, personal communication, 2001). The percentage would
have been far lower had not the investigators been able, from prior knowledge of
existing cases, to remind clinicians that consent was outstanding. Other specialties
have had similar experiences. Introduction of the requirement for consent for cancer
registration resulted in a 70% drop in notifications to the long established Hamburg
cancer register, destroying its comparative value-it is no longer referred to in
European publications (M Parkin, International Agency for Research on Cancer,
personal communication, 2001). An American study on consent found that the
requirement for consent led to selective exclusion of some patients and hence
introduced bias.19 In the United Kingdom, a belief that patient consent was needed
before inclusion in a general practitioner diabetes register contributed to
ascertainment of only 60% of eligible diabetic patients,20 mainly because some
doctors never got round to obtaining consent (S Burnett, UCL London, personal
communication, 1999). A disturbing recent development is that, notwithstanding
official reassurances 9 10 12 some NHS trusts have instructed doctors not to
transfer data about patients unless they do have consent, and this has inhibited
some doctors who were keen to contribute to, for example, cancer registries. This
has already impaired the work of the cancer registries, and the reporting of
infectious diseases might be similarly affected. Anonymising data before transfer It
has been suggested that removal of the identifiers from patient data will obviate the
need for consent, but in a number of health surveillance studies the identifiers are
essential links to other sources of health information about individuals that provide
validation and eliminate duplication (table). An alternative suggestion is to use NHS
numbers instead of such identifiers as names and dates of birth, but at present NHS
numbers are rarely included in routine data sets, so this solution would also
interfere with surveillance. Conclusions Health surveillance is essential to protect
public health, and existing surveillance mechanisms work reasonably well.
Surveillance could be seriously threatened if it was thought that there was an overriding need to maintain patient confidentiality or always to have to seek explicit
consent to sharing of data. We are very concerned that restrictive interpretations of
some of the recent guidance on patient consent would so damage surveillance
mechanisms that they would cease to protect the health of the public, thus resulting
in preventable ill health and deaths.

2NC Link Extensions

Rigid health privacy protections collapses public health
expansive surveillance key
Amy Fairchild (associate professor in the Department of Sociomedical Sciences
and assistant director for scholarly and academic affairs at the Center for the
History and Ethics of Public Health at the Joseph L. Mailman School of Public Health,
Columbia University in New York City) Ronald Bayer (professor of public health and
codirector of the Center for the History and Ethics of Public Health at the Joseph L.
Mailman School of Public Health, Columbia University in New York City) and James
Colgrove (assistant professor in the Department of Sociomedical Sciences at the
Joseph L. Mailman School of Public Health, Columbia University in New York City)
December 2007 Privacy and Public Health Surveillance: The Enduring Tension
http://journalofethics.ama-assn.org/2007/12/mhst1-0712.html
The discovery that cases of paralytic polio in 1955 were caused by a single
manufacturer of Salk vaccine, the linkage of toxic shock syndrome to tampons in
1979, the identification of the sentinel cases of AIDS on the East and West coasts in
the early 1980s, the recognition of West Nile, SARS, and avian flu at the turn of the
twenty-first centurywere all the result of surveillance systems, through which alert
and troubled physicians could communicate with public health officials, thus
enabling emerging patterns to be identified. In each instance, such vigilance made
it possible to initiate measures that could limit the human toll. Surveillance serves
as the eyes of public health. Name-based reporting of cases has provided the
foundation for planning, intervention, and prevention and has been critical for
epidemiological research into patterns of morbidity and mortality for a wide variety
of diseases and conditions. Registries have been essential for tracking individuals
and their conditions over time. Surveillance has also served to trigger the imposition
of public health control measures, such as contact tracing, mandatory treatment,
and quarantine. The threat of such intervention and long-term monitoring has
provoked alarm and rendered surveillance suspect for those concerned about the
unwarranted exercise of state authority in the name of public health. Thus the
history of surveillance has been bounded by a promise and a specter. Over the
course of the 20th century, public health officials reiterated the importance of
surveillance, arguing that without the name and location of diseased individuals
they worked "in the darkness of ignorance" and might "as well hunt birds by
shooting into every green bush" [1]. It was the prospect of what surveillance might
offer that raised hopesfor the delivery of services, for lifesaving knowledge, and
for protection of individuals and communities. Hermann Biggs, a titanic figure in the
history of public health, who was perhaps the most important late 19th- and early
20th-century architect and philosopher of U.S. public health surveillance, made it
clear that names of the diseased were never collected "in order to keep clerks or
adding machines busy" [2]. Toward the end of the 20th century, Surgeon General
David Satcher would state the value of surveillance as plainly as had Biggs: "In
public health, we can't do anything without surveillance. that's where public health
begins" [3]. When surveillance opened the doors to vital services and knowledge, its

subjects could well become among its most ardent advocates, thus underscoring a
politics that goes beyond the politics of privacy. In the late 19th and early 20th
centuries, as public health was extending the ambit of surveillance, the medical
community reacted with hostility, particularly when it came to tuberculosis
surveillance and seemingly threatened to intrude on the sanctity of the clinical
relationship, over which the physician was guardian. Medical Record editor George
Shrady thus complained of TB surveillance, The compulsory step taken is a
mistaken, untimely, irrational, and unwise one.... The real obnoxiousness of this
amendment to the sanitary code is its offensively dictatorial and defiantly
compulsory character. It places the Board [of Health] in the rather equivocal
position of dictating to the profession and of creating a suspicion of an extra bid for
public applause [4]. "Already," he continued, "the profession as a whole has
watched with jealous eye the encroachments of the Board upon many of the
previously well-recognized privileges of the medical attendant" [4]. Over time,
disease reporting was extended to chronic, noncontagious conditions such as
cancer, birth defects, and occupational illnesses. Not only physicians but
laboratories were often required to report cases to local health authorities. The
surveillance of chronic diseases, of course, differs because these conditions do not
represent a direct threat to the health of others. And, indeed, when state and local
health departments first began tracking conditions like congenital malformations
and cancers in the first half of the 20th century, these initiatives typically served
epidemiological or research purposes only. These reporting efforts, critically, also
became linked to the assessment and improvement of clinical care. Tumor
registries, for example, emphasized patient care improvement since the 1950s and,
currently, data from the National Cancer Institute's SEER program (Surveillance,
Epidemiology, and End Results Program) are routinely used for quality improvement
initiatives. It was not until the AIDS epidemic that activists challenged the longstanding tradition of name-based reporting. Even so, as AIDS has become a more
treatable disease, resistance to reporting has all but vanished. In the 1990s, the
promulgation of national standards to safeguard the privacy of medical records, as
dictated by HIPAA (the Health Insurance Portability and Accountability Act),
provoked intense public debate. But there was virtually no opposition to carving out
an exception in the guidelines for the reporting of diseases to public health
agencies. While there was initial uncertainty among physicians and researchers
about whether hospitals could continue to provide cancer data to state registries,
the Department of Health and Human Services made clear that HIPAA did not serve
as an obstacle to reporting. In the early 20th century it was physicians who
spearheaded opposition to surveillance; since the 1970s, patients have often been
at the forefront of challenges to reporting diseases. Parents of children with
disabilities, for example, successfully changed the terms of birth defects
surveillance in Minnesota, requiring the state to allow unwilling parents to opt out of
reporting. Patient advocates within the American Diabetes Association forced New
York City health officials to place limits on an initiative to track cases of diabetes.
But just as often, patients with serious illnesses have pushed for better tracking of
their conditions. Breast cancer survivors have emerged as the most ardent
defenders of universal name-based cancer reporting, recognizing how important
surveillance and the research it makes possible is to their own well-being. Similarly,

communities concerned about "cancer clusters" and environmental threats have

demanded access to the data that only cancer registries can accumulate. Patients
expect their privacy to be protected, of course, but also maintain that a rigid
commitment to privacy could hobble the usefulness of registries. In these instances,
public health officials, committed to the paramount importance of surveillance,
have been extremely wary about disclosing any data that could potentially
compromise individual privacy.

Disrupts biomedical research

Hannson et al 12 (Mats, Centre for Research Ethics & Bioethics at
Uppsala University; Bengt Simonsson, Department of Medical Sciences
at Uppsala University; Nils Feltelius, The Swedish Medical Products
Agency; Joanna Forsberg, Centre for Research Ethics & Bioethics at
Uppsala University; Joerg Hasford, Institut for med
Informationsverarbeitung, Medical registries represent vital patient
interests and should not be dismantled by stricter regulation, July
2012, The International Journal of Cancer Epidemiology, Detection, and
Prevention, p. 3-4)//JL
Rothstein foresees criticism of his proposal for leading to selection bias in research,
delaying the introduction of new treatment and safety procedures in medicine, but
he claims that at present there is an insufficient empirical basis to assert that
adding some level of privacy and autonomy protection to deidentified health
information and biological samples will invariably and unreasonably disrupt
biomedical research (p. 8). However, as has been argued by several, inclusivity
and universality are the keys to successful registry research [10,11]. There is a price
to be paid since all requirements for informed consent, opt-out, re-consent, etc.
imply that the registry will be affected both by those included and those not
included. The likely result is incomplete information and data bank bias that will
prevent researchers from tracking success and failure of treatment and drug
efficacy and safety. The immediate victims of this will be the patients, with those
suffering from rare diseases like CML paying the highest price. There are several
examples of bureaucratic ethical review procedures and requests for consent that
seriously jeopardized the possibility of doing biomedical research, at the end
exposing patients to increased risks [12,13]. There are recent assessments available
of the cost in lives caused by hurdles related to information and consent procedures
[14].

Privacy is a prerequisite to any form of successful health

surveillance
Khaled El Emam (founder and CEO of Privacy Analytics Inc, senior scientist at the
Childrens Hospital of Eastern Ontario (CHEO) Research Institute and Director of the
multi-disciplinary Electronic Health Information Laboratory (EHIL) team) 2014
Public Health Surveillance and Privacy in the Age of Ebola

https://privacyassociation.org/news/a/public-health-surveillance-and-privacy-in-theage-of-ebola/
Being able to introduce anonymization methods into practice to ensure data
custodians are willing to share data for public health purposes is important in the
age of such epidemics as Ebola. The efficiency with which we track and investigate
outbreaks is directly related to the spread of the disease. There is an urgency to get
access to data. And it is not always health data that is important. Ongoing public
health surveillance systems would allow rapid detection of and reaction to
outbreaks. But this can only happen if privacy concerns that currently act as a
barrier are addressed. Privacy does not have to be an obstacle, but it is an issue
that needs be dealt with upfront when these surveillance systems are put into
place. We cannot take for granted that data custodians are willing to share their
data, even when there is an outbreak, as we saw during H1N1.
Thomas R. Frieden (Director, U.S. Centers for Disease Control and Prevention;
Administrator, Agency for Toxic Substances and Disease Registry) September 2012
Non-Communicable Diseases and the New Global Health
http://www.cfr.org/diseases-noncommunicable/non-communicable-diseases-newglobal-health/p35310
Really, let me say one thing about the problem and one thing about the solution.
Noncommunicable diseases are sometimes mischaracterized as diseases of
affluence because we have the concept that as people get richer, they do more
unhealthy things, and these diseases follow. But actually, I think these are
fundamentally diseases of poverty. They're diseases of poverty because in most
countries, not only do they disproportionately affect the poor, but they perpetuate
poverty in individuals, in families, in communities and, perhaps most importantly, in
countries. Noncommunicable diseases are an enormous drag on economic
development, on health care systems, on workplace productivity. And so they have
enormous economic implications for individuals, families, communities, work sites
and countries. The global burden of disease has really shifted. For the first time in
human history, we have more people living in cities than in rural areas. We have
more people who are overweight than underweight. We have more deaths among
adults than among children. And we also have more people dying from
noncommunicable diseases in poor countries than in rich countries, with higher
rates of noncommunicable diseases in poor countries than rich countries. In fact, in
poor countries, half of all deaths from noncommunicable diseases occur before the
age of 70. In rich countries, it's about a quarter of all deaths from noncommunicable
disease before the age of 70. So these are huge differences, and now noncommunicable diseases kill more people than communicable diseases, about twothirds of all of the world's deaths, and that burden is not only high, but it is
increasing and on a trajectory to increase even further.

Mass health surveillance is good its key to medical

effectiveness and drug development
Freedland 14 (Jonathon Freedland is the Guardians executive editor. He also writes for the NYT and New
York Review of Books. He won the Orwell special prize for journalism and the columnist of the year in What the
Papers Say. We now trust no one with our data not even our doctors 1/31/14
http://www.theguardian.com/commentisfree/2014/jan/31/nhs-medical-data-trust-doctors-edward-snowden)///CW

imagine them
looking at your medical records. The private realm may be ever-shrinking in an age when we reveal so
much of ourselves online and when we know the eavesdroppers of the NSA and GCHQ are never far away
but if there's one thing we'd want to keep behind high walls, it's surely the
intimate histories of our mental and physical health . So there can be little surprise that privacy
If you thought someone snooping around your emails and listening to your phone calls was bad,

campaigners are recoiling at the expansion of NHS England's data collection, which from this spring will take in
information from the place where most people experience the NHS: their GP's surgery. Until now, the NHS in
England kept the stats from hospital visits but not from those day-to-day encounters with your local doctor. As
26.5m leaflets pop through letterboxes, explaining the new "care.data" project, groups such as medConfidential.org
are urging patients to opt out in the name of basic privacy. One survey found that up to 40% of GPs plan to keep
their own personal records out of the scheme. My first, unreflective instinct would be to stay out too and others
will surely feel the same way. Indeed, the appeal of that stance says much about the times we live in, both online
and in the physical world. For one thing, less than a year after Edward Snowden's revelations of mass surveillance,

the notion that our medical records will remain closely guarded , viewed only by those
doctors and scientific researchers who need to see them, arouses instant scepticism. Sure, we think. They
said the same about our emails. After Snowden, many will assume that if the authorities want to know
whether we are HIV-positive or once suffered from depression, they'll be able to find
out with just one click. As medConfidential's Phil Booth told the FT: "Everyone agrees medical
research is a good thing but, after the NSA scandal, people are getting wise to the
dangers of these massive data sets." [paywalled link] It doesn't even have to be that sinister. It
wasn't that long ago that government ministers were apologising from the floor of the House of Commons after
Revenue & Customs mislaid two discs containing the names, dates of birth, national insurance numbers and, where
relevant, bank details of 25 million people. What, one wonders now, is to stop the geniuses who brought us that
disaster messing up again, except this time losing not our tax details but the stories of our lives and bodies?

Won't the big

drug companies be desperate to pore over that information, the better to profit from
our frailties? And if private health and life insurance companies get access to that data, won't they start
charging higher premiums if they know what once took us to see the doctor? Given all
those worries, you can see why some want to opt out . And yet that first, gut instinct might
be wrong. It's not just that the vast bulk of the information will be rendered anonymous, with individuals blurred
Advertisement Campaigners worry too about who might want to take a look at all that info.

out in all but the most controlled circumstances, or that there are strict rules in place over access to this
information. Nor even that there is an explicit declaration that this data will not be shared with insurance or
marketing companies so no prospect of a Strepsils ad popping up on your screen just after you've seen your GP

clinical studies only

tell you so much. Sometimes it's mass data you need. It was mass information that disproved the
over a sore throat. Rather, it's the great gain that this information will provide. Small,

link between MMR and autism, or that spotted the connection between Thalidomide and birth defects, or between

Ethically you can't conduct trials on pregnant women or children, so

you're reliant on knowing what's happening in the population. If you can know that
swiftly and at scale, you can act faster and more effectively . As the leaflet popping through
smoking and cancer.

the door puts it: "Better information means better care." The pragmatic truth is that this logic extends even to the

it's through pharmaceutical companies that new

medicines are developed: they're the ones who fund the trials, turning research into medication. As Nicola
Perrin of the Wellcome Trust, which strongly backs care.data, put it to me: " If we want access to the best
possible drugs, the drug companies need access to the best possible information. "
private drug companies. Like it or not,

There is a principle at stake here too. In a subtle piece for the Socialist Health Association, Prof Dave Byrne recalls

the traditional method of teaching medical students, in which a senior doctor on a ward-round would urge them to
look at and learn from real-life individuals and their treatment: care.data is just a hi-tech version of that process,
says Byrne, gathering together doctors' experience of treating patients. Viewed this way, our individual experience
of treatment suitably anonymised is not our private property, even if it should remain private. Those who treated
us have the right to use that experience to benefit others, to help the collective good. But

anonymity is the

key. None of these arguments in favour of care.data works unless we can be sure those rules on access hold firm
and that the identity of individual patients remains concealed and not easily hacked as some currently fear. And

online anonymity remains vexed. All too often it seems we don't have it when we
should, whether through data loss or NSA-style state intrusion. At the same time, we have too much anonymity
yet

when we shouldn't: witness the social media trolls and abusers, or phoney, astroturf campaigners, able to stay
hidden when they would surely shrivel if exposed to the daylight and forced to reveal their true identities. The
larger obstacle confronting this new scheme goes beyond the virtual realm. It is a change that is infecting almost
every aspect of our shared lives: loss of trust. So the government can issue guarantees of privacy protection and
our first thought is of missing discs, GCHQ eavesdroppers or perhaps hacked phones. Too many institutions have
been exposed as having betrayed their unspoken promises,

whether it's MPs, the security services,

the police, the banks or the BBC. For many years the NHS stood alone, immune to
this trend, doctors topping every index of trust. But thanks to Mid-Staffs and
scandals like it, the NHS too has been found wanting. Which is why a good idea like
a project to share our broad, unnamed data can face such resistance. We take
nothing on trust these days not even the word of a doctor.

Medical Research Extensions

Even the current minimal protections provided by HIPAA
drastically impede research
Steinberg and Rubin 9 (Mindy Steinberg and Elaine Rubin. Steinberg is a
program associate at the Association for Academic Health Centers. Rubin is the vice
president for policy and program at AAHC. The HIPAA Privacy Rule: Lacks Patient
Benefit, Impedes Research Growth. 2009. P. 1-2.
http://www.aahcdc.org/Portals/0/pdf/AAHC_HIPAA_Privacy_Rule_Impedes_Research_
Growth.pdf)////EMerz
The Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA),
a regulation designed to protect the privacy of health information, continues to have
a negative impact on the nations research enterprise, according to the latest
survey of academic health center research administrators and principal
investigators by the Association of Academic Health Centers (AAHC). Since the 2003
implementation of the Privacy Rule (45 CFR 160, 164), studies have shown that it
has imposed barriers to research at academic health centers, the nations major
research institutions, thus slowing the pace of research, increasing the costs, and
significantly hindering participation of individuals in important research studies.
Research was not intended to be governed by the HIPAA Privacy Rule, but neither
was it exempted from the regulation. However, the new constructs and restrictions
on information mandated by the Rule have had untold consequences for the
conduct of research and the advance of science and discovery in the United States.
Despite repeated efforts by the research community to highlight the negative
consequences of the HIPAA Privacy Rule, policymakers have made little attempt to
address the Rule and consider options to remedy the situation. With the U.S. facing
critical socioeconomic challenges, including an aging population and the desire for
new treatments and cures for disease and illness, it is essential that policymakers
reexamine the HIPAA Privacy Rule. The AAHC called for changes to the HIPAA
Privacy Rule and recommended options to address these critical research issues
based on evidence from a limited number of focus groups conducted with
researchers throughout the country in 2007.4 This year, to broaden its information
base, the AAHC developed a questionnaire that was administered online to 102
members of the AAHCs executive leadership group of Vice Presidents for Research
as well as other senior leaders (e.g., legal counsel and chief compliance officers)
who are members of the Vice Presidents for Research Workgroup on HIPAA. The vice
presidents for research were also asked to forward the survey to 2-4 principal
investigators at their institution in the interest of including the perspective of
researchers along with that of senior research administrators.

Privacy legislation destroys scientists motivation to conduct

research- its too expensive with protections in place
Steinberg and Rubin 9 (Mindy Steinberg and Elaine Rubin. Steinberg is a
program associate at the Association for Academic Health Centers. Rubin is the vice
president for policy and program at AAHC. The HIPAA Privacy Rule: Lacks Patient
Benefit, Impedes Research Growth. 2009. P. 3.

http://www.aahcdc.org/Portals/0/pdf/AAHC_HIPAA_Privacy_Rule_Impedes_Research_
Growth.pdf)////EMerz
In short, the majority of survey respondents believe the HIPAA Privacy Rule had a
significant negative impact on the scope, pace, and costs of research. The greatest
concern was expressed about the negative impact on the costs of research.
Respondents also indicated they were aware of research studies that were
stopped or never pursued because of Privacy Rule related problems. The
negative perceptions of research leaders are especially significant. The HIPAA
Privacy Rule imposes another limitation on Americas ability to fulfill the promises of
new science. A lack of interest in scientific careers, and decreased federal
funding of research when coupled with the HIPAA Privacy Rule, create a
burdened and troubled environment for the future.8

That turns case- patients health will be worse off if there are
more barriers to DNA research
Steinberg and Rubin 9 (Mindy Steinberg and Elaine Rubin. Steinberg is a
program associate at the Association for Academic Health Centers. Rubin is the vice
president for policy and program at AAHC. The HIPAA Privacy Rule: Lacks Patient
Benefit, Impedes Research Growth. 2009. P. 3.
http://www.aahcdc.org/Portals/0/pdf/AAHC_HIPAA_Privacy_Rule_Impedes_Research_
Growth.pdf)////EMerz
The problems with the HIPAA Privacy Rule are extensive and are likely to be even
broader than the survey suggests. Furthermore, there is no clear evidence that the
Rule is achieving its intended purpose in the research arena. Given the longstanding
history of the Common Rule in research, it would be most expedient and effective to
exempt research from the HIPAA Privacy Rule and to defer to the Common Rule. The
Common Rule an essential safeguard that has worked successfully has been
responsible for ensuring the protection of research participants safety and privacy
for more than 30 years. The negative impact of the HIPAA Privacy Rule on research
ultimately translates into negative consequences for patients, with more
terminally ill patients missing out on the opportunity to participate in
clinical trials that have the potential to save their lives. To remedy this threat
to research and the American people, revision of the HIPAA Privacy Rule is
imperative. The AAHC recommends that research be exempt from the HIPAA Privacy
Rule and that it be solely governed by the Common Rule. Furthermore, the AAHC
recommends a revision of the Common Rule to incorporate more explicit standards
for the privacy of health information and to augment the protections of the Common
Rule to accommodate new technologies and guard against new threats to patient
safety and privacy

Privacy-based critiques fail and undermine research

Hannson et al 12 (Mats, Centre for Research Ethics & Bioethics at
Uppsala University; Bengt Simonsson, Department of Medical Sciences
at Uppsala University; Nils Feltelius, The Swedish Medical Products
Agency; Joanna Forsberg, Centre for Research Ethics & Bioethics at

Uppsala University; Joerg Hasford, Institut for med

Informationsverarbeitung, Medical registries represent vital patient
interests and should not be dismantled by stricter regulation, July
2012, The International Journal of Cancer Epidemiology, Detection, and
Prevention, p. 3-4)//JL
3. Registries criticized for threatening privacy Accordingly, vital patient interests are in the balance in association with the EUTOS for
CML and other similar registrations and data-sharing efforts. However, within the ethics and legal literature collaborations between
medical registries of this kind are seen as controversial because they pose a potential threat to the individual privacy of the

Rothstein has recently argued that collection and use of large quantities of
health information create a substantial challenge for protecting the privacy of
patients and research subjects that is accentuated when biological samples are involved [8]. De-identification, he
suggests, does not solve the problem since the process of removing identifiers implies that someone will
patients. Mark

actually have to do it thus representing an intrusion in private matters. It has also been claimed that re-identification may be
possible by using publicly available databases, provided that one have access to reference samples [9].

Rothstein

suggests that rules about de-identification are insufficient for privacy protection and need to be
comple-mented with rules about notice provisions to patients, such as informed consent, strategies for opt-out, and giving individual
patients a degree of control over the use of data and, where relevant, biological samples. 4.

The critique fails for

four reasons In light of the experience with the EUTOS for CML registry we believe that Rothsteins argument fails for four
reasons. 1. Rothstein foresees criticism of his proposal for leading to selection bias in
research, delaying the introduction of new treatment and safety procedures in medicine, but he
claims that at present there is an insufficient empirical basis to assert that adding some level
of privacy and autonomy protection to deidentified health information and biological samples will invariably and unreasonably
disrupt biomedical research (p. 8). However, as has been argued by several, inclusivity and
universality are the keys to successful registry research [10,11]. There is a price to be
paid since all requirements for informed consent , opt-out, re-consent, etc. imply that the
registry will be affected both by those included and those not included. The likely result is
incomplete information and data bank bias that will prevent researchers from tracking
success and failure of treatment and drug efficacy and safety . The immediate victims of this will
be the patients, with those suffering from rare diseases like CML paying the highest price. There are several examples of
bureaucratic ethical review procedures and requests for consent that seriously jeopardized the possibility of doing biomedical
research, at the end exposing patients to increased risks [12,13]. There are recent assessments available of the cost in lives caused

2. Rothstein acknowledges that research

concerns should not be dismissed lightly, but, he continues: On the other hand, the interests
of patients and the public also deserve respect and consideration (p. 8). His
argument for privacy relies, as stated, on a perceived dichotomy between the clinical
researcher on the one side with the patient and the public at the opposite side, a normative description of
the relationship that is questionable. This dichotomization seems to be a rather common phenome-non [15].
As Dixon-Woods et al. have recently argued, the ethical, legal and sociological accounts of medical research
that influence the policy debates describe research as operating in opposition to the norms
and interests of the general public and of the patient [16]. Based on empirical studies in a pediatric oncology research
context they were, in contrast to this alleged dichotomy, able to show how sentiments of coalition and partnership
characterized the relationships between the patient families, their doctors and the researchers.
3. Rothstein argues for the need of increased protection of privacy and autonomy based
on these interests as fundamentally protected by constitutional law . Wendy Mariner
argues in a similar vein for the need of limiting intrusion into medical privacy and has
suggested that a constitutional challenge could dismantle cancer registration [17]. Health is regarded as an important concern
but must sometimes give way to inherent principles of law, e.g. protection of privacy [18]. That privacy
is a vital interest of citizens and democratic societies is not controversial. However, the values that
by hurdles related to information and consent procedures [14].

associated with a secluded life are all kinds of social value [19]. They presuppose and acquire their
meaning only in a context where various kinds of social relationships with other individuals
are involved. To be banished to seclusion on a desert island, certainly implies that one will be left in peace, but it is not the
kind of situation which people wishing to protect their private life, strive for. Individu-als, as far as their own personal matters
are concerned, have an interest in being left in peace but they also wish to participate in the
possibilities that are available to citizens in a society. This includes having access to new medical knowledge
attainable only when personal medical data is recorded and shared within the format of large well-managed registries. In order to
further strengthen his argument Rothstein suggests that autonomy is only one
aspect of the broader concept of respect for persons (p. 8) and that this should imply closer regulation of registry
research. However, patients have interests also at the end of the research line , e.g. in new
are

possibilities to follow up the effects of medical drugs with regard to treatment response and adverse reactions, and if they became
aware of the costs of stricter regulation undermining the possibilities of participating in the development of scientific knowledge

4. Rothstein is critical of partnership with commercial

interests in association with biomedical research, something not uncom-monly questioned by ethicists and lawyers [20].
However, we suggest that partnership between academic and commercial partners is
essential for making progress in medical research and is intrinsic to concerns about assessment of drug
efficacy, safety and effectiveness. This claim does not imply that one should be nave . For the benefit
of patients sharing of data should go in both directions, also when a pharmaceutical company enjoys a monopoly. Potential
conflicts of interest may arise and should not be taken lightly. The increasing collaboration
they may be more likely to feel disrespected.

between industry and patients organizations should be considered. However ELN provides an interesting example of how doctors
and researchers may be able to collaborate with the pharmaceutical industry while preserving their own integrity. A working party
has just started a controlled trial in order to find out when treatment of CML patients with TKI should be stopped because the patient
will not benefit from prolonged treatment with the drug. Such a study may, arguably, not be in the best (economic) interest of the
drug companies.

HIPAAs protections of individual health records have

prevented vital research
Pritts 13 (Joy L. Pritt. The Importance and Value of Protecting the Privacy of
Health Information: The Roles of the HIPAA Privacy Rule and the Common Rule in
Health Research. 2013. P. 1-2
http://iom.nationalacademies.org/~/media/Files/Activity
%20Files/Research/HIPAAandResearch/PrittsPrivacyFinalDraftweb.ashx)//EMerz
The privacy of personal information, and of health information in particular,
continues to be a vexing issue in the United States. As more and more health
information is computerized, individuals express concern about their privacy and
that they are losing control over their personal health information. To help allay
public concerns, federal rules governing the use and disclosure of health
information were promulgated under the Health Insurance Portability and
Accountability Act (known as the HIPAA Privacy Rule). While the HIPAA Privacy Rule
does not directly regulate researchers, it does restrict the manner in which health
care providers may use and disclose health information for health research. Health
researchers have been critical of the HIPAA Privacy Rule since its inception,
concerned that it would interfere with valuable research. Various research
organizations and others have requested that the Rule be revised to lessen its effect
on research. Most recently, an Institute of Medicine (IOM) committee was formed
and charged with reviewing the impact of the Privacy Rule on health research. This
paper was commissioned by that committee, the IOM Committee on Health
Research and the Privacy of Health Information: The HIPAA Privacy Rule.

Disease Turn - Military

Surveillance key to check tick-based disease outbreaks --specifically likely on military installations
Peterson et al, masters in entomology qualifications of other authors: Medical
Entomologist/epidemiologists, 2015 (Wade, Tick-borne disease surveillance,
published in U.S. Army Medical Department Journal, jan-march edition, Academic
OneFile)//roetlin
Tick-borne diseases (TBDs) represent some of the world's most rapidly expanding
arthropod-borne infectious diseases. (1) (p1) In the United States, ticks are responsible for more
human disease than any other arthropod group. The incidence and the number of
pathogens transmitted by ticks are increasing . For example, Lyme disease is now the most
commonly reported arthropodborne illness in the United States. (2) Anaplasmosis, ehrlichioses, and rickettsioses

TBDs are potentially serious health threats to

troops, civilian employees, and residents at military installations . (2) (p6)
Companion animals and military working dogs (MWD) are also at risk in areas where ticks and TBDs are
are also on the rise. (1) (p1) In most parts of the world,

endemic or emerging. Risk of TBD increases with the introduction of exotic tick species into new areas and the
expansion of historical tick ranges. One example of exotic ticks that effects the United States is Boophilus annulatus
and B microplus, also known respectively as the cattle fever tick and the southern cattle tick, that were imported
here by Spanish colonists who brought tick-infested cattle and horses with them. These ticks transmit a severe
disease to cattle called Texas fever or cattle fever that caused enormous losses to the US cattle industry in the past.
Present efforts to keep this tick out of the United States exist as the Cattle Fever Tick Eradication Program. (3) Nilgai
antelopes, native to India, Nepal, and Pakistan, that were released into southern Texas are also hosts to the cattle
fever ticks, posing a threat as maintenance hosts of cattle fever. (4) There are many other examples of exotic tick
introductions from migratory birds, exotic and wildlife species, and domestic animals. (5) Changes in climate may
also alter the geographic distribution of tick vectors, and in turn, cause a change in the currently recognized
demographic patterns, seasonality, and incidence of TBDs. (1) (p61) For example, the range of the Gulf Coast tick
(Amblyomma maculatum) has historically been along the Gulf of Mexico and southern Atlantic coast as far north as
South Carolina, and extending approximately 100-150 miles inland. However, resident populations of these ticks are
now established in Arkansas, Oklahoma, and Kansas, (6) and they have been collected on the east coast as far
north as Delaware and Maryland. (7) Another example is the lone star tick (A americanum) which has moved
northward as far as Maine and westward into central Texas and Oklahoma. (8) Incidental introductions of these
ticks, and the diseases they carry beyond endemic regions, occur with increasing frequency. This is likely due to the
feeding of immature ticks on migrating birds, and the transportation of tick-infested livestock and wildlife into new
areas. (6) These introductions may also come from pets belonging to people who move from one area to another. In
addition, suburbanization has contributed to the increase in TBD transmission in North America by bringing people
and their pets close to ticks and by creating new tick habitat. (9) In the northeastern United States, the highest risk

As communities continue to
expand into tick habitat, and people are encouraged to enjoy outdoor recreation and
pursue activities such as urban farming, the risk for peridomestic exposure to ticks and TBDs
may increase. The National Notifiable Disease Surveillance System (NNDSS) of the
Centers for Disease Control and Prevention (CDC) maintains a list of diseases that
are considered to be of public interest by reason of their contagiousness, severity,
or frequency. The 7 TBDs on the NNDSS list are shown in the Table. Many of these diseases, which
are caused by closely related tick-borne pathogens, can also be acquired
internationally. There are also many TBDs that can be acquired abroad that do not occur in the continental
for Lyme disease occurs around the homes of those who have been infected. (10)

United States. In addition to transmitting disease, ticks can cause irritation, pain, and swelling at attachment sites,
otoacariasis (invasion of the auditory canal), paralysis, allergic reactions, and anaphylactic reactions. (11) Heavy

Direct effects from TBDs include

troop and MWD morbidity and mortality. There are also many indirect effects, such as illness of
dependents or Department of Defense (DoD) civilian personnel, and related healthcare costs.
Both types of effects can be mitigated through aggressive surveillance, public
infestations of ticks on animals can cause debilitation due to blood loss.

education, and prevention/control programs, together with prompt diagnosis and treatment. (2) (p6) TICK BIOLOGY

AND DISEASE TRANSMISSION Ticks are grouped into 2 separate families. Family Ixodidae, also called hard ticks,
have 4 developmental stages: egg, larva, nymph, and adult. The latter 3 each take one large blood meal and then
molt to the next stage, or lay eggs in the case of the adult. Hard ticks have mouthparts with recurved teeth that
allow them to firmly anchor themselves to hosts while feeding with the assistance of a cement-like substance
secreted by the salivary glands. This allows them to feed for extended periods of time that can vary from 2 to 12
days or longer, depending on species, life stage, and gender. Family Argasidae, also called soft ticks, have the same
4 developmental stages, but most have multiple nymph stages. Soft ticks have mouthparts that allow them to hold
fast to their host, as hard ticks do, but they do not secrete cement. Although some soft ticks can remain attached to
the host for several days, (11) (p501) others can complete a meal within minutes to hours. (12) This is still much
longer than other bloodsucking arthropods such as mosquitoes, and is one of the factors that contribute to their
high vector potential because it increases the likelihood of pathogen ingestion and allows them to secrete large
amounts of host-derived fluid and salivary secretions, which contain pathogens, back into the host. Other factors

ticks efficient disease vectors include a highly sclerotized body that protects
them from environmental stresses, high reproductive potential, and a long life span
that make

(compared to other blood feeding arthropods). Although the majority of TBDs are transmitted during normal feeding
activity, they can be transmitted by other routes as well, including through regurgitation and feces. Argasid ticks
can also release pathogens through excess liquid excreted from the coxal glands located adjacent to the first
segment (coxa) of the front legs. (11) (p512) Adding to their efficiency as vectors, the larvae and nymphs are very
small. The presence of an immature tick on a host often goes unnoticed, enabling the tick to feed to repletion and

Ticks can also

transmit more than one pathogen at a time. For example, Ixodes ticks can simultaneously or
drop off without detection, which increases the likelihood of pathogen transmission.

sequentially infect their hosts with Borrelia burgdorferi, Anaplasma phagocytophilum, and Babesia microti. (1) (p61)
Co-infections with these pathogens have been reported from wild and domestic animals, including dogs, as well as

These infections can result in more severe and longer illnesses and can
complicate diagnoses. (1) (p493) Ticks are also effective disease reservoirs. In some
humans.

species, pathogens can be transmitted from the adult female to its offspring (transovarial transmission) and from
one developmental stage to the next (transstadial transmission). Infected ticks can also transmit viruses to
uninfected ticks while feeding simultaneously on an uninfected host. (11) (p512) Therefore, they can maintain and
transmit infections even if they have not fed on an infected host. SURVEILLANCE Surveillance is the process of
determining the presence of vectors and pests, estimating their general population levels, and determining if
pathogens of concern are present in the population. It gives quantifiable data on which to base control and

analysis
and interpretation of information gained from surveillance is the basis for
developing quantitative and qualitative risk assessments that can be used to
predict the occurrence of pest outbreaks or vector-borne diseases. (13) (p7) Various
education programs and is the starting point in the prevention of any arthropod-borne disease. The

methods can be used to describe disease risk. One commonly used index is called the Entomologic Risk Index (ERI),
an indicator of the number of infected ticks that a person might come into contact with over a set distance. The ERI
is calculated as the number of infected ticks collected over a 1,000-meter drag (described below). Accurate ERIs are
obtained by testing ticks for pathogens to determine tick infection rate. Public health officials can use indices like
the ERI in public education efforts and to determine if, when, and what control measures should be implemented.
(13) (p7)

That collapses military readiness

Peterson et al, masters in entomology qualifications of other authors: Medical
Entomologist/epidemiologists, 2015 (Wade, Tick-borne disease surveillance,
published in U.S. Army Medical Department Journal, jan-march edition, Academic
OneFile)//roetlin
Ticks are one of the major vectors of disease that threatens military personnel,
families, and civilian employees on US military installations . (25) The presence of
tickborne disease in military personnel, including our military working animals, may result in the loss
of training days, decreased force strength, and may adversely affect unit readiness
and effectiveness. Tick-borne disease also affects DoD civilians and the families of
our troops. Soldier and unit readiness may be affected when family members and
companion animals are sickened by TBDs . The information gained from tick
surveillance regarding tick vectors, disease incidence, and pathogen

prevalence is invaluable. It allows medical personnel to educate personnel

regarding tick-bite and TBD recognition and prevention. Tick surveillance information also enables
leaders to make decisions regarding the application of safety and control measures during training and operations
to prevent TBDs. As with any disease, prevention of TBDs is highly preferable to treating the short- and long-term
consequences once they occur. (1(p155))

Readiness solves lashout

Jack Spencer, 2k, Research Fellow in Nuclear Energy Policy at The Heritage
Foundation's Roe Institute for Economic Policy Studies. The Facts About Military
Readiness Sep. 15, 2k. accessed July 31, 2010
http://www.heritage.org/Research/Reports/2000/09/BG1394-The-Facts-AboutMilitary-Readiness//
declines in America's military readiness signal to the rest
of the world that the United States is not prepared to defend its interests.
Therefore, potentially hostile nations will be more likely to lash out against American
allies and interests, inevitably leading to U.S. involvement in combat. A high state
of military readiness is more likely to deter potentially hostile nations from
acting aggressively in regions of vital national interest, thereby preserving peace.
Military readiness is vital because

Disease Turn A2 Privacy

Aggregated data is good doesnt hurt privacy and facilitates
effective treatment
Hannson et al 12 (Mats, Centre for Research Ethics & Bioethics at
Uppsala University; Bengt Simonsson, Department of Medical Sciences
at Uppsala University; Nils Feltelius, The Swedish Medical Products
Agency; Joanna Forsberg, Centre for Research Ethics & Bioethics at
Uppsala University; Joerg Hasford, Institut for med
Informationsverarbeitung, Medical registries represent vital patient
interests and should not be dismantled by stricter regulation, July
2012, The International Journal of Cancer Epidemiology, Detection, and
Prevention, p. 3-4)//JL
Development of medical registries with sharing of data is intrinsic for the protection of
patient benefits and patient safety . If, linked to the medical record, and used also for clinical decision making in
dialogue with the patient the benefit and legitimacy of clinical registries might increase even more. The patient in our view
should have the right to quality assured medical treatment and care and the clinicians and
hospitals should have a corresponding duty to document relevant quality measures for long term follow up of treatment. There
is a well-recognized duty to document at the individual patient level but today there is
a lack of systematic collection and analysis of aggregated registry data . It
was objected by one reviewer that registries for quality assurance are seldom considered a problem from a data inspection point of
view, because the exact use of data is clearly specified at outset and the registries are used for the same, usually repetitive quality

there is an
increasing awareness of the need for aggregated data for quality assessments and
drug efficacy/safety assessments. Recent developments in genomics in fact blur the
traditional line between quality assurance and research through the rapidly
increasing possibilities to identify genotypes as well as environmental factors regulating the treatment
assurance analyses while research implies that new questions are being raised as science develops. However,

benefit/risk scenarios. It is actually strange that the demand of mandatory quality assurance that is common in so many other areas

in order to
assure the patient the best medical treatment available at each time research based on
those registries is necessary and should in principle be approved and supported . From
the patients perspective there is no conflict between the interest of documentation in a
medical record, the interest of follow-up and long-term assessment through medical registries (whether local,
national or collaborative on a global level) and the interest of receiving the at each moment best
available treatment based on research. This, we believe, holds not only for rare diseases like CML but also for
in society is not implemented as rigorously in health care where lives are at stake each day. Furthermore,

all medical treatment.

