Hospitals as Covid-19 Disease Vectors

"For example, we are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system,1 which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line."

From a recent journal article by practitioners in and near Bergamot, Italy.

Who’d of Thunk It?

Mr. Trump had no explanation for why his White House shut down the Directorate for Global Health Security and Biodefense established at the National Security Council in 2016 by President Barack Obama after the 2014 Ebola outbreak, stammering to suggest the coronavirus had been a surprise.

“Well, I just don’t think — I just don’t think that somebody is going to — without seeing something, like we saw something happening in China,” Mr. Trump said. 

Maybe we should just start with, who is thinking — at all? Let's start there.

What Do We Mean When We Talk About “Fault” in Relation to the Corona Virus?

“They would like to have the people come off,” he said. “I would like to have the people stay. I told them to make the final decision. I would rather — because I like the numbers being where they are. I don’t need to have the numbers double because of one ship that wasn’t our fault. And it wasn’t the fault of the people on the ship either. OK? It wasn’t their fault, either. And they are mostly Americans.”

Americans, including our President, are so focused on individual responsibility for health outcomes of any kind, that we can't help but reach for "fault" talk even when discussing an epidemic or pandemic.

Am I My Patient’s Keeper?

I gave a presentation last night to a group of HIV/AIDS pharmacists who have been considering issues at the intersection of patient-pharmacist relationship and public health law.  Pharmacists involved in the care of persons who are HIV positive often are part of a health care team (doctor, nurse, social worker, case manager, pastoral care).  The work is highly specialized and often involves working exclusively with an HIV positive population.  These folks see a lot.

Most of their questions circled around the tension between their obligations to their group's patients and their larger ethical obligations to others (think sexual partners and needle sharers) who may be at undisclosed risk in these relationships.  Missouri law is convoluted, essentially permitting but not requiring non-consensual disclosure of HIV positive status and risk to a spouse or sexual partner. We compare this with New York's relatively new public law requiring such disclosure and the conversation took off from there.

They were a good group. They struggled with the need and desire to build an alliance with their group's patients and their sense that a single-minded focus on only the non-disclosing individual might leave others at risk.

Criminalization of non-disclosed status of HIV conduct was also discussed. Missouri goes one step further and crimnalizes the failure to disclose HIV positive status to a sexual partner. Some of the parmacists were easy with inviting the state in to police the sexual encounter. Others seemed to think that these statutory provisions would drive us further away from a culture of HIV testing, treatment, and even disclosure.

It has been said that we can either criminalize HIV positive status or lower its incidence, but not both.

Good Night, Sleep Tight, and Don’t Let the MRSA Bed Bugs Bite

I have been thinking about bed bugs lately. No, it is not because I
just checked into a hotel. Recent press coverage of our bed bug
infestation has got me thinking or re-thinking my take on bed bugs as a
public health matter.

When I teach and talk about  public health law, I introduce my
students and listeners to public health analysis and to the triggering
of the  exercise of public health law authority through topical
examples. I often start an introduction to public health law with what I
hope will be a vivid example of local significance.  I start small (no
pun intended), building later to a look at the mass pandemics of our

I start with bed bugs.

Bed bugs are ubiquitous and almost universely reviled.  My students
are disgusted by the bed bug specimens I bring to class.  This revulsion
goes a long way, I suspect,  toward fueling press reports of a "bed bug
epidemic." We, however, pause to consider whether bed bug infestation is
a true epidemic and, if so, whether bed bug infestation merits
activation of the full legal and regulatory force of public health law.

When I taught public health at Hastings, we looked at San Francisco's
public health ordinance regarding bed bug infestation.  We consider the
personal cost, mental health implications, and economic cost of bed bug
infestation in a city with a tourism-driven community.  We can find the
legal and regulatory system allocating rights and responsibilities all
around the "epidemic."

Talking about bed bug infestation also introduces my students to the
idea that public health crises often beget public health crises.  In
this case, the virtual ban on the use of certain insecticides plays a
role in the U.S. resurgent bed bug population, though serious public
health concerns put the brakes on routine mass use of these

As anyone who has ever battled bed bugs will tell you, bed bugs are
no laughing matter.  Still, there are moments of levity in the public
health analysis of this infestation. It is inevitable that discussions
of current plans to use popular de-worming agents developed for animal
use on humans (pet owners: think HeartGuard) provoke a smile.

But the most recent news on bed bugs over the last few months has
been sobering. Even a well fed bed bug is quite small, often difficult
to see given their nocturnal ways.  Those who specialize in capturing
them for dissection have begun to report the presence of
community-acquired MRSA (Methicillin-resistant Staphylococcus aureus) in
some communities of bed bugs.

Community-acquired MRSA may be one of our under-diagnosed epidemics.
Even more troubling, our relatively lax approach to MRSA screening and
reporting has begun to blur the line between health care
facility-acquired and community-acquired MRSA. And, yes, bed bug
infestations are not unknown in health care facilities.

Maybe a string of bed bug bites (hence the derivation of the old
chant: breakfast, lunch, dinner) was always more than a nuisance.  Now
it is possibly much more than that.

Of course, much remains to be learned about all of this, particularly
about the rate of MRSA infection in the general bed bug population and
whether or not we can determine if bed bug to human MRSA transmission is
a genuine threat.  In the mean time, bed bugs as possible disease
vectors frame one issue nicely: what role public health law ought play
in allowing surveillance of and requiring treatment of potential disease

A marvelous guest speaker in a health law course once brought me up short
with laughter when he advised the student listeners that the single
most important requirement for a new attorney interested in health law
was to have a strong stomach. Just in case that is not your calling, you
can always check out reports of bed bug infestations in public
accomodations online. 

Cross-posted at