AIDS and the American Health Polity: The History and Prospects of a Crisis of Authority

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First Line of Defense

Averting A ‘Group Grope’ Response To Public Health Catastrophes

Vaccine Safety: Injecting a Dose of Common Sense

258 Review CONTAGIOUS DIVIDES: EPIDEMICS AND RACE IN SAN FRANCISCO'S CHINATOWN by Nayan Shah, pp. 398,18 illustrations. Berkeley: University of California Press, 2001; $50.00 (cloth), $19.95 (paper). Nayan Shah, in Contagious Divides, uses a trichotomy of history, geography, and action to critique 19th- and 20th-century public health debates and practices surrounding San Francisco's Chinatown and its residents. This sophisticated and complex account highlights the structural, institutional, and individual factors that defined health and everyday life from the 1800s to the mid1900s . One of the fundamental arguments made in the book is that control over the image and representation of Chinese people and places is critical to understanding the shifting nature and focus of public health policy and practice. Shah divides the book into nine chapters, each of which focus on specific sets of interactions among illness/health, race, gender, and class that defined in large degree the behaviors of white and Chinese residents and advocates, public health and government agencies, and nongovernmental and nonprofit organizations. Each of the chapters focuses on the ways in which Chinese residents and Chinatown are seen as vectors and incubators for specific diseases or illnesses (such as smallpox, bubonic plague, syphilis, tuberculosis, and Chinese infant and child mortality) and the ways in which regulation, sanitization , and surveillance constitute predominant modes of behavior by government bureaucrats, politicians, and business leaders. For example, in Chapter 2, titled "Regulating Bodies and Space," Shah argues that public health officials and the wider public saw the smallpox epidemic as embodied in Chinese individuals (with public health officials having traced the disease to steamer ships from Asia) and therefore geographically situated in Chinatown. This public health understanding of smallpox as embodied in Chinese people and places motivated policies that mandated the social and spatial containment of Chinese immigrants (i.e., individual isolation and spatial confinement in Chinatown). Using detailed examination of public agency and media descriptions of Chinese residents and residences, the author shows how filth, uncleanliness, and even immorality became strongly associated with Chinese living, both in terms of individual lifestyles (e.g., public accounts focusing on the deviance of Chinese bachelor life, opium dens, and female prostitution) and places (e.g., public health agency evaluations of Chinatown having high-density living and mixing production such as cigar making and laundries with domestic living). Other chapters provide similarly detailed accounts of the construction and reinforcement of the social depiction by white public health officials, Journal of Health Care for the Poor and Underserved · Vol. 13, No. 2 · 2002 ToMmshi 259 politicians, missionaries, and residents of Chinese people and places as vectors of disease and the ways in which Chinese women, Chinese laborers, and nongovernmental and grassroots groups resisted such imagery. Shah explains how these stigmatized and stylized images of Chinese people and places become translated into actions by public health staff, politicians, the courts, missionaries, and residents using varied examples (such as the regulation and attempted abolishment of Chinese laundries in San Francisco, the exclusion of Chinese residents pursued by the upscale communities of St. Francis Wood and Nob Hill, and the examination, regulation, and isolation of Chinese and other Asian immigrants on Angel Island). This book makes several contributions to scholarly understanding of health for marginalized and underserved populations. First, the book's focus on gender highlights the importance of white and Chinese women in the formulation of Chinese social identity and in public health policy design and practice. In particular, the book argues the importance and professionalization of Chinese women as physicians, nurses, and social workers who promoted and provided access to Westernized medicine among Chinese residents and families. Second, the author emphasizes the role of nonstate actors (such as nonprofit, religious, and business groups) in designing, implementing , and resisting public health policies and the widely popular social imagination of Chinese life as filthy, immoral, and exotic. Third, the author makes clear the problematic role of the state in pursuing hygienic public health strategies and in depicting and treating Chinese people and places as vectors of disease. Inter- and intrastate conflicts are often integral core elements in each of the chapters. For example, although local public officials saw bubonic plague as directly...

The brave new world of pandemic resilience.

Roles of Public Health Centers and Cluster-Based Approach for COVID-19 Response in Japan.

Wisconsin Blues conversion model.