Registries dont hurt privacy and are key to solve diseases

empirics prove
Hannson et al 12 (Mats, Centre for Research Ethics & Bioethics at
Uppsala University; Bengt Simonsson, Department of Medical Sciences
at Uppsala University; Nils Feltelius, The Swedish Medical Products
Agency; Joanna Forsberg, Centre for Research Ethics & Bioethics at
Uppsala University; Joerg Hasford, Institut for med
Informationsverarbeitung, Medical registries represent vital patient

interests and should not be dismantled by stricter regulation, July

2012, The International Journal of Cancer Epidemiology, Detection, and
Prevention, p. 3-4)//JL
EUTOS for CML Registry clearly illustrates the benefits of aggregated, longterm clinical data for the assessment of drug effectiveness, in particular for orphan diseases but
the same logic applies to all diseases, i.e. the more standardized, relevant and validated
data available in quality registries, the better. Although values such as autonomy and privacy are
important and should be safeguarded, it must be kept in mind that these registries exist for the
good of patients and therefore it seems inconsistent and even unethical to hinder their
optimal utilization. Transparency and safeguarding personal integrity are necessary to preserve
trust but rules and legislations to protect integrity should not prevent the
development of registries and performance of clinical trials in both national and transnational collaborations. That
would be detrimental to vital patient interest of reaping the benefits of collaborating
The

with others.

Systemic data collection over a wide range of health issues is

inevitable and required for a wide range of issues --- the plans
reversal is bad --- its a linear case turn
Gostin, an internationally recognized scholar in law and public health, professor of
Law at Georgetown University; Professor of Public Health at the Johns Hopkins
University; and the Director of the Center for Law & the Publics Health at Johns
Hopkins and Georgetown Universities, 2001 (Lawrence, Health Information:
Reconciling Personal Privacy with the Public Good of Human Health, published in
Healthcare Analysis vol 9,
A health care system supported by data on almost any relevant subject, accessible
to a diverse and significant number of users, is an integral part of the vision for the
health care system. Plans for the systematic collection, storage, use, and
dissemination of a huge volume of uniform data sets in electronic form are already
under way and have an aura of inevitability. This new health information infrastructure is the
subject of reports published by the Congressional Office of Technology Assessment (Congressional Office of
Technology Assessment, 1993, 1988, 1986), the General Accounting Office (Information Management and
Technology Division, General Accounting Office, 1993a, 1993b, 1991), the National Academy of Sciences
(Donaldson and Lohr, 1994), the Department of Health and Human Services (Task Force on Privacy, U.S. Dept of
Health and Human Servs., 1993; Task Force on the Privacy of Private Sector Health Records, U.S. Dept of Health
and Human Servs., 1995), the Physician Payment Review Commission (Physician Payment Review Commn, Annual
Report to Congress, 1994, 1993, 1992) 322 and the Centers for Disease Control and Prevention.1 The U.S.
Department of Health and Human Services issued final regulations on health information privacy in 2001 (Gostin,

powerful reasons exist for the

broad collection and use of health data. High quality data are needed to help
consumers make informed choices among health plans and providers, to provide
more effective clinical care, to assess the quality and cost effectiveness of health
services, to monitor fraud and abuse, to track and evaluate access to health
services and patterns of morbidity and mortality among under served populations,
and to research the determinants, prevention, and treatment of disease.
2001). Contrary to the assertions of some privacy advocates,

Surveillance is key to solve economysaves money, resources,

and labor
Mirza et al 13 (Nabila, Tera Reynolds, Michael Coletta, Katie Suda, Ireneous Soyiri, Ariana Markle,
Henry Leopold, Leslie Lenert, Erika Samoff, Alan Siniscalchi, and Laura Streichert researchers and analyists for
OJPHI, Steps to a Sustainable Public Health Surveillance Enterprise A Commentary from the International Society
for Disease Surveillance http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733763/ July 2013 JM)

Recognize systematic and ongoing public health surveillance as a core public health function
that is essential for population health, economic stability, and national security. Public
health surveillance data is the foundation of public health programs and is required for a
number of purposes, including: to demonstrate the size and impact of the public health
problem being addressed by a program; to identify the population groups to which additional prevention efforts should be
directed; to determine whether the problem is growing in size or abating; to provide feedback to data
providers; and as part of an overall program evaluation strategy. The significant health impacts and economic
costs of disease outbreaks illustrate the critical importance of effective public health
surveillance and rapid response, as well as the cost of inaction [11]. Table 1 provides examples of the
health and financial burdens posed b y some naturally occurring and intentional infectious disease
outbreaks. The values reported in Table 1 do not fully reflect additional indirect costs of
diseases and their potentially crippling effects on a community , nor do they address costs that
are underreported/ unreported due to lack of data. Higher rates of illness, for example, can lead to
lower worker productivity [11], while premature mortality can reduce the size of the labor
force, both of which have economic ramifications. There is growing evidence that these economic and societal
costs can be mitigated by surveillance systems that are stable ; a stable
system provides the best foundation for identifying whether the problem being addressed is getting bigger
or smaller or disproportionately affecting a section of the population, etc., while still allowing flexibility to
provide useful information quickly about emerging issues . The optimum mix of stability
and flexibility will depend on the purpose(s) of surveillance and the particular health condition
under surveillance. For example, in the case of SARS, an effective surveillance system has the potential
to decrease the size of an epidemic by one-third and the duration by 4 weeks, with significant cost
savings [25]. Another study found that the early detection of an outbreak of highly infectious bacterial meningitis saved
approximately $2 for every dollar invested in infectious disease surveillance [26]. Yet
another evaluation of surveillance practice found that technological improvements in a sentinel influenza-like illness (ILI)
surveillance system in Virginia saved over $9,500 (1,992 hours) in staff-time during the 2007-2008 influenza seasons [27 ].

Ongoing surveillance can also inform the design and evaluation of prevention and
intervention programs in order to control the escalating costs associated with chronic diseases in the U.S. and abroad
[28]. Some experts forecast that chronic disease prevention programs could save up to $48.9
billion per year by 2030 [29], while others predict applying electronic medical record implementation and networking to the
prevention and management of chronic disease will exceed the currently projected $81
billion in annual savings [30].

Bioterror Links
More surveillance is key to solve the aff impacts
White House 12 (The White House, from the President of the United States
Barak Obama, NATIONAL STRATEGY FOR BIOSURVEILLANCE
https://www.whitehouse.gov/sites/default/files/National_Strategy_for_Biosurveillance_July_2012.pdf July 31 2012

JM)
national biosurveillance enterprise is a national security imperative . Our
ability to detect quickly and characterize a potential incident of national significance that
affects human, animal, or plant health is of paramount importance. Rapid detection
and enhanced situational awareness are critical to saving lives and improving incident outcomes,
whether the result of a bioterror attack or other weapons of mass destruction
(WMD) threat, an emerging infectious disease, pandemic, environmental disaster, or
a food-borne illness. Beyond our need to protect domestic interests, and because health threats transcend
national borders, the United States also plays a vital role within an international network of
biosurveillance centers across the globe. For years, there have been dedicated efforts to promote and strengthen biosurveillance capabilities.
A well-integrated,

There exists a strong foundation of capacity arrayed in a tiered architecture of Federal, State, local, tribal, territorial, and private capabilities. We can
strengthen the approach with focused attention on a few core functions and an increased integration of effort across the Nation. In these fiscally

we seek to leverage distributed capabilities and to add value to

independent, individual efforts to protect the health and safety of the Nation
through an effective national biosurveillance enterprise . A key to improving all-hazards
incident management is to focus efforts on collecting, analyzing, and disseminating
information to facilitate timely decisionmaking, whether a health incident is a naturally occurring phenomenon,
challenging times,

accidental, or deliberate in nature. From the individual, to primary care providers, to hospital practitioners, to state and local health officers, to Federal
entities responsible for health emergency response, to the President of the United States, there exists an imperative to identify incidents early and to

goal is to achieve a well-integrated national

biosurveillance enterprise that saves lives by providing essential information for
better decisionmaking at all levels. Our Strategy is to integrate and enhance national
biosurveillance efforts to answer specific key questions that guide decisionmaking in times of crisis; enable more rapid
detection and foster improved situational awareness by further extending a
dynamic, distributed national network of expertise and capabilities ; and put into practice new
thinking to facilitate decisionmaking processes in conditions of significant ambiguity. This enhanced national
biosurveillance capability will be applied broadly to identify and
understand potential human, animal, or plant health impacts resulting
from chemical, biological, radiological, and nuclear (CBRN) and
environmental incidents, as well as influenza and other public health trends, all of which may also be leveraged in the service of
make decisions swiftly to save lives, even amidst great uncertainty. The

global health efforts. We must be resolved to strengthen life-saving biosurveillance capabilities within our existing resources. We can do this by leveraging
more effectively our existing national network of expertise and capabilities, and through targeted enhancements that provide benefits across the
enterprise. There are no higher priorities than the health, well being, and security of the American people.

Outbreak reaction plans require the necessary data in real

time to work effectively
[Lindsey Thomas, Professor @ UC Santa Barabara Pandemics of the future:
Disease surveillance in real time 2014]
In 2013, the World Health Organization (WHO) published a document on the 2009 H1N1 influenza pandemic entitled Evolution of
a Pandemic. This document traces the disease outbreak from April 2009 to August 2010 and documents how the WHO responded to
the crisis. The document particularly

emphasizes the importance of preparedness plans to

mitigating the effects of the pandemic : it claims that investment in developing national and regional
pandemic preparedness plans by WHO member nations had paid major dividends and that these plans helped
make the world better prepared to cope with public health emergencies (WHO 2013a: 9,
43). Such plans involved the active surveillance of diseases and public health
events and rapid response to unexpected, internationally-spreading events (WHO 2013c). Active surveillance
and rapid response are important features of whats known as global health
security, which emphasizes preparing for pandemics before they occur through the
adoption of international frameworks for pandemic response . These frameworks, or
preparedness plans, allow public health officials to react quickly, in real time, to mitigate
the effects of pandemics when they occur (Lakoff 2007). Global health security can be seen as part of a
larger program of preparedness, a security paradigm that emphasizes planning for future catastrophic events in the present.
Preparedness, which moved to the center of United States national security policy after September 11, 2001, has also been adopted
by international organizations like the WHO in order to secure against potentially catastrophic pandemics. It is one among several
modes of what Ben Anderson has called anticipatory action: these modes, which also include precaution and preemption, are all
security paradigms that focus on making possible futures available in the present (Anderson 2010; also see Grusin 2010).
Preparedness emphasizes institutional readiness and emergency management, treating a variety of potential catastrophic threats

Because the probability and severity of

such catastrophes cannot be calculated, preparedness focuses not on trying to
prevent such events but rather on preparing officials and experts for their eventual
emergence. A variety of techniques and technologies make such preparation possible. For global health security, this has
terrorist attacks, hurricanes, pandemicsunder the same rubric.

involved not only the creation of international preparedness plans, but also of international disease surveillance systems that

These systems allow public health officials to collect

and manage huge amounts of data on disease outbreaks as they occur. Such
systems attempt to harness the power of big data to get ahead of the catastrophic
pandemic that is coming, not necessarily in order to prevent it from happening (because we cant), but rather to
monitor emerging infectious disease outbreaks.

better deal with its effects (de Goede and Randalls 2009; Lakoff and Collier 2010).

Health surveillance exists for a reason --- terror results in

unique risks to public health that this surveillance remedies --specifically checks against bioterror
Gostin, an internationally recognized scholar in law and public health, professor of
Law at Georgetown University; Professor of Public Health at the Johns Hopkins
University; and the Director of the Center for Law & the Publics Health at Johns
Hopkins and Georgetown Universities, November 2001 (Lawrence, Public Health
Law In An Age Of Terrorism: Rethinking Individual Rights And Common Goods,
published on HealthAffairs vol 21 no. 6)//roetlin
The balance between individual interests and common goods needs to be
recalibrated in an age of terrorism. Public health agencies should have a robust
infrastructure to conduct essential public health services at a level of performance
that matches evolving threats to the health of the public. This includes a well-trained
workforce, electronic information, surveillance, and laboratory capacity. This paper explains modern
efforts at public health law reform: a Model Public Health Statute and the Model State Emergency Health Powers Act
(MSEHPA), which has been enacted wholly or in part by nineteen states and the District of Columbia. Next, the
paper shows why existing public health laws provide a weak foundation for public health practice. Finally, the paper
offers a systematic defense of MSEHPA, which has galvanized the public debate around the appropriate balance
between public goods and individual rights. PROLOGUE: Following the 2001 anthrax attacks, an outbreak of concern

inadequacies of the public health infrastructure caught the nation in the grip
of a profound ambivalence about what we expect from government . For the past twenty
years distrust of public institutions has severely dampened public health spending
and so dominated the political landscape that even the Institute of Medicines stern warning about
about the

deterioration of the infrastructure in 1988 did not generate renewed investment. Then, in the wake of the anthrax
scare, the refrain suddenly became, Why

arent we better prepared ? The following essay by legal

To
perform its essential functions, the public health system needs legal authority
to act. Yet most of its statutory foundations, which lie primarily in the domain of state
government, have not been updated for half a century . Even before last falls terrorist attacks,
efforts were under way to develop new model laws for the states. The focus of the model legislation is
to confer enough authority that public health agencies can mount adequate
preparations, obtain information, and act in an emergency to protect those who are
threatened. But some sacrifice of personal rights and freedoms is necessary to
achieve this end, and these legal initiatives have been controversial. In a country so tied to rights rhetoric...,
scholar Lawrence Gostin suggests that our collective confusion about public health goes deeper than dollars.

any proposal that has the appearance of strengthening governmental authority was bound to travel in tumultuous
political waters, Gostin concludes. Three Perspectives that follow Gostins paper highlight the extent of the
disagreement that still exists, nearly a year after the model law was last revised. Gostin is ideally suited to clarify
the difficult issues involved. He is a professor of law at Georgetown University; a professor of public health at the
Johns Hopkins University; and director of the Center for Law and the Publics Health, which drafted the Model State
Emergency Health Powers Act at the request of the Centers for Disease Control and Prevention. In defense of a
model act that was written to bring public health law into the modern age. Public and scholarly discourse in the late
twentieth century became highly oriented toward rights. The political community stressed the importance of
individual freedoms rather than the health, security, and well-being of the community. The salience of individualism
could be seen on both sides of the political spectrum. The ideological left favored a set of personal interests,
principally autonomy, privacy, and liberty. This meant that individuals should be free to make choices, restrict the
flow of health information, and have unfettered movement, without regard to the needs and desires of the wider
community. The ideological right favored a set of proprietary interests, principally the freedom to contract, conduct
business, use and develop property, and pursue a profession. This meant that entrepreneurs should be permitted to
engage in free enterprise without the fetters of, for example, occupational health and safety regulations,
inspections and products liability, zoning and nuisance abatements, and licenses. In this civil and property rights
society, the tone has been distinctly antigovernment. The State has been perceived as inefficient, bureaucratic, and
burdensome. Citizens have opposed taxation and broad health and welfare spending as well as oppressive
regulation. From a funding perspective, this has meant that health dollars have been allocated primarily to
advanced biotechnology and health care, which serve the needs of individual patients, particularly those who can
afford private health insurance. Funding for traditional prevention and population-based services represents only a
small fraction of health spending, estimated at around 1 percent at the state level and less than 5 percent at the

public health infrastructure is badly

deteriorated.2 Public health agencies lack the capacity to conduct essential public
health services at a level of performance that matches the constantly evolving
threats to the health of the public. Critical components of that infrastructure include a well-trained
federal level.1 As a result of chronic underspending, the

workforce, electronic information and communications systems, rapid disease surveillance and reporting, laboratory
capacity, and emergency response capability.3 The public health law infrastructure is equally deficient. The law
establishes the mission, functions, and powers of public health agencies. Yet public health laws are highly
antiquated, after many decades of neglect. Very little consideration has been given to modernizing these laws to
reflect advances in public health practice and constitutional law. Reform of public health law is essential to ensure
that public health agencies have clear missions and functions, stable sources of financing, adequate powers to
avert or manage health threats, and restraints on powers to maintain respect for personal rights and liberties.

The

balance between individual interests and common goods needs to be

recalibrated in an age of terrorism. The attacks on the World Trade Center and Pentagon on 11
September 2001 and the subsequent dispersal of anthrax spores through the U.S. postal
system reawakened the public to the importance of public health, safety, and
security.4 The presidents 2003 budget reflects changing priorities, with an influx of funding to prevent and
respond to bioterrorism.5 However, even in this budget, disproportionate funding is devoted to biotechnology rather
than to basic prevention and population-based services.6

Bioterrorism Link Uniqueness

Current electronic system effectiveeconomy, disease
prevention and treatment
Freudenheim 12(Milt, reporter for the NY times, Fast Access to Records Helps Fight Epidemics
http://www.nytimes.com/2012/06/19/health/states-using-electronic-medical-records-to-track-epidemics.html?_r=0
6/19/12 JM)

health departments around the country have long scrutinized data from local hospitals for
indications that diseases like influenza, tuberculosis, AIDS, syphilis and asthma
might be on the rise, and to monitor the health consequences of heat waves, frigid
weather or other natural phenomena . In the years since 9/11, this scrutiny has come to include
signs of possible bioterrorism. When medical records were maintained mainly on paper, it could take weeks to find out that an infection
was becoming more common or that tainted greens had appeared on grocery shelves. But the growing prevalence of electronic
medical records has had an unexpected benefit: By combing through the data now received almost continuously from hospitals and other
medical facilities, some health departments are spotting and combating outbreaks
with unprecedented speed. More than one-third of the nations 5,000 acute care hospitals now use electronic medical records,
Public

and the share of primary care doctors using them has doubled to 40 percent in the last two years, said Dr. Farzad Mostashari, the Obama administrations

technologys spread is helping officials faced with

events of public health significance to know sooner, act faster and manage better,
said Dr. Seth Foldy, a senior adviser to the Centers for Disease Control and Prevention. In February, public health officials
national coordinator for health information technology. The

in Michigan noted an increase in electronic reports from clinical laboratories indicating E. coli cases in several counties. Eleven patients were identified,
including six who were hospitalized. In less than a week, officials had enough evidence to warn the public that the infection appeared to be linked to clover
sprouts in food at the Jimmy Johns sandwich chain, said James Collins, director of the communicable diseases division at the states Department of
Community Health. The chain quickly removed the sprouts, and by April, the 11-state outbreak was over.

You can see it happen in

real time and zero in on the cause faste r, said David A. Ross, director of the Public Health Informatics Institute, a
nonprofit organization that helps write digital standards. That can save both lives and money. In Massachusetts, the data
are being used to prevent hepatitis infections. Medical labs transmit more than 100,000 electronic
reports annually to the state health department. Names are confidential, though available to certain medical
personnel. The agencys software sorts through the reports and every year identifies more than 1,500
cases of hepatitis B for follow-up. Infected women ages 14 to 44 get special attention. Health officials alert their medical providers to
infections; they in turn identify anyone who is pregnant or recently gave birth . Their newborns are vaccinated
and then monitored. Without that prompt protection, those babies risk lifelong infection with hepatitis B and its consequences, liver disease, cirrhosis and
cancer. With paper records, locating at-risk babies would take weeks or months, said Kevin Cranston, director of the infectious disease bureau at the
Massachusetts Department of Public Health. That would be too late to be of benefit to the newborn, he said. Although the C.D.C. recommends prompt

When the
H1N1 flu pandemic broke out in 2009, Wisconsin laboratories generated thousands
of positive H1N1 test results, said Dr. Foldy, who was then chief medical officer of the Wisconsin Health Information Exchange.
We were able to route this electronically into our case management system to alert public health nurses ,
hepatitis B vaccination for all newborns, nationally, four in 10 did not get that protection, according to an agency report last year.

Dr. Foldy said. Because we were getting near real-time information from hospitals, we could see that even with the large numbers of emergency room
visits for flulike symptoms, very few were being admitted as inpatients, he added.

This provided an early glimpse of how

the pandemic was rising and then declining. Public health officials in Marion County, Ind., were among the first to
sound the all-clear in the flu outbreak by tracking the drop in cases from electronic reports from hospitals and laboratories, forwarded by the Indiana

More than 150 health information exchanges are now operating or

These differ from the insurance exchanges mandated under the
Affordable Care Act.) Each exchange receives electronic medical data from clinical laboratories, hospital admissions offices and
Health Information Exchange.

being set up across the country. (

emergency rooms and relays it to relevant public health agencies. Health care providers are required to provide pertinent data electronically to local and

. Using an electronic
records registry, the Urban Health Plan , a network of clinics in the South Bronx and Queens, was able to
triple its caseload of mostly young, low-income asthma patients to 8,100. We are in the
state public health officials, who feed into a national digital network coordinated by the C.D.C. in Atlanta

heart of asthma country, said Dr. Samuel De Leon, a lung specialist who is Urban Healths chief medical officer. His group compared spending per patient

with a Medicaid managed care plan in the city that did not then have electronic monitoring. Using its record system to keep tabs on its patients, Dr. De

For children, we saved about 39

percent of the cost of care. For adults, savings were in the 25 percent range , he said. New
Leon said, Urban Health was able to reduce emergency room visits and hospital admissions.

York City health officials began using electronic medical records six years ago. After reviewing the incoming medical data, city health department officials
recently discovered that smoking rates are a little higher in Staten Island than in the other boroughs. Now, instead of sending trainers on routine visits to
every primary care doctor to help them learn to use electronic records to improve care, the visits are concentrated to help those physicians whose

We can identify and monitor trends in high-priority diseases and health

problems by geography and groups , said Dr. Amanda Parsons, a deputy commissioner at the citys Department of Health
and Mental Hygiene. We can tell where things are improving or getting worse.
patients need it most.

Bioterrorism Impact Uniqueness

Synthetic biology makes bioterror inevitable- creates means
and motive
Rose, 14 -- PhD, recognized international biodefense expert
[Patrick, Center for Health & Homeland Security senior policy analyst & biosecurity
expert, National Defense University lecturer, and Adam Bernier, expert in counterterrorism, "DIY Bioterrorism Part II: The proliferation of bioterrorism through
synthetic biology," CBRNePortal, 2-24-14, www.cbrneportal.com/diy-bioterrorismpart-ii-the-proliferation-of-bioterrorism-through-synthetic-biology/, accessed 8-1614]
synthetic biology has made bioengineering accessible to the mainstream biological community. Non-state actors
who wish to employ biological agents for ill intent are sure to be aware of how tangible bioweapons are becoming as applications of synthetic biology become more
affordable and the probability of success increases with each scientific breakthrough. The willingness of nonIn Part I of this series, we examined how the advancement of

state actors to engage in biological attacks is not a new concept; however, the past biological threat environment
has been subdued compared to that of conventional or even chemical terrorism. The frequency and deadliness of
biological attacks has, thankfully, been limited; much of which can be attributed to the technical complexity or

Despite the infrequency and

ineffectiveness of biological attacks in the last four decades, the threat may be
changing with the continued advancement of synthetic biology applications. Coupled
with the ease of info rmation sharing and a rapidly growing do-it - yourself-biology
apparent ineptitude of the perpetrators developing biological weapons.

(DIYbio)

movement

(discussed in Part I),

the chances of not only , more attacks , but

more deadly ones will inevitably increase . During the last half century terrorist
organizations have consistently had an interest in using biological weapons as a means of
potentially

attacking their targets, but only few have actually made a weapon and used it. The attraction is that terrorist
activities with biological weapons are difficult to detect and even more difficult to attribute without a specific
perpetrator claiming responsibility. Since 1971 there have been more than 113,113 terrorist attacks globally and 33
of them have been biological. The majority of bio-terrorism incidents recorded occurred during the year 2001 (17 of
the 33); before 2001 there were 10 incidents and since 2001 there were 6 (not counting the most recent Ricin
attacks). The lack of a discernable trend in use of bio-terrorism does not negate the clear intent of extremist
organizations to use biological weapons. In fact, the capacity to harness biological weapons more effectively today
only increases the risk that they will successfully be employed.

The landscape is changing : previously

the instances where biological attacks had the potential to do the most harm (e.g., Rajneeshees cults Salmonella
attacks in 1984, Aum Shinri Kyos Botulinum toxin, and Anthrax attacks in the early 90s) included non-state actors
with access to large amounts of funding and scientists. Funding and a cadre of willing scientists does not guarantee

The assertion was thus made that biological weapons are not only
expensive, they require advanced technical training to make and are even more
difficult to effectively perpetrate acts of terrorism with. While it is difficult to determine with certainty
success though.

whether the expense and expertise needed to create biological weapons has acted as a major deterrent for groups
thinking of obtaining them, many experts would argue that the cost/expertise barrier makes the threat from
biological attacks extremely small. This assertion is supported by the evidence that the vast majority of attacks
have taken place in Western countries and was performed by Western citizens with advanced training in scientific

In the past decade the cost/expertise assertion has become less accurate .
there are a number of very dangerous and motivated
organizations that have or are actively pursuing biological weapons. The largest and most
research.

Despite the lack of biological attacks,

outspoken organization has been the global Al Qaeda network, whose leaders have frequently and passionately
called for the development (or purchase) of Weapons of Mass Destruction (WMD). The principal message from Al
Qaeda Central and Al Qaeda in the Arabian Peninsula (AQAP) has included the call to use biological WMDs to
terrorize Western nations. Al Qaeda has had a particular focus on biological and nuclear weapons because of their
potential for greatest harm. Osama Bin Laden, Ayman al-Zawahiri and Anwar al-Awlaki have all called for attacks

using biological weapons, going so far as to say that Muslims everywhere should seek to kill Westerners wherever
possible and that obtaining WMDs is the responsibility of all Muslims. Before the US-led invasion of Afghanistan, Al
Qaeda had spent significant funds on building a bio-laboratory and had begun collecting scientists from around the
world; however, the Afghanistan invasion and subsequent global War on Terrorism is thought to have disrupted their

disruption does
not appear to have changed the aggressive attitude towards obtaining WMDs (e.g.,
more recently U.S. Intelligence has been concerned about AQAP attempting to make
Ricin). The emergence of synthetic biology and DIYbio has increased the likelihood
capabilities and killed or captured many of their assets. Despite the physical setbacks, this

that Al Qaeda will succeed in developing biological WMDs . The low cost and
significantly reduced level of necessary expertise may change how many nonstate actors view bio logical weapons as a worthwhile investment.

This is not to say that

suddenly anyone can make a weapon or that it is easy. To the contrary making an effective biological weapon will
still be difficult, only much easier and cheaper than it has been in the past.

The rapid advancements of

synthetic bio logy could be a game changer , giving organizations currently

pursuing biological weapons more options, and encouraging other organizations
to reconsider their worth. Because the bar for attaining bio logical weapons has
been lowered and is likely to continue to be lowered

as more advances in biological

technology are made, it is important that the international community begin to formulate policy that protects

Disregard for this

consideration will be costly. A successful attack with a potent biological weapon,
where no pharmaceutical interventions might exist, will be deadly and the impact
of such an attack will reverberate around the globe because biological weapons
are not bound by international borders.
advances in science that acts to prevent the intentional misuse of synthetic biology.

Doctor-Patient Trust - Data Breach Inevitable

Patient-Doctor relations low now
Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
Healthcare information systems are largely viewed as the single most important
factor in improving US healthcare quality and reducing related costs. According to a recent RAND
study, the USA could potentially save $81B annually by moving to a universal Electronic Health Record (EHR)
system (Hillestad et al., 2005). Not surprisingly, recent government initiatives have pushed for wide-scale adoption
of universal EHR by 2014 (Goldschmidt, 2005). Yet, IT spending in healthcare sector trails that of many other
industries, typically 35% of revenue, far behind industries like financial services where closer to 10% is the norm

Anecdotal evidences from recent years suggest that a lack of adequate

security measures has resulted in numerous data breaches, leaving patients
exposed to economic threats, mental anguish and possible social stigma (Health Privacy
Project, 2007). A recent survey in the USA suggests that 75% of patients are concerned about
health websites sharing information without their permission (Raman, 2007). Possibly, this
patient perception is fuelled by the fact that medical data disclosures are the second highest
reported breach (Hasan and Yurcik, 2006). In response to these increasing threats to health information and
(Bartels, 2006).

privacy, new regulations at both the state and the federal level have been proposed in the USA, e.g., Health
Insurance Portability and Accountability Act (HIPAA).

Medical identity theft is an expanding issue that current legal

protections fail to prevent
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 8-10
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
With a legislative requirement to notify a data subject of a data breach, the data
custodians duty is triggered upon loss of control of the data, making a breach
notification rule the definitive downstream protective model. Breach notification
laws proliferated because of the dramatic increase in identity theft.27 Although all
federal agencies are subject to a robust breach notification policy,28 federal
legislation to cover private parties has been proposed but not yet passed.29 In
contrast, and in the decade following Californias 2002 example, forty-six states and
the District of Columbia have enacted breach notification laws.31 More recently
attention has turned to medical identity theft.32 It has been argued that
medical identities are highly valued by criminals because of the comprehensive
data that are contained in, for example, a stolen electronic medical record (EMR).33
A 2006 report from The World Privacy Forum focused attention on the issue,34 and
in 2009 the Office of the National Coordinator for Health Information Technology
(ONC) commissioned a study on the subject from Booz Allen Hamilton.35 Today both
HHSs Office of Inspector General36 and the Federal Trade Commission 37 web sites
have information pages concerning medical identity theft. According to a 2012
Ponemon Institute study, 52% of health care organizations experienced one or more

incidents of medical identity theft. The 2013 Survey on Medical Identity Theft (also
conducted by the Ponemon Institute) estimated a 19 per cent increase in
medical identity theft victims year-to-year.39 Relatively few states include
health data within their definition of the personal information subject to breach
notification. Others, true to the US sector-based approach to privacy regulation,
exclude data covered by, say, HIPAA or the Gramm-Leach-Bliley Act of 1999
(GLBA).41 HITECH introduced two closely related breach notification regimes. The
first, introduced by section 13402, requires HIPAA covered entities and HIPAA BAs to
provide notification following a breach of unsecured protected health
information.44 The second, courtesy of section 13407, imposes a similar duty on
vendors of personal health records (PHR) 45 and their third party service providers
46 with regard to Unsecured PHR Identifiable Health Information.47 Rulemaking
authority and enforcement are vested in the HHS regarding the former and the
(Federal Trade Commission) FTC regarding the latter. The regulation of PHRs is a
limited (but ultimately unsuccessful) attempt to expand health data
protection from a narrow sector provider based model (e.g., information held by a
covered entity) to a data-type based model. Unfortunately it stopped short of a
broad datatype model (e.g., by protecting the data itself held by any data
custodian), limiting the custodian cohort to PHR providers.49 It is an interesting
question why HITECH added a breach notification data protection model. Certainly
medical identity theft was being raised as an issue.50 As likely this rethinking of the
approach to data protection may have been triggered by the expansion of personal
health records services offered by non-health companies such as Google Inc.51
Maybe the HITECH architects could not agree on a way to open up the broader and
established HIPAA model to apply to nontraditional custodians of health data (BAs
aside) and so had to settle on a new but limited data protection model as the
legislative alternative. Notwithstanding, the result was that HITECH authorized
regulatory activity by the FTC that would mirror the work of HHS in the more
narrowly defined, traditional health space. Ironically, however, by the time HITECH
was passed the PHR business was slowing and Google Health, the PHR poster-child,
soon would be closed.52

Healthcare data breaches are inevitable

Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
These attackers may have resources ranging from modest financial backing and
computing skills to a well-funded infrastructure . Additionally, the nature of the threats typically
depends on the technical capability of the attackers. Moreover, with the growing underground cyber
economy (Knapp and Boulton, 2006), an individual possessing adequate financial resources
and with the intent to acquire data may be able to buy the services of sophisticated
hackers to breach healthcare data.

Government Access to records greatly expands the risk of data

disclosure
Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
health information privacy has been widely discussed in the social science and
business press (Etzioni, 1999), the academic literature lacks systematic investigation to identify and classify
Although

various sources of threats to information privacy and security. Recent policy-based studies (such as NRC, 1997;
Rindfleisch, 1997) broadly categorise privacy threats, or source of information security, into two areas: 1

organisational threats that arise from inappropriate access of patient data by either
internal agents abusing their privileges or external agents exploiting a vulnerability
of the information systems 2 systemic threats that arise from an agent in the information flow chain
exploiting the disclosed data beyond its intended use (NRC, 1997). Organisational Threats: These threats
assume different forms, such as an employee who accesses data without any
legitimate need or an outside attacker (hacker) that infiltrates an organisations information
infrastructure to steal data or render it inoperable. At the outset, these organisational threats could be

characterised by four components: motives, resources, accessibility and technical

capability (NRC, 1997).

Government will leak private data

Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
organisational threats could be categorised
into five levels, listed in increasing order of sophistication (NRC, 1997): Accidental disclosure:
Healthcare personnel unintentional ly disclose patient information to others (e.g., e-mail message sent to
wrong address or inadvertent web-posting of sensitive data). Insider curiosity: An insider with dataaccess privilege pries upon a patients records out of curiosity or for their own purpose (e.g., a nurse
Recent studies suggest that the broad spectrum of

accessing information about a fellow employee to determine possibility of a sexually transmitted disease or medical
personnel accessing potentially embarrassing health information about a celebrity and transmitting it to the media).

Data breach by insider: Insiders access patient information and transmit it to outsiders for
profit or revenge. Data breach by outsider with physical intrusion: An outsider enters the
physical facility either by coercion or forced entry and gains access to the system.
Unauthorised intrusion of network system: An outsider, including former employees ,
patients, or hackers, intrudes into an organisations network from the outside to gain
access to patient information or render the system inoperable . Systemic Threats: Etzioni
(1999), in discussing the limits to privacy, observed that a major threat to patient
privacy occurs, not from outside of the information flow chain, but from insiders who
are legally privileged to access patient information . For example, insurance firms may deny life

insurance to patients based on their medical conditions, or an employer having access to employees medical
records may deny promotion or terminate employment. Patients or payer organisations may incur financial losses
from fraud including upcoding of diagnoses or for rendering medically unnecessary services.

They cant solve --- technological advances make illegal

dissemination unpreventable
Ruebner and Reis, professor former professor of law at The John Marshall Law
School, 1/1/2004 (Ralph, Leslie, Hippocrates to HIPAA: A Foundation for a Federal

Physician-Patient Privilege, 77 Temp. L. Rev. 505 (2004), published in the Temple

Law Review at The John Marshall Law School)//roetlin
the connection
between the increasing use of interconnected electronic information systems in the
health care context and the loss of health information privacy . 6 3 In doing so, HHS
emphasized the fact that advances in technologies used to collect and disseminate patient
health information have "reduced or eliminated many of the financial and logistical
obstacles that previously served to protect the confidentiality of health information
and the privacy interests of individuals." 6 4 Simply, the pervasiveness of and access to
medical information in electronic form creates the likelihood that such information
will be wrongfully disclosed or used in a manner that may harm the patient . 6 5
HHS commented on the inherent conflict between technology and privacy, in particular,

Technological advancements in information systems "may provide a reason for institutionalizing privacy protections
in situations where the risk of harm did not previously justify writing such protections into law." 6 6

Heath information data breaches inevitable now triggers all

aff links
New York Times April 2015 Patients' Medical Records Under Threat From
Data Breaches http://www.nytimes.com/aponline/2015/04/14/health/ap-us-medbreached-health-records-.html
Your private medical information is under threat. That's according to a study that
found almost 30 million health records nationwide were involved in criminal theft,
malicious hacking or other data breaches over four years. The incidents seem to be
increasing. Compromised information included patients' names, home addresses,
ages, illnesses, test results or Social Security numbers. Most involved electronic
data and theft, including stolen laptops and computer thumb drives. The study
didn't examine motives behind criminal breaches, or how stolen data might have
been used, but cyber-security experts say thieves may try to use patients' personal
information to fraudulently obtain medical services. Cases that didn't involve
malicious intent included private health information being inadvertently mailed to
the wrong patient. Hackings doubled during the study, from almost 5 percent of
incidents in 2010 to almost 9 percent in 2013. Hackings are particularly dangerous
because they can involve a high number of records, said Dr. Vincent Liu, the lead
author and a scientist at Kaiser Permanente's research division in Oakland,
California. "Our study demonstrates that data breaches have been and will continue
to be a persistent threat to patients, clinicians, and health care systems," Liu said.
The study appears in Tuesday's Journal of the American Medical Association. A JAMA
editorial says there's evidence that the incidents are leading some patients to avoid
giving doctors sensitive information about their health, including substance abuse,
mental health problems, and HIV status. "Loss of trust in an electronic health
information system could seriously undermine efforts to improve health and health
care in the United States," the editorial said. Patients should be alert to cyber
threats, including "phishing" emails from hackers posing as doctors, hospitals or
health insurance companies, said Lisa Gallagher, a cybersecurity expert at the

Healthcare Information and Management Systems Society. Those messages require

clicking on a link to get information, and patients should instead should call the
purported sender to verify whether the email is legitimate, she said Patients should
also double check doctor bills and other insurance company information. "Don't
throw away your explanation of benefits. Take a look at them," Gallagher said. "If
you see care that wasn't provided to you, or dates and names of providers that
don't make sense, go to the provider and report that." For the study, Liu and
colleagues analyzed an online database regulated by the U.S. Department of Health
and Human Services and containing mandated reports of breaches in health
information protected by federal privacy law. Over the four years, 949 data
breaches were reported across the country. The numbers climbed annually, from
214 in 2010 to 265 in 2013. Nearly 60 percent involved theft.

