|
|
|
|
|
The Inverse Alchemy of Making Nothing Happen and the Enduring Paradox of
|
|
Author:
Madeline Roberts, PhD, MPH But she has also been contemplating the inherent peculiarities and challenges of a field tasked with transforming something into nothing. “There is a common refrain in public health that captures this paradox: if we do our jobs right, nothing happens. An outbreak does not grow into an epidemic. A child does not go hungry…but because of the nature of our work, many successes go unnoticed. They are evident only in the suffering there might otherwise have been.” Crisis Averted brings into focus the incongruous oddities of working in a field where success, by definition, means something did not occur. Perhaps at least part of what it is to be an epidemiologist is to belong to a collective of professionals able to see the world inverted as though through photo negative—what isn’t there, what didn’t happen. A recent analysis projected that of approximately 117 million children born between 1994 and 2023, routine childhood immunizations will prevent an estimated 508 million illnesses, 32 million hospitalizations, and upward of one million deaths. This translates to an estimated savings of $540 billion in direct medical and non-medical costs and $2.7 trillion in societal costs, the latter of which includes productivity losses from premature death and disability and opportunity costs for parent work absences attributable to caring for sick children. We have seen astounding improvements in child mortality. In 1800, for every one thousand babies born, approximately 46% did not live to see their fifth birthday; by 1900, this decreased to around 23%, and in 2020, 0.7%. Much of this is attributable to simple, not-at-all glamorous advancements such as sanitation and immunizations. But prolonged gains can have an obscuring effect. Rivers writes of adenovirus outbreaks within military training settings, which historically afflicted nearly 50% of new recruits. The development of a military immunization program in 1971 drastically reduced this and prevented an estimated 27,000 hospitalizations. The immunizations were so effective for approximately two decades that the program languished, and vaccine production was discontinued in the mid-1990s. Within months, adenovirus returned, resulting in hundreds of preventable hospitalizations and two deaths of otherwise healthy young men. Rivers writes, “Over the years, the scourge of adenovirus epidemics became a distant memory. Military health professionals knew of the threat in abstract, but they had personally witnessed only the absence of disruption [which] did not equip them with the urgency needed to maintain defenses.” While devoting an entire chapter to novel technologies and their myriad benefits, Rivers argues that we cannot allow fundamental investigative work to be eclipsed by biomedical technological innovations. “For the most important disease detective work, all that is needed is a trained investigator, a notebook or tablet, and a calculator…don’t let the low-tech simplicity fool you. The power of collecting and collating this information is extraordinary.” Indeed, with a hand-drawn dot map, meticulous detective work, and a pen in 1854 London, John Snow was able to approximate the work of modern GIS applications. For all the advances AI has ushered in, Rivers argues that large data models cannot provide nuanced details about case commonalities among the infected or where the problem is concentrated, details upon which investigations can turn. She stands by the humble line list as the most indispensable tool for outbreak investigation. Much of the work of public health now lies in rebuilding relationships and reconfiguring health communication in the post-pandemic social and political landscape. Rivers does not gloss over crucial public health communication errors: “Even when the best way forward is clear, sometimes public health is clumsy at making the case…the job of public health experts is to give people clear guidance about what they will face and how they can protect themselves.” Establishing true partnerships between public health workers and their communities opens a path for collaborative surveillance, preparation, and education.
Crisis Averted
chronicles many of the triumphs and shortcomings of public health but
also includes the raw reflections of someone who has disabused herself
of pretense to take an honest look at the failings of our field along
with its real potential at this moment.
Rivers underscores the importance of
unembellished, fundamental epidemiological investigative work, which
is at the front line of virtually every outbreak and precedes
innovations such as novel vaccines. She reflects on a saying from
defense experts: “You go to war with the army you have, not the army
you might want or wish to have at a later time,” which, in this case,
comprises the people trained and tasked with making nothing happen. |
|
|
