Monday, August 4, 2014

Mixed Messages About Public Health Surveillance

An opinion piece in the Wall Street Journal today left me wondering after I read it.  The piece focuses on how concerned we should be about Ebola.  The writer's opinion is that we should not worry too much.  While this outbreak has been bigger than any in the past and killed more than any in the past, the spread can be contained.  And while someone may emerge as being ill after reaching a more developed part of the world, it would be noticed, contained, and not spread widely.  

The writer mentions his own experience with respect to SARS (he was suspected of having it but did not, fortunately) and concludes the piece talking about international commitments to prevent the spread of disease throughout the world and the reason that the US should invest in science and public health surveillance at home and abroad.  

Many readers might be puzzled by that conclusion.

For control abroad (paritcularly for something like Ebola which is only spread through contact with bodily fluids) the steps to control can be fairly straightforward.   As the writer points out, cultural traditions of family caring for sick individuals at home and touching dead bodies in preparation for burial make avoiding all bodily fluids difficult.  (I do find it interesting that most accounts I have seen don't mention sweat as a bodily fluid by which the disease can be transmitted but it is clearly listed on a WHO website. That may be more of a cause for alarm in countries in which individuals are on public transportation in very close quarters.  Or perhaps for those of us who sweat like crazy at the gymnasium.)  However, the steps toward control are well known and may have as much to do with culture and the availability of personnel than anything else.

Would science help?  For preventing transmission and a cure, of course.  Would surveillance help?  For making sure that a minimal number of people are exposed, of course.  Would education and personnel help?  From what I have read, perhaps this would help more than anything else.  And while education often takes a long time, none of these will help very quickly.

For control at home in the US, it seems like we generally have things under control.  At least the writer does not suggest that there is a need to worry given current circumstances.  So, while a failure to act at all would be a disaster, our current infrastructure supports quite a bit of activity already.  Do we need that much beyond what we are already doing?  How much extra would it cost to go beyond what we are doing?  And if we are not likely to end up with a whole lot of morbidity or mortality with current activities in place, how much more would be prevented?  

I am in favor of wise icreases in investments in multiple aspects of public health and science.  But for an opinion piece to make the argument that there is not much to worry about while saying that investment is the right thing to do--unquestionably--is confusing.  Readers will wonder--appropriately, in my opinion--about how much investment will be needed to make a difference and how much of a difference will be made.  Clearly, in a world of limited resources, we cannot make every possibly investment in every mechanism to control all threats to public health.  This is one that appears to need more justification in light of what is already being done.  Using a potentially questionable line of logic to call for greater investment may not help when there is a clear need to make more sustainbed and larger investments later on.  

I, of course, am not saying that I have zero sympathy for the 1400+ infected so far.  I am saying that we have to live with some public health risks and this may just be one to live with or to leave to the market to solve.   

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