The Frictions That You’ll Encounter

Before I begin, a quick note: I worked on the Zika response in Puerto Rico during November and December of last year. A section of this blog post deals with what is happening in Puerto Rico with regards to investigating Zika cases, and it includes excerpts from news reports indicating that there is a lot of friction between the Puerto Rico Health Department and the Centers for Disease Control and Prevention. For obvious reasons, I will not give you private, confidential, or sensitive information I gained there. And, as usual, any opinions here are my own and not those of anyone who has employed me, my school, friends, colleagues, etc. You know the drill. End of note.

Back in October of 2016, a paper was published by CDC and Puerto Rico Health Department (PRDH) scientists forecasting the number of babies born in Puerto Rico (PR) with Zika-associated microcephaly. The paper in JAMA Pediatrics has the following abstract:

“Importance Zika virus (ZIKV) infection during pregnancy is a cause of congenital microcephaly and severe fetal brain defects, and it has been associated with other adverse pregnancy and birth outcomes.

Objective To estimate the number of pregnant women infected with ZIKV in Puerto Rico and the number of associated congenital microcephaly cases.

Design, Setting, and Participants We conducted a modeling study from April to July 2016. Using parameters derived from published reports, outcomes were modeled probabilistically using Monte Carlo simulation. We used uncertainty distributions to reflect the limited information available for parameter values. Given the high level of uncertainty in model parameters, interquartile ranges (IQRs) are presented as primary results. Outcomes were modeled for pregnant women in Puerto Rico, which currently has more confirmed ZIKV cases than any other US location.

Exposure Zika virus infection in pregnant women.

Main Outcomes and Measures Number of pregnant women infected with ZIKV and number of congenital microcephaly cases.

Results We estimated an IQR of 5900 to 10 300 pregnant women (median, 7800) might be infected during the initial ZIKV outbreak in Puerto Rico. Of these, an IQR of 100 to 270 infants (median, 180) may be born with microcephaly due to congenital ZIKV infection from mid-2016 to mid-2017. In the absence of a ZIKV outbreak, an IQR of 9 to 16 cases (median, 12) of congenital microcephaly are expected in Puerto Rico per year.

Conclusions and Relevance The estimate of 5900 to 10 300 pregnant women that might be infected with ZIKV provides an estimate for the number of infants that could potentially have ZIKV-associated adverse outcomes. Including baseline cases of microcephaly, we estimated that an IQR of 110 to 290 total cases of congenital microcephaly, mostly attributable to ZIKV infection, could occur from mid-2016 to mid-2017 in the absence of effective interventions. The primary limitation in this analysis is uncertainty in model parameters. Multivariate sensitivity analyses indicated that the cumulative incidence of ZIKV infection and risk of microcephaly given maternal infection in the first trimester were the primary drivers of both magnitude and uncertainty in the estimated number of microcephaly cases. Increased information on these parameters would lead to more precise estimates. Nonetheless, the results underscore the need for urgent actions being undertaken in Puerto Rico to prevent congenital ZIKV infection and prepare for affected infants.”

I’m not a big fan of modeling for predicting trends in infectious disease. There are just way too many factors at play, and all of those factors cannot possibly be put into a computer (today, maybe in the future) in order to come out with an accurate prediction of what is going to happen. Nevertheless, if the methodology is sound, the results can be used as a guide on what to expect. In this case, we should see between 110 and 290 cases of microcephaly.

But published reports in the media only show two cases. The first baby with microcephaly was born in October and the second in December. After that, only a total of 16 cases of “birth defects” have been reported.

Now there are news reports that cases of microcephaly in Puerto Rico may be underreported. According to a news report:

“Some observers believe Puerto Rico, which is heavily dependent on tourism, is downplaying the scale of its Zika problem.

“Puerto Rico’s not escaping this. They’re just hiding,” one former US official said of the situation. The individual, who spoke on condition of anonymity, said months ago it was clear “dozens and dozens” of babies in Puerto Rico bore the hallmarks of Zika damage. But territorial health officials declined to label most of them cases of Zika congenital syndrome.

