Third Session

Wednesday, October 26, 2011

“National Emergencies, Pandemics, and Health Policy”

Reading Assignment: Chapters 9-11 and 20-25.

Objectives:

  1. List and discuss the potential political situations worldwide immediate before and during the 1918-19 Spanish flu pandemic.
  2. Describe the public health infrastructure (including information about the capacity and political organization) in the United States during the time of the pandemic.
  3. Identify the national or local legal issues that surfaced as the pandemic spread and the policy decisions that may have ameliorated or worsened the public health impact of the pandemic.
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21 Comments (+add yours?)

  1. Thochaporn Tesasil
    Oct 23, 2011 @ 19:24:51

    Based on the text, while the US was already engaged in World War I, the pandemic would complicate the demand and impact on US resources, impacting civilian and military life. Joining the war that took place at the other side of the ocean had consumed tremendous resources of the country not only for Army troops, but also military equipment and supplies. Medical science resources were also was also directed towards the war efforts (Barry, 2009). However, during the war time, military would provide little or no help to civilian, but draw upon civilian resources (p. 302). When the Spanish Flu attacked America, U.S. resources continued to be directed toward one single aim, winning the war.
    Therefore, the public health infrastructure was weakened, and insufficient to respond to the pandemic crisis. The role of public health to provide the necessary and essential services was limited at city and state levels rather than directed towards a collaborative federal action plan. Because of the war, the public health workforce capacity was inadequate and could function only on a small scale for epidemic investigation. Research had been cut back and focused on the war efforts (Barry, 2009, p. 266). Army laboratories had utilized the majority of laboratory resources including animals, technicians and young researchers. There were insufficient organizations assigned for public health surveillance monitoring and reporting at state and national levels. At that time, US Public Health Service was unorganized and lacked effective leadership. It was unable to acquire funds and resources to respond the pleas from the states.
    Additionally, several federal actions, such as the Espionage Act and Committee on Public Information (CPI) aimed to prohibit any attempts to interfere with military operations which interfered with the Public Health’s role. Initiatives to provide reliable information to communicate to the public were impeded. Ignoring the medical scientists’ recommendation for military quarantine, trying to keep the public calm by blocking the truth, and delays in warning the public impacted morale, delayed or blocked efforts to prevent the spread or contain the outbreaks. However, local communities took on the responsibility for initiatives such as banning all public activities, strict quarantine measures, and encouraging hygienic habits to help minimize the epidemic transmission. In addition, the American Red Cross did try to organize and reach out to provide significant support not only for the military camps, but also to the public during the pandemic. Nevertheless, I personally believe that the impacts of the pandemic would have been significantly different, if America had had no war.

    Reply

    • Dan Corwin
      Oct 24, 2011 @ 23:59:04

      I think that fact the government drew so many resources from the civilian population left the US ripe for some sort of mass epidemic. It was a political debacle and how they left people without proper care. It was also mentioned in the book aroud page 123 and 124 how Wilson would make the nation the instrument to win the war. In this he focused just purely on the war and probably left a lot of domestic affairs to falter. This is likely to have helped contribute to the pandemic. Another thing was how much censorship he had during the war, so if someone mentioned anything remotely against the war effort they were traitors so I am sure some people didn’t want to get arrested over a “simple flu”

      Reply

      • Sarah Botting
        Oct 26, 2011 @ 12:33:51

        I agree with you Dan. I feel like Wilson’s decision to go fully into the war while offhandedly ignoring the problem on the home front was an escalating factor for the pandemic. Resources and wealth were already low to begin with and once they had more troops to treat, their resources became even fewer.

        The lack of freedom of speech about the war and the pandemic was appalling to me. Every single citizen has a right to know about the politics and health care behind their nation’s decision. If people were more well-informed about how to treat influenza, it probably could have saved quite a few lives. For example, people were told not to go to large gatherings. Therefore, people interpreted that as telling people to close their windows and lock up their house so no germs could get in. Unfortunately, this just only turned that house into an incubator for the disease and they saw that their families were still affected by the disease. If the communication between public health officials and citizens was better, I think this pandemic would have had a drastically different result.

