The Police Power And The Police Power And HIV/STDs In The ElderlyHIV/STDs In The Elderly

Edward P. Richards, IIIEdward P. Richards, IIIProfessorProfessorUniversity of Missouri – University of Missouri – Kansas CityKansas CitySchool of LawSchool of Law5100 Rockhill Road5100 Rockhill RoadKansas City, MO 64110Kansas City, MO 64110(816)235-2370/richardse@um(816)235-2370/richardse@umkc.edukc.edu

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OverviewOverview

HIV/STDs As A Special CaseHIV/STDs As A Special Case• HIV - Especially Dangerous To The ElderlyHIV - Especially Dangerous To The Elderly

• General Problem of Communicable General Problem of Communicable DiseasesDiseases

Driven By Changing DemographicsDriven By Changing Demographics Demands A Public Health ApproachDemands A Public Health Approach

• Police Powers To Protect the CommunityPolice Powers To Protect the Community

• Personal Health Services for IndividualsPersonal Health Services for Individuals

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Risk Factors For HIV/STDsRisk Factors For HIV/STDs

Drug UseDrug Use• Sharing NeedlesSharing Needles

• Trading Sex For DrugsTrading Sex For Drugs

Sexual ActivitySexual Activity• FrequencyFrequency• Number Of PartnersNumber Of Partners• PracticesPractices• Core Group DynamicsCore Group Dynamics

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Why Are The Elderly At Why Are The Elderly At Risk?Risk?

Elderly Have Always Been At RiskElderly Have Always Been At Risk• Small NumbersSmall Numbers• Social Stigma Hides CasesSocial Stigma Hides Cases

Changes in Community Changes in Community DemographicsDemographics• Increasing The RisksIncreasing The Risks

• Increasing The NumbersIncreasing The Numbers

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Traditional Health StatusTraditional Health Status

Death Came EarlierDeath Came Earlier• Less Time RetiredLess Time Retired• Less Time WidowedLess Time Widowed• Smaller Population Of ElderlySmaller Population Of Elderly

Not As HealthyNot As Healthy• Underestimated By Life ExpectancyUnderestimated By Life Expectancy• General HealthGeneral Health• Sexual DysfunctionSexual Dysfunction

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Current Health TrendsCurrent Health Trends

Longer Life SpanLonger Life Span• Longer RetirementLonger Retirement• Longer WidowedLonger Widowed• Larger Elderly PopulationLarger Elderly Population

Better HealthBetter Health• Masked By Static Life ExpectancyMasked By Static Life Expectancy• Improvements In General HealthImprovements In General Health• Improvements In Sexual FunctionImprovements In Sexual Function

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Traditional DemographicsTraditional Demographics

No Distinct Elderly CommunityNo Distinct Elderly Community• PoorPoor• Smaller NumbersSmaller Numbers• UnorganizedUnorganized

Dispersed Through The CommunityDispersed Through The Community• Integrated With Extended FamilyIntegrated With Extended Family• Better Social Support NetworksBetter Social Support Networks

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Contemporary Contemporary DemographicsDemographics

Elderly Only CommunitiesElderly Only Communities• Sun City - the AffluentSun City - the Affluent• Supervised LivingSupervised Living• Elderly GhettosElderly Ghettos

Benefits of Homogenous CommunitiesBenefits of Homogenous Communities• Critical Mass for Special ServicesCritical Mass for Special Services• Crime and Violence are for the YoungCrime and Violence are for the Young• No StigmatizationNo Stigmatization• Self-QuarantineSelf-Quarantine

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Risks of Elderly Risks of Elderly CommunitiesCommunities

Better Niche for Communicable DiseasesBetter Niche for Communicable Diseases• Concentration of HostsConcentration of Hosts• More Susceptible PopulationMore Susceptible Population• Increases Social Interaction Spreads DiseaseIncreases Social Interaction Spreads Disease

Ignorance of Larger World ProblemsIgnorance of Larger World Problems• The Elderly Do Not See STDs As Their ProblemThe Elderly Do Not See STDs As Their Problem• Physicians Do Not Look for STDs in the ElderlyPhysicians Do Not Look for STDs in the Elderly

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Why Do Doctors Miss Why Do Doctors Miss HIV/STDs In The Elderly?HIV/STDs In The Elderly?

Mistaken Social PerceptionsMistaken Social Perceptions• Elderly Do Not Have SexElderly Do Not Have Sex• Elderly Do Not Have STDs Even If They Elderly Do Not Have STDs Even If They

Have SexHave Sex• Elderly Are Not Drug AbusersElderly Are Not Drug Abusers

Misleading Medical CuesMisleading Medical Cues• Elderly Already Have Weak Immune Elderly Already Have Weak Immune

SystemsSystems• HIV Dementia Looks Like Other DementiasHIV Dementia Looks Like Other Dementias

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Implications of Missing HIVImplications of Missing HIV

Elderly Die, On Average, 30 Days Elderly Die, On Average, 30 Days From DiagnosisFrom Diagnosis• Increased SusceptibilityIncreased Susceptibility

• Evidence Of Very Delayed DiagnosisEvidence Of Very Delayed Diagnosis

Risks To OthersRisks To Others• Sharing Needles (Not Just Illegal Drugs]Sharing Needles (Not Just Illegal Drugs]

