Public Health and Law Enforcement: Intersecting Interests, Collegiality and Cooperation

Thank you for the privilege of being with you today. One unexpected reward of my job as United States Attorney has been my introduction to the public health community. The only other encounter I can recall having with you was in the sixties when I went to the county health office to take doses of

Until this assignment my world as a lawyer did not intersect with your world of public health. That we didn't intersect more is interesting because we are engaged-in different ways-in a variety of issues in which both of our communities have a critical interest-especially since 9/11. For example, bioterrorism has extremely important health and law enforcement threats; in violent crime we focus on the defendant while you focus on his or her effect on the public; in the area of controlled substances we focus on the traffickers, you on substance abuse issues.

In addressing these issues, we have similar obligations even if we fulfill them in different ways. In the end we have shared goals and each seek to:

* Protect citizens

* Redress wrongful conduct

* Deter, and

* Prepare to respond

Is the reason we have not more closely worked together because we did not recognize our inherent mutual interests? Or was it inadvertent oversight? Or did we believe-do we believe today-there are impediments to us working together in areas of common interest? I don't think we can discount the presence of at least a disincentive to seek out each other's cooperation and coordination. And I think that may be because the methods we use to reach our respective objectives are inherently different.

In law enforcement our flexibility to experiment is more constrained; we hold to a strict standard dealing only with admissible evidence with the focus on a provable result. For us there are evidentiary and constitutional standards and rules for what is presented to a jury for it to decide. For us it is citizen review. We also often work secretly. We don't disclose what we know to avoid tipping off a suspect or because our legal rules require secrecy.

Public health, on the other hand, discloses comprehensive information in order to better warn and treat. Public health uses inductive reasoning to look beyond core facts to hypothesize and test theories. Hypotheses which lead to action are better than allowing a problem to go unaddressed or undisclosed. For you it is peer review, not citizen review.

I understand your world to this extent: playing the percentages is important to protect the public health. Like baseball-putting in a left handed pitcher to pitch to a left-handed batter. The odds urge this choice. To put it in the vernacular: Law enforcement believes you are too imprecise for us.

You are too quick to respond, willing to act on speculation and conjecture. Public health, however, believes law enforcement is too narrow-minded, rigid and pedantic, too conservative and too reluctant, wanting to follow every lead before reaching a firm conclusion on which to act.

What we have are colliding worlds where we rationalize that it is easier, more efficient and less frustrating to go our own ways rather than walk together. What has been the historical result? Incomplete resolution to problems which would have been better addressed with a comprehensive solution.

Is the environment the same today? Do failures in cooperation still occur? Do you remember the movie Outbreak? It was the story of an African hanta virus transported to California. You recall the story: (a) The military's need to keep the virus-especially the antibody-a secret for national security reasons; and (b) the CDC wanted full understanding of the threat and an immediate public health threat response. The military and public health officials claimed they would work together. Instead, they worked against each other.

This is the question for us all: Do we work together or apart? Our experience suggests that we serve the public more efficiently and comprehensively when we cooperate and coordinate. I'd like to explore with you four examples which I submit prove that point. They are:

* Terrorism/bioterrorism response

* "Project Safe Neighborhood" gun violence initiative

* Drug abuse and trafficking, and

* Human trafficking

There probably is no clearer, more contemporary example of public healths and law enforcement's intersecting interests than in the area of terrorism and bioterrorism. Criminal laws have been enacted to protect the public health. 18 U.S.C. sec. 2332 says it is a crime when any person who, without authority, "uses, threatens, or attempts or conspires to use, a weapon of mass destruction," including any biological agent, toxin, or vector....against any person within the United States."

In a bioterrorism response there are two compelling interests, both embodied in this statute: (a) the need to understand the health threat and to protect the public, and (b) the need to hold the bioterrorist criminally accountable. Public health and law enforcement interests are undeniably intertwined in this legislation.

But there are inherent tensions as these two duties are fulfilled. The immediate need to protect human health butts heads with the more methodical, deliberate processing of evidence for a criminal case. We have seen these interests run head-on before. In the Tylenol contamination incident the focus was on the company's response to protect the public health. Law enforcement's interests were a secondary consideration.

