A Model Public Health System Part I

Disease has been a ubiquitous human affliction since the dawn of time, but epidemic disease did not surface until approximately 10,000 years ago when the special case conditions of large populations and poor sanitation became inevitably synonymous with human life (Porter p.17). Fortunately, these changes also spawned the development of sophisticated public health systems to collectively manage epidemic crises. The maintenance of public health has throughout history been one of the most important—yet most difficult—requirements of a thriving community. This is because a public health system must be able to respond to impending epidemic with rapidity and efficiency, but must also acknowledge individuals’ rights to avoid mass resistance. This raises the question of which aspect—collective security waged by public health or the protection of individual liberties—should supersede the other during an epidemic. I intend to provide evidence that a public health system can largely avoid this conflict if it follows certain criteria.
It is important to consider whether personal liberties or the power of public health should be preserved. If public health is granted unrelenting “police powers,” the system may become corrupt. History holds accounts of this, with an example occurring in Tuskegee, Alabama during the 1900s. Syphilitic black men were observed rather than treated in order to map the natural progression of syphilis. This public health system exceedingly transgressed the preservation of individual security in order to attain a disease etiology (HIST171 discussion). Conversely, if a public health system is denied power during a serious epidemic, its strategy to combat the disease may be hindered. There exist incidents of public health struggles, such as the campaign toward worldwide smallpox eradication. In this case, the vaccine for a disfiguring, dangerously fatal disease was available, but was resisted by those who lacked unbiased knowledge of its curative effects and of the necessity for global vaccination. Rather than exhibiting concern for the world at large, their apprehension of an infringement on their rights overruled (Greenough pp.635-639).
When analyzed, representative case studies of epidemic-ridden communities such as these demonstrate the breadth of implicated responses, and help to specify the components which constitute an ideal public health system. I maintain that a public health system can mitigate conflict between individual rights and collective security if it adheres to these stipulations. These include permanence and financial security, regulations to declare outbreaks on local and international levels, some degree of centralization, a promotion of active, continuous disease research, and an incorporation of public education. Most importantly, and in agreement with the observation made during the 1720s by Edmund Gibson, a public health system must be able to override individual rights in the event of epidemic crisis in order to ensure the collective well-being (Slack p.131, from In Time of Plague). The corollary to this last stipulation is of critical importance—the public health system may not dominate individual liberties if its actions reflect moralistic emotions evoked during the initial throes of an impending, novel epidemic. If a public health system uses subjective or racist beliefs to target specific groups without statistical basis or experimental evidence, the resulting strategy will be irrational and ineffective. Susan Sontag suggests, however, that this route has been taken all too often. In AIDS and its Metaphors, she exemplifies the uselessness of one such moralistic strategy (Sontag p.169):
“…The incarceration in detention camps surrounded by barbed wire during World War I of some thirty thousand American women, prostitutes and women suspected of being prostitutes, for the avowed purpose of controlling syphilis among army recruits, caused no drop in the military’s rate of infection….”
In order to prove the significance of an effective public health system, each previously stated aspect will be discussed through historical case studies of cities battling bubonic plague and cholera. Additionally, America’s public health response to AIDS—currently a pandemic disease—will be critiqued according to these public health guidelines.
The first aspect of an ideal public health system is permanence and financial security. Its importance is evident in accounts of the New York City cholera epidemics of 1832, 1849, and 1866. The 1832 and 1849 epidemics were coupled to high morbidity and mortality rates, partly because the advent of cholera generated a hasty appointment of a temporary public health board lacking experience, organization, and sufficient funds. In contrast, the virulence of the 1866 epidemic was significantly hampered. One of the contributing factors of this success was the establishment of the Metropolitan Board of Health, a permanent public health system constituted of practical and socially-minded professionals in multiple disciplines. The Board developed a solid plan and possessed both the stability and confidence to enforce it, as well as the funds to maintain it. The result was the accomplishment of a monumental task twice failed in the past (Rosenberg pp.193-203).

Part II coming soon.