“They’re kind of in denial about what the problem is,” the former official said. “And six months, a year, two years from now there will be all these babies who aren’t learning and all these problems that will come to light.”

Puerto Rico’s health department did not respond to a request for comment, nor did its top epidemiologist.

Last October, without fanfare, the Centers for Disease Control and Prevention stopped reporting the outcomes of pregnancies in US territories in which women had been infected with Zika. Without providing details, the agency simply said that Puerto Rico wasn’t counting cases the same way.

“CDC is using a consistent case inclusion criteria to monitor brain abnormalities and other adverse pregnancy outcomes potentially related to Zika virus infection during pregnancy in the US states and territories. Puerto Rico is not using the same inclusion criteria,” the CDC website states.”

Then, the same reporter has apparently obtained some documents showing the reason that the case definitions are not aligning. This is part of her follow-up report:

“US health officials have privately expressed deep concern that Puerto Rico is downplaying the extent of its Zika problem and have struggled to get a grasp on the issue because of a protracted and ugly dispute with health officials in the territory, according to a document obtained by STAT.

The rift was so contentious that, at one point, health leaders in Puerto Rico refused to meet with their counterparts from the Centers for Disease Control and Prevention. The multipage document suggests that the dispute has obscured the extent of the territory’s Zika problem for more than half a year.

The focus of the dispute centers on Puerto Rico’s handling of a surveillance system set up to track pregnant women and identify infants and fetuses with Zika-related birth defects — and concerns that officials there are undercounting cases. The registry is called ZAPSS (the Zika Active Pregnancy Surveillance System) and the CDC awarded Puerto Rico’s Department of Health $9.5 million in grants to establish and operate it on the island.

But for a period of several months last year, the Puerto Rican official who was the principal investigator on the project declined to communicate with CDC authorities. He also demanded a written apology from a senior CDC figure who had questioned the work of Puerto Rican health authorities before he would resume communication and collaboration.”

Unfortunately, these kinds of interpersonal frictions are not something new in public health responses to crises where multiple agencies are involved. We’re all human, after all. We all come into the response with our own idea of what needs to be done, how, and by whom. What’s worse, most of the people who make it to the upper echelons of their profession are type A personalities who won’t budge on their views.

This all leads to friction.

Friction can either bond (linear friction welding) or destroy.

What is most unfortunate in the situation in Puerto Rico, if the reports that are coming out are true, is that the misclassification of case counts will lead to an incomplete — outright flawed — understanding of the situation there. If you don’t know what is going on, then you don’t know how to attack the problem, you don’t know who or how to help. In essence, the victims of this friction are not the professional careers or the feelings of those involved. The victims are the people being affected by the outbreak.

I saw this same kind of friction during the H1N1 pandemic while working at the state health department. Personalities conflicted, bosses wanted to take the lead, and underlings felts used and abused without credit. I’m not going to deny to you that I came home very angry many times because things that needed to be done — in my opinion — were not being done. What was worse to me was that things being done were uselessly spending our resources.

Again, it happens.

It’s probably going to happen again and again because it is human nature to always be competing with each other. Even when we work as a team toward a common goal, we’re still competing with each other on some level. We want to be promoted, paid better, get the girl, make the grade, earn the title, etc. Rarely will you encounter a player on a sports team who would not take the chance to score a point if given it.

I hope that at one point the players in that drama in PR gain control over their egos and sees the big picture. Because the big picture is about getting the epidemiology right so that the interventions are the best ones. It serves no one, really, to have children be born with defects — preventable ones — and not get services because they’re not counted. In the end, all of this coming to light is even less productive at best, and destructive of lives at worst.

