Philip Alcabes discusses myths of health, disease and risk.

Public Health, not “Preparedness”

The outbreak of recombinant human-swine H1N1 flu, and accompanying events of the past few days, make for a ringing endorsement of sound public health measures, and should put paid to the panic-promoting “preparedness” semantic.

None of the programmatic mainstays of “preparedness” has helped to avert or curtail the new flu outbreaks.

Today’s (26 April) Washington Post reports that U.S. authorities investigating cases in California did not know of Mexican authorities’ concerns over their own outbreak, despite official resolve that international communication is essential to “preparedness.” Syndromic surveillance, in which official agencies monitor large databases of pharmacy prescriptions, hospital admissions, ER visits, and so forth in order to ascertain where clusters of illness might presage incipient outbreaks, didn’t detect the Mexico City or San Luis Potosi outbreaks – or even the cases at St. Francis Prep in Queens, NY. The stocks of oseltamivir are still in their piles and the vaccine directed against this season’s predominant flu strains is of no use. And, of course, none of the surveillance for “emerging” infections allowed anybody to see this recombinant virus coming.

Meanwhile, standard – and very old-fashioned – public health measures continue to serve.

Isolating cases and close contacts, investigating travelers coming from affected locales with respiratory symptoms, closing schools, banning public gatherings, issuing warnings to travelers, and reminding the public not to burden medical facilities by assuming that every symptom is a sign of impending death – these measures are as sensible now as they were in 1918 – or 1665. In fact, even face masks, not exactly the elastic-banded tapabocas that Mexican authorities are handing out today, but an early version thereof, were in use in some places by the 1600s when plague threatened.

Public health, with its empiricism and its aversion to panic, has produced a set of methods for dealing with outbreaks.

They worked, where they could be implemented, during the terrible 1918 flu, and they have worked since – most recently in limiting the spread of SARS in 2003. They don’t work perfectly because nothing does: epidemics can cause dreadful suffering. But public health measures sedately limit the reach of contagion. They don’t take as their premise the absurdity that, because we cannot possibly foresee what germs will harm us next, we must do everything in our power to prepare for everything. Preparation for everything is preparation for nothing.

Preparedness sprang from Bush-era rhetoric, aimed at putting the public into a permanent state of half-panic, by which we could be manipulated into supporting endless war (the “war on terror”) and giving up privacy and civil rights. It was the rhetoric of the campaign against the empty threat of “bioterrorism.” Too many public health professionals went along. This new flu outbreak offers an opportunity to return to sound public health measures.

Officials could signal the shift back to public health by refraining from using the inflammatory language of “preparedness” semantic. In particular, they should avoid talking about “pandemic” flu. Nothing about flu pandemics is relevant here, and the word only serves to incite pointless anxiety. Although flu has been causing outbreaks since at least the 1800s, and has produced a bad epidemic every winter through the 20th century, only once has there been a global epidemic – a pandemic – wherein a single strain caused extreme mortality, far beyond the usual flu-associated death toll. To talk about a pandemic today is to pointedly remind the public of that one, unusual, terrifying event and ignore the decades of methodical flu control that have supervened.

The strongest signal that public health has booted “preparedness” out of the driver’s seat would be to return to complex thinking about flu.

The public health measures that will deal with the current flu outbreak represent the short-term plan, but public health should assert itself in the long-term thinking, too. Before the 20th-century love affair with germ theory and misplaced confidence in antibiotics and antivirals, public health thinking was synonymous with thinking about how all the pieces of society fit together. If we’re going to avoid future outbreaks of flu, as well as Ebola, SARS, and other devastating conditions due to microbes that traffic back and forth between animals and human populations, we have to return to thinking ecologically. Flu isn’t a human problem alone; it’s the result of complex interactions involving animals, both wild and domestic, food production, trade, and travel. A real triumph of public health would be to embrace the approach of the One World, One Health movement, thinking holistically and globally about flu. Restructure the encounter of humans with animals and agriculture, instead of stockpiling vaccine.

If the current outbreak, however much illness and death it produces, moves us to return to more sensible, global, and just public health policy, it might have done the world a favor.

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This entry was posted on Sunday, April 26th, 2009 at 4:47 pm and is filed under Disease, News. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.