In the typical European or North American medical school, students are given scant information on the devastating impact of infectious diseases in the developing world. The schools seem to be in a time-warp, failing to recognize the general threat presented by certain diseases in an age of easy travel and the global village. When Laurie Garrett's best-seller The Coming Plague was published in 1994, I immediately recommended it to medical students and junior doctors for the simple fact that it was exciting, understandable and gripping, and portrayed graphically the threat of emerging infectious diseases. It covered many subject areas influencing human health which are not taught adequately in medical school—for example, the improper use of antibiotics, local and regional warfare, refugee migration, changing social and environmental conditions and poverty. Garrett's anecdotal and scary text illustrated in lay language a range of diseases such as HIV/AIDS, toxic shock syndrome, Ebola virus and Lassa fever. She had mastered an extraordinary amount of medical knowledge and presented it in lay language for all to understand. Laurie Garrett now uses her skills as a health/science reporter and personal experiences from her extensive tours across the globe to produce a copiously footnoted book of her vision of the public health structures which are required to contain the threats that she described earlier. Betrayal of Trust1 is a sprawling 585 pages of text with 23 of notes. The first chapter investigates the pneumonic plague outbreak in India in 1994; the second dissects the 1995 Ebola epidemic in Zaire; the third scrutinizes the collapse of the public health system in the former Soviet Union and the emergence of drug-resistant tuberculosis; the fourth is a controversial discourse on the decline of public health efforts in the USA under its ‘managed care’ and ‘medicine for profit’ health system; the fifth, titled ‘Biowar’ is on the emerging threats of bioterrorism; and the final chapter is an epilogue. Betrayal of Trust is about the globalization of microbes and disease. It is scrupulously researched and referenced—though some medical readers may be troubled by its anecdotal and dramatic style. The basic tenet of the book is that an erosion of public health infrastructure (attributable to factors including lack of political will in the USA, economic decline in the former USSR and poverty in Africa) has led to emergence of new diseases (Ebola, AIDS) and new strains of old diseases (multiple-drug-resistant tuberculosis, whooping cough, diphtheria, methicillin-resistant Staphylococcus aureus). Garrett exposes the dark side of ‘globalization’: wherever travellers go, the microbes will follow. Globalized food production means global risks of microbial infections. Misuse of antibiotics is leading to drug-resistant tuberculosis, malaria, pneumonia, staphylococcal infection. She suggests that we have experienced ‘a betrayal of trust’ at the hands of our national leaders and the various local, state and national public health agencies, which have deteriorated to an alarming degree. Dissecting the rise and fall of the public health system in the USA, Garrett argues that unethical experiments such as the Tuskegee syphilis studies have weakened trust in public health officials; that the poor receive little or no medical care; that assertions of individual rights have restricted the capacity of public health officials to respond to disease with the thoroughness that infectious threats demand; and that globalization serves to exacerbate economic inequality. Wherever you look—Los Angeles, India, Russia, Zaire—you find communities totally unprepared to deal with major epidemics or the threat of bioterrorism. In the USA every year 100 000 Americans die from infections caught in hospitals. In India an outbreak of bubonic plague reflects the failure of public health systems to control a disease easily treated by antibiotics. Ebola virus broke out in a dirty and unequipped hospital in Zaire. Garrett documents how the Russians have misunderstood public health and how the new leaders have neither the interest nor the funds to pursue it. Fifteen states of the former Soviet Union have witnessed a rapid collapse in public health; during a cholera epidemic, officials in one state refused to use the simple oral rehydration therapy. In Garrett's opinion, many of the former Soviet Union states were afflicted, like Zaire and other African nations, by deep-seeded corruption that drained the life blood from their social sectors, just as parasites suck the essence of life from the guts of infected children. A recurrent theme of the book is the low investment by most countries in preventive measures. How can the public health systems be returned to strength and efficiency? Garrett's proposals are hardly new—political will and a modicum of funding; adequate nutrition, clean water, good sanitary systems; proper hygiene and provision of basic medical management; rich nations should help poor ones and in the process place their own houses in order. A very expensive, coordinated and seemingly effective response to ‘terrorism’ has been launched recently by the USA and Europe. After reading Garrett's book one wonders why such investment has not been forthcoming for microbial threats—a terror of enormous magnitude. Garrett points out that ‘public health’ is a negative specialty; if it is working well, nothing bad happens. Politicians then lose interest and funding suffers until something bad does happen—for example, a fatal disease getting out of control. Public health is the most important discipline in medicine, but one would not think so from the way it is taught in medical schools. Our future doctors must be made aware of global health issues and the associated preventive measures. My own school, University College London, is I think the first and only one in the UK to have introduced special study modules and an intercalated BSc in ‘international health’. Betrayal of Trust can be recommended to all readers of the JRSM, and especially to politicians, physicians and health workers who have not yet woken up to the fact that infectious diseases have made a major comeback and will be with us for a long time. In my annual introductory lecture on ‘infectious diseases’ to new clinical students I point out that the human race serves as a culture medium for microorganisms, but that the survival of both microbe and human depends on achievement of equilibrium. This notion offers some comfort, in that an advantage for microbes is unlikely to eliminate the human race. Garrett's book, on the coffee table, will keep us asking, ‘Can we do anything more to prop up public health?’.