In another case, in 1984, the followers of Bhagwan Shree Rajneesh contaminated salad bars and coffee creamers in Oregon with salmonella in an attempt to influence a local election: 751 people became ill; 45 were hospitalized. The initial response was to treat this as a public health issue. But years later, in an unrelated matter, authorities discovered the 1984 contamination had been a terroristic attack. Clearly, there should have been an aggressive law enforcement response in 1984.

Again, in October 2O01, a 67-year-old photo editor for the Sun in Florida was sickened by anthrax. What began as a public health probe became a criminal investigation. We still struggled with balancing the public health/public safety interests in this terrorist attack. This is the post-9/11 terrorism reality. Six months later the doctor who diagnosed the case-initially, it was considered an isolated case-said he believed the federal government's reluctance to recommend other anthrax-fighting antibiotics in addition to Cipro during the earliest days of the outbreak created a bigger problem: "...this scare and this scarcity and this black market for Ciprofloxacin didn't have to occur." We were beginning to think differently, but our response in this new world is still confusing.

The consequences of these acts still are unexpected, expensive and complicated. American Media sold its anthrax-contaminated former headquarters to a developer for just $40,000 for a 68,000-square-foot building on five acres of land but he would have to pay up to $10 million for decontamination.

This incident did do one thing-it began to make us think that while the public health and law enforcement missions are different, they are equally important. As each incident occurs and failure of coordination reoccurs, the evidence builds that we need a new paradigm. We need to acknowledge that we have different jobs to do, that each is important. We need also to acknowledge that we still struggle with each other.

In Washington, D.C., in 2003 public health officials learned about the ricin contamination of the Dirksen Senate Office Building from news reports. The secret Service reported that it did not notify public health officials or other law enforcement agencies for five days. We thought the need to know was limited.

My tour of the CDC in 2002 brought home to me how unfamiliar we are with each other. During my visit I looked down from a bridge that connected two buildings. There below me was a trailer that I was told was used to test ricin and other suspicious substances and where it also could be processed as evidence-two very important functions in a temporary, unsecured facility. It seemed to me it was a place where law enforcement could be invited in but kept out of the way. Yet these are two very important functions, one of which should be integrated into and not kept out of the work of the other agency. The overriding question is: How do you harmonize these two important interests to bring about coordination, cooperation and collegiality? It is an issue I have thought deeply about and about which I have developed deeply-held views. I'd like to share them with you for you to consider. I think these missions are harmonized when the following happens:

* Cooperation and coordination occur most often when there are strong personal relationships.

* Strong personal relationships create collegiality.

* Collegiality allows people to plan and look forward rather than react by looking back.

That has been the course we have followed with public health officials, especially those at the CDC. We have addressed issues of substance, but in a manner that forges personal relationships. And we have used those personal relationships as the basis for developing cooperative strategies and plans that allow public health and law enforcement communities collectively to achieve their objectives. What we have tried to do is create "the culture of cooperation" through:

* Joint seminars, conferences, and discussions

* Joint table top exercises

* Fostering personal interaction

The result is that it is harder to work against another community's interests.

I would like to give you three more successful examples of creating cultures of cooperation where law enforcement and public health have intersecting interests: gun violence, methamphetamine abuse, and human trafficking.

One example is "Project Safe Neighborhoods" which focuses on gun violence. This is a huge public health issue. Teenagers in America are more likely to die from gunshot than from all other natural causes of death combined. We can enforce all day and never address this public health/social issue. It is clear that this is a public health and a public safety concern. "Project Safe Neighborhoods" is working in an at-risk Atlanta neighborhood because we finally have recognized both issues, and through relationships have begun to address them cooperatively. It was a public health goal that did the trick for me. What did we do? We measured results. Bernie Kerik, the former New York City Police Commissioner, told me once: "If you don't measure it, it won't get done." What a truth! Dr. Art Kellerman's suggestion was that we should measure emergency room admissions at Grady Hospital here in Atlanta for gunshot wounds. Grady treats 85 percent of all shooting victims in Fulton and DeKaIb counties here in metro Atlanta. My reaction was "Come on, get real, Art." This won't tell us anything. What do admissions have to do with stopping crime? But he was right. Improving the public's health is what propels support and cooperation. I think it was our most important measurement.