      • Sarah DeRuosi
        Oct 26, 2011 @ 15:26:22

        In response to Sarah:

        The lack of communication among our public figures and the population had an enormous impact on the progression of the pandemic. If public service announcements, or at least information that was truthful, was addressed to the general population, many preventative actions could have taken course. Whether it was the miscommunication of going or not going to the parades, forming your house into an incubator for the virus as a result, I feel the politicians had a large impact on these poor outcomes. What should have been addressed as well, was having the scientists/physicians trying to make breakthroughs for the virus and vaccine, should have had the opportunity to talk with the officials without hesitation. We want to keep communication lines always open.

      • Brittany Fitzpatrick
        Oct 26, 2011 @ 15:50:12

        In response to Sarah D,
        I would agree with you in regards to communication. Perhaps if the truth was displayed in a proper light to those in the affected areas of the pandemic, preventative measures could have positively affected its outcome. Politics and economic situations always influence practically everything that goes on in a society, especially something that is so widespread. However if the government began mandating certain policies in regards to preventative measures that could possibly result in a negative response from those in society that are fearful of government regulation. What sort of things do you think could have possibly been done by the government to positively direct the result of a pandemic? How could this be done so people in society feel as though it is for their own good, as opposed to government regulation?

  2. Premjit Klaipetch
    Oct 24, 2011 @ 11:58:33

    The United States had joined forces with Britain, France, and Italy during World War I when President Wilson sent American troops to Europe. The age eligibility for men was even extended for ages 18 – 45. This included thousand of men and then included nurses and physicians who were drafted and transferred by ship to the war front in Europe. As a result, there was a severe shortage of physicians and nurses during pandemic in the United States.
    When pandemic erupted in the USA in 1918, the public health infrastructure was very fragmented. In addition, access to information related to this contagious disease was often very limited and data often false or inaccurate. When the outbreaks of influenza occurred in the USA, there were few resources and limited infrastructure supports available to provide the manpower and equipment needed to isolate and quarantine the influenza. In addition, the scientists and public health officials had little influence on the politicians and other military officials. The lethal contagious disease has spread from piers to military camps. Some physicians send several calls to warn the military and the leaders in several states to quarantine and prevent the spread of influenza. However, calls to halt the transfer of troops during camps were ignored. Influenza spread from camps to camps.
    Even though the Board of Health tried to warn the public to avoid crowds, the advice did not receive much attention. There was also fear by the military and politicians that information about influenza would cause public panic and interfere with the war effort, therefore, several leaders prevented sharing information about the dangers of influenza to the citizens and falsely reassured the public not to panic. The outbreak would rise dramatically in Philadelphia when Philadelphia’s Liberty Loan Parade would still be held with boy scouts, marines, sailors, and soldiers participating. In addition, thousands of people crowded the parade route. Consequently, two days (which is the incubation period of influenza – twenty-four to seventy-two hours) after the parade, the civilian population would fall ill and in ten days the epidemic would explode from a few hundred civilian cases and one or two deaths a day to thousands of ill individuals and hundreds of deaths each day.

    Reply

    • Dan Corwin
      Oct 24, 2011 @ 23:43:18

      I would have to say the contagious diseases were becoming better known than any other previous era, but I would agree that the dissemination of that information was slow. Sometimes it would be even impeded, such as the section of the book about yellow fever and in Panama. Only a few people thought it was caused by mosquitos and tested his hypothesis. This resulted in 1902 having zero yellow fever deaths and malaria deaths fell by 75 percent. This proves these scientists had the knowledge, what they lacked sometimes was the financial backing as well as the political backing.

