Public Health and Terrorism
Public health is truly a public problem which by its very nature cannot be privatized. Disease control cannot be effectively carried out in limited social or economic classes, or even only in our own species (consider Mad Cow Disease). Complacency about triumphs such as tuberculosis control in the United States after WW II has resulted in disastrous budget cutting for public health in the last several decades.
Public health departments are responsible not only for infectious disease surveillance, but for surveillance of all threats to health, including monitoring the success of accident prevention measures such as seat belts and bicycle helmets. About ten years ago the CDC started a project studying the epidemiology of gunshot wounds to seek ideas about how to reduce their numbers. Congress got wind of this research and cut off the funding for that specific project. Dr. Hrasky, recently at the Monroe Clinic, did a fellowship in orthopedics in New Zealand. He was amazed that the house staff who had not left New Zealand had never seen or treated a human gunshot wound, despite the fact that hunting is a popular sport in that country.
The Center for Disease Control (CDC) in Atlanta is a world resource that happens to be funded by our government. The Center is prepared to send teams anywhere in the world where a disease outbreak seems to threaten a wide area, since air travel permits world wide dissemination of disease during its incubation period, and before it can be recognized by immigration officials. For example, teams from the CDC went to Africa in response to the initial Ebola virus outbreak some years ago. The teams expertise and moral commitment made it possible for them to dictate successful control measures and the epidemic was limited in its geographic extent. Perhaps ultimately the World Health Organization can fill the current role of the CDC, but not presently.
Similar long term commitment and quiet work was behind the CDC's key role in the 2001 anthrax cases. Before the September 11 attack the CDC had presented a course about bio-terrorism in Atlanta for state public health authorities, including those from Florida. This enhanced Florida's early recognition of the initial anthrax cases. Meanwhile over the years the CDC bacteriologists and epidemiologists had amassed a library of DNA fingerprints. of strains of anthrax from all over the world. Within a few weeks of starting to study the new strains they will knew that they were from a common source and they determined the geographic origin of the spores. Collecting these libraries of detailed information about many diseases is an ongoing activity of these bacteriologists when they aren't traveling to "put out fires" of a more immediate nature.
Here is an example of the professional commitment of epidemiologists. In the 1960s there was an epidemic of giardiasis, a diarrheal disease of moderate severity caused by an intestinal parasite. Symptoms developed in Aspen Colorado skiers some weeks after their return to their homes. Local health departments all over the country cooperated in interviewing patients and finding out where they stayed and where they ate in Aspen. A map of Aspen identifying these spots with pins showed a concentration on a particular street. Because Giardia lamblia is usually transmitted by contaminated water, the concentration suggested plumbing defects in that street. Digging up the street confirmed two leaks, one in the ancient wooden sewer pipes left over from Aspen's boom times as a mining town and the other nearby in old fresh water supply pipes, permitting some intake of contamination when the pressure dropped during times of high fresh water demand.
The sequel to this story is a fascinating example of how these public health guys keep busy in their "spare" time. A few years later health authorities reported sporadic cases of giardiasis all over the U.S. in unrelated communities. A number of the affected individuals turned out to be tourists who had been in Leningrad. The CDC gang got out their Aspen questionnaire and plotted a map of Leningrad with the cases “pinpointed” showing the Russians where to dig up the street. Thus the CDC experts were able to help the Russian public health people without even going there.
And now, how about bio-terrorism? If a bio-terrorism attack is to be contain4 the public health system will be intimately involved. Restoring these systems to their maximum capabilities is a priority. Public health authorities have responded heroically to disease epidemics in the past. The methods they use for surveillance of naturally occurring disease are already in place, but need to be strengthened to meet the possibility of unprecedented future challenges.
John Frantz M.D.
October 10, 2001, revised December 2, 2004
On a visit to Peru several years ago among the amazing things we saw were peasant households with many guinea pigs running around more or less unsupervised. This was to provide fresh meat on short notice without need for refrigeration. Guinea pigs’ size and prompt availability were both appropriate. Apparently housewives everywhere like to be prepared for unexpected guests.
The large cathedral in downtown Lima, Peru, has a mural painting of the last supper in Spanish Baroque style. Every plate has four obvious guinea pig legs sticking up from it. On further inquiry I found that Peruvian artists had been trained by the Spanish. They had learned the technique well and had applied some local culture to the details of this painting.
April 4, 2003.