"Project Safe Neighborhoods" is making a significant public health and public safety difference. We can see what actually happened in two ways. First, 91-1 firearms calls dropped by 33 percent in the third quarter of 2003 over the same quarter in 2002; they dropped by 39 percent in the fourth quarter of 2003 over the same quarter in 2002. second, Grady saw 28 percent fewer shooting victim admissions in 2003 compared with 2002. This data is real and it gives us a real goal. People understand these results. They point out the human impact of our work. Law enforcement, public health officials, and the community see the difference we really are making. It is, I think, the best measure of success.

The next example is in the area of methamphetamine abuse. Let's review the drug trafficking organizations' trafficking patterns in our region. When you focus on the destinations it hits you that every destination is a public health issue.

Methamphetamine presents a public health threat on many levels. Impact on the user is the single best example of a drug-induced brain disease, according to Richard Rawson, PhD, Associate Director of the UCLA Integrated Substance Abuse Programs. The effects on users include: disturbed sleep pattern, bad teeth, anorexia, itching/welts, nausea/vomiting, aggressiveness, twitching/lip smacking/tongue protrusion, sexual dysfunction, kidney/liver/lung damage, and brain damage.

How about the effect on families? Children are at an especially high risk of neglect and abuse. The fire risk alone is sobering. This year two parents were sentenced for killing their child in a meth lab explosion. But there also is a risk of gun violence, and risk of exposure to toxins. That's only part of it, however. There are environmental risks as well. One pound of meth generates five to six pounds of toxic waste. Cleanup averages $5,000 and can cost as much as $150,000. Contamination includes underground water.

The only way to attack the meth problem is through a coordinated approach. For example, legislation can be enacted to limit the sale of precursor chemicals such as cold tablets, and to provide civil immunity for good faith reporting of someone suspected of buying precursors for meth production. And we should be advocating each of these together. Judicial steps can be taken through drug courts and intervention with offenders. Public health can conduct outreach and treatment.

My final example is human trafficking. Our office has prosecuted seven cases of slavery and prostitution in which we locked up very bad people. We made a difference but only a slight one. This is a terrible problem and it grieves me that our aggressive efforts only make a slight, incremental difference. The problem is significant but under-appreciated. Here is an example of the travesty mentioned by U.S. Department of Health and Human Services Deputy secretary Claude Alien about a year ago: A thirteen-year-old girl was promised a job in the United States as a waitress. When she got here, she was forced into prostitution. "She was brutally gang-raped to induct her into the business. For the next six months, she was forced to service ten to fifteen men a day. Twice she was impregnated, twice forced to have an abortion, and twice she was back in the brothel the next day. The traffickers circulated her through the trailer brothels and private parties, where she was passed around. She was pistol-whipped and raped if she resisted. The girl was rescued when two girls ran to neighbors who called police. She had multiple sexually transmitted diseases, scar tissue from forced abortions, and was addicted to drugs and alcohol. She had posttraumatic stress syndrome, including severe depression and suicidal thoughts. She was physically, mentally, and spiritually broken."

Closely related is the issue of human trafficking. As we saw in a recent case in Texas, traffickers, in complete disregard for human life, smuggled illegal aliens across the Mexican border by stuffing them in a tractor trailer. In the hot sun of the southwest border the trailer literally baked its cargo. Is this a public health as well as a law enforcement issue? You decide.

I believe that a new "rescue and respond" model is in order. The rescued are our greatest law enforcement response. The public health community is our greatest law enforcement resource. Why didn't we work together before? The answer is because we were myopic, looking at the problems through the lenses of our own interests rather than looking to confront the problem comprehensively.

In conclusion, I have shared with you today four examples showing how we can work together. I pledge to continue to make our case. This conference is another step in the right direction, but there are many more to be taken. We need to work even harder at our personal relationships to cultivate cooperation, coordination and collegiality. This is important work-you need to continue to do it because, ultimately, our communities are counting on us to make a difference.