      Reply

  3. Dan Corwin
    Oct 24, 2011 @ 23:37:24

    List and discuss the potential political situations worldwide immediate before and during the 1918-19 Spanish flu pandemic.
    Immediately before the 1918-1919 flu pandemic the world was embroiled in the Great War (WWI).
    -There was great political tension from outside and within the United States to enter the war and help it’s old world allies. Wilson was very much against the US joining the war, but after hearing Germany’s offer to Mexico to join the war against the US he couldn’t have kept out after that point. Wilson once brought into war put all efforts towards being the victor in it “Wilson used an iron fist minus any velvet glove” (Pg 122), this was to describe his behavior in that Wilson would pour his whole focus and being into one goal and do whatever needed to be done to accomplish this “Wilson pushed the espionage act through” (Pg 123). During this time many rights were being strickly prohibited and people were being forced to conform to what the government wanted them to be like. Any thought or whisper of German or another language was cause for treason.
    Describe the public health infrastructure (including information about the capacity and political organization) in the United States during the time of the pandemic.
    -The infrastructure was changing drastically of the medical fields during the pandemic. The red cross was expanding greatly to meet the needs of the war and lack of nurses. Doctors were also being pushed through schooling to meet the needs of army as well. Gorgas tried to make “corp of practical nurses who lacked the education and training of graduate nurses” This way he could push more nurses to the front and could help, versus waiting to have them properly trained. Back at the home front, there was a huge void of doctors nurses and dentists left from the draft of them to the war front. This left many people without proper medical personal to attend to the sick and injured as well.
    Identify the national or local legal issues that surfaced as the pandemic spread and the policy decisions that may have ameliorated or worsened the public health impact of the pandemic.
    – One major legal issue was that the government left the public “medical care for civilians deteriorated” and this added to what John Barry calls the tinder box. He also mentions how little money was spent on getting proper medical equipment to military bases when the draft was implemented for the war. This meant that men that were sick didn’t get proper car and could potentially get worse, just from lack of care. Also as the winter set in barracks were over crowded and some men still lived in tents causing many to become sick and weak before any hospital could be fully constructed at some bases.

    Reply

  4. Brittany Fitzpatrick
    Oct 25, 2011 @ 15:06:32

    HI Everyone! I am looking forward to hearing the political side of the pandemic this week! Politics have had a significant influence on pandemics of the past. How do you think a pandemic would be affected by politics today in comparison to how it was affected in 1918? How do you think government would direct the outcome and success of a such a possible panic?

    Reply

    • Sarah Botting
      Oct 26, 2011 @ 12:22:01

      In response to Brittany –
      I think it would be actually quite similar today how things were handled. When there are limited resources and fear of death sweeps the nation, a lot of moral, ethical, and political dilemmas cease to be addressed. It is understandable that we are more prepared for an event such as this, but when push comes to shove, officials may fold under pressure. Politics would get in the way of treatment and allow the “more important” people in society to be treated quicker and better.

      With this being said, I still think the government would be of greater assistance to us today due to better resources. The problem is ‘what happens when supplies run out and demands skyrocket?’ I guess I feel like our situation today would be more affected by economical dilemmas than political dilemmas.

      Reply

      • Brittany Fitzpatrick
        Oct 26, 2011 @ 17:39:09

        In response to Sarah,
        Information would spread much faster, and therefore resources would also spread quicker throughout our society. However you make a good point in regards to what would we do when we ran out of supplies–due to recent drug shortages I think this would be a strong possibility. I also think this would be possible due to the current economic situation we are in. However I feel as though pharma would make a large effort to produce and circulate what we would need in regards to medications and supplies. Politics would also have direct effect on medication distribution, it is possible they would regulate distribution to areas in need.

    • Sarah DeRuosi
      Oct 26, 2011 @ 15:38:42

      I feel that no matter how “prepared” our nation feels for a natural disaster/pandemic, the shock of the event always seems to be detrimental and devastating. Even though protocols and procedures have been put into play from past experiences such as 1918, there is always something slightly different that occurs and sends our nation into a state of fear. I agree with Sarah’s response to this post by Brittany in that there is a lot of pressure for the officials to devise the most appropriate plan for as many people in our population, but just like anything in this world, you can’t always please everyone.

      Reply

    • Kristin Pesto
      Oct 26, 2011 @ 19:34:11

      In reply to Brittany’s post: As much as I would like to believe that the government would be totally honest and forthcoming with any pertinent information in a pandemic situation, I think they would still censor the information that would actually reach the public in order to limit panic in the masses. I do believe however, that public health officials this day in age would definitely let the public know how to prevent the spread of an outbreak and would tirelessly try to develop a vaccine like when the swine flu hit a few years ago.