International grant making by U.S. foundations.

Health Official Roles Attending the now virtual meetings of the Association of State and Territorial Health Officials (ASTHO) alumni society facilitates seeing old friends and meeting new members. However, attendance at the alumni society also signifies that someone is a former state or territorial health official (STHO). Often, membership in the ASTHO alumni society has occurred as a planned resignation (eg, retirement, new job offer), but recent experiences suggest a trend of health officials at the state, territorial, and local levels stepping down or being involuntarily removed.1–4 In the current political climate where science in general and public health science in particular has become politicized, the recommendations and decisions of state and local health officials are being scrutinized in the context of public opinion. Most people would agree that public opinion should not influence the interpretation of scientific evidence. However, because public opinion often influences politicians and because health officials commonly serve communities at the pleasure of an elected official, public opinion and politics can unduly influence scientific recommendations. The current COVID-19 pandemic has highlighted numerous instances where this has occurred.5–8 Public health response activities (eg, contact tracing), as well as recommendations regarding stay-at-home orders, social distancing, wearing masks, and other protective health measures, have all been influenced or scrutinized by public opinion and politics.9–12 Public health leaders are not exempt from these critiques. At the August 2020 meeting of the ASTHO alumni society, 5 new members joined the Zoom meeting of dozens of other former STHOs. While recent research shows that on average STHOs have relatively brief tenures (2.5 years) leading state public health agencies,13,14 many involved in leadership and related research have held the assumption that at least local health officials experience more stability and are thereby able to provide more consistent leadership. Alas, in the current age of a politicized COVID-19 response, it seems that no health officials are assured job security. In fact, according to data collected through personal communications and media reports, since March 2020 when the nation declared a state of emergency due to the COVID-19 pandemic, more than 55 state, territorial, and local health officials have become alumni and members of the group of former health officials. Some of this turnover is the result of planned retirements, but the decisions to step down, move on, or retire during the pandemic may be tied to the intense public scrutiny and literal death threats health officials have been receiving while accruing 70-80 plus weekly hours of nonstop public health response work.1–4 Mello et al15 detailed these attacks in their recent commentary, drawing attention to the need to protect public health leaders from violence and harassment. Similarly, this commentary intends to shine a bright light on the intense controversy and conflict public health officials experience in making policy recommendations to elected leaders and the public in the middle of the COVID-19 pandemic. Turnover During the COVID-19 Pandemic One of the first triggers that alerted the National Association of County and City Health Officials (NACCHO) that turnover was going to be problematic was when 3 board members turned over within 1 month early in the pandemic. At that point, NACCHO started tracking turnover more closely. ASTHO was doing the same. Since the start of the pandemic, 18 of the collective 59 STHOs have left office, with at least 33% of this turnover attributable to conflicts with elected officials and/or threats of physical harm/harassment from the public (e-mail with Michael Fraser, PhD, CEO of ASTHO, dated Aug. 9, 2020). Similarly, at the local level, of the 37 county/city health officials who have left office during the pandemic, 30% did so because of COVID-19 response conflicts with local politicians or public threats (e-mail with Lori Freeman, MBA, CEO of NACCHO, dated Aug. 24, 2020). This means that many public health agencies responsible for protecting the public's health are experiencing disruptions in leadership during the most challenging public health event of our lifetime. Leadership turnover is organizationally disruptive to a public health agency during routine operations, but when it occurs during a pandemic it can be especially difficult for the agency's response efforts. Given the many issues leadership turnover creates, it seems prudent that we support health officials staying in their roles as long as possible. Turnover of senior management roles within organizations, especially at the CEO level, is known to have a significantly negative impact on the organization's productivity and effectiveness, and transitions have to be well managed and communicated lest the agency performance deteriorate or stall. In a recent study, where former STHOs were asked to reflect on what would have helped them be more successful in their leadership roles, they reported needing a better understanding of the political process and how to relate to the governor's office before taking the job.16 Former STHOs also highlighted a need to better understand state government overall. The collective skill set of