STEPHEN LEEDER: The public health discipline after Covid-19

Apr 15, 2020

The Coronavirus pandemic draws our attention to the importance of public health in maintaining global human health. Public health as a discipline is distinguished by taking the entire community into account rather than individual patients, and seeking out what can be done to protect and promote human flourishing for all in that community.

Old ways of managing epidemic illness – social distancing and quarantining – have been dusted off and put to good use. These interventions have been necessary because we have no previous exposure to the virus, no vaccine to prevent Covid-19 and no specific medications to treat it. We are as vulnerable as ancient populations exposed to the plague and more recent ones to the Spanish flu. We are desperately fortunate that the virus, generally, causes a non-fatal illness, especially so as it is highly contagious.

What determines public interest, and hence political commitment, to a human activity depends on the relevance of that activity to daily living. Prevention and public health drop down the popularity stakes when they are working well – and nothing is happening. While surgeons can expect grateful patients to leave champagne on their doorstep at Christmas, because their assistance has been visible and recent, a talented public health practitioner who may have prevented much death and suffering on the roads can expect no such thing – because those whose lives have been spared and suffering averted are unknown and unknowing.

Thus, the public health professional communities are often their worst enemies when it comes to making a case for political and financial recognition. Because of their success, investment in prevention and surveillance can be impoverished without public notice or objection to the extent that, while day-to-day activities continue, truly innovative approaches are not developed because of lack of funds.

Also, a touch of triumphalism, if not hubris, can contaminate public discourse about public health, diminishing the importance of surveillance and appropriate response to emerging infectious diseases and epidemics because we have done so well in controlling and preventing them.

Michael Specter, a senior journalist specialising in science and technology, writing recently in the New Yorker, stated that “By the middle of the twentieth century, many scientists had begun to conceive of a world that was largely free of infectious epidemics”. In 1951, [Melburnian] Sir Frank Macfarlane Burnet – a future Nobel laureate in medicine – wrote, “The fever hospitals are vanishing or being turned to other uses. With full use of the knowledge we already possess, the effective control of every important infectious disease —  except for polio — is possible.”

His optimism was understandable. Antibiotics had made many lethal diseases easy to treat; improvements in sanitary conditions had transformed the lives of hundreds of millions of people. In developed countries, typhoid, cholera, and measles—major killers throughout history—had largely passed into memory; even tuberculosis, one of the great scourges of humanity, had been in decline for nearly half a century. By 1972, Macfarlane, writing with the microbiologist David White, was predicting that the “most likely forecast about the future of infectious diseases is that it will be very dull.”

While H.I.V./AIDS provided strong evidence that this view of reality was wrong, aided by epidemics of SARS, Ebola and several influenza variants, the emergence of non-communicable diseases such as heart and vascular diseases (including stroke), obstructive lung disease, diabetes and obesity, and psychiatric disorders as dominant causes of premature death worldwide created a parallel agenda that could only partially be met through clinical care and required public and political action through such community-wider political action as tobacco control, healthy nutrition and the provision of safe and attractive amenities for physical activity. As the adage about walking and chewing gum simultaneously reminds us, it’s hard to do two things at once. And so infectious disease control has had stiff competition.

But relax a little: the reality is not as bad as this analysis suggests. There has been immense investment in health protection worldwide, with breathtaking progress in our understanding of the molecular and genetic biology of infection and host responses to it and the question that presents itself now is, what should we be doing differently in the future to ensure better health?

We need, as with our armed forces, to be well-supplied with early warning systems. And as Korea demonstrated in the Covid-19 outbreak, it helps to have rehearsed – war-gamed even – containment strategies and to have stockpiles of offensive and defensive equipment. Rather than hoarding toilet paper, it would be better to have plenty of personal protection equipment and quarantine facilities at the ready. Most of the time these stores and facilities would stand idle – thank God – but if you need them you need them fast. You need to be able to scramble the jets the moment you know they are required.

In parallel with these basic strategies we should surely consider a review of the institutional structures that support our entire approach to prevention. Toward the end of the Rudd-Gillard era, a preventive services enterprise was established with a broad brief that would have served us well in the current crisis. The Coalition government abolished it once in office, rather as Trump abolished a not dissimilar agency established by Obama. Listen up folks: in a day and age where institutions matter we need to approach to all future threats to health – and dare I mention climate change – at a whole-of-government level just as we do with military defence.

Lest anyone think that I am criticising the current response to Coronavirus, I am not. Of course, aspects of our handling of it could have been better. I am thinking about what’s next. Next time we may not be so fortunate. Preventive imagination should be honoured and rewarded. The life it saves may be yours.

Stephen Leeder is an emeritus professor of public health and community medicine at the University of Sydney

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