Personal Views: Between Chicken Little and the four horsemen of the apocalypse
Authors: Joshua Lipsman
Journal: BMJ (2006)

At a medical meeting in the United States this year, a presentation on avian influenza started with two slides of cartoon drawings, the first, of the feckless Chicken Little of “the sky is falling” fame, and the second, of the four horsemen of the apocalypse. As a local health officer, I feel as if these two images represent the poles of my despair over public health emergency planning.

Tension exists in public health between the rise of public health emergency planning, and our irresistible draw to focus on the real public health problems we face every day. With resources always limited, how do we balance disaster planning with necessary attention to ongoing problems of tobacco, obesity, HIV, maternal/child health, environmental health, and the like? Particularly given the US smallpox vaccination debacle of 2002, we must proceed carefully if we are to sustain our reputation for integrity. I do not wish to be remembered as the official who built this generation's public health equivalent of the Maginot line.


Tension remains between what we see and what we only imagine


Westchester County, New York, where I work, has a population of 940 000, living on 450 square miles north of New York City. Westchester is one of the most affluent counties in the United States, although nearly one in five Westchester households has an annual income of less than $25 000 (£13 273; €19 483) and nearly one in five children lives below the federal poverty level. The county administration is forward looking, with a genuine concern for public health.

Nevertheless, the budget of the county health department from all sources dropped 5% from $33.1m in 2002 to $31.5m in 2006, entailing a reduction in staff of 15%, from 440 to 372 full time equivalent positions. During the same period, Westchester received over $5m in federal bioterrorism funding. Meanwhile, the county has among the highest rates of HIV and AIDS statewide. Clearly, we experience extreme contrasts of wealth and poverty and profound existing public health problems in the face of significant spending for bioterrorism preparedness.

Here is how I have resolved this tension for myself. I recognise that we are building an infrastructure to serve as insurance against a low probability, high impact event. To justify developing this infrastructure in the face of other needs, I strive to ensure that our preparation for the hypothetical is simultaneously applicable to the real. My intention is for our infrastructure-cuminsurance policy to serve double duty today and to be useful in the future, even if our worst fears are never realised.

In our planning, we have emphasised three traditional public health functions: education, surveillance, and control. Public education is crucial for quelling panic, and to support rationing or limits on civil liberties that may need to be imposed. Educating the medical community can be the most direct way to get information about an emerging health threat quickly to local providers who might not have access to official federal and state government releases. Thus, even though funding is long gone for the sort of successful educational campaigns that we mounted against smoking and to promote HIV testing, at least our current public health emergency planning outreach capacity allows us to alert the community to occasional garden-variety disease outbreaks as well as to those of the hothouse sort, should they ever occur.

Passive surveillance is the classic public health technique of receiving and evaluating disease reports. We also have an active surveillance component, consisting of daily data transfers to the health department from 11 acute care hospital emergency rooms and some large outpatient practices. The data are filtered into syndromes and statistical aberrations are investigated. The system is always operational, and has detected the onset of seasonal influenza, a pollen-induced asthma outbreak, and the “Clinton syndrome”—a spike in local emergency room visits for chest pain after Westchester's most distinguished resident underwent emergency coronary artery bypass surgery in 2004.

Finally, though budgetary constraints preclude, for example, implementation of programmes to improve diet and to increase physical activity in the fight against obesity, we are actively controlling other present and future public health problems. Whether applying larvicide and eliminating standing water to control West Nile virus or laying the groundwork for involuntary isolation and quarantine with the local judiciary, medical community, and public safety officials, we are simultaneously practising public health, planning for public health emergencies, and developing public health infrastructure.

Tension remains between what we see and what we only imagine but fear deeply. History will judge whether today's public health paradigm is alarmist or apocalyptic, but regardless, we are doing what we can.