political astuteness appears to be critical for public health leader success, not just in retaining their jobs but also in tackling public health problems from a systems perspective and challenging policy failures and developing new policy approaches as a result.17 Findings from a qualitative study that assessed the perceptions of senior public health agency deputies (eg, those directly reporting to STHOs) suggested that being able to manage and meet gubernatorial expectations was a key characteristic of STHO success.18 However, many in health officer roles have no prior experience in politics and often come from clinical practice, academia, corporate settings, and organizations whose decision making is not determined by legislatures or chief elected officials. Making Improvements to Health Official Positions In an examination of the training and experiences of current and former STHOs, findings indicate that the majority (64.6%) are medical doctors. Approximately half of STHOs have public health degrees (48.3%), but only 21.8% have formal academic training in management or administration.19 While understanding public health issues is important, it is now increasingly clear that health officials require a skill set in operational management, strategic thinking, and change management. These are topics not traditionally covered in medical school, nor always consistent with health officials' expectations before taking the job.20 In fact, common reasons why STHOs reported they were involuntarily removed from their positions include difficulties in managing a situation or because they failed to understand or adequately manage the expectations of elected leadership. With turnover so common and the job so difficult, one has to wonder: who wants to be a health official? Fortunately, for the public's health, there are still individuals who seek the opportunity to serve their community and improve the health and well-being of the public. Given the recent turnover among health officials and experience of leading in a global pandemic, we suggest that now is the time to reach consensus on what success as a health official looks like. Having clear priorities and expectations can also facilitate the development of job descriptions that explicitly clarify what "good" means and how governors or mayors define "success" for their health official appointee.21 Perspectives of success may vary, but the skills necessary include being able to navigate conflict, managing partnerships, communicating effectively in crisis, and having political acumen. Could it be time to establish contracts, including assured term lengths and even severance arrangements for health officers, similar to those that exist for other public sector leaders such as school superintendents, university presidents, and other federal executive roles such as the surgeon general or the FBI (Federal Bureau of Investigation) director? Given the importance of this role, and the expertise needed, it seems unfair to require health officials to put their career and safety at risk every time they have to make tough decisions as part of their job without some protections for doing so. Leading the Way Out of the Pandemic The pandemic has caused a uniquely stressful and sobering time for our nation. In addition to division and unrest stemming from the pandemic, we have unprecedented attention on racism and an urgent need to recognize structural racism as a public health issue.22–26 We are also planning for unprecedented vaccine administration challenges, concurrently during continuing efforts to mitigate COVID-19, and addressing other public health challenges such as drug addiction and suicide that have amplified during the pandemic. State and local health department staff are working nonstop assignments without a light at the end of the tunnel. As many on the front lines of health care and public health response can attest, it is hard to sprint a marathon. To combat the fatigue and to ensure that the essential public health services can be seamlessly provided, agencies should consider crisis management strategies that manage COVID-19 operations separately but in consort with day-to-day agency activities by designating and authorizing a senior deputy to handle routine operations and give top leaders some breathing space. Such alternative "B-team" strategies, although not frequently seen in public health, are an example of an adaptive complex organizational strategy. Leaders can also benefit from leaning on each other and seeking help and advice from people who have done similar work before them, such as STHO alumni. Leadership, especially during a pandemic, can be lonely and difficult work, and no one leader has all of the answers. We need to work together and share ideas and resources and look to our national associations such as ASTHO, NACCHO, and the Big Cities Health Coalition for collective strength. Finally, there is no better time than now to unite the polarities of science and politics. We cannot easily end this pandemic if we do not follow science and allow scientific principles to guide and inform the path forward, while acknowledging the inevitable political pressures of the job. While politics and science often conflict, effective leadership should be supported and sustained in the best interests of health officials and, even more importantly, the communities they serve.

