Thursday, January 7, 2010

Philip Alcabes New Year's Wishes for Public Health

Philip Alcabes' New Year’s Wishes for Public Health

May 2010 be the year when health officials return to the business of alleviating suffering and stop promoting panic.

May CDC become a force for real public health, not an advocate for the risk-avoidance canard. May the new director, Dr. Frieden, stop favoring pharmaceutical companies’ profit making through expansion of immunization. And may he direct the agency to begin to address legitimate public needs, like sound answers about vaccines and autism, and clear communication about what is — and isn’t — dangerous about obesity.

May WHO officials stop playing with the pandemic threat barometer. May WHO begin demanding that the world’s wealthy countries devote at least the same resources to stopping diarrheal diseases, malaria, and TB as they do to dealing with high-news-value problems like new strains of flu. Diarrheal illness kills as many children in Africa and Asia in any given week as the 2009 swine flu killed Americans in eight months. So does malaria. Direct policy, and money, toward sanitation, pure water free of parasites, adequate treatment of TB, mosquito control, and prevention of other causes of heavy mortality in the developing world — not just flu strains that threaten North America, Europe, and Japan.

May public health professionals lose their obsessions with bad habits. May the public health profession return to the problem of ensuring basic rights — access to sufficient food, clean water, decent housing, good education, a livable wage, and adequate child care — and ease up on its moralistic obsessions with nicotine and overeating.

May science be what Joanne Manaster does at her incomparable website: looking at the world with wonder, asking without dogmatic preconceptions how it works, and accepting that its irrepressible quirkiness makes it impossible to know the world perfectly. May science not be the crystal-ball-gazing thing whose so-called “scientific” forecasts are really doomsday scenes worthy of the medieval Church — predictions of liquefied icecaps and rising seas, hundreds of millions of deaths in a flu pandemic, or catastrophic plagues sparked by people with engineered smallpox virus. There are plenty of reasons to be concerned about both the environment and disease outbreaks based on sound here-and-now observations; leave the forecasts of Apocalypse to the clergy, who know how to handle dread.

A new year’s wish (from the valedictory exhortation in Tony Kushner’s Angels in America): “More life!”

By Philip Alcabes | January 4th, 2010 | Categories: Behavior, Disease, Health Professions, Myths, News, Outbreaks, Risk, epidemics, obesity, public health | Tags: CDC, epidemics, germs, healthcare, healthcare reform, housing policy, immunization, obesity, pandemic, plague, preparedness, smoking, swine flu, tuberculosis.


  1. We can let the epidemic have its wanderings and various meanings, But the epidemic is, in a way, always a story, a narrative, an account that is meant (by its teller) to take a stand about what she or he thinks is a problem, to propose, even if subtly, what should be done differently. We might remember this when we are told that we must accept more surveillance or buy new products in order to ward off epidemic threats. When we believe that tax dollars must be spent to fund bio-preparedness exercises because foreign terrorists might create smallpox epidemics, that we should fear promiscuous homosexuals because they spread "superbugs", that we should not vaccinate our children lest they become autistic, or that we should be careful about befriending fat people because the obesity epidemic is "spread through social networks" and threatens our welfare, we might ask what it is we are afraid of. We might consider who benefits by forecasting the new threat, by configuring risk as a consequence of tolerating Islamic fundamentalists, men having sex with men, government immunization programs, or human appetite. We might wonder whether we gain anything more than momentary peace of mind by buying the epidemic story as it is being told. Most of all, we might consider whether there are ways to alleviate the suffering and forestall the premature death that really does occur in the world, rather than still our anxieties by blaming someone else for exposing us to risk.

    The epidemic story is filled, always, with the anxieties that make us tick. It's a story we should read conscientiously, aware of who is telling it and what the message is, bearing in mind that the risk-free life is a mirage.

