Public Health At A Crossroads

In the mid-19th century, London experienced a series of outbreaks of cholera, one of the most frightening and deadly of epidemic diseases. During a ten day period in 1854, over 600 people were struck dead in London’s Soho neighborhood. This outbreak is now seen as the birth of modern epidemiology and public health.

Cholera is one of the most frightening of epidemic diseases. It is caused by a bacteria that lives in contaminated water. Within a few hours to a few days of consuming contaminated water (or food that has come in contact with it) you develop severe—usually painless—diarrhea. What do I mean by severe? Up to a quart an hour of liquid stool, so much that it is often hard to stay hydrated. Without oral or IV hydration, death can occur within hours. And of course, while you are shitting yourself to death, you are also releasing more cholera bacteria into the environment.

But in 19th century London no one knew the cause of cholera, and even the germ theory of disease was in its infancy. At the time, the most popular theory of disease was the “miasma theory”, which supposed that foul air somehow carried the agent of disease to people (hence disease names like “malaria”, literally “bad air”). It was easy to believe this, as the Thames was basically a giant sewer and London was assaulted by what was called “The Great Stink”.

But Dr. John Snow, a respected London physician, didn’t think think too much of miasma theory. “Bad air” didn’t seem to explain his observations of the repeated outbreaks which killed tens of thousands across England and Wales, and in 1854, he conducted what may be the first (or at least close to it) epidemiologic study. He mapped out cases of cholera and recorded where people in the area got their water.

The results were very clear—people drawing their water from the Broad St. pump were much more likely to get sick than people who used local wells. He was able to convince officials to remove the handle from the pump, effectively ending the epidemic.

As a doctor, I sometimes get to help patients make decisions that immediately affect their health—sending someone with chest pain to the emergency department; giving antibiotics for pneumonia; prescribing oral contraceptive pills. It’s extremely rewarding to help patients in their effort to stay healthy. But compared to the practice of public health, doctors like me are a drop in the bucket.

Public health is where we make huge, bulk gains in saving and improving lives. The removal of a pump handle, treatment of sewage, fluoridation of drinking water, vaccination—the list of public health measures that improve and save lives in bulk is impressive.

Vaccination is probably one of the most visible public health measures. In the US it’s easy to take clean water for granted—it’s a largely passive benefit. But you have to actively seek out vaccines.¹ It’s impossible to overstate the impact of vaccinations on the health of Americans.

One study from 2007 estimated that childhood vaccinations were saving about 33,000 lives annually in the US,² and and more recent study shows 154 million lives saved globally (most of whom are children).³ But this is an easy war to lose. As we’ve seen with recent measles outbreaks in the US, it doesn’t take big cracks in our immunization armor to set us back years. Eternal vigilance is the price for our kids’ lives.

Today, this vigilance includes writing and calling your representatives—today.⁴ The latest insanity out of Robert Kennedy, Jr.’s HHS is the firing of the ACIP, the committee tasked with making vaccine recommendations nationally. This was a predictable but horrifying move whose impact is hard to overstate. The ACIP was staffed by many of the nation’s most respected vaccine experts. So far, he has appointed replacements that are well-known antivaccine activists. Your ability to, for example, get a covid shot in the fall may be directly affected. We may lose access to life-saving childhood vaccines. Even if they are still on the market, insurance companies may stop paying for them. Programs to promote shots will disappear, and vaccine numbers will plummet. As we’ve seen with, for example, measles, it won’t take long for kids to sicken and die.

Please, please educate yourself and the people around you, and do whatever you can to advocate for public health. Write your representatives, post on social media, talk about it over cards or coffee. This one won’t be as easy as removing a pump handle. Your lives and those of the people you love depend on it.

Stay well.

-pal

1  An interesting side note here is polio vaccination. We have two type of polio vaccine: one which can be injected (which is the one used in the US) and an oral polio vaccine (OPV). In low resource areas, and areas where polio hasn’t been eliminated, oral vaccines provide some unique advantages. The advantage I find fascinating is “passive vaccination”. The OPV is a live, weakened polio virus. This weakened virus can be shed in the stool, so that, for example, if you give it to a child, she may end up spreading it to her household or other people who live nearby. These folks will consume the vaccine strain of polio when they drink water, change a diaper and touch their mouths, etc., and will be “vaccinated” even if they missed their chance at the vaccine earlier.

2  Roush SW, Murphy TV, Vaccine-Preventable Disease Table Working Group AT. Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. JAMA. 2007;298(18):2155–2163. doi:10.1001/jama.298.18.2155

3  Shattock, Andrew J et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. The Lancet, Volume 403, Issue 10441, 2307-2316.

4  Sample: “Dear Sen./Rep. ______, My name is _______, a resident of ______ and I am writing to express my deep concern regarding the actions of HHS Secretary Robert Kennedy. His latest action to remove the highly-qualified members of the ACIP an replace them with antivaccine activists will cost lives. It will directly impact the ability of me and my family to access vaccinations we need. I urge you to take swift action to reverse these actions and restore this vital link in our public health infrastructure. Sincerely, ___”