      Reply

  5. Suja Thomas
    Oct 26, 2011 @ 11:13:30

    Even though war began in 1914, Wilson was reluctant to embrace war. United States entered the war filled with a sense of selfless mission. It fought alongside Britain, France, Italy and Russia not as an ally but as an Associated Power
    (Barry, 2009). Knowledge of influenza’s epidemiology,was of little use then.Only ruthless isolation and quarantine could affect its course. No scientist and no public health official had the political power to take such an action. The army Gorgs’s urgent and desperate calls to end the transfer of troops were ignored.During the time there was no understanding of what microorganism(pathogen) caused influenza or its pathology/ epidemiology and how it behaved and spread.Every where there was not only shortage of doctors, nurses and hospitals but shortage of coffin. Uncertainty created weakness. New York City Public Heath Department was was facing a special problem: new York City Politics. On Jan. 1, 1918 , Tammany hall reclaimed the control of city. Herman Briggs was the State Health Commissioner. Mayor John Hylan replaced him two weeks after taking control.Hylan fired division chiefs and removed highly respected physicians from the advisory board. Which made the Department leader less. Mean while Mayor appointed Copeland as new health commissioner who had no belief in modern medicine. The public health department in the world was demoralized,internationally respected director of the Bureau of Public Health Education resigned, Deputy commissioner of Health resigned. The mayor replaced him with his personal physician. Even after death occurred in NY City, hospital started filling with influenza cases, Copeland did nothing. when Copeland could no longer deny reality, he imposed quarantine on affected victims and warned” The health Department is prepared to compel patients who may be a menace to the community to go to the hospitals”. He also assured” that the disease is not getting away from the control of health department but is decreasing”. Even though death tools mounted and the numbers kept creeping up. Public health was deteriorating and nation became a tinder box of epidemic. These situations worsened the public health situation during 1918- 1919.

    Reply

  6. Sarah Botting
    Oct 26, 2011 @ 12:25:31

    Society always learns from their past successes and failures, just as we do individually. What do you think were the major successes/failures of the Spanish Influenza that helped our politics and health care society mold into what they are today?

    Reply

  7. Suja Thomas
    Oct 26, 2011 @ 16:23:56

    When the Spanish flu struck in late winter 1918, it quickly spread around the globe, killing 50 million people by the spring of 1919. This century we have sufficient vaccines and antiviral drugs to fight a pandemic. But in the Third World these combatants are in very short supply. In India, where the Spanish Flu is thought to have culled more than 10 million from the population, public health care is still deficient. In China, with a population one third larger again, the situation is not any better. Even for developed countries, where vaccines are readily available, the fraction of the population that routinely subjects itself to inoculation generally hovers around 10 percent. In the event that the public were to receive adequate warnings of an impending pandemic, it’s likely of course that this number could be significantly increased. But even then, it may not matter. By their nature pandemics tend to take us by surprise. The next influenza strain that ravages the human population will probably not be the one we were planning to encounter. When H5N1 on poultry surfaced in the human population of Hong Kong in 1997 it proved to be deadly. The outbreak of a new strain of swine flu in 2009 clearly demonstrated to us that the nature of influenza pandemics is entirely unpredictable. This new strain, an H1N1 variety appears to be very similar to the virus that struck in 1918.

    Reply

    • Sarah DeRuosi
      Oct 26, 2011 @ 19:19:42

      You bring up a very good point, Suja. As in the discussion we are having so far for this third session, it is the element of surprise that makes it so difficult for politicians, scientists, and the rest of the government to prepare for such “attacks.” It almost seems as though we need to have officials whose job is to strictly propose certain scenarios of pandemics that could surface, and devise methods to prevent spreading. We have discussed various changes seen/improved upon since 1918, but what more can still be done to keep the number of individuals affected to a bare minimum? Is there hope for complete preparedness from our nation?

      Reply

      • Kristin Pesto
        Oct 26, 2011 @ 20:10:41

        It seems as though public health officials already consider some “what if” scenarios as we had learned from the preparations that were discussed in the first class. Public health officials had discused where to keep the bodies since they were expecting to have much higher death totals, much like the 1918 Influenza outbreak. And the development of a vaccine for the new strain was undertaken as soon as possible. Since disasters such as 9-11, many businesses and organizations have disaster plans in place and have to review these plans periodically. I’m sure that public health officials have these types of plans in place as well. I think there is no way to be completely prepared for every “what if” situation in the future, but I believe we have made great progress since the 1918 influenza outbreak and would be better prepared today for a pandemic.