    Dread; How Fear and Fantasy Have Fueled Epidemics From Black Death to Avian Flu" By Philip Alcabes; Public Affairs Books, N.Y., 2009

    associate professor of Urban Public Health at Hunter College, visiting clinical associate professor at the Yale Nursing School

  2. His account of the HIV/AIDS epidemic is very extensive, impossible to reproduce in this space.

  3. Here's some of what he says:

    "AIDS was never strictly a homosexual disease -we know now that what the CDC investigators were studying in N.Y. L.A. and S.F.-(anal sex etc.) was not to unique to homosexual men, even in 1981- or even purely a sexually transmitted disease-. The AIDS virus is spread far more effectively when the blood of an infected person is inoculated into an uninfected one- as happens with transfusions and the transfer of blood products such as clotting factor for hemophiliacs and with the reuse of medical injection equipment by means of improper sterilization in medical facilities and needle-sharing among illicit drug users. Transmission of the virus through intercourse is inherently of low probability and people who do contract the virus are highly infectious to others only for a relatively short period. Transmission through contaminated intravenous needles, or by transfusion has been generally responsible when there has been a rapid amplification of a geographically limited focus of infection. That is what happened in the Unite States, where the initial infection occurred in the 70s among drug injectors in N.Y.C. and quickly spread.

    Harm reduction procedures- distribution of sterile needles and syringes, the provision of heroin substitution drugs, safe-injecting clinics with medical attention on hands- gained popularity in Europe But, in America, to view drug use as normal, if ill-advised, would have to been to see blood-borne AIDS spread as a public health nuisance that could be dealt with pragmatically and without rhetoric, along the lines of prevention by vaccine. It would have eliminated the questions of prudence and excess, and thereby would have conflicted with profoundly American fears that helped write the story of the new epidemic."

  4. On the question of the obesity "epidemic":

    Not surprisingly, epidemiological studies of body sizes and longevity have found that obesity is not particularly deadly. Indeed, people who are overweight by the BMI standard have the lowest mortality rates, even lower than people of "normal" weight. Among adults in their sixties, it is far worse to be underweight than short,except in the case of extreme obesity, longevity is greatest for people who are considered overweight by current medical standards. Underweight is the most dangerous condition of all."

  5. Some, and possibly a great many, of the deaths attributed to body mass might equally have been attributed to America's messy health care system and a great many other factors- economic inequality, political powerlessness, and social isolation.

  6. In regards to the "epidemic" of autism: it is primarily of an Administrative nature and, of course, has nothing whatsoever to do with vaccines. There are probably no greater proportion of 'autistic' children now than in the past. We just diagnosis a great many more problems as autism. The autistic child's difficulties in school command attention in a society in which poor school performance- lack of flexibility, rapidity and multiplicity in communication- is understood to signal low earning poor students and children with other behavioral difficulties tend to be diagnosed as autistic.

    Alcabes suggests that "autistic styles resonate for us as disorders nowadays because they seem to embody the very process of contemporary life we find most troubling. The autistic child is said to be disengaged emotionally and emotional disengagement is supposedly characteristic of contemporary social interaction- we bowl alone; our social rites are numbed, allegedly abetted by the Internet and the mobile phone; we play at personal computer games in isolation. The autistic child pays uncanny attention to detail and might cite data repeatedly and fondly, much as our reliance on statistics and lists allegedly makes modern life superficial and saps us of humanistic involvement. The autistic child's attention span is minuscule, and limited attention span is typical of the modern multitasker who supposedly misses out on authentic experience. The autistic style, being different from what we expect yet reminding us of what we revile in modernity, becomes a pathology ."

  7. He also has a section entitle "Beyond Eugenics":

    "Genetic determinism is the old "seed and soil", eugenic explanation in disguise..officials still connect hereditary disease susceptibility to race. "Worthlessness", expunged from the modern public-health lexicon, lingers just behind our jargon of risk. Today, black Americans are said to be at a higher risk of prostate cancer, Hepatitis B and HIV and infant mortality, to name only a few of the health problems of concern. We do know what causes Hep-B, and it is probably more common in African Americans for reasons that have to do solely with social clustering. We do not know completely what causes prostate cancer or infant mortality; they are surely complex. Claiming that people of African descent are predisposed to such conditions explicitly attributes disease risk to genetics and implicitly attributes health to a person's fitness. And it ties fitness to race... racial theories of susceptibility to infection have harrowing historical resonances..."

  8. Thank you for this lovely post. I enjoy your writing style and insights.

    And then I saw your reference to my website and was just totally flattered.

    The world is quirky, and impossible to know fully. Isn't that the truth?