In March 2003, the world discovered, again, that I humanity's battle with infectious diseases continues. The twenty-first century began with infectious diseases, especially HIV/AIDS, being discussed as threats to human rights, economic development, and national security. Bioterrorism in the United States in October 2001 increased concerns about pathogenic microbes. The global outbreak of severe acute respiratory syndrome (SARS) in the spring of 2003 kept the global infectious disease challenge at the forefront of world news for weeks. At its May 2003 annual meeting, the World Health organization (WHO) asserted that SARS is “the first severe infectious disease to emerge in the twenty-first century” and “poses a serious threat to global health security, the livelihood of populations, the functioning of health systems, and the stability and growth of economies.”

One hundred years ago, most wars occurred between nations; today, large-scale violent conflict consists almost exclusively of civil wars in which civilians constitute 30 percent of casualties.’ According to a recent World Bank study of conflict, the poorest one-sixth of the worlds population suffers four-fifths of the consequences of civil wars. While poverty is the greatest risk factor determining a nation’s likelihood of entering into conflict, it is also one of instability’s most predictable consequencet—thus, war is a vicious cycle, and poor nations may remain at risk for intense violence for years or even decades.

A single defining question perennially intrigues scholars and practitioners interested in public heath: To what extent should human rights be limited to protect the community’s health and safety? The question achieved prominence in the aftermath of the attacks on the World Trade Center and Pentagon on September 11, 2001 and with the intentional dispersal of anthrax spores through the U.S. Postal Systein. The conflict between security and public health intensified with the development of the Model State Emergency Health Powers Act (“Model Act”), drafted by the Center for Law and the Public’s Health at the request of the Centers for Disease Control and Prevention. The Model Act grants states consiclernble powers to control persons and property in response to a public health emergency, defined to inclucle bioterrorism or the appearance of novel or previously controlled or eradicated infectious agents or biological toxins.

Critics of international trade agreements often cast them as threats to human health, and they can point to some sobering warnings from world history. Infectious diseases have swept across political boundaries, carried by traders, colonists, and other agents of globalization. Transnational epidemics have laid economies low, undermining political stability. The spread of viruses and bacteria to peoples previously unexposed and therefore lacking immunity has decimated populations and changed the political course of continents. Trade, exploration, and warfare have repeatedly produced encounters between peoples at different levels of agricultural and technological development. Often, the results have been devastating for the disadvantaged group — economic marginalization, loss of sovereignty and culture, and collapse of public health. Yet the rise of civilization — plant and animal domestication, division of labor, technology, and resulting prosperity — was powered in large part by movement of products and knowledge along routes of trade and migration.

Public Health Science and practice expanded during the course of the 20th century. Initially focused on controlling infectious disease through basic public health programs regulating water, sanitation and food, by 1988 the Institute of Medicine broadly declared that “public health is what we, as a society, do collectively to. assure the conditions for people to be healthy.” Commensurate with this definition, public health practitioners and policymakers today work on ;in enormous range of issues. The 2002 policy agenda of the American Public Health Association reflects positions on genomics’ role in public health; national health and safety standards for child care programs; sodium in Americans’ diets; the health and safety of emergency rescue workers; and war in Central Asia and the Persian Gulf.

In 2000, the Center for Disease Control and Prevention’s National Center for Environmental Health issued a report that explored some of the ways in which “sprawl” impacts public health. The report has generated great interest, and state health officials are beginning to discuss the relationship between land use and public health. The CDC report has also produced a backlash. For example, the Southern California Building Industry Association labeled the report “a ludicrous sham” and argued that the CDC should stick to “fighting physical diseases, not defending political ones.”

In retrospect, it is probably unfortunate that this report was funded by an organization called “Sprawl Watch.” “Spraw” is a word that has no clear meaning but is applied to a huge range of issues involving suburban development.

Firearm violence is a major public health problem in the United States. In 2000, firearms were used in 10,801 homicides – two-thirds of all homicides in the U.S. – and 533,470 non-fatal criminal victimizations including rapes, robberies, and assaults. The social costs of gun violence in the United States are also staggering, and have been estimated to be on the order of $100 billion per year.

Illegal gun carrying, usually concealed, in public places is an important risk factor for firearm-related crime. In the 1980s and 1990s, police departments across the country began to develop and implement strategies to address illegal weapons carrying. Often these strategies have involved aggressive efforts to identify and physically search individuals suspected of illegally carrying a firearm.

“Smallpox was always present, filling the churchyard with corpses, tormenting with constant fear all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover.” In 1848, British historian T.B. Macaulay first captured the picture of the devastation smallpox wreaked on its victims, but the “King of Terrors,” as it was dubbed by future president John Adams, had already decimated populations in the ancient world from Greece to Egypt to China. Smallpox had no respect for authority: the earliest identified victim, Pharaoh Ramses V (d.1157 B.C.) was but the first in a long line of monarchs and rulers who succumbed,. including the Hittite king Suppiluliumas I, Aztec Emperor Cuitlahuac, and Queen Mary II of England.