Doctor-Patient Turst Privacy Not Key

Patients dont actually expect privacy
Appari and Johnson 10, ( Ajit, Eric, Tuck School of Business, Information
security and privacy in healthcare: current state of research, Dartmouth, 4, 2010,
http://www.ists.dartmouth.edu/library/501.pdf)//IB
Bansal et al. (2007) developed a set of constructs based on utility theory and prospect theory as antecedents of
trust formation and privacy concern that impact users personal disposition to disclose their health information to
online health websites. In particular, they reported that users current health status, personality traits, culture, and
prior experience with websites and online privacy invasions play a major role in users trust in the health website
and their degree of privacy concerns. On the other hand, in a mail-based survey with adult patients in England,

about 2835% of patients are neutral to their health

information such as age, gender, ethnicity, reason for treatment, medical history, personal habits impacting
health, type of treatment obtained, side effects of treatment being used by physicians for other purpose . Only
about 521% of patients, however, expected to be asked for permission to use their
information by their physicians. Similarly, only about 10% of the patients expected
to be asked for permission if their doctors used their health information for a wide
variety of purposes, including combining data with other patients data to provide better
information to future patients, sharing treatment outcomes with other physicians, teaching
medical professionals and writing research articles about diseases and treatments.
Campbell et al. (2007) found that

No internal link patients dont care

McCarthy 15 (Kevin McCarthy covers healthcare tech and policy regulations, Why EHRs do not harm the
doctor-patient relationship 6/3/15 http://www.nuemd.com/news/2015/06/03/ehrs-do-not-harm-doctor-patientrelationship)
It's no secret that the road to widespread implementation of electronic health records has been a difficult one for
some clinicians. While large providers may have had the capital to throw at a problem like staff training and new
equipment purchases, small practices were faced with financial and operational issues that, while challenging,
proved not to be as unsolvable as some critics had predicted. According to the U.S. Centers for Medicare and
Medicaid Services, over 447,000 providers have implemented and been compensated for EHR systems in their

Now that EHR software has become a large part of the medical industry,
experts have turned their gazes back to an issue that dominated the discussion when federal
agencies first started pushing the platform as reform alternative. The question of how EHRs affect the
physician-patient relationship can seem simple at times - more screens separating clinicians from their
offices.

patients can only seem wrong - but, as EHR Intelligence explained, the underlying factors may point to a different
and more positive interpretation for EHRs in the workplace. Office manners The doctor-patient relationship goes
all the way back to the days when house calls and personal physicians were only the domain of the super wealthy.

every patient has a right to expect their doctors to be open, polite, informative,
and, most of all, confidential. Such a natural relationship fosters trust between both
parties, and when outpatient treatments are the only ones possible, this level of mutual respect is necessary for
both sides to move toward a positive care outcome. However, with the rise of EHRs, especially on mobile
devices, creating a meaningful doctor-patient relationship isn't as easy as it used to
be. In an interview with EHR Intelligence, James Avallone, director of physician research for Manhattan Research,
Today,

explained that EHR use is most certainly up, but its impact on the personal dynamics between patients and doctors
is much less clear. "Whether it is too much or too little, it is difficult for us to say from our perspective," Avallone
said. "In the past four to five years, we have seen a fair share of complaints in terms of the efficiency of EHRs and
how [they are] changing bedside manners for physicians overall. I do think we are starting to see some efficiencies
come about in terms of efficient use of these platforms and that includes at the point of care. It is certainly
something that physicians are getting used to as it becomes more ingrained in their day-to-day behaviors. They
have had more time to streamline workflow and that is something that we are seeing in terms of how these devices
are being used at the point of care." Avallone noted that research from a recent Manhattan study found that 66
percent of physicians self-reported as being more efficient with their EHRs than in the past. While part of this may

be due to a greater sense of familiarity with the product and how to fit it into workflows, EHR vendors have also
caught up with the trends of the day by developing software that intuitively meshes with physicians' daily tasks.

minor annoyance While EHRs may be an easy target for opponents of the technology, studies show that
EHRs are not a top concern among physicians who are worried about losing the
trust and goodwill of their patients. According to a 2013 study published in Health Affairs, only 25.8
percent of physicians reported that EHRs were threatening the doctor-patient relationship. Administrative burdens
like the ICD-10 transition and HIPAA compliance regulations, on the other hand, were noted by more than 41
percent of those surveyed. If industry experts are truly concerned about protecting the quality of the doctor-

EHR software should not be the primary focus. Instead, it should be

patients
may not care so much about the time doctors spend inputting their information into
a piece of software that could save their lives.
patient relationship, then

highlighted during discussions with patients to show them just how powerful it can be. From there,

Healthcare privacy is not key to trust

Dan Munro (Writer for Forbes and Quora specializing in healthcare related topics)
November 2014 Trust Trumps Privacy In Battle For Patient Health Data
http://www.forbes.com/sites/danmunro/2014/11/09/trust-trumps-privacy-in-battlefor-patient-health-data/
Theres no shortage of advocates on behalf of the free your health data
movement. The keywords, of course, are your, health data and free (as in
donating your health data for the global benefit of clinical research). The latest
demand was an article that appeared last week in Wired You Should Share Your
Health Data: Its Value Outweighs The Privacy Risk by Beth Seidenberg, MD (a
partner at the venture firm Kleiner Perkins Caufield & Byers). Dr. Seidenbergs
medical credentials are definitely compelling (including Chief Medical Officer of
Amgen AMGN -0.82%), but its always a red flag to me when a total stranger
(especially one with medical credentials) boldly demands that I should do
anything online with my health which includes my health data. While Dr.
Seidenbergs demand is noble in the conclusion that we can all benefit from the
clinical research, her argument is based squarely on the false premise that privacy
is the largest gating factor in the reluctance of consumers (or patients) to share
their health data. Im sure that privacy is a reason for many, but its certainly not for
me. I know just how easy all health data can be breached and wrote about it
earlier this year when I logged onto the network of a 300+ bed hospital using just a
browser and my desktop PC (here). Its not that the electronic door to the hospital
was unlocked or even open. There was simply no door at all. The only thing
missing was a banner ad saying Click here for free health data. The larger trend
for health data breaches (including this years 2nd largest ever 4.5 million by CHS)
is alarming. But risk of data breach cloaked as privacy is not the issue. At least
its not mine. The issue I see is much larger trust. Given the importance of getting
this priority right, its really tone deaf for anyone anywhere to demand that we do
anything with our personal health data. Dr. Seidenbergs demand makes sense, of
course, because the interests of venture capitalists are well aligned with many
commercial interests in healthcare much of which has been optimized around
revenue and profits not safety and quality. The lack of trust I see is clearly evident
in countless stories of courageous patients, battling openly (almost entirely at their
own expense) for access to their health data. Privacy issues (and HIPAA) are often

cited as the legal reason for prohibiting access, of course, but thats just an excuse.
Absent data security (clearly evident) there is no privacy and the real reason
masquerading behind these false claims isnt privacy protection its revenue
protection. This isnt just hospitals. The data battle for many patients encompasses
medical device manufacturers, pharmaceutical companies and electronic health
record vendors too. Our collective rights as patients are entirely secondary if at
all. Heres one example that appeared just yesterday in the New York Times
Medical Records: Top Secret (by Elisabeth Rosenthal). The story outlines the
continuing case of Mr. Drier a patient Ms. Rosenthal wrote about previously who
was billed $117,000 after a 3hour neck surgery. Mr. Driers efforts to get his health
record (for ongoing management of his health condition) resulted in this summary:
The six-week ordeal included requests that needed to be made via regular mail,
numerous phone calls, consent forms and an estimate for copying fees that totaled
$100. This was topped off by an actual visit to the hospital by Mr. Drier, who sat in
an office until he had paper documents in hand. The problem is enormous and
longstanding. The above example is simply one case that highlights what little
progress weve made in the course of 5 years. I reference that timeframe because
this last September marked the 5year anniversary of Dave deBronkarts battle cry
at the Medicine 2.0 event in Toronto. He opened his keynote with this slide. Working
with his physician Dr. Danny Sands he was finally able to download his health
record electronically. The data that came into view, however, was largely based on
billing records and loaded with inaccuracies (including the fact that an xray from
2003 identified him as a 53 yearold woman). He summarized his experience with
transferring his health data into Google GOOGL +1.71% Health (now defunct) this
way: In other words, the data that arrived in Google Health was essentially
unusable. Dave deBronkart Imagine someone had been managing your data, and
then you looked April, 2009 Hugo Campos is another example. Hugo continues to
work tirelessly on getting access to the data from the cardiac defibrillator inside his
own chest. His TEDxCambridge talk highlights his dilemma and his ongoing battle
with Medtronic MDT -0.73% for access to the data his own heart generates again
to manage his own health. Like other device manufacturers, Medtronic believes they
should own the data and patients who actually generate the data have no legal
rights. The ICD device collects a lot of data about its own function and about the
patients clinical status. Its a pretty complex little computer, but unfortunately,
none of this very valuable data is made available to the patient who originates it.
The best we can do is get a print-out or a hardcopy of an interrogation report
(typically at 6 or 12 month intervals). These reports are designed for doctors not
really for patients so a lot of patients are discouraged from even getting this
information. Its hard to read. Hugo Campos TEDxCambridge 2011 Earlier this
year, I wrote about Anna McCollisterSlipp and her battle with the data that she
needs to manage her Type 1 diabetes. So I have all of this incredible information
literally 24/7 not just from my prescription medical devices but also from my
Fitbit, from a Bluetooth blood pressure monitor, from my digital scale and from a
variety of different iPhone apps that are used for nutrition tracking etc. None of it
connects. Theyre all in completely different data streams, and even though each of
them provides something that would be an incredibly vital element for me to truly
understand how to manage my disease, how to predict when I need to change

insulin in response to exercise, or stress, or schedule changes, or whatever the case

may be I cant get that information all in one place. Even though its electronic
even though its all downloadable in one form or another its all on different
platforms, different computing systems and it doesnt work together. Anna
McCollisterSlipp The View Of Digital Health From An Engaged Patient These are
just a few examples there are millions more most of which will remain forever
silent for reasons of personal privacy (or embarrassment) and they all exist because
the business models dont support sharing data with the people who create it in the
first place patients. Venture capitalists are notably absent when it comes to
funding any patientcentered solutions because theres simply no way to avoid the
first question who pays? Healthcare needs our clinical (and genetic) data for the
purpose of advancing diagnosis and treatment of disease. I get that. Whats hard to
believe is the misaligned priority of demanding our health data in advance of
important efforts to break down the impenetrable barriers of our own access to
our own data. Tone deaf may be a harsh characterization, but if it doesnt apply
here where does it? There is no question that all this data has enormous value,
but getting the priority right makes all the difference in establishing trust. As Dr.
Peter Diamandis suggested in his keynote at CHIME earlier this month, privacy is
dead. Whether hes right or not is immaterial. Trust most certainly isnt dead and
that trumps privacy everywhere. Especially in healthcare.

Beth Seidenberg (M.D. general partner with Kleiner Perkins Caufield & Byers)
November 2014 You Should Share Your Health Data: Its Value Outweighs the
Privacy Risk http://www.wired.com/2014/11/on-sharing-your-medical-info/

Single issue focus under patient-physician trust is flawed - key

issues constantly shift
Steven Pearson and Lisa Raeke (Center for Ethics in Managed Care, Harvard
Medical School and Harvard Pilgrim Health Care, Boston, Mass) 2000 Patients'
Trust in Physicians: Many Theories, Few Measures, and Little Data
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495476/
The importance of trust in patient-physician relationships is not questioned, but our
understanding of it has depended largely on the passionate thoughts and anecdotes
of physicians who cherish the special bond they feel with their patients. For
practicing clinicians and for those who teach medical students and residents, the
elements of physician behavior that foster trust can continue to reflect the instincts
of physician-theorists: competence, compassion, reliability, integrity, and open
communication. A widely accepted empirical conceptualization and understanding
of trust is yet to come. In recent years, other complex and once believed intangible

concepts, those of satisfaction24,25 and health status,26,27 have yielded to

rigorous qualitative and quantitative research, and investigators and policy leaders
now have standardized instruments with which to measure these concepts in a wide
variety of health care settings. Although attempts to operationalize patientphysician trust are in their infancy, with models emerging recently through the
effort of investigators such as Kao and Safran, a refinement and convergence of
techniques may soon allow trust to be measured and discussed as routinely and
rigorously as many other elements of health care. For patient-physician trust to be
strengthened, our ability to measure the mediators and outcomes of trust must
mature. However, a single measure of patient trust is unlikely to achieve longlasting predominance, nor should it. The evolving nature of the health care system
will continue to cast new light on patient-physician relationships. There will be new
threats to trust that appear on the horizon, while other threats will be perceived to
fade in importance. Much as the threat of overly paternalistic physicians provided
the chief concern in the 1970s, researchers are now more interested in measuring
patients' concerns about physicians' conflict of interest in the setting of strong
financial incentives. As the focus of measures of trust have evolved, from the
earliest measure of Dedrick and Anderson to the latest measure of Kao et al.,
measures of patient-physician trust must also continue to evolve to address
changes in the health care system and in how our society views the key elements of
trust.

Doctor-Patient Trust - Uniqueness

Doctor-Patient trust high now
Gregory Giroux (writer for Bloomberg Business News) July 14, 2014 Doctors
Running for Congress Ditch Suits for White Coats www.bloomberg.com/news/201407-14/doctors-running-for-congress-ditch-suits-for-white-coats.html
Its no accident: polls show nurses and doctors are among the most trusted people
in America. Politicians are among the least trusted. All three commercials for Monica
Wehby, an Oregon Republican seeking to unseat Democratic Senator Jeff Merkley,
have shown her in a hospital setting. As a pediatric neurosurgeon, I know firsthand
how devastating Obamacare is for Oregon families and patients, Wehby said in one
of her ads, which was interspersed with footage of the candidate in surgical scrubs.
The Greys Anatomy backdrop comes as Republicans seek to gain control of the
U.S. Senate and, with their House majority counterparts, pass a law repealing
2010s Affordable Care Act. The quest is gaining urgency as Americans become
more accepting of the law. Republicans need a net gain of six seats for a Senate
majority. Fifty-three percent of Americans oppose the law, though just 32 percent
say it should be repealed, according to a Bloomberg National Poll last month. Fiftysix percent say they want to keep Obamacare with small modifications. Wardrobe
Messaging The latest wardrobe preferences for political ads also put distance
between some candidates and the unpopular Congress they are seeking to join.
About 82 percent of Americans say nurses have a high or very high level of
honesty and ethical standards, the top spot among 22 professions rated in a
December Gallup survey. Pharmacists were tied for second at 70 percent, and
medical doctors were tied with military veterans for fourth at 69 percent. Medical
professionals have high approval ratings because people view them as primary
care-givers, said Frank Newport, Gallups editor-in-chief.

Doctor-Patient Truest Uniqueness o/w Link

Doctor-Patient trust is at an all-time low suspicion is deeprooted and privacy doesnt solve
Fiaz Fazili (M.D., King Fahad Hospital Medina La Munawarah Kingdom Of Saudi
Arabia, Surgery; Minimal invasive and acute acre) June 16, 2015 A Lost Trust
http://www.greaterkashmir.com/news/opinion/story/189486.html
Medicine still is a noble profession. To most of us, medicine is more than a job of
care providing- putting patients' interest first. Unfortunately, in quest of big
business, nobility of noble this profession is vanishing, and the doctor-patient trust
is running all time low. Sadly, there is a general perception in public that the ethics
of medical profession have degenerated, Doctors are accused of not attending to
patients with same zeal and compassion as it used to be. Contrarily, in their own
private clinic attitudes often are different. There is a conflicts of Interest. Is your
doctor paid to promote a drug or device? Are doctors prescribing what is best for
you? Today, patients, or their relatives carry a lot of prejudice and preconceived
notions when they enter a doctor's chamber for consultation; a mindset of
suspicions that doctors also behave like businessmen. Recognition and avoidance of
conflicts of interest represent a core issue of professionalism, and are well covered
in State and Indian medical council bye-laws of, as most of our doctors are honest,
follow the rules, avoiding situations in which the interest of the doctor is placed
above that of the patient. Honesty is a major concern in medical ethics and carries
an important value for a medical practitioner where doctor is perceived as a
messiah a healer. Quality of care varies dramatically between individual doctors
and hospitals, but those differences are invisible to patients. Whether it is a
systemic failure, lack of uniformity in standards of care, organizational disarray,
trust deficit or attitude problem. A number of common problems arise within the
'expectation zone', environment, and circumstances. Valley medicos often cry
insecurity, seek action and protection from concerned authorities. Isn't it time to lift
the veil on this sad reality for finding some important remedial measures to restore
the dignity, honor and trust of overwhelming majority of the doctors who dont
succumb to kickbacks or other lucrative incentives from pharmaceutical companies,
who are unwilling to prescribe a drug, or implant a device, refusing facilitation for
conferences, symposiums and research? Generalizing a statement, doctors fleecing
patients in their private clinics or nursing home, is a myth in our valley when you
compare similar circumstances outside the state. Agreeably, there might be a few
even in our state who disgrace the profession, as there are in any profession but
factually majority of doctors are altruistic. I don't say that all doctors are like priests,
not driven by a greed. Some among us do resort to practices that are unethical
practices to make money. This menace once limited to corporate hospitals is now
infiltrating the state administered hospitals through these dishonest elements who
need to be identified and let the writ of law take its course. My humble appeal goes
to public and patients for change in perception, dont look through tainted glasses
on this profession. Our dedicated, intelligent health care staff need recognition of
for the hard work they do.

Doctor-Patient Trust A2 Disease Impacts

Status quo solves antifolates breakthroughs have already
happened and are going to trials
Colin Poitras (writer for the UConn Today) July 23, 2014 Possible Breakthrough
in Battle Against Drug-Resistant Diseases
http://today.uconn.edu/blog/2014/07/possible-breakthrough-in-battle-against-drugresistant-diseases/
In the war against drug-resistant diseases and so-called superbugs, the family of
bacteria known as CREs are a particularly nasty bunch. The bacteria, whose
scientific name is carbapenem-resistant Enterobacteriaceae include notorious
strains of E. coli and Klebsiella and are a constant health concern in hospitals and
nursing homes, where the germs breed in ventilators, catheters, and intravenous
lines. CREs have been flagged as an urgent threat by the Centers for Disease
Control and Prevention because of their strong resistance to antibiotics and easy
transmission between humans. Some CRE bacteria are resistant to all known
antibiotics. The mortality rate is high. As many as 50 percent of patients infected
with CRE bacteria die because there is no drug to fight them. But two UConn
scientists may be gaining new ground against the public health threat. Professors
Amy Anderson and Dennis Wright, along with their students in the School of
Pharmacy, have developed a group of drug compounds that appear to be
particularly effective against CREs in early tests. A lead is a preliminary molecule
that shows promise and is poised for further development. The potent compounds
part of a group of drugs known as antifolates were a long time coming for the two,
who have been searching for effective treatments for drug-resistant diseases like
MRSA, E. coli, and Klebsiella pneumoniae for more than 10 years. Working with
drug-resistant strains is particularly challenging for researchers, as the diseases
constantly morph and evolve to fend off attacks to kill them. It has been a holy
grail to kill these types of CREs, says Anderson, a professor of medicinal chemistry
and interim head of the Department of Pharmaceutical Sciences. These (CRE)
bacteria have an extra thick, tight membrane meshed with proteins that makes it
very hard for drugs to penetrate. Weve spent years trying. After testing hundreds
of different compounds, delicately altering each ones chemical structure with the
hope of finding the magic recipe that would serve as a CRE knockout blow,
Anderson and Wright recently started seeing positive results in one particular group.
Our goal was to inhibit a certain enzyme in the bacteria so it cant function and the
bacteria cant survive, Anderson says. When we finally got a very potent inhibition
of the enzyme, that was definitely a eureka moment. The pair recently received
a five-year, $2.7 million grant from the National Institutes of Health to further study
these compounds and prepare them for clinical trials. Together, Andersons and
Wrights labs have received more than $10 million in federal research support since
they began working on the project. Wright, a professor of medicinal chemistry,
synthesizes the new drugs; Anderson evaluates them and determines the atomic
details of how they interact with their intended target . We want to make
compounds that are potent inhibitors of the growth of the bacteria and at the same
time are safe, with good drug properties, so down the line they will be effective

when used at a clinic, says Wright. At this stage in the research, Anderson and
Wright are trying to learn more about the physical and chemical processes that
allow their compounds to penetrate the armor-like coating around CREs when so
many others have failed. Understanding why their compounds are working may
allow them to apply the same biological chemistry to different compounds that
could be used to fight other persistent infections. Associate professor of pharmacy
practice Jeffrey Aeschlimann from UConn Health is helping with the CRE drug
characterizations. University of Montana professor of chemistry Nigel Priestley is
assisting with testing in early animal pre-clinical trials. Right now, what makes our
compounds attractive is that they seem to have a very low rate of resistance,
says Wright. Weve made compounds that are very hard for these CREs to fend
off.

Recently discovered fungus

Catholic Online July 2014 How one fungus may stop superbugs
http://www.catholic.org/news/health/story.php?id=56093
Scientists at McMaster University in Ontario discovered a compound that instantly
turned off a gene in several harmful bacteria that made them highly resistant to
treatment with a class of antibiotics used to fight so-called suberbug infections.
There are still thousands of children who need just one light in the darkness.
Aspergillomarasmine A (AMA), was the compound that was found in a soil sample
extracted from a common fungus found in soil and mold. Antibiotic resistance is a
growing public-health threat. Common germs such as Escherichia coli (E. coli) are
becoming harder to treat because of increasing immunities to common antibiotics.
In the United States alone, some two million people are infected with antibioticresistant diseases, and around 23,000 die as a result, according to information
released from the Centers for Disease Control and Prevention (CDC). The World
Health Organization (WHO) has called antibiotic resistant a threat to global public
health. Using the compound, the Canadian team was able to disarm a gene-New
Delhi Metallo-beta-Lactamase-1 (NDM-1) that has become the WHO's number one
enemy since it was discovered in 2009. , "Discovery of a fungus capable of
rendering these multidrug-resistant organisms incapable of further infection is huge
" said Irena Kenneley, a microbiologist and infectious disease specialist at Frances
Payne Bolton School of Nursing at Cleveland's Case Western Reserve University.
"The availability of more treatment options will ultimately save many more lives."

Squo solves
Anne Trafton (writer for the MIT News Office) September 21, 2014 Battling
superbugs http://newsoffice.mit.edu/2014/fighting-drug-resistant-bacteria-0921
In recent years, new strains of bacteria have emerged that resist even the most
powerful antibiotics. Each year, these superbugs, including drug-resistant forms of
tuberculosis and staphylococcus, infect more than 2 million people nationwide, and
kill at least 23,000. Despite the urgent need for new treatments, scientists have
discovered very few new classes of antibiotics in the past decade. MIT engineers
have now turned a powerful new weapon on these superbugs. Using a gene-editing
system that can disable any target gene, they have shown that they can selectively

kill bacteria carrying harmful genes that confer antibiotic resistance or cause
disease. Led by Timothy Lu, an associate professor of biological engineering and
electrical engineering and computer science, the researchers described their
findings in the Sept. 21 issue of Nature Biotechnology. Last month, Lus lab reported
a different approach to combating resistant bacteria by identifying combinations of
genes that work together to make bacteria more susceptible to antibiotics. Lu hopes
that both technologies will lead to new drugs to help fight the growing crisis posed
by drug-resistant bacteria. This is a pretty crucial moment when there are fewer
and fewer new antibiotics available, but more and more antibiotic resistance
evolving, he says. Weve been interested in finding new ways to combat antibiotic
resistance, and these papers offer two different strategies for doing that. Cutting
out resistance Most antibiotics work by interfering with crucial functions such as cell
division or protein synthesis. However, some bacteria, including the formidable
MRSA (methicillin-resistant Staphylococcus aureus) and CRE (carbapenem-resistant
Enterobacteriaceae) organisms, have evolved to become virtually untreatable with
existing drugs. In the new Nature Biotechnology study, graduate students Robert
Citorik and Mark Mimee worked with Lu to target specific genes that allow bacteria
to survive antibiotic treatment. The CRISPR genome-editing system presented the
perfect strategy to go after those genes. CRISPR, originally discovered by biologists
studying the bacterial immune system, involves a set of proteins that bacteria use
to defend themselves against bacteriophages (viruses that infect bacteria). One of
these proteins, a DNA-cutting enzyme called Cas9, binds to short RNA guide strands
that target specific sequences, telling Cas9 where to make its cuts. Lu and
colleagues decided to turn bacterias own weapons against them. They designed
their RNA guide strands to target genes for antibiotic resistance, including the
enzyme NDM-1, which allows bacteria to resist a broad range of beta-lactam
antibiotics, including carbapenems. The genes encoding NDM-1 and other antibiotic
resistance factors are usually carried on plasmids circular strands of DNA
separate from the bacterial genome making it easier for them to spread through
populations. When the researchers turned the CRISPR system against NDM-1, they
were able to specifically kill more than 99 percent of NDM-1-carrying bacteria, while
antibiotics to which the bacteria were resistant did not induce any significant killing.
They also successfully targeted another antibiotic resistance gene encoding SHV-18,
a mutation in the bacterial chromosome providing resistance to quinolone
antibiotics, and a virulence factor in enterohemorrhagic E. coli. In addition, the
researchers showed that the CRISPR system could be used to selectively remove
specific bacteria from diverse bacterial communities based on their genetic
signatures, thus opening up the potential for microbiome editing beyond
antimicrobial applications. To get the CRISPR components into bacteria, the
researchers created two delivery vehicles engineered bacteria that carry CRISPR
genes on plasmids, and bacteriophage particles that bind to the bacteria and inject
the genes. Both of these carriers successfully spread the CRISPR genes through the
population of drug-resistant bacteria. Delivery of the CRISPR system into waxworm
larvae infected with a harmful form of E. coli resulted in increased survival of the
larvae. The researchers are now testing this approach in mice, and they envision
that eventually the technology could be adapted to deliver the CRISPR components
to treat infections or remove other unwanted bacteria in human patients. This work

represents a very interesting genetic method for killing antibiotic-resistant bacteria

in a directed fashion, which in principle could help to combat the spread of antibiotic
resistance fueled by excessive broad-spectrum treatment, says Ahmad Khalil, an
assistant professor of biomedical engineering at Boston University who was not part
of the research team. High-speed genetic screens Another tool Lu has developed to
fight antibiotic resistance is a technology called CombiGEM. This system, described
in the Proceedings of the National Academy of Sciences the week of Aug. 11, allows
scientists to rapidly and systematically search for genetic combinations that
sensitize bacteria to different antibiotics. To test the system, Lu and his graduate
student, Allen Cheng, created a library of 34,000 pairs of bacterial genes. All of
these genes code for transcription factors, which are proteins that control the
expression of other genes. Each gene pair is contained on a single piece of DNA that
also includes a six-base-pair barcode for each gene. These barcodes allow the
researchers to rapidly identify the genes in each pair without having to sequence
the entire strand of DNA. You can take advantage of really high-throughput
sequencing technologies that allow you, in a single shot, to assess millions of
genetic combinations simultaneously and pick out the ones that are successful, Lu
says. The researchers then delivered the gene pairs into drug-resistant bacteria and
treated them with different antibiotics. For each antibiotic, they identified gene
combinations that enhanced the killing of target bacteria by 10,000- to 1,000,000fold. The researchers are now investigating how these genes exert their effects.
This platform allows you to discover the combinations that are really interesting,
but it doesnt necessarily tell you why they work well, Lu says. This is a highthroughput technology for uncovering genetic combinations that look really
interesting, and then you have to go downstream and figure out the mechanisms.
Once scientists understand how these genes influence antibiotic resistance, they
could try to design new drugs that mimic the effects, Lu says. It is also possible that
the genes themselves could be used as a treatment, if researchers can find a safe
and effective way to deliver them. CombiGEM also enables the generation of
combinations of three or four genes in a more powerful way than previously existing
methods. Were excited about the application of CombiGEM to probe complex
multifactorial phenotypes, such as stem cell differentiation, cancer biology, and
synthetic circuits, Lu says.

Its already got a patent will be scaled up for commercial and

national needs now
Kenneth Ma (Lawrence Livermore National Laboratory) October 7, 2014 Bio
researchers receive patent to fight superbugs
https://www.llnl.gov/news/newsreleases/2014/Oct/NR-14-10-3.html
Superbugs, or antibiotic-resistant bacteria, have been on the rise since antibiotics
were first introduced 80 years ago. That's because these germ-fighting agents have
lost their punch from being overprescribed and misused, allowing bacteria
pathogens to develop immunities against them. As a result, superbugs sicken nearly
2 million Americans each year and roughly 23,000 people die annually from these
infections, according to the Centers for Disease Control and Prevention. Many more
people die from other conditions that are complicated by antibiotic-resistant

infections. Lawrence Livermore National Laboratory scientists have figured out a

way to reverse this trend by developing novel antibiotics that effectively kill
superbugs. They were recently issued a patent for producing antimicrobial
compounds that degrade and destroy antibiotic-resistant bacteria by using the
pathogen's own genes against it. Their approach can be used to fight superbugs
such as antibiotic-resistant E. coli, Salmonella, Campylobacter, Methicillin-resistant
Staphylococcus aureus (MRSA), Bacillus anthracis and many others. Antimicrobial
compounds available today are designed to treat a host of bacteria, not target
specific ones. While this is effective in the short term, bacteria are able to modify
themselves over time to prevent a number of antibiotics from inhibiting their
growth, rendering the antibiotics useless. To prevent this, the LLNL team created a
process to discover new antibiotics designed to eradicate targeted bacterium
responsible for a specific infection. Their technique uses computational tools and
genome sequencing to identify which genes inside a bacterium encode for lytic
proteins that can be used to kill it. Lytic proteins are enzymes that normally produce
nicks in cell walls that allow cells to divide and multiply. But used in high
concentrations, these enzymes cause rapid cell-wall degradation and cell rupture, a
process known as lysis. Lytic proteins circumvent any defenses that bacteria have
developed against today's broadly focused antimicrobials. Once genes encoding
lytic proteins are identified in a bacterium, Lab researchers synthesize those genes
and produce the lytic proteins in a laboratory setting. They are then experimentally
introduced to the cell walls of targeted pathogens to destroy them. "We knew about
these proteins because they were primarily coded and identified in bacteriophages,
virus particles that attack bacterium and make copies of themselves," said Matthew
Coleman, a member of the LLNL research team. "Bacteriophages need a way to get
out of the bacteria once they make enough copies. So they encode a lytic protein,
called an endolysin that breaks down the cell wall, causing the cell to die. The wall
is what gives the cell its strength." The team's unique discovery was the existence
of lytic proteins that are not associated with bacteriophages. They learned that
bacteria themselves encode their own versions of these lytic proteins, which they
use under tight regulatory control to remodel their cell wall during cell division.
Tight regulatory production means that lytic protein is not overproduced because
too much of it will kill the cells. The team conducted lab experiments that show lytic
protein produced by bacteria killed pathogens more effectively than lytic protein
produced by bacteriophages. LLNL's resources allowed the team to sequence
genomes within a few weeks to obtain information on new pathogens, unknown
bacteria species and even species yet to be sequenced. This data helps the team
determine which genes encode lytic proteins and reproduce those proteins in large
quantities to eliminate targeted pathogens. So far, the team's novel approach has
been extremely effective in lab testing. In CDC experiments, the LLNL-produced lytic
protein killed 100 percent of Bacillus anthracis cells, the bacterium that causes
anthrax. "We can isolate these genes to support the development of effective
antimicrobial agents for commercial and national needs," Coleman said.

Multi-drug resistance is unlikely- Combination therapy

Cobey el al. 15, (Gabriel G. Perron, R. Fredrik Inglis, Pleuni S. Pennings and
Sarah Cobey, Evolutionary Applications, Fighting microbial drug resistance: a
primer on the role of evolutionary biology in public health, 23 MAR 2015,
http://onlinelibrary.wiley.com/doi/10.1111/eva.12254/full)//IB
shortage of new antibiotics motivated the search for novel strategies to manage
resistance evolution. For example, combination therapy showed that some antibiotics have
nonlinear inhibitory activities when used together (King et al. 1981; Yeh et al. 2009). Extensive
phenotypic screens revealed that many classes of antibiotics could inhibit the effects of other
antibiotics given their modes of activity (Yeh et al. 2006), often caused by regulatory conflicts in the
The

expression of the antibiotics cellular targets (Bollenbach and Kishony 2011) or by reductions in bacterial growth

Subsequent studies have shown that such interactions could

modulate resistance evolution (Yeh et al. 2009): Multidrug resistance is unlikely to evolve
against sets of antibiotics that inhibit each other's activity, as resistance evolution
to one antibiotic would expose the bacterium to the full efficiency of the second
antibiotic (Michel et al. 2008). However, additional clinical trials are required to see whether this finding can be
rates (Ocampo et al. 2014).

put into practice.

Alt Cause Laundry List

Series of factors affect the doctor-patient relationship and
trust
Goold and Lipkin 99 (Susan Dorr Goold, MD, MHSA, MA, Received from the
Division of General Medicine, University of Michigan Medical Center, Ann Arbor,
Mich. AND Mack Lipkin, Jr., MD, New York University Medical Center, New York)(The
DoctorPatient Relationship: Challenges, Opportunities, and Strategies, J Gen Intern
Med. 1999 Jan; 14(Suppl 1): S26S33. doi: 10.1046/j.15251497.1999.00267.x)//ASMITH
A series of organizational or system factors also affect the doctorpatient
relationship. The accessibility of personnel, both administrative and clinical, and
their courtesy level, provide a sense that patients are important and respected, as
do reasonable waiting times and attention to personal comfort. The availability of
covering nurses and doctors contributes to a sense of security. Reminders and userfriendly educational materials create an atmosphere of caring and concern.
Organizations can promote a patient-centered culture,29 or one that is profit- or
physician-centered, with consequences for individual doctorpatient relationships.
Organizations (as well as whole health care systems) can promote continuity in
clinical relationships, which in turn affects the strength of in those relationships. For
instance, a market-based system with health insurance linked to employers' whims,
with competitive provider networks and frequent mergers and acquisitions, thwarts
long-term relationships. A health plan that includes the spectrum of outpatient and
inpatient, acute and chronic services has an opportunity to promote continuity
across care settings. The competition to enroll patients is often characterized by a
combination of exaggerated promises and efforts to deliver less. Patients may arrive
at the doctor's office expecting all their needs to be met in the way they themselves
expect and define. They discover instead that the employer's negotiator defines
their needs and the managed care company has communicated them in very fine or
incomprehensible print. Primary care doctors thus become the bearers of the bad
news, and are seen as closing gates to the patient's wishes and needs. When this
happens, an immediate and enduring barrier to a trust-based patient-doctor
relationship is created. The doctorpatient relationship is critical for vulnerable
patients as they experience a heightened reliance on the physician's competence,
skills, and good will. The relationship need not involve a difference in power but
usually does,30 especially to the degree the patient is vulnerable or the physician is
autocratic. United States law considers the relationship fiduciary; i.e., physicians are
expected and required to act in their patient's interests, even when those interests
may conflict with their own.9 In addition, the doctorpatient relationship is
remarkable for its centrality during life-altering and meaningful times in persons'
lives, times of birth, death, severe illness, and healing. Thus, providing health care,
and being a doctor, is a moral enterprise. An incompetent doctor is judged not
merely to be a poor businessperson, but also morally blameworthy, as having not
lived up to the expectations of patients, and having violated the trust that is an
essential and moral feature of the doctorpatient relationship.31 Trust is a fragile
state. Deception or other, even minor, betrayals are given weight disproportional to

their occurrence, probably because of the vulnerability of the trusting party (R.L.
Jackson, unpublished manuscript).

Alt Cause Staff/Expertise

Budget cuts and staff shortages short-circuit all health
surveillance
Edward Richards (Harvey A. Peltier Professor of Law and Director, Program in
Law, Science, and Public Health at the Paul M. Herbert Law Center, Louisiana State
University) 2009 DANGEROUS PEOPLE ,UNSAFE CONDITIONS T HE
CONSTITUTIONAL BASIS FOR PUBLIC HEALTH SURVEILLANCE The Journal of Legal
Medicine, 30:2750, http://biotech.law.lsu.edu/Articles/ULGM_A_369622_O.pdf
The Constitution grants broad authority for public health surveillance. As long as
public health authorities do not use administrative searches as a subterfuge for
criminal law searches, the courts will uphold these searches when they are
conducted either pursuant to an area warrant or through the reg- ulated industries
exception to a warrant requirement. Surveillance, however, is just the first step in
protecting the public health and safety. Surveillance data must be combined with
good epidemiologic analysis, and then become the basis for public health
interventions. There have been few abuses of public health administrative searches.
Public health authorities, if anything, have been too reticent to use proper
surveillance techniques. Although some of this reticence is because of con- cerns
about being seen as violating individual rights, most of it stems from lack of staff
and other resources. 113 Despite the push on public health preparedness since the
terrorist attacks on September 11, 2001, health departments around the United
States continue to suffer budget and staff cuts. The impacts of these cuts are
exacerbated by legislatures pushing ever-increasing responsi- bilities on health
departments without providing the budgets or staff to carry out these new tasks.
114 The hardest issue for public health policy makers is to avoid pressures to
transform public health agencies into extensions of the Department of Homeland
Security. As we have seen from the adoption of Draconian emergency powers laws,
it is more difficult to maintain a balance between individual rights and community
protection than to attempt to satisfy political pressures by swinging wildly between
extreme positions.

Staff and expertise shortages take out the aff

Bernard Choi (Injury Prevention Research Centre, Medical College of Shantou
University, Shantou, China and Department of Epidemiology and Community
Medicine, University of Ottawa, Ottawa, Canada) 2012 The Past, Present, and
Future of Public Health Surveillance Scientifica Volume 2012 (2012), Article ID
875253, 26 pages http://dx.doi.org/10.6064/2012/875253
To avoid fragmentation in national surveillance efforts [107, 144], there is a need for
federal agencies to provide national facilitation to foster interstate and intercounty
collaboration. Central guidance can lead to coordination across states and counties,
interstate technology transfer, and opportunity to learn from the successes and

failures of other localities. Needless expense, unnecessary development time, and

failure to rapidly share information on innovative systems can be avoided [205]. No
attempt to meet the current challenges in public health surveillance will succeed
unless it recognizes the fundamental importance of providing and maintaining a
cadre of highly trained and motivated public health professionals in every local
health agency in the country [5]. To use surveillance information to better prioritize,
plan, deliver, and evaluate programming, public health staff must possess the
required knowledge and skills. While it is neither feasible nor necessary for all staff
to receive postgraduate academic training, a greater proportion of the public health
workforce will need to acquire the knowledge and skills necessary to effectively
understand and use surveillance concepts and techniques. Public health
surveillance systems must be strengthened by (1) allocating resources, including
human resources, for the effective use of health surveillance data and tools and (2)
recognizing the need for existing staff to acquire new skills [77].

