In mid-April 2009, I noticed that the influenza season in Mexico had not ended the way it should. I contacted friends and acquaintances in Mexico City and other parts of the country to ask them what they were seeing. Epidemiologist colleagues told me that they had noticed the same thing. A season that should have been trending down was not doing so, and local hospitals and clinics were being overrun by people with respiratory symptoms.
That night, I emailed my fiancee (now my wife) and told her that I had a bad feeling about what was going on. I told her that it made no sense for Mexico to still be seeing their season being so prolonged. The US season was winding down, though. I remember writing to her that I hoped I was wrong.
After that whole thing was done and over with in 2010 (because it swung around and hit us twice in 2009), I wondered if there was something that we could have done to stop it. By “we,” I mean us in public health. At the time, I was just a freshman epidemiologist with a couple of years of experience. In ten years time, I would be a doctor of public health, and we would be facing another pandemic… The next pandemic.
Can pandemics be stopped? In one word: Yes. But it is very complicated. For example, the HIV/AIDS pandemic could have been stopped if enough resources had been put into place the minute it was identified as a sexually-transmitted infection. HIV was infecting the “undesirables,” though, and enough leaders (religious and political) were calling it a godsend to get rid of said undesirables. It was a punishment from above, not the continuation of a zoonosis that had started decades earlier.
Respiratory infections are a whole other animal, though, especially the ones with relatively (RELATIVELY) low fatality rates. Those with higher rates, like Ebola, kill the hosts before the infection is spread too widely. (Global travel is challenging that, however.) Those that infect you, incubate, and then attack but leave you well enough to have you go to school or work have the ability to really cause disruptions.
I mean, look out the window right now if you’re March 2020.
Bacterial pandemics, like the ones that cholera has caused, are mostly under control by our ability to deploy control measures (clean water and vaccines) and antibiotics. But we’re also entering a sort of “post-antibiotic” era where bacteria are evolving faster than we can make antibiotics against them. So future bacterial pandemics will also require control measures that are not pharmaceutical in nature.
What we can do — and we should do at the end of this pandemic — is have a foolproof, well-researched, practiced yearly, top-of-the-line pandemic preparedness plan that spans the entire spectrum of everything we know has happened and could happen. From what a person will do in their everyday life to what small businesses will do when left with no workers and no employees, to what big groups and organizations will do to keep the disease from spreading. We can’t go blind into the next one — like we did into this one — because the next one could be the big one.
Then there are the epidemics and pandemics of non-communicable diseases, like obesity, diabetes and opioid use/abuse. Those are going to be super-difficult to figure out, perhaps more difficult than infectious disease. This is because we are social animals who’ve managed to separate into tribes and social strata. If something is happening to “them” and not “us,” and it will stay “over there” and not come “here,” we kind of look the other way.
Here’s an example… In Philadelphia, like in other cities in the United States, there is an epidemic of opioid use and opioid overdoses going on. Many of the people using and abusing opioids are using heroin, an injected opioid. (You can also smoke it, by the way.) When people inject heroin and other drugs, their risk for blood borne infections skyrockets. They share needles or trade drugs for sex (that is performed unsafely), and they get infections with Hepatitis B, Hepatitis C and HIV.
Look at what happened in Indiana, that bastion of public health.
No doubt, Philadelphia is lining up to be the next epicenter of both overdose and blood born infections… If it isn’t already. To counter this, city health officials and health leaders have proposed a safe injection site. In a safe injection site, the user goes in, gets a clean needle and a place to rest. They get medical supervision while they use their drug of choice. Should something go sideways, they get immediate medical attention.
But drug addiction — against all evidence — is thought by many to be something that happens to “them,” the “others,” the undesirables. It doesn’t happen to “us,” the clean people, the God-fearing people. And if something is to be done for “those poor people,” it better not be done in our back yard, or my neighborhood, or anywhere that could possibly make me think that help is happening at all.
On Monday, March 16, 2020, supporters and detractors of a safe injection site in Philadelphia came together to give their opinion on a bill that would ban such help for “those people.” As you can imagine, the discussion was lively, including some gems like:
“Why would we want to be the first to experiment on this?… “It makes no sense whatsoever. I’m full of compassion for [people suffering from drug addiction], but I’m more full of compassion for my residents and all the residents symbolized by these civic associations.”
There are no safe injection sites in the United States, but there are plenty in other parts of the world. Those other sites have shown success in reducing overdoses and in guiding users into recovery programs. On top of receiving clean needles and medical supervision, they also are referred to care, and many of them take it. Some place in the United States, a place where these programs are needed, is going to be the first place, the “experiment.”
But the comments did not stop there.
Capozzi’s sentiment was echoed in the testimony of South Philly resident Anthony Giordano, who represented a community group called Stand Up South Philly and Take Our Streets Back.
“Safe injection sites are not safe,” he said. “Allowing people to consume illegal drugs of unknown composition in a so-called medical facility is beyond my comprehension. How is this safe? Helping people further harm themselves under the guise of a legitimate medical intervention just doesn’t make any sense.”
Some people tried to use science and reason:
“It amazes me that we’re sitting here talking about making a medical decision and we’re listening to public opinion,” she said. “We need to make this based on information like Dr. Farley suggested: medical consensus, meta-analyses and a medical opinion.”
Milas was unique among the four medical professionals because the opioid crisis had affected her a bit more personally. She had two sons die of opioid overdoses – one was 27 and other 31, she said.
“At the 100 legal supervised injection sites worldwide, there are no recorded deaths,” she testified. “Had my sons overdosed at a Safehouse-type facility, they would have had a 100 percent chance of survival.”
Roth piled on.
“The scientific evidence from peer-reviewed journals on these sites is clear,” she testified. “They reduce overdose mortality rates, HIV, environmental hepatitis risk, they improve access to health and social services, they help reduce substance use and help people enroll in treatment. Furthermore, they’ve helped improve community health and safety. In neighborhoods where a [safe injection site] exists, there are actually reductions in public injection and improperly discarded syringes, reductions in drug-related crime, and the demand for ambulance services for opioid-related overdoses goes down.”
You can read the rest of the South Philly Review article to see how one of the legislators used a very flawed non-scientific “study” to support his claims that safe injection sites are absolute evil. That’s where scientific discourse in public policy has gone… To unsubstantiated and flawed opinion surveys.
As I’ve stated before, several times, public health in the United States and in much of the world is all about politics. You better pray that the right political party is in power, or the right people are in power, so that the decisions that need to be made are informed by evidence and science more than the “what ifs” of public opinion. This is Democracy getting in the way of things, unfortunately.
As we saw in Wuhan, China, when authorities there felt the need to shut down cities, they did so without any apparent issues. (There might have been issues, but we’ll be darned if we ever find out.) That’s an authoritarian government for you in a very collectivist society. Can you imagine trying to shut down even a small town here in the United States? With people with guns? And SUVs?
So, yeah, we might not be able to stop this pandemic, or the next one. After all this, I’m going to focus on having what I call “premier” surveillance systems and response plans. We’re going to learn a lot from this pandemic, and I plan to make it my life’s work (on top of all of my other work) to make sure we don’t forget about this time, next time.
Until next time… Thanks for your time.
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
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