This article examines the Emergency Medical Treatment and Labor Act (EMTALA) in a public health emergency context. Congress enacted EMTALA in 1986 to prohibit the practice of “patient clumping,” which involved hospitals’ refusal to undertake emergency screening and stabilization services for individual patients who sought emergency room care, typically because of insurance status, inability to pay, or other grounds unrelated to the patient’s need for the services or the hospital’s ability to provide them. But in fact EMTALA, whose conceptual roots can be found in the Hospital Survey and Construction Act of 1946 (Hill Burton) as well as an evolution in both the common law and state statutes related to hospital licensure, can be viewed as having a far broader purpose than protection of individuals, and indeed, one that is related to the protection of communities and the public health.

Senate Bill 1435, the “Prison Rape Elimination Act of 2003,” was introduced into the Senate on July 21, 2003, and in less than a week passed both the Senate and House by unanimous consent. The Bill was presented to President Bush on September 2, 2003, and he signed it two days later on September 4, 2003. The stated purposes of the Act are far-reaching and ambitious:

1. (1) establish a zero-tolerance standard for the incidence of prison rape in prisons in the United States;

2. (2) make the prevention of prison rape a top priority in each prison system;

3. (3) develop and implement national standards For the detection, prevention, reduction, and punishment of prison rape;

4. (4) increase the available data and information on the incidence of prison rape, consequently improving the management and administration of correctional facilities;

5. (5) standardize the definitions used for collecting data on the incidence of prison rape;

Changes in the scope of health policy in the United States are creating opportunities and obligations for lawmakers and the lawyers who advise them. These changes are the result of a new politics of policy for the health of populations. The new politics is connecting areas of policy that, because they have had separate histories, are governed by distinct, usually uncoordinated laws and regulations.

The subject of the new politics of health policy is what the Iowa Senate President, speaking in a plenary at the 2003 conference on Public Health Law in the 21st Century, called the “quality of life, what the people think is important.” An increasing number of leaders in general govemment–people who run for office and their staff–have practical reasons to make policy that acknowledges the expanding scope of what their constituents define as health policy.

As therapeutic advances in the treatment of AIDS began to emerge in the late 1980s and public health began to have more to offer than just the threat, or the perceived threat, of quarantine or partner notification, fissures began to appear in the alliance against named HIV reporting that had emerged a few years earlier. In 1989, New York City’s Health Commissioner stated that the prospects of early clinical intervention warranted “a shift toward a disease-control approach to HIV infection along the lines of classic tuberculosis practices,” including the “reporting of seropositives.”

Although his proposal met with fierce and effective resistance, it is now clear that his call represented part of a national trend. The CDC continued to press for cases of HIV to he reported by name to health departments, an effort that assumed the dimensions of a campaign. It was supported by a growing number of public health officials.

No one questions the importance of protecting human subjects of research, but over the past few years dissatisfaction has surfaced with the manner in which the protection is conferred by the federal regulatory system referred to as “The Common Rule. ” Some of the criticism surfaces in print. Some bubbles out anecdotally in conversations among researchers, with complaints about the review process being virtually inevitable whenever the topic arises. Like those in other disciplines that differ more or less dramatically from the world of clinical medical research around which the Common Rule was conceptualized, public health researchers, particularly those working in official public health agencies, have experienced some tension and difficulty in adapting to the rules. The Centers For Disease Control and Prevention (CDC) has adopted guidelines that require Common Rule review for “research” but not “practice” activities.

“Public health practice” consists of activities and Programs managed by public health agencies to promote health and prevent disease, injury, and disability. Some of these activities might be deemed to fit within the broad definition of “research” under federal regulations, known as the Common Rule, designed to protect human research subjects. The Common Rule defines research as “a systeniatic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Public health activities that might under some circumstances be considered research include disease reporting, review of medical records, surveys, interviews, focus groups, specimen collection (blood, urine, etc.), and laboratory testing (both identifiable and anonymous).

There are questions about the extent to which the Common Rule applies or was intended to apply to public health practice: and it has been suggested in any case that Common Rule regulation of public health practice may not be socially optimal for both practical and principled reasons.

Protecting the privacy of individually-identifiable health data and promoting the public’s health often seem at odds. Privacy advocates consistently seek to limit the acquisition, use, and disclosure of identifiable health information in governmental and private sector settings. Their concerns relate to misuses or wrongful disclosures of sensitive health data that can lead to discrimination and stigmatization against individuals. Public health practitioners, on the other hand, seek regular, ongoing access to and use of identifiable health information to accomplish important public health objectives. The collection and use of identifiable health data by federal, tribal, state, and local health authorities support nearly all public health functions and goals.

Identifiable health data are the lifeblood of public health practice. When aggregated, these data help authorities monitor the incidence, patterns, and trends of injury and disease in populations. Health data are acquired by public health authorities through testing, screening, and treatment programs.