Alt Cause Commercialization/Pharma

Alt causes commercialization of health and Ebola
Collins 14 (Sam P.K. Collins is a health reporter for ThinkProgress. He previously provided general news
coverage of the D.C. metropolitan area for the Washington Informer, and wrote reports of President Barack Obamas
activities as a White House press pool reporter for American Urban Radio Networks. Sam holds a masters degree in
public policy, and a bachelors degree in journalism and mass communication from George Washington University.
Americans Dont Trust The Medical Profession 10/23/14
http://thinkprogress.org/health/2014/10/23/3583625/americans-skeptical-doctors/)///CW

Americans count among the least trusting of the medical profession, according to an
international health care survey . The findings, which appeared in a recent issue of the New England
Journal of Medicine, show significant levels of suspicion of doctors, especially among those who make less than
$30,000 annually. Researchers studied public health polls dating back four decades, including one conducted by a
consortium of universities between 2011 and 2013 during which people in 29 countries answered survey questions.
In that poll, 58 percent of Americans said they trust the medical profession, placing the United States in 24th place
with Croatia. It fits with decades of data on the American publics trust in institutions, in general, Michael
Gusmano, a scholar at the Hastings Center, a Garrison, N.Y.-based research institute that focuses on health care,

Skepticism of the medical profession hasnt happened without any

reason. Experts point to unequal access to health care and the commercialization
of American medicine as key factors at play in that damaged relationship. Some people say that
told WebMD.

members of the medical field often seem more concerned about protecting their financial interests than caring for

Big Pharma has historically tried to

influence the advice that doctors give patients , something that may make Americans wary of the
patients, especially those from less affluent backgrounds.

field in general. In exchange for their endorsement of prescription medications, physicians receive free samples and
gifts that include coffee mugs emblazoned with the drug companys logo, tickets to sporting events, expensive
dinners, and trips to exotic destinations. At the peak of Big Pharmas profitable relationship with the medical
industry in 2007, more than 100,000 representatives made visits to more than 650,000 physicians across the
country. This can sometimes have a direct effect on patients. A Centers for Disease Control and Prevention (CDC)
study in August, for example, found that doctors in hospitals with a strong black patient base encouraged
breastfeeding to expectant mothers at a rate 15 percentage points less than that of their white counterparts, due in

Americans mistrust of the

medical industry has been on full display in the weeks since American Ebola patient
zero Thomas Eric Duncan died in a Dallas hospital. Days after CDC officials assured
Americans that the disease would spread no further, two nurses who treated
Duncan tested positive for Ebola. Many of the nurses who had direct contact with patient zero before he
part to a relationship between the facility and manufacturers of baby formula.

succumbed criticized the medical establishment, saying nurses at Presbyterian Hospital in Dallas treated Duncan
for days in an open space in the emergency room under constantly changing protocols and without sufficient
protective gear. The controversy has discouraged some Americans from trusting what CDC officials are saying

nearly half of Americans

dont think their local hospital could safely treat an Ebola case . That has facilitated the
spread of panic about Ebola anxiety that may pose a bigger threat to Americans than the
virus itself. Instead of listening to federal health officials, many Americans have looked to
sensationalized media reports and reckless words of commentators and politicians as
about the United States ability to contain the virus. According to one recent poll,

indicators of Ebolas impact in the United States. There are other examples of how some Americans mistrust of the
medical profession undermines public health. An increasing number of parents are skipping or delaying their
childrens recommended vaccination, due in part to a belief that the injections cause autism and other sicknesses.
Members of the scientific community beg to differ, especially since vaccinations in the last two decades have
prevented nearly 700,000 deaths. But the parents who choose to delay their kids vaccines dont trust scientists
opinions on the subject. The study recently published in the New England Journal of Medicine does have another
significant finding: Even when Americans are skeptical of the medical industry as a whole, they do trust their own
doctor. So information about things like Ebola and vaccinations might need to come from those immediate sources
rather than national spokespeople.

Genetics Surveillance Data Leaks Inevitable

Impossible to keep genetic data anonymous data leaks
inevitable
Gina Kolata (Medical reporter for the New York Times) June 2013 Poking Holes
in Genetic Privacy http://www.nytimes.com/2013/06/18/science/poking-holes-inthe-privacy-of-dna.html?pagewanted=all&_r=0
For years now, a steady stream of research has eroded scientists faith that DNA can
be held anonymously. The first shock came in 2008, when David W. Craig, a
geneticist at TGen, a research institute in Phoenix, and his colleagues imagined a
theoretical problem. Suppose you are trying to learn what percentage of
intravenous drug users are infected with hepatitis, and you collect DNA from
discarded needles and amass it in a database to look for signs of the virus in the
genetic material. Is there any way, they wondered, to find a particular persons DNA
is in this soup of genes? Most researchers would have said the task was impossible,
worse than looking for a needle in a haystack. But Dr. Craig and his colleagues
found a way to do it, exploiting the four million or so tiny, and usually
inconsequential, differences in DNA letters between one individual and another.
With their method, using the combinations of hundreds of thousands of DNA
markers, the researchers could find a person even if his or her DNA constituted just
0.1 percent of the total in the mix. So explosive was the finding that Dr. Craig
deliberately chose to write about it only very technically. The N.I.H. understood what
he had accomplished, though, and quickly responded, moving all genetic data from
the studies it financed behind Internet firewalls to prevent the public or anyone not
authorized from using the data and, it was hoped, to protect the identities of
research subjects. But another sort of genetic data so-called RNA expression
profiles that show patterns of gene activity were still public. Such data could not
be used to identify people, or so it was thought. Then Eric E. Schadt of Mount Sinai
School of Medicine discovered that RNA expression data could be used not only to
identify someone but also to learn a great deal about that person. We can create a
profile that reflects your weight, whether you are diabetic, how old you are, Dr.
Schadt said. He and a colleague also were able to tell if a person is infected with
viruses, like HPV or H.I.V., that change the activity of genes. Moreover, they were
able to make what they called a genetic bar code that could be used to identify a
person in a number of DNA databases. Then, this year, in perhaps the most
disturbing exercise, Yaniv Erlich, a genetics researcher at the Whitehead Institute,
used a new computational tool he had invented to identify by name five people
from their DNA, which he had randomly selected from a research database
containing the genes of one thousand people. Experts were startled by what Dr.
Erlich had done. We are in what I call an awareness moment, said Eric D. Green,
director of the National Human Genome Research Institute at the National Institutes
of Health. Research subjects who share their DNA may risk a loss of not just their
own privacy but also that of their children and grandchildren, who will inherit many
of the same genes, said Mark B. Gerstein, a Yale professor who studies large genetic
databases. Even fragments of genetic information can compromise privacy. James
Watson, a discoverer of DNAs double helix shape, had his genes sequenced and

made the information public except for one, the sequence for ApoE, a gene that
has a variant linked to an increased risk of Alzheimers disease. Researchers
noticed, though, that they could still figure out if Dr. Watson had that variant by
examining the DNA on either side of the gene he had removed. They did not reveal
whether he had it. With so many questions about the privacy and security of genetic
data, researchers wonder what research subjects should be told. Leaks and
identification of study subjects will never be completely avoidable, said George
Church, a Harvard geneticist. And as much as investigators might like to find a way
to keep genetic data secure and private, he does not think there is an exclusively
technical solution. If you believe you can just encrypt terabytes of data or
anonymize them, there will always be people who hack through that, Dr. Church
said. He believes that people who provide genetic information should be informed
that a loss of privacy is likely, rather than unlikely, and agree to provide DNA with
that understanding. Other researchers say the idea is not far-fetched, and some
suggest that scientists be licensed before they are given access to genetic
databases, with severe penalties for those who breach privacy. My fear is not so
much that someone will take everyones genomes and put them on the Web, Dr.
Gerstein said. It is that a graduate student in some lab somewhere will navely post
bits of genomes on his Facebook page. The idea is that before he could get access
to genomes, he would be taught he cant do that. And if he did he would lose his
license. The amount of genetic data that has been gathered so far is minuscule
compared with what will be coming in the next few years, Dr. Altshuler noted,
making it important to address the problems before the data deluge makes them
worse. We see substantial issues, he said. We want to have serious discussions
now.

Genomic data breaches happen all the time- the health system
does not have enough protections in place to secure private
genetic information
McEwen et al 13 (Jean E. McEwen, Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health,Ethical, Legal, and Social Implications
Program, Division of Genomics and Society, National Human Genome Research
Institute, National Institutes of Health. Joy T. Boyer, Senior Program Analyst,
and Kathie Y. Sun, Program Analyst. Evolving Approaches to the Ethical
Management of Genomic Data. February 28, 2013.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665610/)//EMerz
The genetic studies and test protocols that dominated the field 1520 years ago
were generally highly targeted, and tended to view the risks to participants or
patients (apart from the physical risks associated with blood drawing) as
straightforwardly informational [1719]. Thus, consent materials in use prior to the
mid-2000s, if they mentioned non-physical risks at all, tended to focus on the
potential for breach of privacy, with insurance and employment usually listed as the
two areas of main concern [2022]. Data security measures of the time were, by

todays standards, remarkably low tech, often consisting of little more than coding
samples and data and storing samples and data in locked freezers and cabinets.
Still, consent forms, if they addressed the issue at all, typically described the risk of
a security breach as low; at the time that assessment seemed reasonably accurate,
predating as it did the development of massive, web-accessible genomic databases
and expanded data sharing norms. Early consent forms rarely addressed the issue
of whether individual findings from studies would be returned to participants [20,
21]. The usual default presumption was that they would not be [23], because most
findings emanating from studies of the time interrogated only limited regions of the
genome, so the likelihood of generating incidental findings (apart from occasional
evidence of undisclosed adoption or misattributed paternity [24]) was relatively low.
Another feature of early consent forms was their characteristically narrow scientific
scope [8, 20, 21]. Most described only the immediate study for which samples were
being collected or the specific disease being analyzed; although the possibility of
sharing with close collaborators working on the same disease was sometimes
mentioned, obtaining broad consent to an unspecified range of future uses was the
exception, not the norm. Often, consent documents were simply silent about
plans for any future sharing, and in such cases, the absence of an explicit
prohibition against sharing was generally interpreted (or, at least over time
came to be interpreted) as tacit permission to share [23]. In 1994, longpercolating concerns among bioethicists about the practice of using stored, linkable
samples without obtaining new consent from those from whom they had been
obtained culminated in the publication of a highly influential paper that
recommended against continuing this practice [25]. Following this recommendation,
consent documents gradually began to be written with greater specificity about
whether, with whom, and for what purposes, samples and data would be shared. In
practice, however, the recommendation was often interpreted as applying only to
prospectively collected samples. Thus, as was recently called to public attention in a
best-selling book, archived samples collected under widely varying and sometimes
questionable consent conditions and cell lines derived from such samples - are
often still being used today.

Genetic Surveillance No Impact

Theres no impact to genetic discrimination- their evidence is
just rhetoric
Begley 4 (Sharon Begley. Senior health & science correspondent at Reuters. Bill
Seeking to Ban DNA Discrimination Isn't Really Necessary. February 6, 2004.
http://www.wsj.com/articles/SB107595572756521572)//EMerz
When it comes to genetic discrimination, there is a yawning chasm between rhetoric
and reality. As law professor Henry Greely of Stanford University puts it, "Genetic
discrimination is a much greater threat in people's fears than it is in reality, today or
in the foreseeable future....Failure to ban [it] will not make the sky fall, [or] the
employment markets crumble." Genetic discrimination means being denied
employment or health insurance (or being charged more for it) as a result of testing
positive for a gene that raises your risk of developing a disease such as cancer or
Alzheimer's. Since at least 1990, it has been cast as the dark underbelly of the
human genome project, which dutifully set aside 3% to 5% -- almost $100 million -of its annual budget to study such ethical, legal and social issues. Francis Collins,
director of the project, has called genetic discrimination "a vexing problem" and
praised the Senate's "important" bill. The emperor, however, is wearing skivvies.
Just as genome enthusiasts, and much of the media, have hyped the medical
benefits of decoding humankind's double helix, so they (and we) have grossly
overstated the threat and the reality of genetic discrimination. If you probe beneath
the anecdotes, evidence of genetic discrimination melts away. Bioethicists and
genetic counselors, for instance, say they've heard of people being fired or denied
health coverage after testing positive for a risk gene, but concede they know of no
such patients firsthand. When they do offer an actual case, it turns out that the
discrimination was based not on a predictive genetic test (finding a genetic variant
that raises the risk of cancer, perhaps) but on family history or actual symptoms of,
say, the blood disorder hereditary hemochromatosis. That may be medical
discrimination, but it isn't genetic discrimination as usually understood. In an effort
to get beyond anecdote, a 2000 study examined the effect of state laws barring
genetic discrimination in health insurance. To their surprise, Mark Hall and Stephen
Rich of Wake Forest University in Winston-Salem, N.C., found that states with such
laws had no fewer cases of genetic discrimination than states without them. Why?
Because you can't have fewer cases than zero, and zero is about how much genetic
discrimination the study turned up. "We found almost no cases of health insurers
asking for or using the results of predictive genetic tests," Prof. Hall says. "The laws
have so little impact because almost no genetic discrimination is occurring," as
more-recent studies confirm. Dawn Allain, president of the National Society of
Genetic Counselors, agrees: "We haven't seen any real cases of genetic
discrimination." Health insurers have little financial incentive to set rates based on
predictive genetic tests, Prof. Hall explains. For group coverage, it's much simpler to
tote up last year's costs and factor in inflation. For individual coverage, people
change carriers so frequently that even if they develop a disease 15 years down the
road, as a genetic test might predict, it will likely be on another insurer's dime.
Although the warnings of bioethicists (including, Prof. Greely sheepishly admits, "an

earlier version of myself") haven't come true, some now argue that we need federal
legislation for symbolic reasons, to protect people from even the theoretical risk of
genetic discrimination. This "what harm does it do?" argument is OK, says William
Nowlan, chief medical officer of the National Life Insurance Co., Montpelier, Vt., who
has written widely on the myth of genetic discrimination. But then let's admit that
the Senate bill addresses a problem that exists solely in the public's imagination. As
far as I can tell, the bill's only real benefit would be to allay the fears of people who
reject genetic tests in the belief that a positive result could make them uninsurable
and unemployable. That's a worthwhile goal. But it comes at a cost. By enshrining
genetic status in federal law, we reinforce the widespread and pernicious
belief that DNA is destiny. It isn't. Risk genes for common diseases aren't like
those for the exceedingly rare Huntington's or Tay-Sachs, where carrying the gene
means you definitely will get the disease. Instead, risk genes are low in what
biologists call "penetrance:" They increase your chance of developing the disease,
but to nothing like 100%. In one fascinating 2000 study, Swedish scientists
calculated that genes account for less than half of the risk of developing 11
common cancers. The cancers with the highest genetic component, the study
found, are prostate (42%) and colorectal (35%). A woman's risk of getting breast
cancer if her identical twin does is only 13%. Supporters of the genetic
discrimination bill should make clear that what they want to guard against is no
more than a theoretical risk. They should make equally clear that the risk genes
they're so worried about are not all they're cracked up to be.

Even if genetic surveillance contains invasive information, it

doesnt require much protection- few people are qualified to
read DNA
Lauss et al 13 (Georg Lauss, Arndt Bialobrzeski, Matthias Korkhaus, Karoliina
Snell, Johannes Starkbaum, Andra E. Vermeer, Jukka Weigel, Herbert Gottweis, Ilpo
Heln, Jochen Taupitz, Peter Dabrock. BEYOND GENETIC PRIVACY PAST, PRESENT
AND FUTURE OF BIOINFORMATION CONTROL REGIMES. 2013. http://privategen.eu/uploads/media/PRIVATE_Gen_FINAL-REPORT_2013_01.pdf)//EMerz
Ultimately, some genetic information might merit special treatment because it has a
number of characteristics which, although they may be individually present in
respect of other forms of information, are present to a high degree in the case of
genetic information and combine to give it a special status in some contexts. [p.31]
The report emphasizes the importance of context. Genetic information might not
always be sensitive in itself. What makes genetic information and arguably
information in general sensitive is its context and the way a piece of information is
combined with other information. Since information about a person or a state of
affairs takes on meaning only if it is put into a social context and if it is combined
with other information, it was even be argued that genetic information is even
better protected from widespread third-party misuse than other types of (medical)
information because it requires a high level of expert knowledge and expert
resources to read it and interpret it in meaningful ways. In a certain sense, it has a

comparably high legibility threshold [24]. Moreover, empirical research has shown
the likelihood that genetic information and its related research may be seen as
problematic, but it appears that people perceive other types of information as being
sensitive, as well, and that their concerns revolve around the concrete context in
which data and materials are used and the intention behind a particular inquiry

Genetic Surveillance Good - Crime

Genetic research base is key to solving violent crimes and
exonerating criminals
[David H. Kaye, Penn State Law Trawling DNA Databases for Partial Matches:
What is the FBI Afraid of? 2009]
Across the globe,

many countries have established DNA databases-collections of

computer-searchable records of the DNA profiles of suspected or convicted
offenders.' England started the first national criminal DNA database in 1995.2 In the United States, the state
and federal databases as combined in the National DNA Index System (NDIS) hold over seven
million short tandem repeat (STR) profiles from convicted offenders as well as a growing number of
people who were merely arrested or detained. 3 When investigators recover a DNA sample from
the scene of a crime, they can search these databases to discover if any of the
recorded profiles match. Such "cold hits" from these database trawls have led
police to serial rapists and murderers who have long eluded detection . 4
Indeed, even dead men have been "accused " through this technology. 5 In addition, database
trawls have considerable potential to solve common property crimes .6 In one case, an
observant police inspector in Finland noticed a dead mosquito in a stolen vehicle. 7 The mosquito's body contained
human blood from its last meal. Testing the blood against Finland's database yielded a DNA profile match, giving the
police a likely suspect.8

At least 10,000 people are wrongfully convicted annually for

crimes they didnt commit the plan stop the exoneration
process and is a helping hand in human rights abuse
[Shaun King An exoneration happens every three days in America. What
this really says about our justice system March 24th 2015]
1,569 men and women in
the United States, most of them African American, have been completely
exonerated after being wrongfully convicted and sent to prison . The number of people
exonerated for wrongful convictions actually broke a record high in 2014 with 125
exonerations, including six people who were actually on death row awaiting
execution. Less than every three days in our country, some man or woman is released back into society after
spending a tragic portion of their life behind bars for a crime they never committed . Few injustices can
compare to the horror of spending one hour in prison for something you didn't do.
According to the National Registry of Exonerations at the University of Michigan,

Ricky Jackson of Ohio spent 341,640 hours, or 39 years, behind bars before he was exonerated. Just a teenager
when he was convicted, he was nearly a senior citizen when he was released. Jonathan Fleming was serving the
25th year of a 25-year sentence when he was finally exonerated after a wrongful conviction. Glenn Ford, on death
row for 30 years in Louisiana, was 64 years old when he was released and was exonerated. Stricken with lung

that nearly 10,000 people

are likely to be wrongfully convicted for serious crimes annually . Another study estimates
that as many as 340 people are likely to have been executed in the United States
before they were properly exonerated. This is a travesty. Anyone who says otherwise is sick.
cancer, he was only expected to live a few more months. One study determined

Jump below the fold for more. But the conversation should not end at our conclusion that these wrongful convictions
are a travesty. It appears, though, that an entire section of America refuses to believe that police or prosecutors can
ever do any wrong at all. Except they do. Often. Detective Louis Scarcella of the NYPD is accused of framing
suspects, forcing fake confessions, and using the same single eyewitness for multiple murders. Many men who were
wrongfully convicted under his watch have recently been exonerated and 50 of his cases are under review. Chicago

has now been called the "false confession capital" as more and more details are uncovered on how the city's police
officers are torturing men and women to confess to crimes they didn't commit. They were so good at it, in fact, that
Detective Richard Zuley was brought from Chicago to Guantanamo Bay to directly oversee one of the most brutal
torturing operation in modern history. The prosecutor of Glenn Ford, shipped off to death row at Angola State Prison
in Louisiana in 1984, now openly admits that he was "sick ... arrogant, judgemental, narcissistic and very full of
myself" when he sought the wrongful conviction of Ford, who spent 30 years of his life in one of the most brutal
prisons in the world. Four police officers in Fort Lauderdale, Florida, were just caught sending texts to one another
about "killing nigg*rs" and giving them the "early death penalty." This is not okay. It's wrong. Our justice system is
altogether broken. This brokenness, though, must not be understood in some abstract way. It's broken because the
people leading it are often sick, disturbed racists who care very little for those on the receiving end of their
sickness. It's not good enough to simply give wrongfully convicted men an insufficient check and an apology.

We

must repair the broken system so these instances go away for good.

Genetic surveillance stops crime

Lindey 11 (Brooke, reporter for CTV news Vancouver, Could a new technique
catch a serial rapist in B.C.? http://bc.ctvnews.ca/could-a-new-technique-catch-aserial-rapist-in-b-c-1.597435 1/18/11 JM)
A contentious DNA analysis that helped snag one of America's most notorious
suspected murderers could be used in the hunt for a serial rapist in Vancouver,
according to a lawyer who pushed to have it approved south of the border. DNA
evidence has linked a single unknown man to three sex assaults in Vancouver, and
police say he could be responsible for five more unsolved cases. But the genetic
evidence taken at the scene of the assaults doesn't match anyone in the national
DNA databank, and police have been left to plead with the public for tips. Vancouver
police made a public appeal for help on Thursday, but five days later, there are no
new leads. In the U.K. and some parts of the U.S., police would have had
one more option before hitting a dead end. That's because laws in those
places allow investigators to search for partial matches in the offender DNA
databank and identify possible family members of unknown criminals. "Using
familial DNA searching, you can continue to try and solve a case when those other
steps have failed," said Rockne Harmon, a retired California deputy district attorney
and one of the technique's biggest proponents. "We do know that crime seems to
run in families for complicated reasons." Privacy advocates have lobbied against
allowing the new technique in Canada, arguing that it submits relatives of convicted
offenders to unfair genetic surveillance. But thanks to familial DNA searching, Los
Angeles police were able to identify Lonnie Franklin Jr. as a suspect in the brutal
"Grim Sleeper" killings -- the murders of at least 10 people over 25 years. When
investigators compared genetic samples taken from the scenes of the Grim Sleeper
murders with California's offender DNA database, there were no exact hits, but
investigators were able to create a list of about 150 close matches -- potential
family members of the vicious murderer. Analysts then compared the Y sex
chromosomes from those 150 people with the Grim Sleeper's, and found a match so
close, the offender had to be either the father or the son of the serial killer. As it
turns out, Franklin's son had recently been arrested, and swabbed for DNA. When
police followed the elder Franklin to a restaurant, they were able to take a sample
from his cup, and found a perfect match for the Grim Sleeper's DNA. Familial DNA
searching is currently not permitted in Canada, and in the U.S., only California and
Colorado allow it, although Virginia appears to be on the brink of approval. Harmon
was the driving force behind California's decision to allow the unique searching

technique, and he says that Canada should consider it, too. "Why would you have
a law that would keep you from something that can solve crimes?" he told
ctvbc.ca. "It'll help make the world a safer place."

Solvency Circumvention
Federal oversight cant minimize health surveillance- the
biggest offenders are private businesses that use big data
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 13-16
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
Big data is so named because of its unprecedented volume and for its complexity,
diversity, and timeliness. Big data refers not only to the collection and storage of
extremely large data sets but also the data mining and predictive analytic routines
that process the data, the latter being understood as [t]echnology that learns from
experience (data) to predict the future behavior of individuals in order to drive
better decisions.74 Essentially big data is the latest type of business intelligence
(BI), or, to frame it slightly differently, the latest BI analytics are what extract value
from big data. 75 Not surprisingly, MBA-speak business jargon dominates the space.
Thus, according to Gartner, Inc., Big data is high-volume, -velocity and -variety
information assets (sic) that demand (sic) cost-effective, innovative forms of
information processing for enhanced insight and decision making.76 It is important
not to underestimate one of these three propertieshigh-variety. Big data does not
use structured databases (or at least is not as reliant on them as previous
generation systems such as credit reporting) but is capable of absorbing highvariety data. Data sources (or data pools) continually change and expand; yet big
data is seems adept at digesting them. As described in a recent report by the
Centre For Information Policy Leadership, While traditionally analytics has been used
to find answers to predetermined questions, its application to big data enables
exploration of information to see what knowledge may be derived from it, and to
identify connections and relationships that are unexpected or were previously
unknowable. When organisations employ analytics to explore datas potential for
one use, other possible uses that may not have been previously considered often
are revealed. Big datas potential to yield unanticipated insights, the dramatically
low cost of information storage and the rapidly advancing power of algorithms have
shifted organisations priorities to collecting and harnessing as much data as
possible and then attempting to make sense of it.77 The analytics of big data seek
to predict the behavior not only of populations or cohorts but also of individuals. In
Predictive Analytics: The Power to Predict Who Will Click, Buy, Lie, or Die, computer
scientist Eric Siegel explained the distinction as follows: Forecasting makes
aggregate predictions on a macroscopic level. How will the economy fare? Which
presidential candidate will win more votes in Ohio? Whereas forecasting estimates
the total number of ice cream cones to be purchased next month in Nebraska,
predictive technology tells you which individual Nebraskans are most likely to be
seen with cone in hand.78 In the context of health information the business
intelligence grail is to identify and exploit a patients differential health status.
According to Neil Biehn with such segmentation organizations can more easily

identify anomalous buying behavior and make intelligent product and offer
recommendations that are statistically more likely to be purchased. Biehn
continues, If two customers are alike but not buying the same products, the data
analysis can advise which opportunities the sales team might be missing,
concluding [t]his is the type of Big Data viability that moves the needle in the real
world.79 The privacy implications of individuated big data analysis are profound.
Beyond the expropriation or using objections to such data collection and
processing, such as Commissioner Brills critique quoted at the beginning of this
article,80 the computer modeling of predictive analytics predicts a world of
dehumanizing data determinism, described by FTC Chairwoman Edith
Ramirez as the judgment of persons not because of what theyve done, or what
they will do in the future, but because inferences or correlations drawn by
algorithms suggest they may behave in ways that make them poor credit or
insurance risks, unsuitable candidates for employment or admission to schools or
other institutions, or unlikely to carry out certain functions.81 Finally, there is the
Doomsday scenarioa big data breach. The industrial scale data-warehousing
model is the antithesis of the silo model of data storage used in the preinformation age. The lack of data liquidity (with all of its informational
disadvantages) inherent in that model meant that there was little profit or harm in
an isolated security breach. The opposite is true with big data storage. However,
there are reports that big data brokers are not immune from the same security
breaches that are plaguing other businesses.82

Individuals willingly give up their health records by using nonprotected mediums- means state legislation cant solve
Terry 14 (Nicolas P. Terry. Big Data Proxies and Health Privacy Exceptionalism.
2014. P. 19-21
https://www.ftc.gov/system/files/documents/public_comments/2014/01/0000489091.pdf)//EMerz
Ironically one of the greatest threats to an individuals health privacy is . . .
the individual. One of the first examples of theretofore HIPAA-protected data
migrating to HIPAA-free space was during President George W. Bushs administration
at a time when the slowing of the administrations provider-curated EMR program
coincided with the launching of PHR platforms by Google and Microsoft.96 As a
result the HITECH Act architects attempted to protect for the first time health data
that migrated from a protected to an unprotected (or marginally protected) zone.
However, they chose to do so with a swiftly outmoded, downstream breach
notification model.97 In the interim different (and unregulated) technologies have
emerged that encourage patient rather than provider curation of health
data. The most obvious example is the federal governments Blue Button
technology that allows patients to download their records to their own devices. The
Blue Button approach to patient access and hence control of their health data has
become a rallying cry for many (if not all) patient privacy advocatesand has been
encouraged by President Obamas administration. 101 Indeed, then ONC National
Coordinator Farzad Mostashari announced a Blue Button Mash-Up challenge to build
software for patients designed to combine their downloaded Blue Button

information with other data sources.102 At root such patient curation of health data
bespeaks autonomy and is symbolic of patient ownership of the data. However, it
fails to take into account one practical limitationthe canonical version of the
record will remain in the providers control and one legal limitation that only the
provider-curated copy is protected by HIPAA-HITECH. In contrast, the patientcurated copy attracts little meaningful privacy protection. Well-meaning privacy
advocates should think carefully before promoting this autonomy-friendly control
model until data protection laws (not to mention patient education as to good data
practices) catch up with patient curated data. A similarly dichotomous result is likely
as the medically quantified self develops. The quantified-self movement
concentrates on personal collection and curation of inputs and performance. 103
Obviously, health, wellness and medically inflected data will likely comprise a large
proportion of such data. A similar, if less formal, scenario is emerging around health
and wellness apps on smartphones and connected domestic appliances such as
scales and blood pressure cuffs. 104 Smartphones are crammed with sensors for
location, orientation, sound and pictures that add richness to data collection.105
And there is ongoing and explosive growth in the medical apps space that seeks to
leverage such sensors. More and more we are going to demand control of
information about ourselves and generate medically inflected and core
health data about ourselves. These processes will in most cases lead to
medically inflected data that exists outside of the HIPAA-HITECH protected zone.

Circumvention inevitable- police legally collect DNA all the

time
Scherr 13 (Albert E. Scherr. Professor of Law, University of New Hampshire.
Genetic Privacy & the Fourth Amendment: Unregulated Surreptitious DNA
Harvesting. 2013. P. 448-449. http://georgialawreview.org/wpcontent/uploads/2015/02/Download-PDF-V47-I2-Scherr.pdf)//EMerz
So why does the law regard genetic privacy issues in criminal and civil contexts
differently? Why do surreptitious-DNA harvesting practices by private parties get
appreciably more legal scrutiny than such practices by police? One broad-brush
answer is that society places more value on the public-safety goal of solving crimes
than on the needs of amateur genealogists, divorce lawyers, and genetic
researchers. That broad-brush answer is unsatisfactory. Current Fourth Amendment
jurisprudence on surreptitious harvesting creates an all-or-nothing dynamic. If a
putative suspectone for whom the police have some reasonable suspicion but not
enough for a search warrantabandons his DNA in a public place, the police can do
with the sample what they will, without limitation. The police can do the same for a
suspect for whom they have only a hunch. They can also do the same for someone
for whom they have no suspicion, including a victim or a witness. They can do so
without a suspects, a witnesss, or a victims consent or knowledge. If surreptitious
DNA harvesting is not a search under the Fourth Amendment, the police can do
whatever they want with anyones DNA.

Solvency - Alt Causes

Too many alt causes
Outdated legal codes
THEIR AUTHOR Gostin, an internationally recognized scholar in law and public
health, professor of Law at Georgetown University; Professor of Public Health at the
Johns Hopkins University; and the Director of the Center for Law & the Publics
Health at Johns Hopkins and Georgetown Universities, November 2001 (Lawrence,
Public Health Law In An Age Of Terrorism: Rethinking Individual Rights And
Common Goods, published on HealthAffairs vol 21 no. 6)//roetlin
public health law infrastructure is equally deficient . The law establishes the mission,
functions, and powers of public health agencies. Yet public health laws are highly antiquated, after
many decades of neglect. Very little consideration has been given to modernizing
these laws to reflect advances in public health practice and constitutional law. Reform of public health
law is essential to ensure that public health agencies have clear missions and functions, stable sources of
The

financing, adequate powers to avert or manage health threats, and restraints on powers to maintain respect for
personal rights and liberties.

Underfunding and infrastructure

THEIR AUTHOR Gostin, an internationally recognized scholar in law and public
health, professor of Law at Georgetown University; Professor of Public Health at the
Johns Hopkins University; and the Director of the Center for Law & the Publics
Health at Johns Hopkins and Georgetown Universities, November 2001 (Lawrence,
Public Health Law In An Age Of Terrorism: Rethinking Individual Rights And
Common Goods, published on HealthAffairs vol 21 no. 6)//roetlin
As a result of chronic underspending, the public health infrastructure is
badly deteriorated.2 Public health agencies lack the capacity to conduct essential
public health services at a level of performance that matches the constantly
evolving threats to the health of the public . Critical components of that infrastructure include a welltrained workforce, electronic information and communications systems, rapid disease surveillance and reporting,
laboratory capacity, and emergency response capability.

Faulty allocations and income inequality

THEIR AUTHOR Gostin, an internationally recognized scholar in law and public
health, professor of Law at Georgetown University; Professor of Public Health at the
Johns Hopkins University; and the Director of the Center for Law & the Publics
Health at Johns Hopkins and Georgetown Universities, November 2001 (Lawrence,
Public Health Law In An Age Of Terrorism: Rethinking Individual Rights And
Common Goods, published on HealthAffairs vol 21 no. 6)//roetlin
In this civil and property rights society, the tone has been distinctly antigovernment .
The State has been perceived as inefficient, bureaucratic, and burdensome. Citizens have opposed
taxation and broad health and welfare spending as well as oppressive regulation .
From a funding perspective, this has meant that health dollars have been allocated primarily to

advanced biotechnology and health care, which serve the needs of individual
patients, particularly those who can afford private health insurance. Funding for
traditional prevention and population-based services represents only a small fraction of
health spending, estimated at around 1 percent at the state level and less than 5 percent at
the federal level.1

Solvency A2 Judicial Modelling

No court influence now
Liptac 08, (Adam, New York Times US, U.S. Court Is Now Guiding Fewer
Nations, September 17, 2008,
http://www.nytimes.com/2008/09/18/us/18legal.html?pagewanted=all)//IB
American legal influence is waning. Even as a debate continues in the court over whether its
decisions should ever cite foreign law, a diminishing number of foreign courts seem to pay
attention to the writings of American justices. One of our great exports used to be constitutional
But now

law, said Anne-Marie Slaughter, the dean of the Woodrow Wilson School of Public and International Affairs at
Princeton. We

are losing one of the greatest bully pulpits we have ever had . From 1990
Supreme Court cited decisions of the United States
Supreme Court about a dozen times a year, an analysis by The New York Times found. In the six
years since, the annual citation rate has fallen by half , to about six. Australian state
supreme courts cited American decisions 208 times in 1995 , according to a recent study by
Russell Smyth, an Australian economist. By 2005, the number had fallen to 72. The story is
similar around the globe, legal experts say, particularly in cases involving human rights. These days,
foreign courts in developed democracies often cite the rulings of the European Court of
Human Rights in cases concerning equality, liberty and prohibitions against cruel treatment, said Harold
Hongju Koh, the dean of the Yale Law School. In those areas, Dean Koh said, they tend not to look to the
rulings of the U.S. Supreme Court. The rise of new and sophisticated constitutional courts elsewhere is
one reason for the Supreme Courts fading influence, legal experts said. The new courts are,
moreover, generally more liberal than the Rehnquist and Roberts courts and for that
reason more inclined to cite one another. Another reason is the diminished reputation of the United
States in some parts of the world, which experts here and abroad said is in part a consequence of the
Bush administrations unpopularity around the world. Foreign courts are less apt to justify their
decisions with citations to cases from a nation unpopular with their domestic
audience. Its not surprising, given our foreign policy in the last decade or so, that
American influence should be declining, said Thomas Ginsburg, who teaches comparative and
international law at the University of Chicago. Aversion to Foreign Law The adamant opposition of some
Supreme Court justices to the citation of foreign law in their own opinions also plays a
role, some foreign judges say. Most justices of the United States Supreme Court do not cite foreign
case law in their judgments, Aharon Barak, then the chief justice of the Supreme Court of Israel, wrote in
the Harvard Law Review in 2002. They fail to make use of an important source of inspiration, one
through 2002, for instance, the Canadian

that enriches legal thinking, makes law more creative, and strengthens the democratic ties and foundations of
different legal systems.

Surveillance K Links
Trying to curtail the medical surveillance state starts from the
wrong positionignoring the interaction between the self and
the collective body leads to reinforcing the biopolitics of the
state and recreates the impacts of the 1AC through risk
calculations
Baur and Olsen 9 (Susanne, professor at the University of Copenhagen, and
Jan, professor at University of Copenhagen, Observing the Others, Watching Over
Oneself: themes of medical surveillance in society
file:///C:/Users/Jessi/Downloads/3252-5562-2-PB.pdf 2009 JM)
This paper is an attempt to explore the reconfiguration of space, body and gaze in
recent biomedicine. The constellations of the body and the medical gaze and their
location in space were closely intertwined with specific epistemologies of medical
science and practice at different historical periods. Michel Foucault localized the
birth of the clinic in the spatialization of disease and bodies, which took place with
the structuring of hospitals according to nosological categories (Foucault 1963).
Inspired by Foucaults analyses of the clinical space, David Armstrong coined the
term surveillance medicine as a significant alternative model to hospital
medicine and pathology, which emerged during the 20th century around the
observation of seemingly healthy populations (Armstrong 1995: 393). Medical
thinking in terms of surveillance embraces probabilistic rationality and prediction,
which have continuously proliferated in medical research and in public health, for
instance in early diagnostics or decision-making in the clinic and in preventive
medicine. Drawing on examples from clinical diagnostics on the one hand and
population health surveillance on the other hand, we explore recent
reconfigurations of the clinical gaze in western biomedicine. In these recent forms of
diagnostic monitoring an augmented space of digital visualization and statistical
data, an abundance of numbers and images is created and the clinical gaze is being
delocalized. In large-scale epidemiological studies, health data from whole
populations are used for risk calculations that inform policy making. Both
the body and society are governed by data analyses and numerical profiling;
interventions are made in a rationality of prevention at ever earlier stages. This
paper thus refers to developments that take place within western biomedicine and
are products of the latter; in a global perspective, however, there remains a digital
divide in terms of access and availability of information technologies. Our themes
monitoring the patient-body and population surveillance can be read as
representing both poles of biopower, in the sense the term has been introduced
by Foucault: the gaze is directed both upon the individual body and the self
as well as upon the collective population body. Taking up these two poles of
biopower, we explore the digitized and transparent individual patient body of the
clinic on the one hand and the epidemiological databases originating through public
health surveillance practices on a population scale on the other hand. In doing so,
we pay particular attention to the more distributed forms of contemporary

surveillance, which go beyond the classic spatialization of the body in the clinic and
the accounts of Jeremy Benthams panopticon (Foucault 1975). Drawing on
surveillance studies, we take inspiration in the concept of panopticism and
synopticism, as proposed by Thomas Mathieson (1997). In other words, we are
asking about who is observing and who is being watched. What
constellations between individuals, bodies and data do we encounter in the worlds
of biomedicine and epidemiology? Which specific modes of knowing do such digital
assemblages bring about? What is the location of the body and knowledge on the
body is it still in the macroanatomic body or rather on the hard drive or in
population databases? How do imaging and visualization techniques mediate
medical procedures, clinical and political decision-making? What kinds of body and
control practices do we face with the data avalanches of imaging techniques and
databasing in the health sector? In exploring these questions, we will examine
selected biomedical sites and contexts in which surveillance is at work often as
taken-for granted and widely accepted if not desired practice. By exploring the
effects of surveillance from perspectives situated in the cultural studies of medicine,
this article attempts to expose the digital reconfiguration of the body as object of
medical monitoring and intervention.