  8. Kristin Pesto
    Oct 26, 2011 @ 20:43:09

    Hello everyone. Ponder this for a moment. On page 144 in “The Great Influenza” a journal distributed to the army’s physicians called “Military Surgeon” stated that “every single activity of this country is directed toward one single object, the winning of the war; nothing else counts now, and nothing will count ever if we don’t win it.” What if this wasn’t the case? Consider how different the allocation of the resources would have been and how civilians would have been cared for if political officials like health care workers had to take an oath to practice politics ethically and consider the welfare of humanity. How do you think the situation would have differed?

    Reply

  9. Mattie Ross
    Oct 27, 2011 @ 02:34:26

    Hi Everyone,

    My topic is on the International Reporting of Disease. I’m going to give an overview and a hypothetical at the end.

    In 1918 there was very little reporting of the Influenza pandemic. Governments did not want it to interfere with morale or the war effort by letting the enemy know that they were being weakened by the disease. As a result it is possible that many of the people who contracted influenza would not have.

    The only country that did report the disease was Spain because they were neutral during the war and did not censor the press. So the pandemic was given the nickname Spanish Flu (which I’m not sure they appreciate since the disease did not originate there, which could be implied by the name).

    Today there continue to be reasons why a country would want to hide information about epidemic disease, usually to prevent economic harm. For example, a country may derive a lot of money from tourism and if there is an epidemic disease there people may not want to or may be discouraged from visiting that country.

    Another example is exports of food. Other countries may react by banning the import of animal products because of where the disease originates or just because of the name it was given. One of the reasons H1N1 (swine flu) was given the clinical sounding name was that a number of countries had banned pork imports or slaughtered pigs. Another economic loss arises from when it may be necessary to kill livestock to contain the disease (in 1997 the avian flu was contained by killing every chicken in Hong Kong).
    These economic harms can have a very strong impact on developing countries.

    There are some possible ways to encourage the reporting of epidemic diseases. Some examples are: eliminating unnecessary penalties for those countries that report, tying the willingness to report to the access and benefit sharing of medical countermeasures and public health assistance, or conditioning access to vaccine stockpiles on whether or not a country is providing adequate information (I do not particularly agree with this last one but it could be used as a rationing measure if necessary).

    In addition to not providing enough information countries can also overreact and implement unnecessary measures. To prevent this there could be consequences for countries that choose politically expedient measures such as travel restrictions and trade barriers (when they are not necessary or would not do any good). Also countries could be encouraged to implement only science-based response measures and discourage those that are not.

    To hopefully illustrate this I’m going to give you hypothetical with a couple questions and see where that goes:

    It is summer 2016 in Brazil, shortly before the Summer Olympics are to begin. In July the first cases of influenza begin to emerge in hospitals in Rio de Janeiro. This strain seems to be showing signs that it will have a similar impact as the 1918 influenza virus.
    1. How do you think the government is going to want to respond with regards to reporting these cases and why?
    2. If they do report the cases, how do you think other countries could respond?

    Reply

  10. Kevin Cassidy
    Nov 06, 2011 @ 23:53:06

    Hypothetical #1

    Nurse Smith is employed by Albania Medical Center. One day her supervisor informs her that she will be vaccinating inmates from nearby Albania County Correctional Facility, who are coming to the hospital. Frank, an inmate at Albania County Correctional Facility, is one of Nurse Smith’s patients. Before administering Frank shots for tetanus, pneumonia and influenza, Frank tells Nurse Smith, “I’ve already had each of these vaccinations twice recently, while I was incarcerated at other prisons.” Nurse Smith responds, “That’s not what your chart says,” and gives Frank the vaccinations. Frank later comes down with hypothyroidism and claims he will have to take medication for the rest of his life. Thereafter, Frank sues Nurse Smith in her official and individual capacities for damages. Frank also asks for an injunction on the administration of vaccinations to inmates, so that others will not be subjected to the harm that he has suffered.

    A: This fact pattern is loosely based on Wright v. Mitchell, which is from the Northern District of Texas. Under the doctrine of qualified immunity (rooted in the 11th Amendment) a medical professional under a contract with the state to provide medical services to inmates on even a part-time basis is considered to be acting “under color of state law” and does not have liability. The only way that Nurse Smith could be found liable would be if Frank could show that she had acted with deliberate indifference and that her conduct was objectively unreasonable. The court in Wright stated that even if the inmate really was vaccinated previously, the nurse still would not be liable unless it could be shown that she was aware that giving the inmate more vaccine would cause him injury. In this case the court also did not grant an injunction.

