Public Health Part II

Next, it is important to consider the necessity of “epidemic declarations.” The denial of an epidemic’s presence has been detrimental to the response of San Francisco and India’s plague outbreaks. When plague threatened India, its government delayed formal declaration of its epidemic status and continued to ignore basic sanitation and public health. Instead, the government focused on reassuring businesses of its viability and controlling panicked crowds as crucial medications slipped into the black market (Bidwai, p.480). Similarly motivated, San Francisco postponed declaration of its first plague outbreak in an attempt to preserve its economic market (Risse p.262). In both cases, the results were devastating, and concealment of the epidemic’s existence only succeeded in reducing confidence and trust among the local public and foreign nations.
The third criterion is general centralization of both public health branches and medical theory. A public health system must be able to maintain its operations and oversee decision-making; however, it should not be so centralized as to make it vulnerable. Iraq’s public health provides an example of extreme centralization in which electrical power stemmed solely from Baghdad, and its annihilation severely handicapped all water purification, sanitation, and medical sites (Alla p.655). Essentially, centralization left the country susceptible to an unrestricted cholera outbreak.
In contrast, medical professionals should maintain a high degree of uniformity and discourse in order to prevent “quack physicians” from taking advantage of the medical sphere and advertising bogus therapies. Medical centralization includes the establishment of common, reliable therapies and of universal, publicly known beliefs about an epidemic. The lack of common remedies or a “paramount authority” during the New York City cholera outbreak in 1832 and 1848 created skepticism and distrust among patients. With some physicians still practicing humoral techniques, and others using diverse or radical methods, a patient encountered a dizzying array of “cures” upon requesting medical treatment (Rosenberg pp.70-72). Patients quickly lost confidence in their physicians and essentially in their public health system.
The fourth condition is continual, active disease research. Countries lacking access to current research literature or sophisticated laboratories are inevitably less advanced in disease diagnosis and treatment. Iraq’s recent cholera outbreak was aggravated by a delay in laboratory testing of suspected cholera cases due to an embargo placed on operation of their local laboratories. This forced physicians to diagnose all cases symptomatically, and prevented accurate record-keeping (Alla p.656). Active research is also necessary to continually stimulate the development of robust new treatments, and to prepare for predicted health crises. Post-September 11th Americans rely on active research regarding vaccine and bioweapon stockpiles in the unfortunate event of another terrorist attack.
Lastly, an ideal public health system requires public education. Demystifying the aspects of a novel disease often decreases “disease metaphors” connected to the sufferer. The ability to reduce a disease to an etiological phenomenon, and to communicate this to the general public, may decrease discrimination and prejudice toward disease victims (Sontag pp.3-4). It often also contributes to public involvement in combating the epidemic. Public activism was critical in San Francisco’s plague epidemic of 1908. Their Citizen’s Health Committee succeeded in conveying the true nature of plague, based on bacteriological knowledge and proven modes of transmission. The public campaign encouraged prevention against a disease that did not discriminate, and discredited assumptions that Asian-Americans were the source of plague. This created a much different reaction from that displayed during the previous plague outbreak in which Asians were unethically targeted and punished due to the moral preoccupations of their public health system (Risse p.280).
If a public health system abides by the above criteria, it can presumably avoid resistance, yet still enact aggressive remedies to combat an epidemic. Essentially, this system can be regulated by a community which is willing to temporarily forego their rights for the health of the populace, and which understands and supports the actions taken by their government. The measures presented above promote stability in the event of crisis, which is an obvious advantage.
The debate of collective security versus individual liberties is currently being scrutinized concerning public health strategies to combat AIDS. This syndrome is truly pandemic, now encompassing Asia, South America, the Caribbean, and Eastern Europe, as well as Africa and America (Kennedy, “Pandemic”). In America, information about this syndrome and appropriate, ethical answers to questions regarding prevention, treatment, and privacy issues are constantly sought. Current questions directly related to United States public health regulations include whether name-reporting of HIV positive test-takers, partner notification, or HIV tests for all pregnant women should be mandated, whether needle exchange programs are truly beneficial, and what information is appropriate for sex education in elementary or middle schools (AIDS Opposing Viewpoints). This open debate stimulates public activism and constant debate regarding measures taken by public health systems.
When regarding the public health guidelines presented above, most public health systems in the United States seem to be striving for the ideal balance between individual rights and authoritative power. Permanent systems are a fixture of every state, and money is available. Moreover, although available funds are not sufficient to cover the many possible routes for the AIDS campaign (some examples include public education about prevention, HIV testing, development and distribution of AIDS therapies, and foreign AIDS assistance), the question of where this money should be concentrated is open for discussion and reform by all Americans. Regarding declaration of AIDS as an epidemic, this criterion was virtually impossible to fulfill, as the symptoms of HIV infection may require ten years to be manifested. By the time the connection between transmission of the disease, the viral source, and the resulting symptoms was made, the epidemic was in full swing and millions were already infected. The criterion of medical and therapeutic centralization is evident—AIDS “cocktails” of multiple HIV inhibitors are most commonly used and people of any class can typically attain publicly-funded medical assistance by a trained physician. Public education is widespread—beginning as early as elementary school. Finally, active research is fervently being conducted by many dedicated scientists. Their advancements have decreased public fear of contracting AIDS by debunking the rumored modes of “casual transmission.”
However, room for improvement still exists concerning preservation of patients’ rights. “High risk groups” still fear infringements on their privacy should their status be disclosed. They may be publicly discriminated, or suffer unemployment and refused insurance policies. This public intolerance stems from the inherent virtues of responsibility and personal choice held by many Americans. AIDS victims are assumed to have chosen taboo behaviors such as drug abuse or unsafe sex, and metaphorically, AIDS is seen as a punishment for this sexual or social deviance (Sontag p.150). In order to prevent this transgression of patients’ liberties, public health systems must uphold strict confidentiality should they choose to release health information.
The question of individual liberties versus collective security during epidemic crisis is a very sensitive one, which cannot easily be answered. Edmund Gibson spoke in the 1720s, yet his observation is still a subject of controversy. This is exemplified by Edward Richards’ comment, made nearly three centuries later:
“…In the case of an evolving epidemic...it may be necessary to choose between protecting the population and collecting evidence that would be admissible in a criminal investigation….”
Richards asserts that this conflict can be minimized “by careful planning,” which may be done through adherence to the criteria presented above. The power implicated by public health will not be deemed coercion if the populace is knowledgeable of the epidemic’s etiology and trusts and supports their system. Above all, a successful public health system requires public cooperation. In this ideal model, public health does not endorse “desperate remedies,” but rather finely-tuned, researched strategies that will eradicate the disease effectively and with the fewest casualties possible.
The ideal public health system proposed above may never exist. As quoted by Paul Slack (Slack p.131, from In Time of Plague),
“…Reactions to threats to public health are never purely “scientific,” carefully judged instrumental responses to precisely identified dangers; and they always involve restrictions on civil liberties of a more or less severe kind….”
The only true conclusion to be made is that public health must be negotiated for it to be successful. Only by coupling adequate power with proper, publicly mandated checks and balances can a public health system truly secure the two most important missions it carries—public well-being, and the support and trust of its community.