Health monitoring relies on statistics that are informed by the

biopolitical statetheir evidence is predicated off of skewed
data epistemes have constructed to support themselves
Baur and Olsen 9 (Susanne, professor at the University of Copenhagen, and
Jan, professor at University of Copenhagen, Observing the Others, Watching Over
Oneself: themes of medical surveillance in society
file:///C:/Users/Jessi/Downloads/3252-5562-2-PB.pdf 2009 JM)
Monitoring population health has a long tradition in demography, government
statistics and social policy; in 18th century political arithmetic, population thinking,
probability theory and the field of political economy were closely entangled
(Desrosires 1998). The production of population data has long been intertwined
with biopolitical frameworks, e.g. of central state governance, life insurance and
actuary reasoning. The panoptic constellation of monitoring and managing a
collective population body continues to play a central role in contemporary
concepts and practices of evaluation and governance. In public health, surveillance,
as defined by Alexander Langmuir, means the continued watchfulness over the
distribution and trends of incidence through the systematic collection, consolidation
and evaluation of morbidity and mortality reports and other relevant data for
purposes of prevention of disease or injury (Langmuir 1992). Epidemiologist Alfredo
Morabia described surveillance as the bedrock of public health (Morabia 2000: 22);
securing generation and access to valid data is critical in epidemiologic research.
Survey and monitoring techniques bring about statistical entities and make them
perceptible; subsequent data visualization works as a tool for inspection of multiple
aspects at a glance, similar to techniques of mapping. A survey is an act of
viewing, examining and inspecting; the term survey originated in 19th century

land surveys and geology (Converse 1987). Different from land surveys for the
mapping of geographical space, the data patterns visualized in epidemiology refer
to multiple levels and diverse contexts. The extent and modalities in which data are
collected has differed between countries; often so-called routine data such as
demographic data on births and deaths (vital statistics) are collected for the entire
population. The Nordic countries maintain central population registries which allow
record linkage between different sectors (for example population registries, social
services and health care data). Health research relies heavily on data from these
routine administrative monitoring techniques as well as on the data recording
systems of health-related registries. Registry research has become a sub-discipline
in epidemiologic research in the Nordic countries (Mortensen 2004). Further, specific
epidemiological studies are usually conducted for representative samples of the
population, for example longitudinal follow-up studies or cross-sectional surveys.
Health surveys among representative or random samples of the population are used
to gain quick comparative snapshots of the populations health. Not only has the
anatomic atlas of the macroanatomical body been replaced by a statistical and
digitized body; at a population level health and disease are documented for
instance in national cancer atlases, as done for example in Denmark since the
1970s. Visual mapping as part of descriptive epidemiology creates new
epistemological infrastructures; the surveillant gaze takes up these new data
patterns as grids of orientation, in which one is able to navigate. More than a
metaphor the visual episteme plays is key to design and display of health statistics.
Alluding to the objectivity effects of photography, Catherine Waldby has described
epidemiological surveillance as an imaging process that is conceived to provide
accurate photographs of population health (Waldby 1996: 99). Graphs, charts and
tables visualise and spatialize data; they mediate research design and risk
communication. While as part of state administrative procedures, routine data are
recorded and stored to evaluate health and disease at the population level, it is also
new forms of accountability that drive the implementation of monitoring and
evidence-based decision-making; these in turn nurture the need for documentation,
visibility and transparency. This data hunger of quality management has
contributed to the vast bureaucracies that accompany medical practice
and health care systems.

The plan fails only questioning broader surveillance

structures solves
Whetton 13 (Suzanne, Lecturer at University of Tasmania, Health
informatics discourses and the use of personal health information:
Which piper, which tune, who pays?, July 2013, University of
Tasmania, http://eprints.utas.edu.au/17110/2/whole-Whetton-thesis.pdf)//JL

The health informatics community has the option of continuing to participate in

discussions within the parameters established by the privacy framework, or it may go beyond
these parameters to challenge the dominant approach to personal health
information management and, in doing so, address issues beyond a private
trouble/public interest level. To adopt this form of critique would mean exploring
alternative approaches to conceptualizing information management issues. It would
mean challenging the representation of the privacy framework as neutral. It would also mean
identifying links between the collection of personal health information and broader social
practices and power relations in Australia. Such a challenge would invoke broader
questions of social control and warn of the dangers of the creeping
surveillance society (Bennett, 2011, p. 485). It would explain this creeping surveillance
society in terms of disciplinary power and control not only of some individuals and groups but of the population
as a whole. The willingness to critique is increasingly imperative as the Australian Government
progresses its plans for an Individual Health Identifier (IHI) and a Personally Controlled Electronic Health Record (PCEHR). As
health information networks expand to intersect with other personal information networks, creating the
potential for new, more widespread and more intrusive forms of surveillance, it becomes even
more imperative that the health informatics community participate in the critical
debate.

Biopolitical disease surveillance sets the stage for the

militarization of health and society culminates in
authoritarianism
Youde 10 (Jeremy Youde is a professor of Political Science at the University of Minnesota Duluth,
BIOPOLITICAL SURVEILLANCE AND PUBLIC HEALTH IN INTERNATIONAL POLITICS p. 31-34)///CW

increased surveillance associated with biopolitics focuses on

overly militarized responses. As we redefine infectious disease as a security threat, critics have warned
that governments may inappropriately rely on traditional security apparatuses to
address the problem. Deudney raised a similar concern with the environment. If environmental degradation
The other major concern about the

is deemed a security threat that concerns national and international stability, it may lead political leaders to call
on military forces to confront the threat. Militaries may be useful for traditional threats, but they may be poorly

Militaries can and do play a

role in biopolitical surveillance . Some of this is concentrated on the members of the armed forces.
Military commanders have an obvious interest in ensuring that their forces are
healthy and able to respond to situations as they arise. The military often creates its own parallel public health
infrastructure specifically for its members. Like any other public health system, the military seeks to monitor,
treat, and prevent illnesses. However, those same capabilities can be extended to monitor
civilian populations. Militaries may have laboratory and diagnostic capabilities beyond those of traditional
equipped to respond to environmental degradation or infectious disease.73

public health organizations. They may also have the logistical and organizational capabilities to facilitate rapid
deployment in epidemic regions and the communication technologies to communicate with WHO officials in a
timely manner.74 Indeed, in developing countries, the military may be the only organization with these

Such an extension of military capabilities into decidedly nonmilitary

realms raises fears of the militarization of society. Chretien et al. suggest that some
governments have essentially turned the provision of public health services and
disease surveillance over to military forces by providing health services for civilians in remote
areas and reporting military surveillance data to the ministry of health.75 This extends the role of the
military into a more prominent place within the domestic arena. The connections between
military forces and public health are not limited to developing countries. Within the United States, much
capabilities.

of the global infectious disease surveillance system is linked to the Department of Defense (DoD). In the 1990s,

the U.S. government established the Global Emerging Infectious Surveillance and Response System (GEIS). The
system set up mobile laboratories that could quickly respond to disease outbreaks around the world. Interestingly,
GEIS comes under the administrative aegis of the DoD, not one of the diplomatic or humanitarian bureaucracies
in the government. Their location in the DoD, as opposed to the United States Agency for International
Development (USAID) or Center for Disease Control (CDC) demonstrates how seriously the United States views the

Surveillance becomes
inextricably linked with the military and the deployment of military
personnel in foreign countries. Fears arise that this could cloud the states response,
leading to rely too heavily on military, as opposed to health, means. It also could
response to infectious disease as a key national security strategy.76

potentially place the military in a strong position for ensuring and regulating the populations health. Pandemic
influenza preparations have further stoked fears about the links between biopolitical surveillance and the role of
the military. In 2005, U.S. President Bush released the document National Strategy for Pandemic Influenza. The
document focuses on preparedness, surveillance, and containment. This strategy calls upon government officials
at the local, state, and federal government to develop mitigation strategies, build greater lines of communication
between officials, and collaborate with international partners. To contain an outbreak, the strategy acknowledges
that military capabilities may be used domestically to provide additional medical facilities and to engage in
infrastructure-sustainment activities.77 Bush expanded upon the militarys potential role during a press
conference. He remarked: If we had an outbreak somewhere in the United States, do we not then quarantine that
part of the country, and how do you then enforce a quarantine? Whenits one thing to shut down airplanes; its
another thing to prevent people from coming in to get exposed to the avian flu. And who best to be able to effect
a quarantine? One option is the use of a military thats able to plan and move.78 Some have seized upon this

governments are using the threat of an infectious

disease outbreak to introduce an overly militaristic response that could border on
martial law. The United States pandemic influenza program specifically carves out a special role for the
potential role for the military as proof that

military in providing medical services, enforcing quarantines, and ensuring continuity of government and
economy. Some critics of this program have argued that it essentially allows for the declaration of martial law.79

military to institute some sort of quarantine, as he suggests the National

would serve only to increase stigmatization and
discrimination. This would drive people further away from medical attention and
Greger argues that using the

Strategy for Pandemic Influenza allows,

exacerbate an epidemic.80 Irwin Redlener, the dean of Columbia Universitys Mailman School of Public Health,
called the militarized aspect of the governments response extraordinarily draconian and equated it with martial
law.81 More bombastically, Michael Osterholm, an advisor to the U.S. government on its pandemic flu
preparations, paints the following doomsday scenario: Border security would be made a priority, especially to
protect potential supplies of pandemic-specific vaccines from nearby desperate countries. Military leaders would
have to develop strategies to defend the country and also protect against domestic insurgency with armed forces
that would likely be compromised by the disease.82 He goes on to discuss the fallout from the governments
failure to properly securitize pandemic influenza: Someday, after the next pandemic has come and gone, a
commission much like the 9/11 Commission will be charged with determining how well government, business, and
public health leaders prepared the world for the catastrophe when they had clear warning. What will be the
verdict?83 Osterholms prognostication envisions widespread looting and the need for roaming militias to ensure
access to drug supplies as he envisions millions of people dying. He speaks strongly about the need to protect our
borders to prevent people from coming to the United States to get Americas drugs. This also suggests that
pharmaceutical manufacturing capabilities may become a national security issue, as could access to antiretroviral
drugs in developing countries. Garrett notes that pharmaceutical patent protections are stoking anti-Western

concerns about the

role of the military in responding to a disease outbreak get to the very
heart of surveillance. Fears have arisen about the potential for overt coercion going hand in
hand with increased government surveillance in public health . Government officials have
sentiments in some countries, threatening to create greater problems.84 These

linked increasing adherence with universal standards embodied within increased health surveillance with a loss of
sovereignty, attempts to weaken the state, and domination by Western states.

***Impact Framing***

No War - General
No risk of global war economic costs, democracy, treaties,
interdependence and multiple other reasons check conflict escalation
[John Aziz, former economics and business editor @ The Week. Don't worry: World
War III will almost certainly never happen 2014]
Next year will be the seventieth anniversary of the end of the last global conflict. There have been points on that timeline such as
the Cuban missile crisis in 1962, and a Soviet computer malfunction in 1983 that erroneously suggested that the U.S. had attacked,
and perhaps even the Kosovo War in 1999 when a global conflict was a real possibility. Yet today in the shadow of a flare up
which some are calling a new Cold War between Russia and the U.S. I believe the threat of World War III has almost faded into
nothingness. That is,

the probability of a world war is the lowest it has been in

decades, and perhaps the lowest it has ever been since the dawn of modernity. This is certainly a view that current data
supports. Steven Pinker's studies into the decline of violence reveal that deaths from war have fallen and fallen since World War II.
But we should not just assume that the past is an accurate guide to the future. Instead, we must look at
the factors which have led to the reduction in war and try to conclude whether the decrease in war is sustainable. So what's
changed? Well, the first big change after the last world war was the arrival of mutually assured destruction.
It's no coincidence that the end of the last global war coincided with the invention of atomic weapons. The possibility of complete
annihilation provided a huge disincentive to launching and expanding total wars . Instead, the
great powers now fight proxy wars like Vietnam and Afghanistan (the 1980 version, that is), rather than letting their rivalries expand
into full-on, globe-spanning struggles against each other. Sure, accidents could happen, but the possibility is incredibly remote. More

nobody in power wants to be the cause of Armageddon. But what about a

non-nuclear global war? Other changes economic and social in nature have made that highly unlikely too. The world
has become much more economically interconnected since the last global war. Economic cooperation
treaties and free trade agreements have intertwined the economies of countries around the
importantly,

world. This has meant there has been a huge rise in the volume of global trade since World War II, and especially since the 1980s.
Today consumer goods like smartphones, laptops, cars, jewelery, food, cosmetics, and medicine are produced on a global level, with
supply-chains criss-crossing the planet. An example: The laptop I am typing this on is the cumulative culmination of thousands of
hours of work, as well as resources and manufacturing processes across the globe. It incorporates metals like tellurium, indium,
cobalt, gallium, and manganese mined in Africa. Neodymium mined in China. Plastics forged out of oil, perhaps from Saudi Arabia, or
Russia, or Venezuela. Aluminum from bauxite, perhaps mined in Brazil. Iron, perhaps mined in Australia. These raw materials are
turned into components memory manufactured in Korea, semiconductors forged in Germany, glass made in the United States.
And it takes gallons and gallons of oil to ship all the resources and components back and forth around the world, until they are finally
assembled in China, and shipped once again around the world to the consumer.

In a global war, global trade becomes a

nightmare. Shipping becomes more expensive due to higher insurance costs, and riskier because it's subject to
seizures, blockades, ship sinkings. Many goods, intermediate components or resources including energy supplies like coal and oil,
components for military hardware, etc, may become temporarily unavailable in certain areas. Sometimes such as occurred in the
Siege of Leningrad during World War II the supply of food can be cut off . This is why countries hold strategic
reserves of things like helium, pork, rare earth metals and oil, coal, and gas. These kinds of breakdowns were troublesome enough in
the economic landscape of the early and mid-20th century, when the last global wars occurred. But in today's ultra-globalized and

economic adaptation even for large countries like Russia and

would be crushing, and huge
numbers of business and livelihoods would be wiped out. In other words, global trade interdependency has
become, to borrow a phrase from finance, too big to fail. It is easy to complain about the reality of big business
influencing or controlling politicians. But big business has just about the most to lose from breakdowns in global trade. A
ultra-specialized economy? The level of

the United States with lots of land and natural resources required to adapt to a world war

practical example: If Russian oligarchs make their money from selling gas and natural resources to Western Europe, and send their
children to schools in Britain and Germany, and lend and borrow money from the West's financial centers, are they going to be
willing to tolerate Vladimir Putin starting a regional war in Eastern Europe (let alone a world war)? Would the Chinese financial
industry be happy to see their multi-trillion dollar investments in dollars and U.S. treasury debt go up in smoke? Of course, world
wars have been waged despite international business interests, but the world today is far more globalized than ever before and wellconnected domestic interests are more dependent on access to global markets, components and resources, or the repayment of
foreign debts. These are huge disincentives to global war. But what of the military-industrial complex? While other businesses might
be hurt due to a breakdown in trade, surely military contractors and weapons manufacturers are happy with war? Not necessarily. As
the last seventy years illustrates, it is perfectly possible for weapons contractors to enjoy the profits from huge military spending
without a global war. And the uncertainty of a breakdown in global trade could hurt weapons contractors just as much as other
industries in terms of losing access to global markets. That means weapons manufacturers may be just as uneasy about the
prospects for large-scale war as other businesses. Other changes have been social in nature. Obviously,

democratic

countries do not tend to go to war with each other, and the spread of liberal democracy is correlated
against the decrease in war around the world. But the spread of internet technology and social media has brought
the world much closer together, too. As late as the last world war, populations were separated from each other by physical distance,
by language barriers, and by lack of mass communication tools. This means that it was easy for war-mongering politicians to sell a
population on the idea that the enemy is evil. It's hard to empathize with people who you only see in slanted government

Today, people from enemy countries can come together in cyberspace and find out that the "enemy"
is not so different, as occurred in the Iran-Israel solidarity movement of 2012. More importantly, violent incidents
and deaths can be broadcast to the world much more easily. Public shock and disgust at the brutal reality of
propaganda reels.

war broadcast over YouTube and Facebook makes it much more difficult for governments to carry out large scale military
aggressions. For example, the Kremlin's own pollster today released a survey showing that 73 percent of Russians disapprove of
Putin's handling of the Ukraine crisis, with only 15 percent of the nation supporting a response to the overthrow of the government
in Kiev. There are, of course, a few countries like North Korea that deny their citizens access to information that might contradict the
government's propaganda line. And sometimes countries ignore mass anti-war protests as occurred prior to the Iraq invasion of

has made it much harder for

war-mongers to go to war. The greatest trend, though, may be that the world as a whole is getting
richer. Fundamentally, wars arise out of one group of people deciding that they want whatever another group has land, tools,
2003 but generally a more connected, open, empathetic and democratic world

resources, money, friends, sexual partners, empire, prestige and deciding to take it by force. Or they arise as a result of grudges
or hatreds from previous wars of the first kind. We don't quite live in a superabundant world yet, but the long march of human
ingenuity is making basic human wants like clothing, water, food, shelter, warmth, entertainment, recreation, and medicine more

This means that countries are less desperate to go to war to seize

incentives for world war are
far lower than they were in previous decades, and the disincentives are growing. The apocalyptic visions of a
ubiquitous throughout the world.

other people's stuff. But the tendency toward inertia is strong. It is clear at least that the

new world war between nations or empires that three generations of children have been raised into continue to diminish.

Empirics prove that mutually assured destruction prevents war

because all actors are rational and nuclear war is
fundamentally unwinnable
Tepperman 9 (Jonathan Tepperman is an editor, writer, and analyst working on international affairs. He
was appointed Managing Editor of Foreign Affairsthe magazine published by the New Yorkbased Council on
Foreign Relationsin February 2011. Tepperman has a BA in English Literature from Yale University and law
degrees from Oxford and NYU. He is Vice Chairman of the Halifax International Security Forum and a Fellow of the
New York Institute of Humanities. How Nuclear Weapons Can Keep You Safe 8/28/9
http://www.newsweek.com/how-nuclear-weapons-can-keep-you-safe-78907)///CW
The argument that nuclear weapons can be agents of peace as well as destruction rests on two deceptively simple

nuclear weapons have not been used since 1945 . Second, there's never
been a nuclear, or even a nonnuclear, war between two states that possess them .
observations. First,

Just stop for a second and think about that: it's hard to overstate how remarkable it is, especially given the singular
viciousness of the 20th century. As Kenneth Waltz, the leading "nuclear optimist" and a professor emeritus of
political science at UC Berkeley puts it, "We now have 64 years of experience since Hiroshima. It's striking and
against all historical precedent that for that substantial period, there has not been any war among nuclear states."
To understand whyand why the

next 64 years are likely to play out the same way you need
all states are rational on some basic level . Their leaders may be stupid,
petty, venal, even evil, but they tend to do things only when they're pretty sure they can
get away with them. Take war: a country will start a fight only when it's almost certain it can get what it
wants at an acceptable price. Not even Hitler or Saddam waged wars they didn't think they
could win. The problem historically has been that leaders often make the wrong gamble and underestimate the
other sideand millions of innocents pay the price. Nuclear weapons change all that by making the
costs of war obvious, inevitable, and unacceptable . Suddenly, when both sides have the ability to
turn the other to ashes with the push of a buttonand everybody knows itthe basic math shifts. Even the
craziest tin-pot dictator is forced to accept that war with a nuclear state is
unwinnable and thus not worth the effort. As Waltz puts it, "Why fight if you can't win and might lose
everything?" Why indeed? The iron logic of deterrence and mutually assured destruction is so
compelling, it's led to what's known as the nuclear peace : the virtually unprecedented stretch since
to start by recognizing that

the end of World War II in which all the world's major powers have avoided coming to blows. They did fight proxy
wars, ranging from Korea to Vietnam to Angola to Latin America. But these never matched the furious destruction of
full-on, great-power war (World War II alone was responsible for some 50 million to 70 million deaths). And since the
end of the Cold War, such bloodshed has declined precipitously. Meanwhile, the nuclear powers have scrupulously
avoided direct combat, and there's very good reason to think they always will. There have been some near misses,
but a close look at these cases is fundamentally reassuringbecause in each instance, very different leaders all

For 13
days in October 1962, the United States and the Soviet Union each threatened the other with
destruction. But both countries soon stepped back from the brink when they recognized that a
came to the same safe conclusion. Take the mother of all nuclear standoffs: the Cuban missile crisis.

war would have meant curtains for everyone. As important as the fact that they did is the reason why: Soviet leader
Nikita Khrushchev's aide Fyodor Burlatsky said later on, "It is impossible to win a nuclear war, and both sides

nucleararmed enemies slide toward war, then pull back, always for the same reasons . The
best recent example is India and Pakistan, which fought three bloody wars after independence
before acquiring their own nukes in 1998. Getting their hands on weapons of mass destruction didn't do
anything to lessen their animosity. But it did dramatically mellow their behavior. Since acquiring atomic
weapons, the two sides have never fought another war , despite severe provocations (like
realized that, maybe for the first time." The record since then shows the same pattern repeating:

Pakistani-based terrorist attacks on India in 2001 and 2008). They have skirmished once. But during that flare-up, in
Kashmir in 1999, both countries were careful to keep the fighting limited and to avoid threatening the other's vital
interests. Sumit Ganguly, an Indiana University professor and coauthor of the forthcoming India, Pakistan, and the
Bomb, has found that on both sides, officials' thinking was strikingly similar to that of the Russians and Americans in
1962. The prospect of war brought Delhi and Islamabad face to face with a nuclear holocaust, and leaders in each
country did what they had to do to avoid it.

No War Nuclear Winter

Nuke war is unlikely conventional weapons are prioritized and there is no impact
to nuclear winter
Brian Dunning (co-founded and was chief technology officer for Buylink,
technical editor for FileMaker Advisor Magazine, hosted and produced Skeptoid:
Critical Analysis of Pop Phenomenon, winner of the 2010 Parsec Award for "Best Fact
Behind the Fiction Podcast".[14] In August 2010 he received an award recognizing
his contributions in the skeptical field from the Independent Investigations Group
(IIG) during its 10th Anniversary Gala) 2011 Nuclear War and Nuclear Winter
http://skeptoid.com/episodes/4244
Other cataclysmic events have proven that the nuclear winter scenario is not at all far-fetched. The eruption of

Mt. Pinatubo in the Philippines, also in 1991, threw some 17 million tons of
particulates into the upper atmosphere that caused global temperatures to drop by about a
degree for several months. Sunlight dropped by 10%. This temperature drop did not,
however, have any long-term effect on agriculture. Pinatubo was only a blip compared the the K-T
extinction event of some 65 million years ago, when a theorized asteroid hit us with one hundred million megatons
of destructive force, lighting virtually the entire world on fire. The evidence of this is called the K-T boundary, a layer
of clay found all around the world. Sunlight was reduced by 10-20% for ten years, which caused a massive
cascading extinction of species from plants to herbivores to carnivores.

But we shouldn't expect

anything like this to happen from a nuclear war . Times continue to change, including the nature of
warfare. Nations no longer stockpile the megaton class weapons popular in the 1950s and
1960s; typical yields now are a fraction of a megaton . The United States' conventional
capability is now so good that it can effectively destroy an entire nation's
ability to wage large-scale war overnight, using only conventional weapons. But that doesn't mean
the nuclear forces are no longer needed. Should a superpower strike first against the United States with nuclear
weapons, the response would more than likely be nuclear, bringing Mutually Assured Destruction into play. But what
about a small nation striking first? What about nukes in the trunks of cars parked in major cities? In the modern era,
it's much less clear that any superpower would necessarily have anyone to shoot back at. And so, while the nuclear
winter scenario is a good prediction of the effects of a worst-case scenario, when all the variables are at their least
favorable, the strongest probabilities favor a much less catastrophic nuclear autumn ;
and even those effects depend strongly on variables like whether the war happens during the growing season. A
bomb in Los Angeles might result in history's worst firestorm, while a bomb in the mountains of Pakistan might
create no fires at all. The simple fact is that

there are too many unpredictable variables to know

what kind of climate effects the smoke following nuclear fires will produce, until it actually happens. Obviously
we're all very mindful of the many terrible implications of nuclear combat, and if it ever happens, the prospect of a
nuclear autumn will likely be among the least of our concerns. The physicist Freeman Dyson perhaps described it
best when he said "(TTAPS is) an absolutely atrocious piece of science, but I quite despair of setting the public
record straight... Who wants to be accused of being in favor of nuclear war?"

Nuclear winter cant be proventheir studies are politically

biased
AIP (American Institute of Physics) 2011 Wintry Doom
https://www.aip.org/history/climate/Winter.htm
Atmospheric scientists were well-placed to take up the question of smoke from a
nuclear war. Measurements like Crutzen's of the effects of soot and the like had greatly advanced since the
1975 study. Richard Turco and others, working on the dinosaur extinction problem, had developed a computer
model of a haze-filled atmosphere, and it had occurred to them that dust lofted by the explosions of a nuclear world
war might have effects comparable to the dust from an asteroid impact. Meanwhile the surprising observation that

a giant dust storm was cooling the atmosphere of Mars had inspired two more scientists, James Pollack and Brian
Toon, into new calculations of dust effects. This led them into work with Carl Sagan on how the aerosols emitted by

scientists joined forces to calculate the

consequences of an exchange of hydrogen bomb s. Their ominous conclusion was that
the sooty smoke from burning cities could bring on a "nuclear winter " months or even
years of cold so severe it would gravely endanger living creatures .(8) The scientists did this
work mainly for public consumption. When they announced their results in 1983, it
was with the explicit aim of promoting international arms control . Surely the likelihood that
volcanic eruptions could affect climate. Now these scattered

all-out nuclear war was literally suicidal would persuade nations to reduce their arsenals? As a side effect, the

computer
models were so simplified, and the data on smoke and other aerosols were still so poo r,
that the scientists could say nothing for certain . Critics, mostly people opposed to nuclear
disarmament, quickly pointed out the deficiencies. In the mid 1980s, detailed studies confirmed that a
nuclear war would probably alter global climate temporarily. But as Schneider and a
coauthor explained in a widely read article, it was not likely to bring an apocalyptic winter, but it
studies helped to improve scientific understanding of how aerosols could affect climate.(9) The

would bring a damaging "nuclear fall." (According to more recent research, smoke following even a limited, regional
war would probably dim sunlight enough to kill many more people through starvation than would die directly under
the bombs.)(10)

No War - A2 Irrational Actors

Even the wildest leaders are deterable if Mao and Stalin
didnt start a nuclear war then nobody will
Tepperman 9 (Jonathan Tepperman is an editor, writer, and analyst working on international affairs. He
was appointed Managing Editor of Foreign Affairsthe magazine published by the New Yorkbased Council on
Foreign Relationsin February 2011. Tepperman has a BA in English Literature from Yale University and law
degrees from Oxford and NYU. He is Vice Chairman of the Halifax International Security Forum and a Fellow of the
New York Institute of Humanities. How Nuclear Weapons Can Keep You Safe 8/28/9
http://www.newsweek.com/how-nuclear-weapons-can-keep-you-safe-78907)///CW

Nuclear pessimistsand there are manyinsist that even if this pattern has held in the past, it's crazy to
rely on it in the future, for several reasons. The first is that today's nuclear wannabes are so
completely unhinged, you'd be mad to trust them with a bomb . Take the sybaritic Kim
Jong Il, who's never missed a chance to demonstrate his battiness, or Mahmoud Ahmadinejad, who has
denied the Holocaust and promised the destruction of Israel, and who, according to some respected Middle East
scholars, runs a messianic martyrdom cult that would welcome nuclear obliteration. These regimes are the ultimate

the thinking goesand there's no deterring rogues. But are Kim and
Ahmadinejad really scarier and crazier than were Stalin and Mao? It might look that way
rogues,

from Seoul or Tel Aviv, but history says otherwise. Khrushchev, remember, threatened to "bury" the United States,
and in 1957, Mao blithely declared that a nuclear war with America wouldn't be so bad because even "if half of
mankind died the whole world would become socialist." Pyongyang and Tehran support terrorismbut so did
Moscow and Beijing. And as for seeming suicidal, Michael Desch of the University of Notre Dame points out that
Stalin and Mao are the real record holders here: both were responsible for the deaths of some 20 million of their

Yet when push came to shove, their regimes balked at nuclear suicide,
and so would today's international bogeymen . For all of Ahmadinejad's antics, his power is limited,
and the clerical regime has always proved rational and pragmatic when its life is on the line. Revolutionary Iran
has never started a war, has done deals with both Washington and Jerusalem, and sued for peace in its war
with Iraq (which Saddam started) once it realized it couldn't win. North Korea, meanwhile, is a tiny,
impoverished, family-run country with a history of being invaded; it s overwhelming preoccupation is
survival, and every time it becomes more belligerent it reverses itself a few months later (witness last week,
own citizens.

when Pyongyang told Seoul and Washington it was ready to return to the bargaining table). These countries may be
brutally oppressive, but

nothing in their behavior suggests they have a death wish .

Yes War - General

Nuclear war is possible India, Pakistan, China, North Korea,
and terrorism
Duz 14 (Sergei Duz is a writer for the Voice of Russia, Nuclear war more likely than ever: threat comes from
South Asia and nuke terrorists 1/2/14 http://sputniknews.com/voiceofrussia/2014_01_02/Nuclear-war-more-likelythan-ever-threat-comes-from-South-Asia-and-nuke-terrorists-1915/)
The main reason for this is the ongoing erosion of the non-proliferation regime, experts say. The Non-Proliferation
Treaty has been continuously bashed as "unfair," but it is in fact the exclusive geopolitical environment and

ensuing nuclear responsibility of a handful of states that has so far kept mankind
away from the total wipeout. The theory of reciprocal deterrence wasnt there all
the time. A long two decades after the A-bomb was invented, the powers who had it in their arsenals thought of
it as fair game, a weapon you could actually use in a conflict, rather than a deterrent. The Cuban Missile
Crisis came as a wakeup call. It brought home the danger of nuclear weapons and led to the nonproliferation regime as conceived by the so-called "nuclear club," which included the Soviet Union, the US,
Britain, France and China. Under the NPT, only countries that made and set off a nuclear bomb prior to January 1,
1967 were granted the status of a nuclear power. Washington, London and Moscow were the first to sign the treaty
in 1968, with Paris and Beijing committing themselves to it years later. But all of the signatories abided by the
rules. Those times have passed. NPT controls have become so loose and new nuclear powers so
numerous, theres no counting them anymore. India, Pakistan, Israel and North Korea have never even applied for
"nuclear club" membership. On the contrary, they created their own shadow club with no rules. The official club
with all its nukes poses less threat to the human race than this bunch of neophytes. Volatility has spread,
though South Asia plays a separate role in it. "Some South Asian countries have a full arsenal of nukes," says Pyotr
Topychkanov, a senior researcher at the International Security Center of the Institute of World Economy and
International Relations at the Russian Academy of Sciences. "They have enough nuclear warheads and vehicles.
They have only one equal in the Middle East, which is Israel. Iran has no nuclear weapons yet." "The same is true

North Korea, which has weapon-grade fissile nuclear materials. They have built and tested explosive
countries that really cause
concern are India, Pakistan and China. China and Pakistan are longtime partners, including their
of

devices, but its still a long way to fully-fledged nukes for them." "The

nuclear agenda. India borders on China and Pakistan and is certainly aware of this partnership. It doesnt have faith
in either. Were a conflict to spark off, it would be trilateral and include not only India and Pakistan, but India,
Pakistan and China." About 30 to 40 countries are on their way towards nuclear status. Many of them are inches
away, like Germany, Japan and Canada, who could have had an A-bomb long ago but simply didnt wish to. The
Sunni Saudi Arabia has hinted it will make a bomb the moment the Shiite Iran lays its hands on one. The principle
of uncontrolled nuclear proliferation was formulated back in 1965, when Pakistans foreign chief Zulfikar Ali Bhutto
said: "Theres a Christian bomb, a Jewish bomb and now even a Hindu bomb. Its high time we got a Muslim bomb."

Nuclear terrorism is yet another problem. Terrorists cant make a nuke. But they do know how
to pit countries and eventually provoke them to an inadequate response . Theres no
lacking of short-sighted politicians who can take that last step, for instance Republican Senator Steve Buyer who
nudged the government after 9/11 to nuke Tora Bora caves, instead of sending a task force to Afghanistan. In that

the threat of a full-scale nuclear war has transformed into the menace of a
local nuclear conflict, or even a string of them. You shouldnt be lulled by their seeming locality though,
since a precise nuclear strike will be felt globally, says PIR Center Internet Project Director Andrei Baklitsky. "A
nuclear conflict will have dramatic consequences for all of us, because nuclear
weapons are weapons of mass destruction . They are not selective. A nuclear attack in the Middle
sense,

East would be most tragic, first of all, because of its huge oil fields, and a burning oil field is a big trouble. Secondly,
any strike on the Middle East will skyrocket oil prices across the world and plunge the global economy back into an
even worse economic crisis that before. The consequences of using an A-bomb in an Indo-Pakistani conflict would
be just as grave for these densely populated countries, driving millions of refugees out of their homes and turning
agriculture lands into barren wastes." Unfortunately, the world is home to many paradoxes.

Despite a drop in

amounts of nuclear weapons worldwide, the collapse of the bipolar world has made
the risk of a manmade apocalypse palpable.

Nuclear war is possible accidents and poor risk calculation

Gobry 14 (Pascal-Emmanuel Gobry is a writer and fellow at the Ethics and Public Policy Center. His writing
has appeared at Forbes, The Atlantic, First Things, Commentary Magazine, The Daily Beast, The Federalist, Quartz,
and other places, The end of nuclear deterrence 12/12/14 http://theweek.com/articles/441584/end-nucleardeterrence)///CW

the public mind has pretty much forgotten about the existence of
nuclear weapons, except in the Middle East. And yet, they still exist thousands and
Since the end of the Cold War,

thousands of them, ready to destroy all of human civilization several times over. In response, a new nuclear
disarmament movement is getting underway. This week, I attended the Vienna conference on the Humanitarian
Impact of Nuclear Weapons. (Full disclosure: one of the sponsoring organizations, the Nuclear Threat Initiative,

absolute destruction that

can be caused by nuclear weapons. I came in as a supporter of the doctrine of nuclear deterrence,
invited me all expenses paid.) The conference was striking in describing the utter,

which says that the world's major power-brokers should have nuclear weapons as a way of preventing a new world
war. Advocates of this doctrine point to the Cold War, which never went hot, as a success for deterrence. But
supporters of disarmament including the Red Cross, Pope Francis, and, believe it or not, Henry Kissinger say
that's wrong. These are serious, sober-minded people, not just pie-in-the-sky activists, and they say that

deterrence doesn't work in a multipolar world . Instead, the presence of nuclear weapons
just creates an incentive for more proliferation, as small countries try to one-up their
regional adversaries. What's more and this was the most striking thing at the conference they point to
the risks inherent in the existence of nuclear weapons. History has recorded many close calls in which
nuclear weapons were almost fired. (This, in turn, could have led to a nightmare scenario where an accidental strike

in 2007, six U.S. nuclear warheads went

missing because of a bureaucratic mistake. Then there's the story of the U.S. nuclear missile launch
officer with the drug problem. If this stuff can happen in the U.S., which has the oldest, best-funded, and
most sophisticated nuclear force, one shudders to think about what might be going on in
Russia or Pakistan. Given the way human nature and technology works, advocates warn, it is not a matter of
if, but when a catastrophic accicent will occur . The only solution is simply to ban nuclear weapons for
good. This is where I started rethinking my position. A lot of research has shown that human brains are
wired in such a way that it is very difficult for us to rationally process risks that have
a very low probability but a very high cost. This is essentially what caused the 2008
financial crisis: a very low risk was treated as non-existent, so that when the event occurred, the system
is met with a riposte, triggering Armageddon.) For example,

collapsed. This is exactly the kind of risk we are talking about with nuclear weapons.

Peace isnt inevitable framing it as such increases the risk of

conflict by altering threat perceptions
Jehangir 12 {Hamza, Research Associate on a National Priorities Research
Project (Texas A&M Qatar), Masters of Arts, International Relations and
Globalization (University of Salford, UK) and Bachelor of Social Science, International
Relations (SZABIST, Islamabad, Pakistan), Realism, Liberalism and the Possibilities
of Peace, E-IR, 2/19, http://www.e-ir.info/2012/02/19/realism-liberalism-and-thepossibilities-of-peace/}
When Plato said that only the dead have seen the end of war, his remarks
echoed the history of his time. War was all too often of an occurrence in ancient
Greece, so much so that it mightve been considered a necessity in some cases
but a menace in others. From Platos time to the contemporary period of political
science and international relations theorizing, philosophers and theorists have been

primarily concerned with discovering human nature, its role in social and political
life as well as ways and means of giving meaning to human life. Peace has been
central to this process of inquiry and thought which has led humanity to its present
condition. Theories of peace and war have been central to this cognitive exercise.
However, in the last three centuries, relations between nation-states have taken
the central stage. Theories have come to light which illuminate our understanding
of how nations interact, what causes them to go to war, what motivations might
they have to establish peace and how these causes and motivations might be
managed to reach a stage where peace is not an armistice in a war as Thucydides
(431BCE) stated but a virtue, a state of mind, a disposition for benevolence,
confidence, justice as Baruch Spinoza (1670) considered it to be. Nonetheless,
there are still considerable obstacles that remain in the pursuit of peace.
Theorists have outlined them and literature has shed light on these hurdles whereas
in some cases the pre-occupation with peace has also led towards a more hostile
state of international affairs amongst nations as well as peoples.

Yes great power war realism, fear of worse alts, failed

political processes, violent human nature their evidence
twists definitions to exclude our scenarios
Lyon 14 {Rod, director of the strategy and international program at the Australian
Strategic Policy Institute, executive editor of The Strategist, No, Great Power War
Isnt Obsolete, The Diplomat, 8/22, http://thediplomat.com/2014/08/no-greatpower-war-isnt-obsolete/}
August has seen a wave of reflection on major war. Its a question we seem to revisit every time the key anniversaries of WWI and

pundits are
keen to draw parallels between 1914 and 2014though on its face its not
apparent to me why 2014 should be more like 1914 than 2013. Academic strategists familiar
with their disciplinary history will know that the issue of whether major wars obsolete received a
detailed coverage back in Survival magazine in the late 1990s. To save readers the trouble of digging through their
archives, one contributor, John Mueller, argued that it was obsoletegone the way of slavery and duelingwhile
WWII roll around, but especially this year because its the 100th anniversary of the outbreak of WWI. Some

others wrestled partly over how to define obsolescence and even more over how to define major war. Was the Vietnam War major?

