The Crisis of Public Health Revisited: Implications for Social Work

********** The February 2001 National Health Line addressed the growing crisis in the nation's public health system (Gorin, 2001). As the article noted, concerns about the state of public health are not new. In 1988 the Institute of Medicine stated that our public health system was in disarray (cited in Gorin). Six years later, a group of experts noted that budget restrictions had limited severely the ability of public health departments to respond to infectious disease (cited in Ryan, 1997). More recently, the Institute for the Future (2000) stated that during the past 30 years the public health system has operated under pressure of resource scarcity; limits in leadership, and organizational fragmentation (pp. 8--9). Similarly, in a massive study of the public health system, Laurie Garrett (2000), a Pulitzer Prizewinning journalist, described the U.S. system as being in shambles. The events of September 11 and the subsequent anthrax attack have exacerbated this crisis. This article considers some implications of these events for our public health system. A note of caution is in order. This article is being written at the beginning of November 2001 and almost certainly will be outdated by the time it appears in print. Such a lag is inevitable in a journal such as Health & Social Work, which is published quarterly. The problem of currency is particularly acute now, when events are changing dramatically on a daily basis. At the same time, the broad outlines of future trends seem dear. THREAT OF BIOTERRORISM The importance of public health became clear after the attack on the World Trade Center, when New York City's public health infrastructure mobilized to deal with the crisis. The anthrax attacks have further signaled the importance and limitations of our public health system. Moreover, anthrax may only be the tip of a bioterrorist iceberg, which we ignore at our peril (Cole, 2001; Drexler, 2001). The worst-case scenario, almost too awful to contemplate, would be an outbreak of smallpox (Brownlee, 2001). Smallpox is a highly contagious virus. The World Health Organization (WHO, 2001) has called it "one of the most devastating diseases known to humanity." Although a vaccine can prevent or delay the development of symptoms in individuals exposed to the virus, smallpox has no known cure. With great effort, the World Health Organization, under the leadership of Dr. Donald Henderson, successfully eradicated smallpox in 1977 (Garrett, 2000). However, the former Soviet Union and the United States preserved laboratory samples of the virus (Garrett). Unfortunately, the precise location of the Soviet sample is unknown. With the demise of the Soviet Union, tens of thousands of scientists who had been engaged in bioweapons research were forced to find new employment. This raised the chilling possibility that some scientists may have sold their expertise, and perhaps biological agents, to other countries (Garrett). Governments stopped immunizing against smallpox years ago, and the world has a short supply of the vaccine; if unleashed, the virus could spread quickly (Altman, 2001). A full-blown epidemic could result in as many as two billion (!) deaths worldwide (Garrett, 2001).Although a smallpox attack is unlikely, after September 11th, it cannot be ruled out (Brownlee, 2001). SPREAD OF INFECTIOUS DISEASE Concern about infectious disease is not limited to the issue of bioterrorism. During the 20th century, chronic diseases gradually replaced infectious diseases as the leading cause of death, particularly in developed nations (Tulchinsky & Varavikova, 2000). Despite this, infectious diseases remain a serious and growing problem. In January 2000 the government's National Intelligence Council (NIC, 2000) described infectious disease as an emerging threat to international stability and national security. Since 1973 older diseases, such as tuberculosis and malaria, have reappeared in more virulent form, and newer incurable diseases, such as HIV and hepatitis C, have appeared (NIC). …