Remembering the neglected tropical diseases

The Papanicolaou test--or Pap smear test--is one of the most effective cancer screening tests available, and its ability to detect premalignant conditions has contributed to the decline in cervical cancer morbidity and mortality in the United States since its development in 1941. The success of this screening test has created confidence among women, health-care providers, and public health officials. However, this screening tool is not perfect: false-negative findings are a special concern because they can delay necessary follow-up of and treatment for women who have cervical cancer precursor lesions or invasive cervical cancer. Recent media attention has focused on cytology laboratories that have been closed as a result of deficiencies (including a high proportion of false-negative reports), and in some states legal action has been taken against individual laboratories. With the advent of revised federal regulations implementing the Clinical Laboratory Improvement Amendments (CLIA) of 1988, scrutiny of the quality of cytology laboratory practice has increased. Between 1992 and 1994, a total of 10 cytology laboratories were closed by regulatory action of the Health Care Financing Administration because they were considered a threat to the public's health. Although such closures represent <1% of CLIA-certified cytology laboratories, the attendant publicity may trigger anxiety among women. Public health officials must respond to those concerns with appropriate clinical and community actions to ensure the health and safety of women whose Pap smears were evaluated by the closed laboratories. There are no published recommendations to help develop a public health response to the regulatory closure of a cervical cytology laboratory. In April 1994, the Association of State and Territorial Public Health Laboratory Directors, through a cooperative agreement with CDC, convened a working group to provide background on the current practice of clinical cervical cytology in the United States, summarize the CLIA regulations that established specific quality assurance standards for this specialty, and recommend actions that a public health agency may initiate to deliver a measured response to laboratory closings and other regulatory sanctions. This report includes this background and summary of the workshop. The working group made three recommendations: (a) public health officials should plan for a cervical cytology laboratory closure, then, when a laboratory is closed by regulatory action, they should (b) assess the severity of the situation and determine an appropriate response and (c) provide accurate, timely information to the public.

Lessons from the COVID-19 Pandemic—Unique Opportunities for Unifying, Revamping and Reshaping Epidemic Preparedness of Europe’s Public Health Systems

Public health officials rely on science to understand the needs of the public and how to best protect the public’s health. At the same time, politics and plays an essential role in determining what resources will be devoted to public health. Unfortunately, public health officials often focus exclusively on the scientific and medical aspects of their work, ignoring the practical political and legal concerns necessary to achieve their goals.This relationship between science and politics can be seen especially clearly in the United States’ effort to build the Panama Canal - and the struggle with malaria and yellow fever that accompanied effort. Public health and sanitation officials assigned to the project, led by Dr. William Crawford Gorgas, understood the science behind these diseases, and they understood at a practical level what needed to be done to prevent the spread of the diseases.Unfortunately, for the first year of American presence in Panama, little progress was made. Public health officials were unable to get the resources they needed to prevent these diseases from spreading.This article examines why, in spite of public health officials’ understanding of the science behind yellow fever and malaria, they were unable to bring about the necessary changes to fight the diseases. These reasons include (1) the fact that many of the engineering and political officials on whom the public health workers relied failed to understand the scientific basis of their work, (2) the low priority that public health and sanitation were given in the institutional structure of the enterprise, (3) the unwieldy bureaucratic structure of the enterprise, and (4) a lack of political ability on the part of public health officials.After approximately one year of failure, Dr. Gorgas and his team were finally able to get the support that they needed to carry out their projects. Some of the changes that led to this success include (1) a general reorganization of the canal-building enterprise, making it more efficient and less bureaucratic, and (2) increased advocacy for public health to leaders who were in a position to make changes.Today, as then, public health is often given low priority. Understanding the factors that led to the initial failure and to the eventual success of public health officials in Panama can help current officials to better use to tools of government to work toward their goals.