Mandelbaum argued that perhaps major war was just a poor

policy option nowadaysbecause of the steep rise in the costs and the thin rewards for
success. Its intriguing that the question about the obsolescence of war is typically qualified by
the adjective major. No one seems particularly keen to claim that nasty little
Was the Cold War a war? Michael

warsin particular, nasty little wars in faraway placesare obsolete, perhaps because

they

patently arent. From memory, Mueller didnt want to call those conflicts wars, though; he saw those more as
opportunistic predation (Thats the reason the cover of his book, The Remnants of War, features an imagefrom the Balkan

Then 9/11 came along and sideswiped that

whole debate. The nasty little wars of the 1990s didnt stay in faraway places. A
superpower got up and marched off to waralbeit a war against al Qaeda, its supporters, and all its
works. Somewhere along the line the mission became conflated with a host of other problems,
and Washington ended up obsessing about the Global War on Terror for longer than it
conflict in 1991of a thug swigging from a bottle.)

Washingtons behavior at least answered one question related to the

Big One: did great powers still go to war? Yes. Now, the question still unanswered
unanswered since 1945 if you think major war has to be hot; unanswered since 1991, if you think major war can be cold is
whether or not major powers still go to war with each other. Psychologist Steven Pinker has
recently argued that the better angels of our nature are making us turn away from
violence. Im not wholly convinced by his argumentthe better angels of our nature seem
pretty militant to me, and always have been. (See Ephesians, 6:12.) But academic research from
probably should have done. But

a few decades back suggests that great-power wars against each other arent common. Jack Levy in his research on war in the
international system between 1495 and 1975 found only nine of what he would call world warswars where almost all great
powers were involved. Much more commonly, he found interstate wars113 of which engaged a great power. I cite those figures
to underline two points. First, if world wars are rare, maybe we dont need special explanations to say why there hasnt been one

Lets put aside the academic

arguments and look straight at the case that most worries us. Is a great-power war
between the U.S. and China possible ? I think we could answer that question directly: possible, yes; likely, no.
Great powers, especially nuclear-armed ones, dont go to war with each other lightly. But
sometimes wars happen. And they arent accidents. Theyre about
international order. Theyre about, as Raymond Aron said, the life and death of states.
And the principal reason for fighting them is that not doing so looks like a worse
alternative. Moreover, the paths to warincluding rare major-power warare not
reserved solely for conventionally-armed states. Where both powers are nucleararmed we should expect a conflict, even one at the lower rungs of the escalation ladder, to be fought with a high degree of
political control, and an understanding that the objectives of the conflict are limited. Naturally, it would help if
both sides shared a common understanding of where the firebreaks were between
conventional and nuclear conflict, and already had in place a set of crisis-management procedures, but its possible
that neither of those conditions might exist . (Neither would prevent a war, but both would provide
a better sense of the likely escalation dynamics of a particular conflict.) Indeed, its because major war is
possible that we retain such a keen interest in war termination. Unconstrained
escalation doesnt lead to a happy place.
since 1945 (hot) or 1991 (cold). Second, that definition of major war is still a problem.

Yes War A2 Interdependence

Trade doesnt solve war empirics prove it only applies for two
Western nations
Hafner-Burton and Montgomery 12 (Emilie M. Hafner-Burton PhD is a professor at the
University of California, San Diego. Alexander H. Montgomery is Department Chair and Associate Professor of
Political Science at Reed College. He has a B.A. 1996, Physics, University of Chicago. M.A. 1999, Energy and
Resources, University of California at Berkeley. M.A. 2003, Sociology, Stanford University. Ph.D. 2006, Political
Science, Stanford University. He has published articles on dismantling proliferation networks and on the effects of
social networks of international organizations on interstate conflict. His research interests include political
organizations, social networks, weapons of mass disruption and destruction, social studies of technology, and
interstate social relations. War, Trade, and Distrust: Why Trade Agreements Dont Always Keep the Peace)///CW
Many before us have been skeptical of the claim that interdependence promotes peace among states. It is well

international institutions can have adverse effects on conflicts among

member states, mismanaging crisis situations and worsening conflict intensity (Gallarotti, 1991),
understood that

or producing rivalry among states due to their relative social positions (Hafner-Burton and Montgomery, 2006). We
are nevertheless among the first to directly tackle the principal claims supporting the liberal thesis that trade
institutions dampen conflict, and to propose an explanation for why conflict often characterizes outcomes. This is

we observe significant instances of violent conflict4 between PTA

members: the 1990s alone included border clashes between Armenia and Azerbaijan, members of the
important because

Commonwealth of Independent States (CIS); the outbreak of war in the Great Lakes, with foreign involvement in
the Democratic Republic of Congo from Angola, Namibia, Rwanda, Uganda, and Zimbabwe, all members of the
Common Market for Eastern and Southern Africa (COMESA); the Iraqi invasion of Kuwait and violent border
clashes between Egypt and Sudan, all members of the Council of Arab Economic Unity (CAEU); and fighting
between India and Pakistan, members of the South Asian Association for Regional Cooperation (SAARC). North and
South Korea frequently are involved in violent incidents; both are members of the Global System of Trade
Preferences Among Developing Countries (GSTP). A majority of these disputants are also members of the WTO.
Powers contends that in Africa, 16% of all militarized international disputes registered by the Correlates of War

These examples show

clearly that members of the same trade institution can and do conflict, that conflict
often breaks out into violence, and that commerce is frequently not enough to keep
the peace. They stand in sharp contrast to the liberal expectation that trade institutions dampen conflict
through an increase in trust. Trade institutions do increase repeated contact between
members; however, contact does not necessarily build trust or a sense of
community. The lessons of European integration theory suggest that building community through upgrading
data from 1950 to 1992 occurred between PTA members (Powers, 2003, 2004).

the common interest between PTA members requires a minimum level of homogeneity: a pluralist social structure,
a high level of economic and industrial development, and ideological similarity (Haas, 1960). Security communities
are also most likely to develop through economic relations among Western nations, as even the most
institutionalized forms of integration in the developing world cannot be said to create the mutual identification at
the core of the concept (Bearce, 2003). Although evidence suggests that economic integration has led to the
formation of a collective identity and trust among member states of the European Union over time, it is well
understood that democratic features of liberal democracies enable the community in the first place (Russett and

The liberal argument that trade institutions dampen conflict by building

applies to the Western
world of advanced democratic nations. Yet the overwhelming majority of trade institutions manage
trade between partners that include at least one developing or nondemocratic
state, and there is no evidence to show that these institutions build trust over asymmetrical distribution of
Oneal, 2001: 166).

trust among leaders to overcome commitment problems consequently chiefly

gains. Boehmer, Gartzke, and Nordstrom cogently argue that states that belong to many different international
institutions may have a greater number of international interests to competitively defend and a greater array of
opportunities to enact aggressive behavior in defense of those perceived interests (Boehmer et al., 2002). We

trade institutions create and shape states interests,

affecting not only the number of potential issues for dispute, but also establishing
conditions that can lead to distrust. Institutions do this by placing states in social positions of power
extend this argument one step further;

within international relations, which shape expectations for behavior by defining which issues are legitimate for

contestation via military means and enable states to coerce, bribe, reward, or punish each other. We address this
possibility in the next section.

Leaders value short-term benefits of aggression over longterm economic harms economic MAD fails
Solomon 15 (Jon Solomon is a writer at Information Dissemination, a naval information blog. He is citing
Eric Lorber and Jacquelyn Schneider. Eric Lorber is a PhD candidate in Political Science at Duke and a JD candidate
at the University of Pennsylvania Law School. His research focuses on civil-military relations, the use of force
against non-state actors, and the credibility of security guarantees. He has been a fellow at the Duke University
American Grand Strategy Program, worked for the RAND Corporation, and is currently an adjunct staff member at
the Institute for Defense Analyses. Jacquelyn Schneider is a PhD student in Political Science at George Washington
University. Her research focuses on the intersection of national security, technology, and political psychology and
covers a diverse range of topics from intelligence to unmanned technologies to cyber policy. She has won awards
for Best Graduate Student Paper at both the International Studies Association Annual Meeting (Foreign Policy
Section and International Security Studies Section) and the Southwestern Social Sciences Association Annual
Meeting and is a two-time award winner of the AFCEA National Intelligence Writing Contest. She holds a B.A. in
Economics and Political Science from Columbia University and a M.A. in Political Science from Arizona State
University. The Fallacy of Mutually Assured Economic Destruction 4/24/15
http://www.informationdissemination.net/2015/04/the-fallacy-of-mutually-assured.html)///CW

economic
sanctions cannot serve as standalone deterrents against aggression by another state. They noted
In an excellent War on the Rocks article last week, Eric Lorber and Jacquelyn Schneider argued that

in particular how prospect theory and credibility considerations affect the utility of threatened economic
punishments as a deterrent within an opponents decision-making: while these new, sophisticated sanctions

the prospect of such damage may

not deter aggressive actors from taking immediate actions contrary to U.S.
interests. For example, in the case of Russia, while the sanctions have certainly taken a toll, the Russian
often cause medium- and long-term damage to a countrys economy,

economy, when supported by capital reserves, is sufficiently resilient to put off the worst impacts of the sanctions
for a few years. In the short-term, however, Russia has been able to annex Crimea and exercise significant influence

while the prospect of economic damage

may loom down the road, this risk may be insufficient to deter an aggressive actor
from pursuing short-term benefits... Likewise and in the Russia context, given the discord among
in rebel-controlled areas deep in Eastern Ukraine. Thus,

European Union member states about how to respond to additional Russian aggression, Russia may not believe that
the United States and the European Union will impose additional, extremely painful sanctions on the country, and
therefore may not be deterred from engaging in additional destabilizing action in Ukraine. They conclude that a
defender must understand the aggressive actors intentions and motivations in order to determine whether
deterrence by economic punishment is likely to succeed: Policymakers in Washington need to do better than
conclude that these sanctions will cause economic pain, therefore they will deter. Rather, they must analyze
whether the particular sanctions on the table will influence a malicious actors decision-making. In other words,
the opponents leaders political objectives and perceptions of the strategic circumstances (including pressures
stemming from domestic popular passions) are central variables in determining a deterrence policys probable
efficacy. While all deterrence policies face this challenge to some degree, it tends to especially impact deterrence

The amount of threatened pain must significantly exceed the

opponents discomfort with continuing to honor the status quo . A threat of certain national
by punishment.

economic catastrophe is not sufficient if opponents leaders value some other political objective more highly or
suffer from exceptional strategic desperation. Japanese leaders proved that exact point in their decision for war

This does not change if a threatened

economic catastrophe would affect both the aggressor and the defender .
This is the premise behind mutually assured economic destruction, a concept
rooted in the longstanding idea that the likelihood of war between competing states
decreases as their economic interdependence increases . In theory, two competing countries
should be mutually restrained by the risk of devastating their entwined economies. One does not have to
look that far back into history to see the fallacy in this thinking : the aggressors in both
World Wars valued other objects more highly than the prospects of economic
disaster (to the extent economics factored into their calculus at all).
during the late summer and early fall of 1941.

Trade doesnt solve war

Martin et. al. 8 (Phillipe, University of Paris 1 PantheonSorbonne, Paris
School of Economics, and Centre for Economic Policy Research; Thierry MAYER,
University of Paris 1 PantheonSorbonne, Paris School of Economics, CEPII, and
Centre for Economic Policy Research, Mathias THOENIG, University of Geneva and
Paris School of Economics, The Review of Economic Studies 75, 2008)
Does globalization pacify international relations ? The liberal view in political science argues that
increasing trade flows and the spread of free markets and democracy should limit the incentive to use military force
in interstate relations. This vision, which can partly be traced back to Kants Essay on Perpetual Peace (1795), has
been very influential: The main objective of the European trade integration process was to prevent the killing and

however, that during the

18702001 period, the correlation between trade openness and military conflicts is
not a clear cut one. The first era of globalization, at the end of the 19th century, was a period of
rising trade openness and multiple military conflicts, culminating with World War I .
Then, the interwar period was characterized by a simultaneous collapse of world
trade and conflicts. After World War II, world trade increased rapidly , while the number of
conflicts decreased (although the risk of a global conflict was obviously high). There is no
clear evidence that the 1990s, during which trade flows increased dramatically, was
a period of lower prevalence of military conflicts, even taking into account the increase in the number
destruction of the two World Wars from ever happening again.1 Figure 1 suggests2

of sovereign states.

Yes War A2 Deterrence

Deterrence fails correlation isnt causation and complex
situations mean nuclear war is always possible prefer
magnitude to probability
Pelopidas 15 (Benot Pelopidas is a lecturer (assistant professor with tenure) in international relations at
the University of Bristol (Global Insecurities Center) and an affiliate of the Center for International Security and
Cooperation at Stanford University. He has been awarded two international prizes for his research, from the
International Studies Association and the James Martin Center for Nonproliferation Studies. His research focuses on
the global politics of nuclear vulnerability, cases of near-use of nuclear weapons, and lessons learned from global
nuclear history and French nuclear policies. His is currently completing an edited volume on the experience of the
Cuban missile crisis worldwide as an early set of experiences of global nuclear vulnerability and its implications for
security, responsibility, and alliance dynamics. Challenging the Assumptions of Classical Nuclear Deterrence
Theory: The War That Must Never Be Fought 3/12/15, can be downloaded at
http://www.hoover.org/research/challenging-assumptions-classical-nuclear-deterrence-theory)///CW

We cannot know for sure what caused the absence of great-power wars over the last
seventy years.17 We are left with dueling counterfactuals and the need to bet and trust.18 The opponents of
the goal of a world without nuclear weapons create a false dichotomy between what we know for a fact and what
we hypothesize. On the one hand, they argue, is the hard fact of the nuclear peace; on the other hand are other

nuclear peace is not a fact. It is a hypothesis trying

to link two observable facts: the existence of nuclear weapons in the world since 1945 and the absence
hypotheses or counterfactual reasonings. But the

of war between the United States and the Soviet Union during the same period. The fact is that the idea of the
nuclear peace and competing explanations share the same status : all are hypotheses, requiring a
rerun of the history of the last seventy years without nuclear weapons to see whether war would have broken out.
The nuclear peace hypothesis is no less a counterfactual than its rivals.19 It faces the challenge of proving a

faith in the nuclear peace becomes a bet or a matter of trust.20

complex and tightly coupled systems like nuclear weapons are
doomed to fail eventually, even if the frequency of failure is very low. This is because
their complexity and tight coupling dont allow for anticipating and testing of every
possible failure.21 Given this epistemological challenge, which relies ultimately on
the trust one puts in one potential cause of peace at the expense of the others and on the expected timing of
nuclear versus non-nuclear disasters, at least one question arises: is seventy years a high
enough standard of evidence for us to surrender our fate to nuclear weapons forever?22
negative. In these circumstances,
Moreover, we know that

Multiple factors complicate nuclear deterrence

Lyon 15 (Dr Rod Lyon is a Fellow - International Strategy. Rod was most recently a Senior Analyst with ASPI.
He has previously lectured in International Relations at the University of Queensland where he taught courses on
conflict, international security, and civil-military relations. His research interests focus on a range of problems
associated with global security, nuclear strategy and Australian security. He previously worked in the Strategic
Analysis Branch of the Office of National Assessments between 1985 and 1996. As a Fulbright scholar in 2004, he
was a visiting research fellow at Georgetown University in Washington DC, researching a project on the future of
security partnerships in the post-September 11 environment. He was appointed to the National Consultative
Committee on International Security Issues in April 2005. The New Dilemmas of Nuclear Deterrence 7/3/15
http://thediplomat.com/2015/07/the-new-dilemmas-of-nuclear-deterrence/)///CW
With nuclear modernisation programs under way across a range of countries,

Russia asserting its right to

deploy nuclear weapons in the Crimea , NATO reviewing the role of nuclear weapons in the alliance,
and a recent report in the US arguing for a more versatile arsenal of tactical nuclear
weapons, its clear the worlds revisiting an old problem: how to build effective nuclear deterrence
arrangements. Since the end of the Cold War, thinking about deterrence issues has been mainly confined to the
academic and think-tank world. But policymakers are now having to re-engage with those issues. And the problem

we no longer enjoy the luxury of a bipolar world . Indeed, as Therese Delpech

observed in her RAND monograph Nuclear deterrence in the 21st century, nowadays the actors are more
has a new twist:

diverse, more opaque, and sometimes more reckless . Done properly, deterrence is a contest
in threats and nerve, orto use Thomas Schellings phraseologythe manipulation of risk. (The chapter so titled
in Schellings Arms and influence is a great starting point for anyone wanting to think through the broader
deterrence problem.) That helps explain why some thought the concept ugly. Its hard to make a policy
threatening massive damage to societies and civilians sound noble and aspirational. Still, the bad news is that the
alternatives are worse. And if deterrence is going to remain the dominant approach in nuclear weapon strategy, we
need to fit the strategy to the contemporary geopolitical environment. Historical experience of the deterrence
problem is greatest in relation to two competing superpowers, separated by intercontinental distances, endowed

Weve had
relatively little experience of nuclear deterrence in contests between giants and
midgets (US v North Korea), between established and fast-rising powers (US v China), and
with the resources to manage challenges, and both knowing well the costs of major war.

amongst players in a multipolar system. Even our understanding of the role nuclear deterrence plays in relations

the old
superpower deterrence model might not fit those new challenges well. Indeed, maybe the
between regional rivals (think South Asia) remains under-developed. Its entirely possible that

old model doesnt even fit the USRussian strategic relationship well these days: Russias no longer governed by a
sclerotic CPSU. Some years back INSS Elaine Bunn (now a senior official in the Obama administration) wrote a
paper unpacking the notion of tailored deterrence introduced in the 2006 Quadrennial Defense Review. True,
deterrence has always been characterized by particular strategic wrinkles, but Bunns paper was an attempt to
bring those wrinkles to the fore in relation to the possibility of a nuclear-armed North Korea, Iran, or transnational
terrorist group. Her exploration of three different forms of tailoringtailoring to specific actors and specific
situations; tailoring capabilities; and tailoring communicationshelps to illustrate the growing complexity of the
deterrence challenge. It now seems likely that were headed back into a set of complicated deterrence debates. A

a degree of restraint by a giant

engaged in a conflict with a midgetmight well risk flagging unintended messages
in another. In the giantmidget case, almost any crossing of the nuclear threshold by the
giant risks imposing a set of desperate choices on the midgets leadership , and
strategy that might make sense in one strategic settingfor example,

desperate choices tend not to be good ones. Deterrence in the context of an established power versus a fast-rising

One effect of a deterrence-dominated world is to reward

passivity over initiative. As Schelling notes, in the world of the arthritic, passivity tends to be the default
choice. But fast-rising powers arent arthritic. Turning one aside from a revisionist agenda will
probably be more challenging than deterring another established player. Multipolarity brings its own
wrinkles, including a more mixed set of adversarial relationships, asymmetrical contests, inadvertent
signalling, and third-party exploitation of bilateral rivalries . Capability issues become more
power has a different wrinkle.

vexed: actors require the capabilities to deter and defend against another, but also the residual capabilities to
remain a player in other contests. The pressure must surely be towards larger rather than smaller arsenals. And
reputational issues become more dominant: just as Margaret Thatcher fought the Falklands War in part to show the
Soviet Union that the West wouldnt buckle in the face of force, so too players in a multipolar nuclear world will
want to show resolve in one contest because of its implications for others. Finally, and perhaps most
controversially,

deterrence turns upon a credible threat to cross the nuclear threshold if

push comes to shove. During the 1960s the US advocated a doctrine of flexible response , arguing
for a model of deterrence that would fail in small packets rather than in one catastrophic breakdown.
Notwithstanding the giantmidget problem outlined above, theres usually good sense behind such a doctrine: it
makes deterrent threats more credible, avoids global annihilation in any initial crossing of the nuclear threshold,
maintains a degree of intra-war deterrence from the options still on the table, and optimizes prospects for

historically the doctrine invited questions about the relative

balance between usability and credibility in US nuclear policy questions buried rather than
negotiated war termination. But

resolved by the end of the Cold War. Tailoring, messaging, usability, credibility, and thresholds: I suspect
policymakers will soon be thinking about all those questions again, across a range of deterrence relationships.

Asymmetry of multipolar world takes out deterrence theory

Goodby 15 (James E. Goodby has served in the US Foreign Service, achieving the rank of Career Minister,
and was appointed to five ambassadorial-rank positions by Presidents Carter, Reagan, and Clinton, including
ambassador to Finland. He taught at Georgetown, Syracuse, and Carnegie Mellon Universities and is Distinguished
Service Professor Emeritus at Carnegie Mellon. Ambassador Goodby has worked with former Secretary of State
George Shultz at Hoover since 2007. He is a research fellow at the Hoover Institution and a senior fellow with the
Center for Northeast Asia Policy Studies at the Brookings Institution. He was a Distinguished Service Professor at

Carnegie Mellon University from 1989 to 1999 and is now a professor emeritus. Selected for the US Foreign Service
through competitive examinations in 1952, Goodby rose to the rank of career minister in the Senior Foreign Service
and was given five presidential appointments to ambassadorial rank, including ambassador to Finland (198081).
During his Foreign Service career he was involved as a negotiator or as a policy adviser in the creation of the
International Atomic Energy Agency, the negotiation of the limited nuclear test ban treaty, START, the Conference
on Disarmament in Europe, and cooperative threat reduction (the Nunn-Lugar program). Goodbys awards include
the Presidential Distinguished Service Award, the State Departments Superior and Distinguished Honor Awards, and
the Commanders Cross of the Order of Merit of Germany. He was named a Distinguished Fellow of the US Institute
of Peace in 1992. He was the recipient of the inaugural Heinz Award in Public Policy in 1995. In 1996, he was
awarded an honorary doctor of laws degree by the Stetson University College of Law. The New Dilemmas of
Nuclear Deterrence 7/3/15 http://thediplomat.com/2015/07/the-new-dilemmas-of-nuclear-deterrence/)///CW
During the Cold War, nuclear deterrence was essentially a US-Soviet calculation. After the Cold War, China began
to loom larger in US planning, but the premise that deterrence was essentially a bilateral interaction remained. In
the future, situations that are not demonstrably bilateral may become the norm. Even
now, but especially in the event global nonproliferation efforts fail to meet current challenges, the nuclear

deterrence calculations of the United States and other states armed with nuclear weapons will have to
be based on a much more complex set of global and regional dynamics. In such a system, if
nuclear weapons were used or even if their use were threatened, there would be an
action-and-reaction effect that might involve several nations, not just two as in the Cold War
paradigm. For example, the alert status of nuclear delivery systems probably would be changed to a higher level

movements of air and naval forces equipped

with nuclear weapons. A great deal of ambiguity can be expected in the event of a
nuclear explosion as to which nation had detonated a nuclear weapon . Once nuclear
weapons attacks occurred, terminating the war could be difficult . Conceivably, three or four
nuclear-armed states could become engaged in hostilities that might have originated
with just one nation initiating a nuclear attack. The dynamics of nuclear conflict in the Middle
East, South Asia, or Northeast Asia would require qualitatively different deterrent
calculations from those the five Non-Proliferation Treaty nuclear weapons states have been accustomed to
of readiness by several nations. There might be

making. Catalytic nuclear war was one of the worries of the Kennedy and Johnson administrations. It meant that
the United States could become engaged in a nuclear war because a nuclear-armed US ally had used a nuclear
weapon and their common adversary, the Soviet Union, had decided to use nuclear weapons in response. Those
worries would also figure in a complex world of perhaps fifteen or so nuclear-armed states, which would also
include the unknown capabilities of terrorist groups and the likelihood that cyber-mischief would accompany any
nuclear attack. How does one measure strategic stability in such a situation?

Luck, not deterrence, accounts for nuclear peace

Pelopidas 15 (Benot Pelopidas is a lecturer (assistant professor with tenure) in international relations at
the University of Bristol (Global Insecurities Center) and an affiliate of the Center for International Security and
Cooperation at Stanford University. He has been awarded two international prizes for his research, from the
International Studies Association and the James Martin Center for Nonproliferation Studies. His research focuses on
the global politics of nuclear vulnerability, cases of near-use of nuclear weapons, and lessons learned from global
nuclear history and French nuclear policies. His is currently completing an edited volume on the experience of the
Cuban missile crisis worldwide as an early set of experiences of global nuclear vulnerability and its implications for
security, responsibility, and alliance dynamics. Challenging the Assumptions of Classical Nuclear Deterrence
Theory: The War That Must Never Be Fought 3/12/15, can be downloaded at
http://www.hoover.org/research/challenging-assumptions-classical-nuclear-deterrence-theory)///CW

Luck is too often taken as a confirmation that nuclear deterrence kept the peace.28 But luck should
not be misread as successful deter- rence.29 More accurately, as Thomas Schelling noted, leaders of

states can make threats that leave something to chance 30

recognizing that things could spiral out of control and nuclear weapons could be used even if
they do not intend to use themto make those threats more credible. But including luck in a successful
deterrence strategy, as if you could control it, is both a conceptual confusion and a
nuclearweapon

retrospective illusion.31 Luck was on our side this time, but this is not a consequence of purposeful action.
For example, during the night of October 2627, 1962, at the height of the Cuban missile crisis , an
American U-2 spy plane strayed into Soviet airspace over the Arctic. Soviet fighter jets
scrambled to intercept the U-2 while F-102 interceptors were sent to escort it home and prevent Soviet MIGs from

missiles had been

replaced with nuclear-tipped ones and their pilots could decide to use nuclear
weapons. According to Scott Sagan in The Limits of Safety, the interceptors at Galena were armed with the
freely entering US airspace. Given the circumstances, the F-102s conventional air-to-air

nuclear Falcon air-to-air missiles and, under existing safety rules, were authorized to carry the weapons in full
readiness condition in any active air defense mission.32 Fortunately, the spy plane turned back
and the Soviet jets held their fire.33 There are many other instances in which deterrence cannot account for
favorable outcomes.34 Robert McNamara was direct about the role of luck during the Cuban missile crisis:
According to former Soviet military leaders, at the height of the crisis, Soviet forces in Cuba possessed 162 nuclear
warheads, including at least 90 tactical warheads. [And the United States. was not aware of that at the time.] At
about the same time, Cuban President Fidel Castro asked the Soviet ambassador to Cuba to send a cable to Soviet
Premier Nikita Khrushchev stating that Castro urged him to counter a U.S. attack with a nuclear response. Clearly,
there was a high risk that in the face of a U.S. attack, which many in the U.S. government were prepared to
recommend to President Kennedy, the Soviet forces in Cuba would have decided to use their nuclear weapons

submarines trailing the

U.S. Naval vessels near Cuba each carried torpedoes with nuclear warheads. Each of
the sub commanders had the authority to launch his torpedoes. The situation was even
rather than lose them. Only a few years ago did we learn that the four Soviet

more frightening because, as the lead commander recounted to me, the subs were out of communication with
their Soviet bases, and they continued their patrols for four days after Khrushchev announced the withdrawal of
the missiles from Cuba. The lesson, if it had not been clear before, was made so at a conference on the crisis held
in Havana in 1992. . . . Near the end of that meeting, I asked Castro whether he would have recommended that
Khrushchev use the weapons in the face of a U.S. invasion, and if so, how he thought the United States would
respond. We started from the assumption that if there was an invasion of Cuba, nuclear war would erupt, Castro
replied. We were certain of that. . . . [W]e would be forced to pay the price that we would disappear. He
continued, Would I have been ready to use nuclear weapons? Yes, I would have agreed to the use of nuclear
weapons. And he added, If Mr. McNamara or Mr. Kennedy had been in our place, and had their country been
invaded, or their country was going to be occupied . . . I believe they would have used tactical nuclear weapons.
I hope that President Kennedy and I would not have behaved as Castro suggested we would have. . . . Had we
responded in a similar way the damage to the United States would have been unthinkable. But

human

beings are fallible [emphasis added].35 This fascinating account shows how lack of information,
misperception, and ideology could have led to disaster if we had not been lucky. But false information, lack of
information, and misperceptions were not the only reason why luck was the decisive cause of the positive outcome
of the Cuban missile crisis. Limits of safety, limits of command and control, and organizational problems also have

Many serious safety problems, which could have

resulted in an accidental or unauthorized detonation or a serious provocation to the Soviet
to be taken into account. As Scott Sagan wrote:

government, occurred during the crisis. None of these incidents led to inadvertent escalation or an accidental war.
All of them, however, had the potential to do so. President Kennedy may well have been prudent. He did not,

sloppy
practices in nuclear weapons management have occurred at all levels of decisionmakers, leaders, nuclear safety and security teams, and top-level military personnel in most nuclear-weapon
however, have unchallenged final control over U.S. nuclear weapons.36 Most-recent studies show that

states. They also show the limits of learning from past sloppy practices. Confidence in perfect nuclear safety is still
a matter of wishing for the best and relying on luck.37 One telling example of this occurred at Minot Air Force
Base in North Dakota in 2007. This offers a well-documented case of multiple sloppy practices and suggests the

six US nuclear-armed cruise

missile warheads were mistakenly flown to Barksdale Air Force Base in Louisiana. They had
been placed by mistake under the wings of a B-52; the weapons had not been guarded appropriately
limits of learning after the incident was identified. On August 2930, 2007,

during a thirty-six-hour period. Had the plane experienced any problems in flight, the crew would not have followed
the proper emergency procedures.38 After this widely publicized case of sloppy practices,39 US Secretary of
Defense Robert Gates emphasized the need for responsibility in handling nuclear weapons: The problems were
the result of a long-standing slide in the Services nuclear stewardship. . . . For your part, you must never take
your duties lightly. There is simply no room for error. Yours is the most sensitive mission in the entire US
military.40 Change and improvement were supposed to follow, but even on the base where the incident took
place and where the Secretary of Defense came to give his speech, it was necessary to repeat the order to leave
no room for error. In April 2013, one officer from the 91st Missile Wing at the same Air Force Base in North Dakota

was punished for sleeping on the job while having the blast door open behind him. (Sleeping wasnt prohibited on
a twenty-four-hour shift, but leaving the blast door open was.) He was one of two missile officers sanctioned that
year for such a fault and he told his superiors that it wasnt the first time.41 Air Force officers told the Associated
Press that such violations of the safety procedures had happened more often than just in the two documented
cases.42 The limits of safety, the limits of command and control, and the persistence of sloppy practices even in

luck is likely to have been even more important

than we can document here. three different groups) of the payload installed in those cruise missiles, those
the US nuclear forces suggest that the role of

procedures were not followed. The quotes for the account of this particular accident are taken from the
unclassified account available in the February 2008 report from the Defense Science Board Permanent Task Force
on Nuclear Weapons Surety, entitled Report on the Unauthorized Movement of Nuclear Weapons. There are no
reliable records of nuclear weapons accidents or close calls in most nuclear-weapon states.

A2 Tepperman
Teppermans thesis ignores complexities and accidents
expert consensus
Shaw 9 (Douglas B. Shaw serves as the Associate Dean for Planning, Research, and External Relations at the
George Washington Universitys Elliott School of International Affairs with a concurrent appointment as an Assistant
Professor of International Affairs. Doug previously served as Director of Policy Planning in the Office of the President
at Georgetown University, on the U.S. Department of Energys Nuclear Material Security Task Force, at the U.S.
Arms Control and Disarmament Agency, and in leadership roles for a number of non-governmental organizations
including Physicians for Social Responsibility, the Lawyers Alliance for World Security, and the Institute on Religion
and Public Policy. Doug holds a Ph.D. in international relations from Georgetown University and has lectured on
nuclear nonproliferation and disarmament on four continents. Newsweek misrepresents nuclear weapons
scholarship 9/1/9 http://nukesonablog.blogspot.com/2009/09/newsweek-misrepresents-nuclearweapons.html)///CW
Jonathan Teppermans thesis in his September 7th Newsweek article Why Obama should Learn to Love the
Bomb that a growing and compelling body of research suggests that nuclear weapons may not, in fact, make the

badly misrepresents the state of scholarship on this crucial topic .

Tepperman references a handful of scholars to make his argument while
dismissing the majority who disagree with him. George P. Shultz, William J. Perry, Henry A.
world more dangerous
First,

Kissinger, and Sam Nunn opposed this view in two op-eds in the Wall Street Journal and other leading scholars and
practitioners participated in a 2007 conference at Stanford University, now memorialized as a 500-page volume,

Tepperman
suggests a robust understanding of how deterrence relates to todays challenges
where none exists. Nuclear deterrence scholar Sir Lawrence Freedman observed a lost
generation of nuclear weapons specialists in remarks at the Elliott School of International Affairs
Reykjavik Revisited. Scores of experts are summarily excluded from Teppermans article. Second,

this spring and Commander of the U.S. Strategic Command, General Kevin Chilton, observed this summer we have

More
scholarship is needed to translate nuclear optimism and other Cold War concepts
into the Twenty-first Century. Third, in over 2,700 words on deterrence, not one of
them is accident. This is a catastrophic flaw in characterizing scholarly debate on
nuclear weapons. Kenneth Waltz, cited by Tepperman as the leading nuclear optimist underlines this point
allowed an entire generation to skip class, as it were, on the subject of strategic deterrence.

by co-authoring a book titled The Spread of Nuclear Weapons: A Debate Renewed with Stanford Universitys Scott
Sagan who has done decades of careful scholarship to demonstrate the relevance of accidents to nuclear

Teppermans iron logic of deterrence is undermined by a more unstable

plutonium logic that can only be understood by the combined lights of physics,
engineering, political science, economics, and at least more than a dozen other
disciplines that James Doyle of Los Alamos National Laboratory argues constitute nuclear
security science. The nuclear future ahead of us is long, imperfect, and badly in
need of more research and more informed public debate .
deterrence.

A2 Empirics
Their empirics argument is historically false
Pelopidas 15 (Benot Pelopidas is a lecturer (assistant professor with tenure) in international relations at
the University of Bristol (Global Insecurities Center) and an affiliate of the Center for International Security and
Cooperation at Stanford University. He has been awarded two international prizes for his research, from the
International Studies Association and the James Martin Center for Nonproliferation Studies. His research focuses on
the global politics of nuclear vulnerability, cases of near-use of nuclear weapons, and lessons learned from global
nuclear history and French nuclear policies. His is currently completing an edited volume on the experience of the
Cuban missile crisis worldwide as an early set of experiences of global nuclear vulnerability and its implications for
security, responsibility, and alliance dynamics. Challenging the Assumptions of Classical Nuclear Deterrence
Theory: The War That Must Never Be Fought 3/12/15, can be downloaded at
http://www.hoover.org/research/challenging-assumptions-classical-nuclear-deterrence-theory)///CW
The limits of nuclear deterrence as a peacemaker23 Critics of abolition portray a world without nuclear weapons as
warprone and believe that nuclear weapons are a necessary and sufficient cause for great-power peace.

This is

only the latest instance of an idea that has repeatedly been proven wrong, since at
least 1860: the expectation that the unprecedented destructiveness of a new weapon
system and the threat of its use will put an end to war. This was wrong for dynamite,
submarines, artillery, smokeless powder, the machine gun, and poison gas.24 Was
nuclear deterrence a necessary and sufficient cause for peace among great powers? Most critics of the idea of a

They argue that the nuclear-armed states

never fought a war against each other.25 This can now be proven wrong. The 1969 border clash
between China and Russia26 and, more recently, the 1999 Kargil crisis between India and
Pakistan show that the conventional wisdom that a nuclear-armed state cannot be attacked is historically
inaccurate. Moreover, nuclear-armed states have been attacked by non-nuclear-weapon
states on multiple occasions. US troops were attacked by Chinese forces in 1950 in Korea and by
Vietnamese forces in the 1960s and 1970s; Israel was attacked by Syria and Egypt in 1973
and by Iraq in 1991; and in 1982, Argentina invaded the British Falkland Islands.27 This narrows down
world without nuclear weapons maintain that it was.

the claims for nuclear weapons as peacemakers. More importantly, even this narrower claim needs to be
reexamined taking into account two facts: (1) avoidance of several nuclear disasters was due to luck and cannot
be explained by nuclear deterrence; and (2) deterrence as a strategy has favored more risk-prone strategies and
in some cases made war possible instead of preventing it.

High-Magnitude, Low Probability = Good

High magnitude, low probability events first
Bostrom 13
[Nick, Philosopher and professor (Oxford), Ph.D. (LSOE), director of The Future of
Humanity Institute and the Programme on the Impacts of Future Technology, of
course, hes also the inaugural recipient of The Eugene R. Gannon Award for the
Continued Pursuit of Human Advancement, Existential Risk Prevention as Global
Priority, Global Policy, Vol 4, Issue 1, http://www.existential-risk.org/concept.html]
existential risk is one that threatens the premature
extinction of Earth-originating intelligent life or the permanent and drastic destruction of its potential for desirable future development
(Bostrom 2002). Although it is often difficult to assess the probability of existential risks, there
are many reasons to suppose that the total such risk confronting humanity over the next few centuries is
significant. Estimates of 10-20% total existential risk in this century are fairly typical among those who have
1. The maxipok rule 1.1. Existential risk and uncertainty An

examined the issue, though inevitably such estimates rely heavily on subjective judgment.1 The most reasonable estimate might be substantially higher

the strongest reason for judging the total existential risk within the next
few centuries to be significant is the extreme magnitude of the values at stake.
Even a small probability of existential catastrophe could be highly practically
significant (Bostrom 2003; Matheny 2007; Posner 2004; Weitzman 2009). Humanity has survived what we might call
natural existential risks for hundreds of thousands of years; thus it is prima facie unlikely that any of
or lower. But perhaps

them will do us in within the next hundred.2 This conclusion is buttressed when we analyze specific risks from nature, such as asteroid impacts,
supervolcanic eruptions, earthquakes, gamma-ray bursts, and so forth: Empirical impact distributions and scientific models suggest that the likelihood of

In contrast, our species is

threats we have no track record of surviving. Our
longevity as a species therefore offers no strong prior grounds for confident optimism. Consideration of specific existentialrisk scenarios bears out the suspicion that the great bulk of existential risk in the
foreseeable future consists of anthropogenic existential risks that is, those arising from human activity. In particular,
extinction because of these kinds of risk is extremely small on a time scale of a century or so.3

introducing entirely new kinds

of existential risk

most of the biggest existential risks seem to be linked to potential future technological breakthroughs that may radically expand our ability to manipulate

As our powers expand, so will the scale of their potential

consequences intended and unintended, positive and negative. For example, there appear to be significant existential risks in some of the
advanced forms of biotechnology, molecular nanotechnology, and machine intelligence that might be developed in the decades ahead. The bulk
of existential risk over the next century may thus reside in rather speculative
scenarios to which we cannot assign precise probabilities through any rigorous statistical or
scientific method. But the fact that the probability of some risk is difficult to quantify does
not imply that the risk is negligible. Probability can be understood in different
senses. Most relevant here is the epistemic sense in which probability is construed as (something like) the credence that an ideally reasonable
observer should assign to the risk's materializing based on currently available evidence.4 If something cannot presently be
known to be objectively safe, it is risky at least in the subjective sense relevant to
decision making. An empty cave is unsafe in just this sense if you cannot tell whether or not it is home to a hungry lion. It would be rational
for you to avoid the cave if you reasonably judge that the expected harm of entry outweighs the expected benefit. The uncertainty
and error-proneness of our first-order assessments of risk is itself something we
must factor into our all-things-considered probability assignments . This factor often
dominates in low-probability, high-consequence risks especially those involving
poorly understood natural phenomena, complex social dynamics, or new technology, or that are
difficult to assess for other reasons. Suppose that some scientific analysis A indicates that some
catastrophe X has an extremely small probability P(X) of occurring. Then the probability that A
has some hidden crucial flaw may easily be much greater than P(X).5 Furthermore, the
the external world or our own biology.

conditional probability of X given that A is crucially flawed , P(X|A), may be fairly high. We
may then find that most of the risk of X resides in the uncertainty of our scientific
assessment that P(X) was small (figure 1) (Ord, Hillerbrand and Sandberg 2010).