• Sexual ActivitySexual Activity

Strategies To Prevent Strategies To Prevent HIV/STDsHIV/STDs

Personal Health Services Personal Health Services ApproachApproach

Public Health Police PowerPublic Health Police Power

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Personal Health Services Personal Health Services ApproachApproach

EducationEducation• Safe SexSafe Sex• Avoid Sharing NeedlesAvoid Sharing Needles• Importance Of Getting TestedImportance Of Getting Tested

Role Of Health Care ProvidersRole Of Health Care Providers• Must Recognize DiseaseMust Recognize Disease• Must Counsel All PatientsMust Counsel All Patients

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Public Health ApproachPublic Health Approach

Same Personal Health EducationSame Personal Health Education Recognizes That Education Often FailsRecognizes That Education Often Fails

• Does Not Reach EveryoneDoes Not Reach Everyone• Some Do Not Understand ItSome Do Not Understand It• Some Do Not Think It Applies To ThemSome Do Not Think It Applies To Them• Some Do Not Care About Risks To Others Some Do Not Care About Risks To Others

Public Health Adds Active Case Public Health Adds Active Case Finding And InterventionFinding And Intervention

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The Public Health Police The Public Health Police PowerPower

"[T]he liberty secured by the Constitution of the "[T]he liberty secured by the Constitution of the United States to every person within its jurisdiction United States to every person within its jurisdiction does not import an absolute right in each person to does not import an absolute right in each person to be, at all times and in all circumstances, wholly free be, at all times and in all circumstances, wholly free from restraint. There are manifold restraints to from restraint. There are manifold restraints to which every person is necessarily subject for the which every person is necessarily subject for the common good. On any other basis organized society common good. On any other basis organized society could not exist with safety to its members.”could not exist with safety to its members.” Jacobson v. Massachusetts, 197 U.S. 11 (1905), Jacobson v. Massachusetts, 197 U.S. 11 (1905), quoted in Hendricks at 356-367.quoted in Hendricks at 356-367.

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Disease ReportingDisease Reporting

"Unquestionably, some individuals' concern for their own "Unquestionably, some individuals' concern for their own privacy may lead them to avoid or to postpone needed medical privacy may lead them to avoid or to postpone needed medical attention. Nevertheless, disclosures of private medical attention. Nevertheless, disclosures of private medical information to doctors, to hospital personnel, to insurance information to doctors, to hospital personnel, to insurance companies, and to public health agencies are often an essential companies, and to public health agencies are often an essential part of modern medical practice even when the disclosure may part of modern medical practice even when the disclosure may reflect unfavorably on the character of the patient. Requiring reflect unfavorably on the character of the patient. Requiring such disclosures to representatives of the State having such disclosures to representatives of the State having responsibility for the health of the community, does not responsibility for the health of the community, does not automatically amount to an impermissible invasion of automatically amount to an impermissible invasion of privacy.”privacy.”Whalen V. Roe, 429 U.S. 589, 602 (1977)Whalen V. Roe, 429 U.S. 589, 602 (1977)

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Case FindingCase Finding

Contact Tracing/Partner NotificationContact Tracing/Partner Notification• VoluntaryVoluntary• Most People Want To HelpMost People Want To Help

Works Because Of Core Group DynamicsWorks Because Of Core Group Dynamics• Small Subset Accounts For Most Small Subset Accounts For Most

TransmissionTransmission• Contact Networks Are RedundantContact Networks Are Redundant• Interview Enough People And You Get All Interview Enough People And You Get All

The NodesThe Nodes

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InterventionsInterventionsNewly Identified Contacts

Important Because HIV Is Hard To CatchImportant Because HIV Is Hard To Catch Warn That They Have Been ExposedWarn That They Have Been Exposed Counsel About The Disease And Counsel About The Disease And

PrecautionsPrecautions Help Them Get Tested And Medical Help Them Get Tested And Medical

CareCare Interview Them About Their ContactsInterview Them About Their Contacts Add To Surveillance DatabaseAdd To Surveillance Database

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Infected Contacts Who Infected Contacts Who Continue Unsafe ActivitiesContinue Unsafe Activities

Tuberculosis Is The Best ModelTuberculosis Is The Best Model• Warn And CounselWarn And Counsel• Increasing RestrictionsIncreasing Restrictions• No Myth Of Self-ProtectionNo Myth Of Self-Protection

What About HIV?What About HIV?• Mental Health Confinement If Demented?Mental Health Confinement If Demented?• Megan’s Law Approach?Megan’s Law Approach?• Prosecution For Reckless Endangerment?Prosecution For Reckless Endangerment?

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Community EthicsCommunity Ethics

The Constitution And The United The Constitution And The United States Supreme Court Support States Supreme Court Support Broad Public Health PowersBroad Public Health Powers

How Do We Decide When We How Do We Decide When We Should Use These Powers To Should Use These Powers To Protect The Vulnerable?Protect The Vulnerable?

Have Individual Rights Undermined Have Individual Rights Undermined Public Health?Public Health?

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Population EthicsPopulation Ethics

The Constitution And The United The Constitution And The United States Supreme Court Support States Supreme Court Support Broad Public Health PowersBroad Public Health Powers

How Do We Decide When We How Do We Decide When We Should Use These Powers To Should Use These Powers To Protect The Vulnerable?Protect The Vulnerable?

Have Individual Rights Undermined Have Individual Rights Undermined Public Health?Public Health?