    Hypothetical #2

    Cliff is a member of the United States Marine Corp. Roger is Cliff’s commanding officer. In 2003, while preparing for deployment in Iraq, Cliff refuses an order from Roger to take a new vaccine for cutaneous anthrax. Cliff says he wants an independent expert to provide independent testing of the vaccine before he takes it. Cliff also states that the order violates his constitutional right to refuse unwanted medical treatment. Roger tells Cliff that he is being ordered to take the vaccine, but Cliff does not comply and his case is sent to a military court. Was it legal for Roger to order Cliff to be vaccinated?

    A: This hypothetical is loosely based on United States v. Schwartz, which was decided by the United States Navy-Marine Corps Court of Criminal Appeals. The order was lawful because it had a valid military purpose of retaining servicemembers’ readiness capability in the face of a biological attack. The soldier who refused to take the vaccine was found to have violated a lawful order. He received a bad-conduct discharge and confinement for 45 days.

    Infringements on Civil Liberties: World War I to the War on Terror

    The book describes several instances where the Government infringed on civil liberties during World War I, such as the freedom of speech. More recently following September 11, the security policies instituted by the Government have also been controversial. Two of the more controversial counterterrorism policies adopted by the Government have been the detention of terrorism suspects and the PATRIOT Act.

    I. Detention of Terrorism Suspects

    In November of 2001, U.S. Attorney General John Ashcroft gave a speech describing the Justice Department’s new focus on homeland security and terrorist threats. He announced that since September 11, the Justice Department had “engaged in an aggressive arrest and detention campaign of lawbreakers with a single objective: to get terrorists off the street before they can harm more Americans.” Ashcroft stated that the Justice Department would be “equally aggressive” to the Justice Department under Robert F. Kennedy which advertised that it would “arrest a mobster for spitting on the sidewalk if it would help fight against organized crime,” by arresting and detaining “any suspected terrorist who has violated our laws.” Consequently, after September 11, broad statutory immigration authorities were used to detain and also deport non-citizens from Muslim countries. As a result of these policies, less than two months after September 11, the United States had detained 1,182 people in the investigation of terrorism. Moreover, unlike other wars the United States has been engaged in, there is no telling when the War on Terror will end. Therefore, it is possible that many of these detainees could be facing life sentences without ever having a trial. These policies also led to accusations of racial profiling.

    “The attorney general has extremely broad discretion in how and when to enforce immigration obligations; any immigrant community he targets will inevitably include many persons here in violation of their visas. In this sense the immigration law functions largely as the traffic law for drug law enforcement; it affords a convenient pretext for targeting millions of individuals. And just as the traffic laws facilitate “driving while black” enforcement, so the immigration law has permitted ethnic profiling.”

    According to the Council on American Islamic Relations prior to 9/11 80% of Americans disapproved of racial profiling (the use of racial generalizations as a factor in determining whom to stop and search), while after 9/11 60% of Americans favored ethnic profiling as long as it was directed at Arabs and Muslims.

    II. Patriot Act

    The civil liberties that the Patriot Act infringes on are similar to many that were threatened during World War I. The Patriot Act makes foreign nationals deportable for associational activity. They can also be deported for speech and detained without a finding that they pose a danger or flight risk. The Patriot Act has been characterized as denying foreign nationals rights of political association, political speech, due process and privacy. It also authorizes “preventive detention.”
    The book describes networks of tipsters (members of communities across the country that would report un-American behavior to authorities). While the Government proposed asking for volunteers in the telecommunication industry after 9/11 for similar purposes, Congress decided against doing so.

    Sources:

    John Ashcroft, Reorganization and Mobilization of the Nation’s Justice and Law Enforcement Resources, ATTORNEY GENERAL ASHCROFT AND DEPUTY ATTORNEY GENERAL THOMPSON ANNOUNCE (Nov. 8, 2001), http://www.justice.gov/archive/ag/speeches/2001/agcrisisremarks11-08.htm.

    Aziz Z. Huq, Why Does the Public Cooperate With Law Enforcement?: The Influence of the Purposes and Targets of Policing, 17 PSYCH. PUB. POL. AND L. 419 (2011).

    DAVID COLE, ENEMY ALIENS: DOUBLE STANDARDS AND CONSTITUTIONAL FREEDOMS IN THE WAR ON TERRORISM (2003).

    Reply

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