Possibilistic thinking best for decision-making

Clarke 5
[Lee, member of a National Academy of Science committee that considered
decision-making models, Anschutz Distinguished Scholar at Princeton University,
Fellow of AAAS, Professor Sociology (Rutgers), Ph.D. (SUNY), Lee Clarke's Worst
Cases: An Interview with Lee Clarke, UChicago press,
http://www.press.uchicago.edu/Misc/Chicago/108597in.html]
Why focus on worst cases? They probably wont happen, right? Why not focus on scenarios that
have a greater degree of probability? Lee Clarke: One of the main ideas in Worst Cases is that we can use
possibilistic thinking to balance probabilistic thinking. Over the past couple of hundred years
probabilism has come to be thought of as the only way to reason rationally. But I
think that it sometimes makes perfectly good sense to take worst case
consequences into account when people are making decisions. For example, the chances of getting into a
commercial airline crash are extremely low. People who fly know that, and thats why theyre willing to defy gravity
every day. But they also know what happens if the plane gets into serious trouble at
thirty thousand feet. Thats worst case, possibilistic thinking. It is reasonable to
worry about both. It is true, in a sense, that worst cases probably wont happen. Still, as the
political scientist Scott Sagan has said, things that have never happened before happen all the
time. Just think of Chernobyl or 9/11. They had a low probability of occurring at any given time, but
who would say now that we should have ignored them? Its the same kind of thing as when
you buy life insurance. Is it likely that you will die today? Probably not. But if you have life insurance youre actually betting the insurance
company that, in fact, you will die today. Is that irrational? Not at all. We say that people who dont
buy life insurance are irresponsible.
Question:

Consequentialism Good
Public Health surveillance requires consequentialist framingpublic health outweighs minor violations of rights most of the
time
Petrini 13 (Carlo Petrini. Unit di Bioetica, Presidenza, Istituto Superiore di
Sanit.Ethics in Public Health Surveillance. 2013. P. 352.
http://www.scielosp.org/pdf/aiss/v49n4/v49n4a05.pdf)EMerz
The ethical problems posed by public health surveillance have been specifically
addressed in numerous studies in the past, and various factors have led to an
increase in this interest in recent years, including the diffusion of new and
unforeseen epidemics and a greater awareness of and sensitivity towards the issues
involved [57]. The checklists shown above can help to assess the compatibility of
public health surveillance programmes with ethical principles. One of the major
problems highlighted by these tools is the fact that, given the virtual impossibility of
obtaining informed consent, programmes for public health surveillance frequently
necessitate an infringement of the principle of autonomy. Today it is widely
accepted that Overriding individual autonomy must be justified in terms of the
obligation of public health to improve population health, reduce inequities, attend to
the health of vulnerable and systematically disadvantaged persons, and prevent
harm. In addition, data elements collected without consent must represent the
minimal necessary interference, lead to effective public health action, and be
maintained securely [15]. Returning to Childress and co-authors, they suggest five
useful conditions intended to help determine whether promoting public health
warrants overriding such values as individual liberty or justice in particular
cases. These conditions encapsulate the key criteria referred to in the various
checklists. They are: effectiveness; proportionality; necessity; least infringement;
public justification [55]. In summarising the criteria listed above it may also be
helpful to refer to a proposal formulated by the noted biolaw expert Lawrence
Gostin on the spread of Severe Acute Respiratory Syndrome (SARS). His concise
proposal makes a suitable and practical conclusion: Coercive measures, which
violate individual rights, are acceptable when: - the risk to public health is
demonstrable; - the intervention is likely to be effective, cost-effective, not overly
invasive, fairly distributed; - the process for pursuing intervention is just and
publicly transparent [58].

Utilitarianism Good
Adopt a framework of public health utilitarianism this avoids
the traditional trap of sacrificing the few for the many but
maintains the best possible consequences
Gostin 10 (Lawrence O. Gostin has more qualifications than any other card put out in the past 30
years. He is University Professor, Georgetown University's highest academic rank conferred by the
University President. Prof. Gostin directs the O'Neill Institute for National and Global Health Law and
was the Founding O'Neill Chair in Global Health Law. He served as Associate Dean for Research at
Georgetown Law from 2004 to 2008. He is Professor of Medicine at Georgetown University, Professor
of Public Health at the Johns Hopkins University, and Director of the Center for Law & the Public's
Health at Johns Hopkins and Georgetown Universities. Prof. Gostin is the Director of the World Health
Organization Collaborating Center on Public Health Law & Human Rights. He also serves on the WHO
Director-General's Advisory Committee on Reforming the World Health Organization. In 2007, the WHO
Director-General appointed Prof. Gostin to the International Health Regulations (IHR) Roster of Experts
and the Expert Advisory Panel on Mental Health. In a 2012 systematic empirical analysis of legal
scholarship, independent researchers ranked Prof. Gostin 1st in the nation in productivity among all
law professors, and 11th in in impact and influence. Public Health Law, Ethics, and Human Rights:
Mapping the Issues http://www.publichealthlaw.net/Reader/ch1/ch1.htm)///CW
The application of general ethical principles to public health decisions can be difficult and complicated. Since the

public health is to achieve the greatest health benefits for the greatest number of people, it draws
from the traditions of utilitarianism or consequentialism. The public health model, argue Buchanan
mission of

(2000) and his colleagues, uncritically assumes that the appropriate mode of evaluating options is some form of
cost-benefit (or cost-effectiveness) calculation the aggregation of goods and bads (costs and benefits) across

Public health, according to this view, appears to permit, or even require, that
the most fundamental interests of individuals be sacrificed in order to produce the
best overall outcome. This characterization misperceives, or at least oversimplifies, the
public health approach. The field of public health is interested in securing the
greatest benefits for the most people. But public health does not simply aggregate benefits and
burdens, choosing the policy that produces the most good and the least harm. Rather, the overwhelming
majority of public health interventions are intended to benefit the whole population,
without knowingly harming individuals or groups. When public health authorities work in the
individuals.

areas of tobacco control, the environment, or occupational safety, for example, their belief is that everyone will

public health focuses almost

exclusively on one vision of the common good (health, not wealth or prosperity), but this is
not the same thing as sacrificing fundamental interests to produce the best overall
outcome. The public health approach, of course, does follow a version of the harm
principle. Thus, public health authorities regulate individuals or businesses that endanger the community. The
benefit from smoking cessation, clean air, and safe workplaces. Certainly,

objective is to prevent unreasonable risks that jeopardize the publics health and safety e.g, polluting a stream,
practicing medicine without a license, or exposing others to an infectious disease. More controversially,

public

health authorities often recommend paternalistic interventions such as mandatory seat belt
or motorcycle helmet laws. Public health authorities reason that the sacrifice asked of
individuals is relatively minimal and the communal benefits substantial . Few public
health experts advocate denial of fundamental interests in the name of paternalism. In the public health model,

individual interests in autonomy, privacy, liberty, and property are taken seriously,
but they do not invariably trump community health benefits . The public health approach,
therefore, differs from modern liberalism primarily in its preferences for balancing public health favors community

Characterizing public health as a utilitarian

sacrifice of fundamental personal interests is as unfair as characterizing liberalism
as a sacrifice of vital communal interests. Both traditions would deny this kind of oversimplification.
benefits, while liberalism favors liberty interests.

Bioethics in the context of health surveillance requires that the

government value public health over individual interests
Childress 2 (James Childress. University Professor and the John Allen
Hollingsworth Professor of Ethics at the University of Virginia. Public Health Ethics:
Mapping the Terrain. 2002. P. 171. file:///C:/Users/Emily/Downloads/Childress_et_al2002-The_Journal_of_Law,_Medicine_&_Ethics.pdf)//EMerz
In view of public healths goal of producing net health benefits for the population,
this meaning of public is very important. In measurement and analysis, the
numerical public reflects the utilitarian view that each individual counts as one
and only one. In this context, ethical analysis focuses on issues in measurement,
many of which raise considerations of justice. For example, how should we define a
population, how should we compare gains in life expectancy with gains in healthrelated quality of life, and whose values should be used in making those judgments?
Second, public is what we collectively do through government and public agency we can call this political public. Government provides much of the funding for a
vast array of public health functions, and public health professionals in
governmental roles are the focal point of much collective activity. In the United
States, as Lawrence Gostin notes, government is compelled by its role as the
elected representative of the community to act affirmatively to promote the health
of the people, even though it cannot unduly invade individuals rights in the name
of the communal The government is a central player in public health because of the
collective responsibility it must assume and implement. The states use of its police
powers for public health raises important ethical questions, particularly about the
justification and limits of governmental coercion and about its duty to treat all
citizens equally in exercising these powers. In a liberal, pluralistic democracy, the
justification of coercive policies, as well as other policies, must rest on moral
reasons that the public in whose name the policies are carried out could reasonably
be expected to accept.I Third, public, defined as what we do collectively in a broad
sense, includes all forms of social and community action affecting public health - we
can call this communal public. Ethical analysis on this level extends beyond the
political public. People collectively, outside of government and with private funds,
often have greater freedom to undertake public health interventions since they do
not have to justify their actions to the political public. However, their actions are still
subject to various moral requirements, including, for instance, respect for individual
autonomy, liberty, privacy and confidentiality, and transparency in disclosure of
conflicts of interest.

Using a cost benefit analysis to address health surveillance is

key to balance conflict of interests
Childress 2 (James Childress. University Professor and the John Allen
Hollingsworth Professor of Ethics at the University of Virginia. Public Health Ethics:

Mapping the Terrain. 2002. P. 171. file:///C:/Users/Emily/Downloads/Childress_et_al2002-The_Journal_of_Law,_Medicine_&_Ethics.pdf)//EMerz

Conceptions of morality usually recognize a formal requirement of universalizability
in addition to a substantive requirement of attention to human welfare. Whatever
language is used, this formal feature requires that we treat similar cases in a similar
way. This requirement undergirds casuistical reasoning in morality as well as in law.
In public health ethics, for example, any recommendations for an HIV screening
policy must take into account both past precedents in screening for other infectious
diseases and the precedents the new policy will create for, say, screening for
genetic conditions. Much of the moral argument will hinge on which similarities and
differences between cases are morally relevant, and that argument will often,
though not always, appeal to general moral considerations.* We can establish the
relevance of a set of these considerations in part by looking at the kinds of moral
appeals that public health agents make in deliberating about and justifying their
actions as well as at debates about moral issues in public health. The relevant
general moral considerations include: producing benefits; avoiding, preventing, and
removing harms; producing the maximal balance of benefits over harms and other
costs (often called utility); distributing benefits and burdens fairly (distributive
justice) and ensuring public participation, including the participation of affected
parties (procedural justice); respecting autonomous choices and actions, including
liberty of action; protecting privacy and confidentiality; keeping promises and
commitments; disclosing information as well as speaking honestly and truthfully
(often grouped under transparency); and building and maintaining trust. Several of
these general moral considerations - especially benefiting others, preventing and
removing harms, and utility - provide a prima facie warrant for many activities in
pursuit of the goal of public health. It is sufficient for our purposes to note that
public health activities have their grounding in general moral considerations, and
that public health identifies one major broad benefit that societies and governments
ought to pursue. The relation of public health to the whole set of general moral
considerations is complex. Some general moral considerations support this pursuit;
institutionalizing several others may be a condition for or means to public health
(we address this point later when we discuss human rights and public health); and
yet, in particular cases, some of the same general moral considerations may limit or
constrain what may be done in pursuit of public health. Hence, conflicts may occur
among these general moral considerations

Utilitarianism Bad
Health care should use a deontological approach the ends
dont justify the means
MM 07 (Mornings Minion is a Catholic blog, Utilitarianism in Health Care 8/23/07 http://voxnova.com/2007/08/23/utilitarianism-in-health-care/)///CW
On all three grounds, she argues that social justice considerations do not support a transfer from the young and
healthy to the old and sick on social justice grounds. As I read this, I felt there was something very wrong with her
reasoning. Personally, I am in favor of single payers systems, and on the record as saying so. But Im the first to
admit that there are valid Catholic arguments against single payer systems. There is nothing intrinsically evil about
choosing to fund health care in a different manner. But still, at least from a Catholic perspective, there is
something fundamentally flawed in McArdless reasoning. Here is the problem: it treats social justice not from the

from utilitarianism. Like

it is only outcomes that matter, and these outcomes are
defined in terms of maximum utility, or happiness (utilitarianism is of course, a special application of
consequentialism). The main problem, of course, is that it takes no account of whether an
act is inherently right or wrong, irrespective of consequences. This kind of thinking arose directly from
point of view of the common good, but from an individualist ethic ultimately derived
all teleological philosophies,

the Enlightenment, and a flawed concept of rationality based on what can be demonstrated empirically. As Pope

it is the calculation of consequences that

determines what should be considered moral and immoral . I think this manner of thinking
Benedict noted, in a world based on calculations,

owes as much to Thomas Hobbes as it does to classic utilitarians like Bentham. It was Hobbes who, more than
anybody else, led to the idea of social contracts overtaking the common good as the object of policy. Hobbes did
not see humanity as an organic community underpinned by the common good; he saw instead a collection of
individuals all seeking mastery over each other, necessitating some form of social contract to keep the peace.

The individual is everything, the community, nothing . It follows naturally that social justice flows
from the aggregation of individual happiness, rather than an organic conception of the common good. But the
common good stems from the dignity, unity and equality of all people, not some
mechanical calculation. It refers to the sum total of social conditions which allow people, either as groups
or as individuals, to reach their fulfilment more fully and more easily. It is the social and community dimension of
the moral good. While it is underpinned by the dignity of the human person, it is not an individualist ethic; rather, it
recognizes that there is no fulfilment if the individual does not recognize that he or she exists with others and
for others. To see the bankruptcy of the contracts approach to justice, consider abortion. Clearly, the unborn are
not agents that can participate in a social contract. Clearly, their welfare must therefore be discounted, and
subjugated to the welfare of others, who are proper contracting agents. It is this notion that underpins the proabortion position today, and it stems from a failure to understand the encompassing and organic nature of the

a classic utilitarian calculus to argue that

social welfare is not increased by a transfer from the young and healthy to the old
and sick. Its all about individuals, and welfare is limited to wealth. Whereas the right to health care is regarded
by the Church as basic to the common good, the utilitarian approach instead sees only a collection
of individuals out for themselves, and therefore largely responsible for their own
health care. Within this individualist ethic, a social contract can indeed justify redistribution, but this is based on
common good. Back to health care. McArdle engages in

extremely limited characteristics, such as luck and personal worthiness. Nowhere in sight is the core principle of

Nowhere is the
idea that our interdependence coupled with the right to health care may call for the
young and healthy to look after the needs of the old and infirm , irrespective of
solidarity, a a firm and persevering determination to commit oneself to the common good.

circumstances. And that is what troubled me most about McArdles reasoning.

Evaluate the debate through the lens of personalism

utilitarianism alone fails but combining it with an ethic for
constant respect for a humans dignity solves
Petrini and Gaintoti 08 (Carlo Petrini PhD is with the Bioethics Unit, Office of the
President, Italian National Institute of Health, Rome, Italy. Sabina Gainotti works at The National
Center for Rare Diseases in Rome and focuses on Qualitative Social Research, Quantitative Social
Research, and Ethics. A personalist approach to public-health ethics
http://www.who.int/bulletin/volumes/86/8/08-051193/en/)///CW
Philosophical theories are also applied to bioethics and public-health ethics. In public health, some positions are
more common: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (Kantian
theories), views that emphasize sociality and solidarity (communitarianism).1 Utilitarianism asserts that
decisions should be judged by their consequences, in particular by their effect on the total sum of individual
wellbeing. Following this view, public-health policies must be aimed to produce the greatest happiness of the

is very intuitive in public health but has some limitations.

Difficulties arise for example in the measurement of wellbeing which can be defined with
reference to an individuals personal experiences or to more objective and measurable components, e.g. qualityadjusted life years (QALYs) or disability-adjusted life years (DALYs).36 However, the most important
critique to utilitarianism is grounded on the view that it easily leads to unfairness
and to the sacrifice of individual rights and freedoms to warrant the public utility .37
Individual rights and freedoms are the main good to be preserved in Kantian theories .
Kant argued that human beings ought to be treated with respect, as ends in themselves ,
greatest number.35 This approach

not as means to another individuals ends.38 This assertion has important consequences in public-health policies,
but is not without ambiguities. Indeed two kinds of liberalism can be drawn: libertarians and egalitarians.39
Libertarians believe that only negative rights deserve protection to warrant individual freedom. By contrast,
egalitarian liberals argue that the right to choice is meaningless without adequate resources. Respectively, the two

Critics
of utilitarianism and liberalism point out that these theories neglect the collective
dimension of public-health ethics that is strongly valued in communitarianism.
Communitarianism values highly the social dimension of health-care policies and
involves visions of the appropriate social order and the virtues that will maintain
such an order in a particular community. However, a basic question in communitarianism is: who
decides what is virtuous? Every community could define its own norms or, by contrast, a single
form of good society may serve as a reference for all communities. Ethics-of-care feminism can also be
mentioned. Ethics-of-care proponents argue that real people live in families and real caring
relationships are not impartial, impersonal or equal. Health-care policies must hence consider the
factual dimension of caring, which is mostly carried out by women, and must be more supportive
towards caring roles.39 All the outlined theories in our view may offer a contribution to a continuing
perspectives entail a minimal or, vice versa, a strong state intervention for the sake of individual health.

discussion about how to deal ethically with public-health matters and how to organize society. What is missing in
these theories is a clear definition of the concept and value of the human person: a primary point in personalism.

Personalism may offer some compensation for the

conflicts and shortcomings of principlism. For reasons of comprehensiveness, it might be useful here
From traditional philosophy to personalism

to mention its most elementary, and possibly obvious, aspects. Personalism should not be confused with
individualism, which considers auto-decisions as the main (or only) constitutive feature of person.

Personalism

is based upon our common shared human nature . It takes as its primary ethical principle that all
human beings deserve respect. A human is the only being capable of self-reflection and comprehension of the
meaning of life.40 The principles of ontologically- based personalism in bioethics may be summed up as
follows:31the defence, intangibility and sacredness of human life; the therapeutic principle whereby any
intervention on life is justified only if it has a therapeutic purpose; the freedom and responsibility principle, where
freedom recognizes respect for life as its objective limitation; the sociality and subsidiarity principle, consisting of
the achievement of common good through individual well-being.Some consider the traditional value of the person
as a cumbersome dimension. Hence some modern thinkers focus on the individual but not on the person. Post

modern philosophers not only dissolve the concept of person but also that of subject.41 Excessive positions like
these are also present in bioethics. Still bioethics, especially when applied to clinical and experimental issues, is
generally attentive to the individual person. The problem arises in defining the person and the moment when

Personalism
strongly emphasizes the need to protect the weakest and the sickest persons in
society. In a personalistic view, the being and dignity of the person are fundamental and inalienable values.
Moral actions can thus be measured in respect of the persons being and dignity .42 This
he/she begins and ends, from the status of the human embryo to the dignity of the dying.

can be stated through a formulation that is similar to the second Kantian imperative: the person should never be
treated as a simple means, as an instrument that can be used for the purpose of achieving any other end: on the
contrary, the person should be treated as an end, or more specifically respecting, and in some cases promoting,
its own ends.43 In Kants philosophy, however, this imperative has a negative connotation.44 Personalism does
not simply exclude negative behaviours but requires positive attitudes. Personalism and its application to public

personalistic principles include a set of duties which

derive from respect of the person. These include respect of the individuals
autonomy, the safeguard of confidentiality within a collective and potentially depersonifying framework, the effort to guarantee equity and equal opportunities for
everyone in the allocation of health-care resources .45,46 Personalism is not opposed to other
health When applied to public health,

ethical theories as it can have both points in common and divergences with them. In a personalist view, for

the consequentialist-utilitarian approach can certainly be part of a publichealth policy as long as the lives and well-being of individuals are preserved .47
example,

Respect for individual rights and freedom is also an essential requisite of human coexistence if it comes with regard
to the correct exercising of freedom that is bonded to respect for life. In public health there might be cases where

A minimum limit however should

never be exceeded and decisions should never heavily penalize a persons living
conditions. If the wellbeing of the community is at stake, personalism does not exclude
moderate patronizing. Gerald Dworkin defines patronizing as the interference with a persons freedom
freedom must be sacrificed to the advantage of the common good.

of action for reasons which exclusively refer to the wellbeing, good, happiness, needs, interests or values of a
person who is subjected to the coercion.48 A moderate form of patronizing is justified both in serious or emergency
circumstances (such as during epidemics where persons need to be isolated to prevent the spread of a disease),
and in routine conditions where the subject may not be in full charge of the situation and hence it becomes
necessary to force certain behaviours (such as the compulsory wearing of seatbelts). Cautionary policies based on
the precaution principle are also significant in terms of public-health ethics. When scientific data are contradictory
or quantitatively scarce, it is possible to appeal the precautionary principle. This principle shows the need for
making temporary decisions that may be modified on the basis of new facts that eventually become known.49
Some authors have singled out the precautionary principle as one fundamental value in public-health ethics,
alongside justice, transparency and the choice of the least restrictive alternative for peoples autonomy.50 Special
importance has been attached to the precautionary principle by European ethics.51 Its relevance is also underlined
by the Italian Committee on Bioethics and the Pontifical Council for Justice and Peace, with reference to the ethics of
social and collective problems and to environmental issues.52,53 Personalism strongly values principles of sociality
and solidarity. However, the individuals good is the basis for common good. The social dimension of personalism,
which was highly emphasized at the beginning of the 1920s, contributed to the renewal of classical personalism and
the foundation of the modern personalism of Emmanuel Mounier and Jacques Maritain.54,55

Utilitarian framing of health surveillance is flawed- it overlooks

individual health issues and autonomy
Rubel 12 (Alan Rubel. Ph.D., Department of Philosophy, University of WisconsinMadison; J.D., magna cum laude, University of Wisconsin Law School Assistant
Professor. Justifying Public Health Surveillance: Basic Interests, Unreasonable
Exercise, and Privacy. 2012. P. 9-10.
https://kiej.georgetown.edu/home_files/22.1.rubel.pdf)//EMerz

Parmet provides some important guidance in applying this perspective to assessing

the health of populations when she compares and contrasts the population
perspective with utilitarianism. In her view, utilitarianism provides some support for

the population perspective insofar as it is a maximizing theory. The difference

between the two is that the good to be maximized on the population perspective is
much narrowerhealth within a defined group instead of utility among all
individuals (2009, p. 15). However, the view that the population perspective, and
hence public health generally, seeks to maximize group health (Parmet 2009, p.
16) is problematic. The comparison with utilitarianism shows why. Utilitarianism is a
moral theory that is consequentialist, welfarist, and sum-ranking: it is concerned
with the consequences of actions (rather than with, for example, virtues or respect
for autonomy), the consequence that matters is individual welfare, and the best
state of affairs is the one in which the aggregate welfare of all relevant individuals is
maximized. The population perspective mimics utilitarianism insofar as it is
consequentialist and sumranking (i.e., maximizing) and differs only in that the
consequence that matters is health within a population (presumably measured in
terms of quality-adjusted life years, disability-adjusted life years, or the like). The
problem comes in using the population perspective to determine policy. It is true
that public health interventions can at times be justified insofar as they can
maximize health within a population in cases in which individuals acting alone or
along with health care providers would failconsider the efficacy of public
sanitation measures relative to individual efforts to drink clean water absent such
measures. But if our guiding principle is health maximization, interventions
at the individual level will be justified if they do in fact increase aggregate
health. The state of affairs with such an individual intervention will rank ahead of
the state of affairs without it. In other words, a sum-ranking view fails to distinguish
individual and population health and therefore is liable to opt for individual health
interventions on the grounds that they increase population health, independently of
whether they comport with individuals own senses of good. A related problem is
that a consequentialist view that maximizes the particular good of health within a
population will necessarily subordinate nonhealth interests. Some individual
behaviors decrease aggregate health only insofar as the decision-makers health
decreases (e.g., avoiding doctors, being sedentary, not flossing). Surely, though,
some efforts to change those behaviors would be unwarranted on the grounds that
people are within their rights to engage in them.7 Thus, coercive measures to
increase aggregate health require at least some justification to override individual
autonomy. That justification might be the negative effects of individual behaviors on
others health, sufficient risk to individual health to warrant strongly paternalistic
actions, or something else altogether, but simple appeal to marginal increase in
aggregate health would not suffice.

Utilitarianism is bad in the context of public health

surveillance substitutes individual welfare for state affairs
Rubel 12 (Alan Rubel. Ph.D., Department of Philosophy, University of WisconsinMadison; J.D., magna cum laude, University of Wisconsin Law School Assistant
Professor. Justifying Public Health Surveillance: Basic Interests, Unreasonable
Exercise, and Privacy. Kennedy Institute of Ethics Journal, Volume 22, Number 1,
March 2012, pp. 1-33 (Article). John Hopkins University Press, DOI:
10.1353/ken.2012.0001. Card from P. 9-11. )//ASMITH

Although the research/practice distinction fails to provide an adequate guide for

resolving conflicts between public health surveillance and privacy, another
approach, which takes the proper scope of public health into account, may be more
promising. Just how to understand the term public health is the subject of
significant debate. For instance, there is a question as to whether factors that affect
healthsuch as education, homelessness, and human rightsare constitutive of
public health (Rothstein 2002). Nonetheless, for the purposes of this article, it is
promising to begin with the traditional view that public health should be understood
as population health. The Institute of Medicine states that public health is what a
society does collectively to assure the conditions for people to be healthy
(Committee for the Study of the Future of Public Health 1988, p. 19; Rothstein 2002,
p. 145). A full articulation of this kind of view comes in a recent book by Wendy
Parmet. Parmet offers an account of public health that centers on what she calls the
population perspective. According to this view, health is understood from a social
or community perspective, and the health of populations qua populations is an
important goal of social life ( 2009, p. 14). Parmet provides some important
guidance in applying this perspective to assessing the health of populations when
she compares and contrasts the population perspective with utilitarianism. In her
view, utilitarianism provides some support for the population perspective insofar as
it is a maximizing theory. The difference between the two is that the good to be
maximized on the population perspective is much narrowerhealth within a defined
group instead of utility among all individuals (2009, p. 15). However, the view that
the population perspective, and hence public health generally, seeks to maximize
group health (Parmet 2009, p. 16) is problematic. The comparison with
utilitarianism shows why. Utilitarianism is a moral theory that is consequentialist,
welfarist, and sum-ranking: it is concerned with the consequences of actions (rather
than with, for example, virtues or respect for autonomy), the consequence that
matters is individual welfare, and the best state of affairs is the one in which the
aggregate welfare of all relevant individuals is maximized.6 The population
perspective mimics utilitarianism insofar as it is consequentialist and sumranking
(i.e., maximizing) and differs only in that the consequence that matters is health
within a population (presumably measured in terms of quality-adjusted life years,
disability-adjusted life years, or the like). The problem comes in using the population
perspective to determine policy. It is true that public health interventions can at
times be justified insofar as they can maximize health within a population in cases
in which individuals acting alone or along with health care providers would fail
consider the efficacy of public sanitation measures relative to individual efforts to
drink clean water absent such measures. But if our guiding principle is health
maximization, interventions at the individual level will be justified if they do in fact
increase aggregate health. The state of affairs with such an individual intervention
will rank ahead of the state of affairs without it. In other words, a sum-ranking view
fails to distinguish individual and population health and therefore is liable to opt for
individual health interventions on the grounds that they increase population health,
independently of whether they comport with individuals own senses of good. A
related problem is that a consequentialist view that maximizes the particular good
of health within a population will necessarily subordinate nonhealth interests. Some

individual behaviors decrease aggregate health only insofar as the decision-makers

health decreases (e.g., avoiding doctors, being sedentary, not flossing). Surely,
though, some efforts to change those behaviors would be unwarranted on the
grounds that people are within their rights to engage in them.7 Thus, coercive
measures to increase aggregate health require at least some justification to
override individual autonomy. That justification might be the negative effects of
individual behaviors on others health, sufficient risk to individual health to warrant
strongly paternalistic actions, or something else altogether, but simple appeal to
marginal increase in aggregate health would not suffice. Fortunately, there is a
better way to interpret public health from the population perspective and using it to
guide action, which I refer to as the basic interests approach, following a framework
developed by Alex London (2003).8 Even though one natural interpretation of
population healththe one Parmet explicitly makes and which Mark Rothstein
argues is implicit in other accountsis aggregative and sum-ranking, it need not be
(Rothstein 2002, pp. 14546; Parmet 2009, p. 16). A different approach is to see
public health as securing a set of interests that is public in the sense that the
interests are shared by all members of a society, just in virtue of the fact that they
are reasonable, rational persons.9 To see why, it is useful to consider John Rawlss
understanding of primary goods. People in a modern, liberal democracy have widely
diverging interests and projects. Some people will want opportunities for certain
types of athletic recreation, others will seek intensive religious experiences, still
others will look to intellectual or artistic projects, and many will order their lives
around interest or social groups. Often these will conflict. For example, creating the
opportunity for people to play baseball on a new field might undermine others
opportunity to hunt in the location where the field would be placed, and vice versa.
That is exactly as we would expect in a pluralistic society. These interests are
personal interests. However, the existence of such a society requires social
cooperation, which on Rawlss view demands that citizens in the society be able to
exercise two moral powers: the ability to form and revise a conception of the good
(i.e., to be rational) and the ability to form a sense of justice and what is right and
hence the ability to abide by fair terms of cooperation (i.e., to be reasonable) (1996,
pp. 3012). Based on this conception of a citizen, Rawls posits that each citizen has
a number of fundamental interests (or primary goods) regardless of his or her
particular conception of the good and personal interests. Among these are basic
rights, liberties, and opportunities, and social bases for self-respect. They also
include certain natural goods, among them health, which are only partly a
function of the basic structure of society (1999, p. 54). The important point here is
the idea that there are basic interests that every person in a society would want
more of, and those interests must be treated as basic in a liberal, pluralistic society.
Being deprived of the basic goods undermines persons ability to form their own
conceptions of the good and to be reasonable such that they can abide fair terms of
social cooperation. Moreover, restriction of a persons basic interests (e.g.,
deprivation of basic rights and liberties, curtailment of opportunities, imperilment of
health) gives rise to a claim on the rest of society to ameliorate these restrictions.

Utilitarianism justifies viewing people as only valuable for their

contribution to larger society which justifies discrimination and
destroys value to life
Hunnell 15 (Dr. Denise Jackson Hunnell is a Fellow of Human Life International. She graduated
from Rice University with a BA in biochemistry and psychology. She earned her medical degree from
The University of Texas Southwestern Medical School. She went on to complete a residency in family
medicine at Marquette General Hospital, Marquette, Michigan. She also teaches anatomy and
physiology at Northern Virginia Community College Woodbridge Campus. Other affiliations include the
American Academy of Family Physicians, The Catholic Medical Association, and the National Catholic
Bioethics Center. She received her certification in health care ethics from the National Catholic
Bioethics Center in 2009. When Utilitarianism Designs a Healthcare System
http://www.truthandcharityforum.org/when-utilitarianism-designs-a-healthcare-system/)///CW

Emanuel, the architect of President Obamas signature health care legislation, has penned a
provocative piece published in The Atlantic and entitled Why I Hope to Die at 75. In this essay he argues
that people over the age of 75 are a drain on society and it would serve the common good if they
Ezekiel

would just die sooner rather than later. He is very clear that he is not advocating for euthanasia or assisted suicide.

he is doing is laying the groundwork for age-based rationing of health care . It

must be understood that Dr. Emanuel is a utilitarianist. He believes that the value of a person lies in his
contribution to the economic structure of a society. Non-contributors are worth less than those
who are economically productive and are therefore entitled to less of the community resources,
But what

including health care. Nurse_in_geriatryEmanuel argues that age associated declines in mental-processing speed
and creativity make older individuals a burden. He notes that most great scientists, writers, composers, and artists
have made their most significant contributions by the time they are in their late forties or early fifties. He declares
that it is a rare individual who still has the intellectual capacity to produce great work past the age of 75, so we

It is quite
disturbing to read his cold assessment of those with even the most minor
disabilities associated with age. He has no respect for the elderly enjoying their golden years and
should stop striving for longevity at that point and refuse all life-prolonging medical care.

pursuing avocations instead of professional excellence: The American immortal, once a vital figure in his or her
profession and community, is happy to cultivate avocational interests, to take up bird watching, bicycle riding,
pottery, and the like. And then, as walking becomes harder and the pain of arthritis limits the fingers mobility, life
comes to center around sitting in the den reading or listening to books on tape and doing crossword puzzles. And

many of us would counter his arguments with a discussion of the noneconomic benefits the elderly provide. I have had the good fortune to know several centenarians in
then Of course,

my lifetime. They provided a window to the past that could not be captured in any history textbook. I think of my
relationships with several of my grandparents and great-grandparents who lived well past the age of 75 and know
that my life was immeasurably enriched by these encounters with my elders, even when they were challenged by
infirmities and disabilities. I hope to similarly influence my own grandchildren. Ezekiel Emanuel discounts any value
to familial relationships. In fact he states, Our living too long places real emotional weights on our progenythere
is much less pressure to conform to parental expectations and demands after they are gone. His further

He is concerned that if he lives past

the age of 75, he will be remembered as a burden instead of as someone who was
vibrant and a joy to be around. After laying out his arguments for why life after age 75 is just not worth
living, Emanuel goes on to outline the health care policy implications of his position.
After the age of 75 he advocates for virtually no health care . No screening tests, no treatment
explanation of this reveals a prideful, self-centered motivation.

for cancer, no flu shots, no antibiotics. Palliative care to keep the elderly comfortable is all that he sees as
reasonable. Here is where Emanuel errs most dramatically. He is judging the patient as to his worthiness for
treatment, instead of judging the treatment as to its worthiness for the patient. There is no question that there are
many medical tests and treatments that are not appropriate for patients over the age of 75. Following cholesterol
levels, screening mammograms in asymptomatic women, screening colonoscopies for colon cancer are all tests that
can be discontinued by this age. However, the reason is not that patients over the age of 75 are not valuable
enough to receive this medical care. It is that the burden these tests impose on the elderly is not justified by the
expected benefit of these tests. Decisions about the appropriateness of any medical test or intervention need to be
made on an individual basis, taking into account the specific burden to benefit analysis for a given treatment in a
given patient. Arbitrarily declaring that all those over the age of 75 are unworthy of anything but palliative medical

care is unjust ageism. Caring for an elderly relative can present physical, emotional, and financial challenges. But

facing these challenges is an opportunity for great spiritual growth . We are better people
and create a better society when we generously love and care for those with infirmities and disabilities. Through
their lives, the elderly generously offer us the opportunity to cultivate virtue. As Pope Francis said, A population
that does not take care of the elderly and of children and the young has no future, because it abuses both its

Emanuel explicitly rejects such thinking as existential

nonsense: Many of us have suppressed, actively or passively, thinking about God, heaven and hell, and
memory and its promise.

whether we return to the worms. We are agnostics or atheists, or just dont think about whether there is a God and
why she should care at all about mere mortals. We also avoid constantly thinking about the purpose of our lives and
the mark we will leave. Is making money, chasing the dream, all worth it? Indeed, most of us have found a way to
live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis. We

Emanuel that he
cannot see the value of human life in any terms other than economic productivity .
have gotten into a productive routine that helps us ignore them. I actually feel sorry for Ezekiel

How sad that he does not cherish the rich dimensions the elderly add to our lives. We learn from their experiences,
their faith, and, yes, even their suffering. The question before us in American health care policy is whether or not
we will value each human life from the moment of conception to the moment of natural death and treat each

will we follow the utilitarian approach and declare

whole classes of the population as economically unproductive and therefore
unworthy of medical care?
individual according to his individual needs. Or,

Social injustices worsen health- recognizing human rights is a

step in the right direction that allows us to make effective
policy changes
Childress 2 (James Childress. University Professor and the John Allen
Hollingsworth Professor of Ethics at the University of Virginia. Public Health Ethics:
Mapping the Terrain. 2002. P. 177. file:///C:/Users/Emily/Downloads/Childress_et_al2002-The_Journal_of_Law,_Medicine_&_Ethics.pdf)//EMerz
We have noted potential and actual conflicts between promoting the good of public
health and other general moral considerations. But it is important not to exaggerate
these conflicts. Indeed, the societal institutionalization of other general moral
considerations in legal rights and social-cultural practices generally contributes to
public health. Social injustices expressed in poverty, racism, and sexism
have long been implicated in conditions of poor health. In recent years, some
evidence suggests that societies that embody more egalitarian conceptions of
socioeconomic justice have higher levels of health than ones that do not.20 Public
health activity has traditionally encompassed much more than medicine and health
care. Indeed, historically much of the focus of public health has been on the poor
and on the impact of squalor and sanitation on health. The focus today on the social
determinants of health is in keeping with this tradition. The data about social
determinants are impressive even though not wholly uncontroversial. At any rate,
they are strong enough to warrant close attention to the ways conditions of social
justice contribute to the publics health. Apart from social justice, some in public
health argue that embodying several other general moral considerations, especially
as articulated in human rights, is consistent with and may even contribute to public
health. For example, Jonathan Mann contended that public health officials now have

two fundamental responsibilities - protecting and promoting public health and

protecting and promoting human rights. Sometimes public health programs
burden human rights, but human rights violations have adverse effects
on physical, mental, and social well-being and promoting and protecting
human rights is inextricably linked with promoting and protecting
health.2 Mann noted, and we concur, that, ultimately, ethics and human rights
derive from a set of quite similar, if not identical, core values, several of which we
believe are captured in our loose set of general moral considerations.22 Often, as
we have suggested, the most effective ways to protect public health respect
general moral considerations rather than violate them, employ voluntary measures
rather than coercive ones, protect privacy and confidentiality, and, more generally,
express rather than impose community. Recognizing that promoting health and
respecting other general moral considerations or human rights may be mutually
supportive can enable us to create policies that avoid or at least reduce conflicts.
While more often than not public health and human rights - or general moral
considerations not expressed in human rights - do not conflict and may even be
synergistic, conflicts do sometimes arise and require resol~tion.~~ Sometimes, in
particular cases, a society cannot simultaneously realize its commitments to public
health and to certain other general moral considerations, such as liberty, privacy,
and confidentiality. We have tried to provide elements of a framework for thinking
through and resolving such conflicts. This process needs to be transparent in order
to engender and sustain public trust.

Disease Outweighs
Disease is the greatest impact- more people die from disease
than all wars combined- disease spread is the root cause of
structural prejudice and the biggest threat to security
Selgelid 9 (M.J. Selgelid. Center for Applied Philosophy and Public Ethics (CAPPE),
The Australian National University, Canberra, Australia. Public Health: Pandethics.
2009. http://www.sciencedirect.com/science/article/pii/S0033350608003314)//EMerz
The ethical importance of infectious diseases is partly revealed by the fact
that their consequences are almost unrivalled.1 Historically, they have
caused more morbidity and mortality than any other cause, including
war.2 The Black Death eliminated one-third of the European population over the
course of a few years during the mid 14th Century; tuberculosis killed 1 billion
people from 1850 to 1950; the 1918 flu killed between 20 and 100 million people;
and smallpox killed between 300 and 500 million people during the 20th Century
alone, i.e. three times more than were killed by all the wars of that period.
Infectious diseases are currently the biggest killers of children and young adults,
and the continuing threat of infectious diseases is revealed by the emergence of
many new infectious diseases during recent decades [including human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), Ebola,
severe acute respiratory syndrome (SARS) and avian influenza], the growing
problem of drug resistance and the spectre of bioterrorism. Second, infectious
diseases raise difficult ethico-philosophical questions of their own. Although
measures such as surveillance, mandatory treatment and vaccination, isolation and
quarantine may sometimes be important to the protection of public health, they
may each involve infringement of basic rights and liberties, i.e. the right to privacy,
informed consent to medical intervention, and freedom of movement. Given that
most deny that either the goal to promote public health or the goal to protect
individual rights and liberties should always take absolute priority over the other, a
difficult ethical question is how to strike a balance between these two types of goals
in cases of conflict. Third, the topic of infectious disease is closely connected to the
topic of justice. Malnutrition, dirty water, overcrowded living and working conditions,
lack of sanitation and hygiene, poor education, and lack of access to health care
make poor people more likely to become infected and more likely to suffer poor
outcomes when infection occurs. As bad health, in turn, exacerbates poverty, a
vicious cycle promotes both poverty and disease. Fourth, infectious diseases are
prone to promote fear, panic, stigma, discrimination, and emotional and
irrational decision and policy making. Fifth, and finally, infectious diseases
pose threats to security. Security dangers are associated with fast-moving
infectious disease outbreaks that overwhelm response capacity and cause
chaos. In 2007, the World Health Organization described pandemic influenza as
the most feared security threat,8 and former US President George W. Bush
suggested that a military response may be necessary in the event of a flu
pandemic. Security may also be jeopardized for economic reasons in the case of

slower-moving epidemics. HIV/AIDS, for example, has brought numerous African

societies to the verge of economic collapse. Historical studies reveal that factors
such as high infant mortality, low life expectancy and decreasing life expectancy
especially salient in sub-Saharan Africa at present, largely as a result of HIV/AIDS
are among the most reliable indicators of societal upheaval.

Prefer a focus on non-communicable chronic diseases

Zarocostas 10 (John Zarocostas is a Geneva-based independent international correspondent and
broadcaster, with more than 20 years experience in covering international global issues, including world health,
development and humanitarian issues. His news dispatches have been published in The Lancet, The BMJ, McClatchy
Newspapers, the International Herald Tribune, The National Law Journal, The New York Times, The Straits Times,
Lloyd's List, The Canberra Times, The Globe & Mail, The Times, The Irish Times,The Journal of Commerce, and the
South China Morning Post. Need to increase focus on non-communicable diseases in global health, says WHO
http://www.bmj.com/content/341/bmj.c7065)///CW

Governments worldwide need to increase the priority given to fighting noncommunicable diseases especially in the poorest nations, the World Health Organization says. The sense
of urgency by WHO is driven by the high and projected increases in the prevalence rates of noncommunicable diseasescardiovascular diseases, cancers, diabetes, and chronic lung diseases. These
four major groups of diseases share four risk factorstobacco use, unhealthy diet, physical inactivity, and the
harmful use of alcohol. Ala Alwan, WHOs top official for non-communicable diseases and mental health, said, The
reason for the focus on these four major group of diseases is because they are responsible for about 80-85% of
mortality due to chronic diseases, and because they also share the same risk factors. Dr Alwan told reporters the

magnitude is increasing globally. Non-communicable diseases are currently

responsible for 60% of all deaths, or more than 35 million deaths every year, of which 80% occur in low
and middle income countries. Up to 25% of deaths from non-communicable diseases occur in people under 60
years of age, he said. They are not only an enormous health problem, but they are also a problem that has very
negative socioeconomic consequences, he added. Dr Alwan said that according to mortality estimates in all
regions except Africa more than 50% of deaths are caused by non-communicable diseases and among these, the
leading cause of death is cardiovascular disease. The WHO predicts that global mortality from non-communicable
diseases will increase by 17.6% during 2006 to 2015; by more than 24% in some regions such as Africa, and by

treatment and health care for people with

non-communicable diseases is also expensive , and increasing, Dr Alwan said. In poor
populations a substantial proportion of families with a relative with cancer or heart
disease will experience catastrophic expenditure , which will drive the family below the poverty
23% in the Western Pacific and South East Asia. The

line. We see higher levels of risk factors like tobacco, and overweight and obesity in the lower social-economic
class[es] and we also see the highest prevalence of diabetes occurring in developing populations, he said. Dr
Alwan, a former minister of health of Iraq, also highlighted that

non-communicable diseases are

largely preventable if we address risk factors with tobacco control, address unhealthy diet and physical
inactivity. He said international efforts to implement a global strategy to control and prevent non-communicable
diseases is leading to the development of indicators similar to the millennium development goals together with a
monitoring mechanism. Greater priority needs to be given to non-communicable diseases
in health and broader development agendas, he said. Dr Alwan added that the private sector, including the food
and beverages industries, also has to provide some solutions. These include responsible marketing, especially for
children, and a greater emphasis on more healthy products.

Prefer chronic disease media creates a bias toward ISIS and

nuclear war
Fisher 14 (Max Fisher is a writer at Vox, Threats to Americans, ranked (by actual threat instead of media
hype 8/17/14 http://www.vox.com/2014/10/17/6988377/threats-to-americans-ranked-ebola-isis-russiafurniture)///CW

Americans are inundated with media coverage and politicians warning them of dire
threats: Ebola, the Islamic State of Iraq and Syria (ISIS), the war on Christmas. The truth, though, is that
the most-hyped threats are often not actually that threatening to Americans, while
larger dangers go mostly ignored. That should tell you something about how our political system and
media can distort threats, leading Americans to overreact to minor dangers while ignoring the big, challenging,
divisive problems like climate change that we should actually be worried about. An actual poll featured on

Obsessing about possible threats is something of a beloved

national past-time here in America, which is objectively one of the safest places on
Earth, so we want to help you do it right. Here, then, is a highly un-scientific and incomplete ranking of threats to
Fox News (Nick Martin)

the United States sorted by the current danger to Americans, worst-case danger to Americans, and how freaked
out you should be. 9) Ebola Threat to Americans: If you are an American in West Africa in close proximity with
Ebola victims, the threat is moderate. If you are an American health worker in the US assisting an Ebola victim or
someone who frequently comes into physical contact with one, the threat of infection is minor if you use proper
protective equipment. Otherwise, the threat is pretty close to zero. Worst-case scenario: The outbreak could get
much worse in West Africa, but even in that scenario the disease will remain unlikely to affect many Americans
outside of the region. How freaked out should you be: If you have loved ones in Liberia, Sierra Leone, or Guinea, it
is not unreasonable to urge them to take all possible precautions. Otherwise, you would do better to worry about
the other items on this list. A health worker demonstrates Ebola treatment practices in London (Dan
Kitwood/Getty) 8) Your own furniture Threat to Americans: According to a report by the Consumer Product Safety
Commission, just under 30 Americans are killed every year by "tip-over," which is when "televisions, furniture, and
appliances" fall onto their owners. The report also found that over 40,000 Americans receive "emergency
department-treated injuries" from tip-over every year. Worst-case scenario: This is America. We can always find
ways to make a bigger, heavier, deadlier TV. How freaked out should you be: Council on Foreign Relations scholar
Micah Zenko found that tip-over kills about as many Americans per year as terrorism does, and injures many more.
In theory, then, you should be just as freaked out by tip-over as you are by terrorism. Based on the fatality rate, you
should be much more freaked out about tip-over than you are about Ebola. 7) ISIS Threat to Americans: Presently,

ISIS has no demonstrated intent

or capability to launch such an attack. And since 2001, the US has gotten much, much
better at preventing terror plots. Worst-case scenario: ISIS does control a giant stretch of territory,
the threat to Americans outside of Iraq and Syria is extremely low, as

boast thousands of fighters (some with Western passports), earn lots of oil revenue, and field heavy US-made
weapons seized from the Iraqi army. Oh, and it now has access to rotting but still-deadly chemical weapons. They
could decide to use those resources to try to attack the US, or could allow other terrorists to use their territory as a
safe haven. How freaked out should you be: Not very. If ISIS decides to turn its attention to attacking the US, the
prospect it might succeed is real, but remote. And even if it did pull off a successful attack, it would almost certainly
kill only a small fraction of the number of Americans that guns and cars are virtually certain to kill every single
year. Smoke from a battle between Iraqi Kurds and ISIS (SAFIN HAMED/AFP/Getty) 6) The flu Threat to
Americans: The flu kills thousands of Americans every year, many times more people than Ebola. The elderly and
infirm are especially at risk. Worse-case scenario: An especially bad outbreak in 2004 killed 48,000 Americans.
How freaked out should you be: If you're elderly, very young, or immunosuppressed, you should get a flu shot or
nasal spray immediately. (Even if you're not, you should still get off your lazy butt and get a flu shot, unless you are
some kind of monster who doesn't care about herd immunity.) But if you're young and otherwise healthy, you'll

No
one wants a global thermo-nuclear war between the West and Russia, including Vladimir Putin.
probably be fine even if you do catch the flu. 5) World War III breaking out in the Baltics Threat to Americans:

But his meddling in Baltic NATO countries like Estonia, which the US and Western Europe are committed to defend,
could inadvertently trigger what we avoided throughout the Cold War: open military conflict between the major
nuclear powers. Both Putin and President Obama have threatened as much to try to scare one another out of acting
aggressively. Worst-case scenario: Russia does in Estonia what it did in Ukraine, that snowballs into war between
Russia and the US/NATO, and the nukes start falling. How freaked out should you be: To be very clear:

the odds

of this happening are extremely low. But the danger is real enough that everyone is taking it seriously
(Russia is holding major nuclear exercises). If it did happen, it would be many, many times worse than every other
item on this list combined. Russian tanks in a military parade in St. Petersburg (OLGA MALTSEVA/AFP/Getty) 4)
Climate change Danger to Americans: Potentially dire. The greatest near-term harm may be from a rise in extreme
weather events. Over the next 100 years, that could include deadly heat waves, droughts, flooding, and a rise in
sea levels that would affect coastal cities. Worst-case scenario: The world is trying to limit the global temperature
rise to 2C, because any more than that is considered dangerous. A temperature rise of 4C would cause
"substantial species extinctions" and "large risks to global and regional food security," as well as rising sea levels,
according to the Intergovernmental Panel on Climate Change. In other words, a total catastrophe. How freaked out
should you be: If you care about the world your kids and grandkids will grow up in, pretty freaked out. Averting
disaster requires immediate, massive, global cuts to carbon emissions. With the US and China particularly dragging

their feet, it may simply be too late. 3) Guns Danger to Americans: Guns kill more than 30,000 Americans every
year, about as many deaths as caused by motor vehicles. But only about one in three of those deaths is a homicide.
A few thousand are from accidents but most are due to suicide. Worst-case scenario: We have already chosen to
live in a society with the world's highest gun ownership rate and some of its loosest gun control laws, so the worstcase scenario is pretty much here. Still, gun deaths per year are on the rise. How freaked out should you be: It all
depends on whether you see America's uniquely permissive gun laws as worth the trade-off. But you and, yes,
your children are at risk, regardless of your views about gun regulations. A customer inspects a totally legal
AR-15 assault rifle at a gun store in Wendell, North Carolina (Chuck Liddy/Raleigh News & Observer/MCT via Getty)
2) Traffic accidents Danger to Americans: Very high. About 34,000 deaths in 2011 (the last year with complete
data), more than one in four of all deaths related to unintentional injures. Worst-case scenario: Drunk driving. Don't
do it. How freaked out should you be: The motor vehicle death rate is declining, but getting in your car is still

1) Heart disease and cancer (tie) Danger to Americans: The

number-one and number-two killers in the US, collectively responsible for just over
50 percent of all American deaths. Worst-case scenario: These could become even
deadlier as Americans get unhealthier. Heart disease correlates with rising obesity.
Cancer rates also correlate with obesity, smoking, and other unhealthy practices .
dangerous. Stay alert and don't drink.

How freaked out should you be: The odds are that one of these two things will kill you, so you should be thinking

it's pretty easy to reduce that risk by making healthy lifestyle

choices and screening regularly for cancer. Much easier for any given American, at least, than
about this. The good news:

combatting West African Ebola outbreaks or Middle Eastern terrorist groups.

Extinction- engineered pathogens

Sandberg, 8 -- Oxford University Future of Humanity Institute research fellow
[Anders, PhD in computation neuroscience, and Milan Cirkovic, senior research
associate at the Astronomical Observatory of Belgrade, "How can we reduce the risk
of human extinction?" Bulletin of the Atomic Scientists, 9-9-2008,
thebulletin.org/how-can-we-reduce-risk-human-extinction, accessed 8-13-14]
The risks from anthropogenic hazards appear at present larger than those from
natural ones. Although great progress has been made in reducing the number of
nuclear weapons in the world, humanity is still threatened by the possibility of a
global thermonuclear war and a resulting nuclear winter. We may face even greater
risks from emerging technologies. Advances in synthetic biology might make it
possible to engineer pathogens capable of extinction-level pandemics. The
knowledge, equipment, and materials needed to engineer pathogens are more
accessible than those needed to build nuclear weapons. And unlike other
weapons, pathogens are self-replicating, allowing a small arsenal to become
exponentially destructive. Pathogens have been implicated in the extinctions of
many wild species. Although most pandemics "fade out" by reducing the density
of susceptible populations, pathogens with wide host ranges in multiple species
can reach even isolated individuals. The intentional or unintentional release of
engineered pathogens with high transmissibility, latency, and lethality might be
capable of causing human extinction. While such an event seems unlikely today,

the likelihood may increase as biotechnologies continue to improve at a rate rivaling

Moore's Law.

Emerging diseases and bioterrorism are comparatively the

largest impact
Milne 4 Formerly a practicing veterinarian in New Jersey and Maryland, Dr. Milne
attended Johns Hopkins University in 1987-88 where he earned a master's degree in

public health with a concentration in epidemiology. For six years, he worked for the
New Jersey Department of Health in risk assessment as well as legislative and
regulatory review, and finally served as Emergency Response Coordinator. Dr. Milne
joined Tufts University's Center for the Study of Drug Development in 1998 as a
Senior Research Fellow, after graduation from law school. His research interests
include the evaluation of regulatory initiatives affecting the pharmaceutical and
biotechnology industries, and incentive programs for the development of new
medicines for neglected diseases of the developing world. Dr. Milne is currently
Assistant Director at the Center and a member of the bar in New Hampshire
(Christopher, Racing the Globalization of Infectious Diseases: Lessons from the
Tortoise and the Hare, 11 New Eng. J. Int'l & Comp. L. 1)
Although we have faced planet-killing events such as nuclear brinkmanship during the Cold War and megameteors colliding with earth in pre-history, the most imminent threat is one we face everyday from the
globalization of infectious diseases. Leading authorities in government, medical institutions, and schools of public health have
been ringing the warning bell for over a decade about the major threats to global public health. 2Link to the text of the note Threats such as

infectious diseases in the developing world, drug resistant bacteria, and the problem of multiple HIV
strains, remain unaddressed. The public health community lacks answers to key scientific questions for an AIDS vaccine, and needs
to press harder on research for a tuberculosis (TB) vaccine, a process which could take twenty to fifty years. 3Link to the text of the note Experts
believe that the threat warning level has risen from orange to red , comparing the
circumstances favoring a pandemic today to the "Perfect Storm," due to the continuing increase of
worldwide antimicrobial resistance, diminished U.S. capacity to recognize and respond to microbial threats,
and the likelihood of intentional releases of biological agents . The sources of this public health challenge derive from
a panoply of emerging and re-emerging natural plagues, thirty of which have been recognized just in the last few decades with thirteen occurring in North
America. 4Link to the text of the note According to Anthony Fauci, Director of the National Institutes [3] of Allergies and Infectious Diseases (NIAID),
emerging diseases are defined as ones that have not been previously recognized, such as acquired immunodeficiency syndrome (AIDS) or severe acute
respiratory syndrome (SARS). Comparatively, re-emerging disease has usually been in existence for a long time but has changed location, as did the West
Nile Virus. Dr. Fauci considers bioterrorism to be a part of the continuum of emerging and re-emerging diseases, and points out that when it comes to

Infectious diseases with the potential

to be global killers come in two basic forms: the "slow epidemic," taking months or years to reach pandemic status,
with an insidious onset and long latency, that resists treatment - the archetypical example being AIDS, 6Link to the text of the note and the
"fast epidemic," rapidly spreading from country to country , typically aerosol-borne, with
fairly quick onset, and high mortality and morbidity - most recently manifested in pandemic SARS. 7Link to the text
of the note Both forms have potential uses as bioweapons , although most of the counter-terror attention focuses on the
bioterror: "The Worst Bioterrorist May be Nature Itself." 5Link to the text of the note

SARS-like diseases. Part II of this article will discuss the scenarios for a global pandemic presented by SARS, AIDS, or bioweaponized incarnations - what
they have done, what they could do, and why it is so hard to stop them. Part III will describe the scope of the public health problem, particularly the
globalization factors that serve as enablers of the pandemic potential of these diseases, as well as a host of ill-defined "x" factors that have served to
further complicate the dynamics of dealing with these global killers. Part IV will consider solutions to the problem by discussing what we have versus what
we need. Part V will present recommendations for how government, pharmaceutical and biotechnology industries, as well as international nongovernmental organizations can be part of the solution. Lastly, Part VI provides a conclusion. "Ring around the rosie, pocket full of posies, Ashes, ashes we all fall down!" - According to legend, a children's rhyme dating from the time of the plague in medieval Europe. II. Scenes from a Plague SARS has
been compared to the bubonic plague of the Middle Ages, but the Black Death was not a "fast epidemic" due to the limitations of its [4] mode of
transmission, as well as the modes of medieval transportation. While SARS is somewhat comparable to flu epidemics of the last century and to the
putative bioterror agents of today, AIDS has the dubious distinction of being closer to the experience of the Black Death. However, unlike that ancient
pandemic, which was more limited temporally and geographically, AIDS is embarking upon what, Dr. Peter Piot, executive director of UNAIDS, refers to as a
"true globalization phase." 8Link to the text of the note A. Black Death Redux The superlatives used to describe the public health impact of AIDS never
seem to be exhausted. One commentator noted that AIDS will soon exceed the death toll of the Bubonic Plague, making it the most "numerically lethal
pandemic" the world has ever known. 9Link to the text of the note The World Health Organization (WHO) refers to it more prosaically, but with similar
notoriety, as the "toughest health assignment the world has ever faced." 10Link to the text of the note Even after twenty years, AIDS is still something of a
medical and scientific conundrum. Diversity of the virus increases with duration of infection, further complicating drug treatment. 11Link to the text of the
note Vaccine development is similarly complicated due to existence of ten major genetic types or clades of HIV-1, each with a distinct geographical
spread. 12Link to the text of the note What we do know is that AIDS is caused by an infection with the human immunodeficiency virus (HIV), transmitted
through unprotected sex, sharing hypodermic needles, transfusions of contaminated blood, or from mother to child during pregnancy, labor, delivery, or
breast-feeding. The virus attacks the immune system by infecting white blood cells, known as CD4+ cells, making it difficult for the body to fight off
infections. AIDS itself is considered the final stage of HIV disease. 13Link to the text of the note Without treatment, HIV will progress to full-blown AIDS
within nine to eleven years, and is usually fatal within two years after that point. 14Link to the text of the note The AIDS/HIV toll is [5] approaching forty
million infected, with fourteen thousand new infections daily and ninety-five percent of new infections occurring in the developing world. 15Link to the text
of the note What we do not know is just how soon and how much of an impact AIDS will have. In sub-Saharan Africa, only an estimated ten percent of the
predicted illness and death has occurred; the full impact on people, communities, and economies is still to come. 16Link to the text of the note
Nonetheless, one forecast is that seventy million will die of AIDS by 2020, mostly in Africa and Asia. 17Link to the text of the note Besides its own deathdealing impact, AIDS exacerbates the morbidity and mortality of other "slow epidemics" like malaria and tuberculosis, and drains resources that would
otherwise be dedicated to their treatment. 18Link to the text of the note By 2010, a report by the Central Intelligence Agency (CIA) states that five

countries - Nigeria, Ethiopia, Russia, India, and China - will suffer a total of fifty to seventy-five million cases of HIV/AIDS. 19Link to the text of the note For
a preview of the AIDS wasteland that faces us without a serious course change, consider the devastation wrought by AIDS on Botswana. Before the AIDS
epidemic reached Botswana in the early 1990s, per-capita income had risen tenfold over the previous thirty years, primary school enrollment had doubled,
and infant mortality had decreased almost threefold. A decade after AIDS swept over the land, thirty percent of the country's economic growth was erased
and the number of years each citizen is expected to contribute to the economy has been reduced from fifteen-to-thirty productive years to just five.
Moreover, one-fifth of Botswana's children will soon be AIDS orphans. 20Link to the text of the note Botswana now has the lowest life expectancy of any
country in the world at 30.8 years of age, which is about three times less than the highest life expectancy of 83.5 years in the European nation of Andorra.
21Link to the text of the note At the current pace, close to [6] fifty percent of the world's population could live in countries gripped by the AIDS pandemic
by the end of the decade. B. Cold Virus on Steroids The official acronym for severe acute respiratory syndrome is SARS-CoV, which derives from the fact
that it is a coronavirus, the same family of viruses that cause the common cold. However, SARS acts more like a cold virus pumped up on anabolic
steroids. According to statistics, the recent outbreak of SARS was both debilitating and deadly: eleven percent of its victims died; sixty percent required
hospitalization; twenty to thirty percent needed treatment in intensive care units with intubations; six to twenty percent suffered respiratory sequelae; and
thirty to sixty percent experienced post-traumatic stress. 22Link to the text of the note Ultimately, the SARS pandemic led to ten billion dollars in
economic losses. 23Link to the text of the note The SARS incubation period is typically six days, but can range anywhere from two to twenty days. SARS
is more environmentally stable than other respiratory viruses. However, unlike most respiratory viruses the role of seasonality is unknown, noting that
most respiratory viruses are winter creatures. SARS is primarily transmitted by respiratory droplets or fomites (i.e., inanimate objects or substances that
transfer an infectious agent), in health care and hospital settings, but also by contaminated sewage. Old age and co-existing illness are contributory
factors to SARS, but children tend to contract a more mild form of the illness. SARS is believed to be of an animal origin, but unlike most other species
jumpers, SARS has also become efficient at human-to-human transmission. 24Link to the text of the note Although we are still learning from the SARS

animal pathogens pose major risks;

pandemic, some lessons are clear:

a problem in a remote area can become a world
problem within weeks; molecular virology can identify and sequence genetic structures of new pathogens within weeks; the epidemiological tracks of a
disease can be followed even in remote areas; basic infection control measures work well; and the phenomena of the superspreader (i.e., an infected
person responsible for a disproportionate number of transmissions), airborne transmission, and heightened risk to health care workers (i.e., twenty-one
percent of SARS infections were in health care workers 25Link to the text of the note) complicate control efforts. 26Link to the text of the note Another
lesson is that [7] humans can be the worst enemy regarding transmission. Four SARS outbreaks occurred within one year in Singapore, Taipei, and Beijing
from laboratory accidents. 27Link to the text of the note The loose ends that dangle perilously from the tail of the SARS epidemic caused one SARS
researcher to remark ominously: "this is not the end of the story ." 28Link to the text of the note C. Black Wind of Death A warning on a radical Islamic
fundamentalist website stated that a "Black Wind of Death" would soon be visited upon the enemies of Islam. Some believe that this statement refers to
the use of a bioweapon. A conservative estimate of the number of naturally occurring potential bioterror agents is about seventy to eighty, but the
possibilities for genetically engineered pathogens are practically limitless. In fact, the pioneers of the Soviet bioweapons program were able to refine the
"binary inoculary," in which treatment of the first microbe would set off infection with a more deadly second microbe. The combinations were limitless, but
the results were always the same - the ultimate nightmare. For example, if a person contracts a dreaded disease, such as the plague, and is treated with
tetracycline, the treatment may unleash a second disease lying dormant, such as Ebola, for which there is no cure. The question remains: How much
lethal know-how is out there? In the 1980s, the Soviets' bioweapons industry employed about sixty thousand people, half of whom were scientists. In the
past thirty years, critical masses of two to three thousand new pathogens have appeared; some developing from nature and some designed in the lab, but
not always as bioweapons. Fully mapping and understanding the complex interactions of hosts and pathogens for the known biological entities that could
be weaponized would take decades. 29Link to the text of the note D.A. Henderson, senior advisor for the Center for Biosecurity at the University of
Pittsburgh, framed this problem: "Like it or not, I'm afraid the threat is with us forever." 30Link to the text of the note [8] "Globalization, after all, is
fundamentally about market expansion, the rise of new political, social, and cultural movements, and changes in the state and institutions." - Hitchner,
Tufts University III. Scope For better or worse, globalization is also about public health. The scope of the public health challenge faced today must now

globalization, public health must also

be taken into account. This is especially true for infectious diseases, as West Nile virus,
monkey pox, SARS, avian flu, and antibiotic-resistant bugs are only the beginning. According to one
be considered within the context of other globalization factors. Just as addressing the problems of

expert, "the new normal" has become a public health problem uniquely created by globalization. 31Link to the text of the note A. The Global Village: A
Good Place to Raise Deadly Offspring 1. The Urbanization Triplets: Crowding, Poverty, and Destruction of Habitat Certain sequelae of globalization have
been identified as facilitating the spread of global infectious diseases. Urbanization, which is defined as rapid population growth in the cities, especially in
tropical and subtropical areas in less developed countries, results in large populations coming into closer contact with one another, increasing the
probability of infectious diseases. Urbanization is also characterized by poverty and poor sanitation. 32Link to the text of the note Poverty is considered
both a cause and an effect of widespread disease. For instance, poverty often results in malnutrition, which in turn weakens the population's ability to fight
off diseases, such as malaria. Malaria can cause the deaths of up to half of a million children per year in sub-Saharan Africa alone, resulting in a loss of one
percent of the region's GNP. 33Link to the text of the note Urbanization and poverty also contribute to overcrowding in hospitals and health care facilities,
which then leads to a struggle with sterilization and isolation procedures. Cross-contamination through blood and instruments occurs more readily. Due to
the favorable environment, microbes increase in number and become more diverse through mutations. If a virulent "bug" pops up, it has a good chance of
becoming established quickly. Urbanized areas are often large population centers and are served by [9] modern transportation routes. Once an individual
becomes infected, they are only a plane ride away from anywhere in the world. 34Link to the text of the note Urbanization also causes destruction of
natural habitats, resulting in the release of previously unknown infectious diseases. Many such diseases have been unleashed by the increased human
contact with animal reservoirs, due to altered land-use patterns and changing movement of animal and human populations. 35Link to the text of the note
In fact, many of the thirty or so new pathogens recognized in the past three decades originated in animals. 36Link to the text of the note 2. The "T-way"
of Global Plague Through the pathways provided by the "3Ts" of globalization -

paved the way for pandemics

travel, trade, and tourism - humans have

inadvertently
. Two million people travel internationally everyday, 37Link to the text of the note with
approximately five hundred million traveling by commercial airlines every year, 38Link to the text of the note and millions of tons of food, hazardous
materials, and waste in transport daily. 39Link to the text of the note With international travel increasing by fifty percent each decade, the prospects of
containing new outbreaks of disease are diminishing. 40Link to the text of the note We are no longer protected by formerly formidable natural barriers like
oceans, and even less so by artificial barriers, such as political borders. B. The "X" Factors: The Known, the Unknown, and the Unknowable The factors
discussed are complex and their impacts are still under study, but to some degree, they are "known" factors that are quantifiable in the calculus of
planning for the future. There are also a number of biological, environmental, socioeconomic, cultural, legal, and political factors that continue to crop up
in unpredictable manners. Some were previously unknown but have been factored into the problem equation. Others seem to be so random in occurrence
and incalculable as to outcomes [10] that the ultimate impacts remain "unknowable." 1. Microbial Resistance Resistant strains to antibiotics developed
within a few years of the discovery of antibiotics some fifty years ago. However, according to the United States Food and Drug Administration (FDA), the
difference now is that resistance is no longer an isolated problem, especially in hospitals. 41Link to the text of the note For example, in the United States,
about seventy percent of bacteria causing infections in hospitals are resistant to at least one of the most common drugs used to treat them. 42Link to the
text of the note In the United Kingdom, the infection rate for methicillin-resistant Staphylococcus aureus, a common hospital contaminant, has risen sixhundred percent over the last ten years. 43Link to the text of the note The WHO warned that due to the overuse of antibiotics in rich countries and the
under use in poor countries, drug resistance is a worldwide problem. The result is wasting of billions of dollars that could have been better spent on
research and development (R&D) for infectious disease treatments over the last few years. 44Link to the text of the note Antibiotics are not the only
medicines with resistance problems. The main drugs used to combat AIDS, the so-called anti-retrovirals (ARVs), are also a source of concern. A recent
study showed that ten percent of all newly infected patients in Europe 45Link to the text of the note are infected with drug-resistant strains. In San
Francisco, the rate is twenty-seven percent. 46Link to the text of the note According to a recent survey of infectious disease specialists in the U.S., only
forty-one percent of patients are able to be treated with the most commonly used ARV regimen, while another forty-five percent are on back-up regimens.
For fourteen percent of infected patients, treatment with ARVs has all but failed. 47Link to the text of the note [11] Experts agree that resistance is also a

problem in the developing world, 48Link to the text of the note further complicated by factors such as counterfeit drugs, irregular access to treatments,
environmental degradation, inconsistent compliance, and diversion of drugs to the black market. 49Link to the text of the note 2. Sociocultural None of
the problems associated with the globalization of infectious diseases seem to be confined to one part of the world. For instance, half of reported polio
cases worldwide occurred in Nigeria, due to disruption of vaccination efforts. This interruption stemmed from a rumor that the United States government
was clandestinely implementing population control by adding contraceptives to the vaccine. 50Link to the text of the note In the U.S., a surgeon recently
reported that a several-year-long effort to convince a hospital staff to regularly use a sixty percent alcohol gel for hand disinfection was almost thwarted
by a rumor that the gel would reduce fertility. 51Link to the text of the note Actions taken by the general public are often at cross-purposes with actions
taken to protect the public health. One of the most crucial problems involved with tackling AIDS in the developing world is the extreme fear and social
stigma associated with the disease. These sentiments are exemplified by violence and abuse against woman in Africa 52Link to the text of the note and
discrimination against HIV patients by their own families and hospitals in India. 53Link to the text of the note In the U.S., the population is so risk-averse
that the construction of three Biosafety Level Four labs in California, Texas, and Massachusetts are being vigorously disputed by residents. 54Link to the
text of the note [12] 3. Legal The criminal element always seems to find a way to further complicate an already complicated situation, which is not
dissimilar to opportunistic infections. Up to ten percent of the world's drug supply is counterfeit, and may be perhaps as high as fifty percent in many
developing countries. 55Link to the text of the note Diversion of medicines to the black market is most common in certain parts of the developing world,
but occurs universally. Serostim, a growth hormone prescribed to fight wasting syndrome in AIDS patients, has found an underground recreational use as a
bodybuilding drug in the United States. The drug costs about eighty thousand dollars for a year's supply, often paid for by Medicaid, but on the black
market, it can fetch two thousand dollars for a week's supply. 56Link to the text of the note Even a new disease, such as SARS, did not take long to
develop a criminal element. In May 2002, the FDA issued a special alert regarding internet marketing of bogus SARS prevention products. 57Link to the
text of the note In addition to violations of the law, tensions exist within the law as well. The needs of bioscience and the concerns for biosecurity are
often adverse. The regulations for "select agents" are so confusing that one researcher was reportedly arrested simply because he traversed a room where
a select agent was stored. 58Link to the text of the note Such incidents are one reason why an international group of scientists seeks to keep SARS off the
select agents list, arguing [13] that restrictions would stifle research and hurt public health efforts. 59Link to the text of the note However, other experts
acknowledge that the transfer of knowledge among scientists is often a leaky process, and scientists may become unwitting accomplices to global
bioterror. 60ALink to the text of the note careful balance must be struck between freedom in research endeavors and controls designed to prevent the
misuse of material and knowledge. 61Link to the text of the note Conflicts of law also exist between public health and privacy. Due to the evolving nature
of the newly implemented medical privacy regulations under the Health Insurance Portability and Accountability Act (HIPAA), 62Link to the text of the note
state health officials believe themselves to be limited in releasing information regarding deaths from the flu or other reportable diseases, due to new legal
protections afforded to patients. However, HIPAA contains a public health exception, and most officials argue that releasing certain information is required
by state public health laws to provide information about risk factors that the public should be aware of. 63Link to the text of the note The United States
Security and Exchange Commission (SEC) has become embroiled in this problem as well. SEC regulations are an issue, not only due to antitrust laws
prohibiting collaboration on countermeasures by "competing" companies, 64Link to the text of the note but also due to accounting regulations that
determine when a company can recognize revenue from a stockpile. Under the current scheme, the United States Department of Health and Human
Services (HHS) plans to purchase vaccines, but have companies store them until needed to avoid additional cost and logistical problems for HHS. Problems
then arise under current SEC regulations, as entities may not declare revenue from undelivered products. 65Link to the text of the note [14] 4. The

Global infectious disease, bioterror, and national security are becoming

strange bedfellows. The HHS Secretary announced in the fall of 2003 that grants totaling 350 million dollars over five years would be made
Ultimate "X" Factor

available for the establishment of eight Regional Centers of Excellence for Biodefense and Emerging Infectious Diseases Research (RCEs), stating: "These
new grants add to this effort and will not only better prepare us for a bioterrorism attack, but will also enhance our ability to deal with any public health
crisis, such as SARS ." 66Link to the text of the note Concern regarding the public health crisis precipitated by SARS was believed to have caused some
"holdouts" waffling on support of Bioshield to come on board. 67Link to the text of the note The President of the Association of State and Territorial Health
Officials believes that the infusion of dollars into bioterrorism awareness has helped to improve the public health system capacity to deal with health
emergencies in general. 68Link to the text of the note Internationally, the Security Council of the United Nations (UN) discussed a health issue for the
first time as a threat to world stability: HIV/AIDS in Africa. 69Link to the text of the note The African, Caribbean, and Pacific Ocean sectors of the World
Trade Organization (WTO) petitioned the WTO's Council for Trade-Related Aspects of Intellectual Property Rights (TRIPS) to find a solution to the deadlock
over access to affordable drugs, as the outbreak of diseases such as SARS had made it "a matter of urgency." 70Link to the text of the note The deadlock
was broken. In a report by the United States National Intelligence Council, experts emphasized the worldwide threat presented by infectious disease to
military capacity, socioeconomic development, international trade and travel, and global stability. 71Link to the text of the note [15] However, common
goals can sometimes result in competition instead of cooperation when time, money, and resources are limited. The media reported that National Institute
of Health (NIH) studies on AIDS, TB, malaria, and other infectious diseases would be shortened in length due to a White House mandate shifting funding to
development of an anthrax vaccine. 72Link to the text of the note While the NIAID budget grew twenty-fold from 1980 to 2004, the increase was mainly
due to efforts to combat changing priorities of life-threatening infectious diseases, such as AIDS in the 1990s and bioterror in the 2000s. 73Link to the text
of the note In fact, the NIAID budget allotment for AIDS R&D has flat lined for 2002 through 2005, while the biodefense budget went up from $ 200 million
in 2002 to $ 1.6 billion slated for 2005. 74Link to the text of the note In a survey of nearly four hundred scientists, forty-six percent felt that government
spending on bioterror R&D diverts monies from more important investigative work. 75Link to the text of the note Internationally, in January 2002, the
WHO's Executive Board stated that it was focusing attention on the health effects of poverty, but also needed to devote attention to preparations for
"newer threats such as the deliberate use of anthrax and smallpox agents." 76Link to the text of the note C. The World as a Marketplace, Health Care as
a Business Due to the globalization of infectious diseases, the distinction between national and international public health programs have as little
relevance as political borders. 77Link to the text of the note However, this also implies that public health counter-measures must be considered within the
context of market realities driving globalization. There is a strengthening current within the international public health community to consider access to
health care as a universal human right shared by rich and poor alike. 78Link to the text of the note However, one must inquire: Where does the money for
health research come from? Independent [16] foundations and charities contribute only about four percent of the billions spent globally each year on
health research. 79Link to the text of the note Regarding medicine, a sizeable amount of the funding for basic research comes from governments, but the
lion's share of the funding for applied research that turns concepts brewing in test-tubes on lab benches into bottles for injection on clinic shelves comes
from private industry. In particular, these are the major pharmaceutical companies, also known as "big pharma." 80Link to the text of the note They don't
call it big pharma for nothing! The industry's financial might and resources are impressive. When the list of the world's one hundred largest public
companies by market value is released each year, close to one-fifth are pharmaceutical companies. Monsanto, a life-science multinational corporation, has
a R&D budget more than twice the R&D budget of the entire worldwide network of public sector tropical medicines research institutes. 81Link to the text

These resources must be brought to bear if the global community is to

make any headway against the globalization of infectious diseases . However, this is where the
of the note

economic and political realities of globalization are actualized. According to previous work on providing incentives to industry to conduct R&D for
neglected parasitic and infectious diseases in the developing world, five disincentives must be addressed: lack of interest on the part of big pharma; an
unfavorable cost/risk ratio for big pharma; the fact that only impoverished markets exist for the products of such R&D; the difficulty of directing capacity in
the Northern hemisphere to address the needs of the South; and the realities of the vaccine market. 82Link to the text of the note