We Need to Pay Attention to What Is Going on in Puerto Rico

I’ve been doing a lot of reading about Puerto Rico since I agreed to go down there to help in the Zika outbreak. According to most media reports, the situation in Puerto Rico is quite dire from a financial and demographic standpoint. Crime is high, yes, but it’s not any higher than Baltimore, where murder is an almost daily thing. I’ve said before that Puerto Rico might as well be our 51st State, but we sure treat it like a foreign country.

From the Wall Street Journal:

“A decadelong recession has left one in nine residents out of work and roughly half dependent on the cash-strapped government for health care. Net migration to the U.S., where Puerto Ricans can move with no restrictions, was 250,000 so far this decade. The island’s labor force shrank 20% in the past 10 years, compared with 5% growth in the U.S.

Puerto Rico’s population slide is the worst since the Census Bureau began its first tally in 1920. Mario Marazzi, who runs the Puerto Rico Institute of Statistics, says the continuing decline might be rivaled only by the extinction of the indigenous Taíno people after the arrival of Spanish settlers in the 16th century.

As more people leave, the government faces greater pressure to cut jobs. The number of students in public schools is 40% lower than it was a decade ago, while the number of teachers has grown. Puerto Rico operates as many correctional facilities as it did in 2004, despite a 26% drop in inmates.

Puerto Rico ended up in its current situation because of a string of haphazard policies by federal officials going back decades. On top of that, local leaders have struggled to cut spending and boost tax collections. Instead, they borrowed to make up for recurring revenue shortfalls.

Federal tax credits long cultivated a robust manufacturing sector, steering the island away from agriculture after World War II and into a major hub for pharmaceutical and medical-device makers. Then Congress ended those incentives. When the last expired in 2006, many high-paying drug makers packed up for Singapore and Ireland.”

So, like with almost every big financial crisis, the current crisis in Puerto Rico could have been avoided, or at the very least prevented. Of course, the 2008 “Great Recession” didn’t help things. If you think you had it bad in the “Rust Belt,” then magnify it by a lot on the island.

In terms of healthcare, things are also bad. From the New York Times:

“The first visible sign that the health care system in Puerto Rico was seriously in trouble was when a steady stream of doctors — more than 3,000 in five years — began to leave the island for more lucrative, less stressful jobs on the mainland.

Now, as Puerto Rico faces another hefty cut to a popular Medicare program and grapples with an alarming shortage of Medicaid funds, its health care system is headed for an all-out crisis, which could further undermine the island’s gutted economy.

On an island where more than 60 percent of residents receive Medicare or Medicaid — an indicator of Puerto Rico’s poverty and rapidly aging population — the dwindling funds have set off outpourings of concern among patients and doctors, protest rallies and intense lobbying in Washington.

And while the crisis is playing out most vividly today, its cause dates back decades and stems, in large part, from a vast disparity in federal funding for health care on the island compared with the 50 states. This disparity is partly responsible for $25 billion of Puerto Rico’s $73 billion debt, as its government was forced to borrow over time to keep the Medicaid program afloat, according to economists.”

People in Puerto Rico pay the exam same rate in taxes (though not Federal Income Tax) than people on the mainland, but the Medicare/Medicaid reimbursement level is less than that of any of the States or the District of Columbia. That whole tax thing may in itself be something that needs to be looked at, but you go tell people who are seeing their economy in the dumps that they have to pay more taxes. Go ahead. Get back to me on how well it went.

The strain on the healthcare system is one of the reasons why the request has gone out for help with Zika. Puerto Rico is in the “goldilocks” zone for Zika, and this has translated to a ton of cases in a relatively short time. (There have also been outbreaks of Dengue and Chikungunya, so you know the mosquitoes are there and they’re biting a lot of people. Couple that with a failing health infrastructure, and it’s all a recipe for disaster.

There are still many uncertainties about Zika, and there are uncertainties about how the government in Puerto Rico will deal with the budget shortfall, the exodus of residents (and physicians) to the mainland, and the issues of unemployment and social decline that come with a declining economy. It’s going to take a lot of time and a lot of work to get to a place that is, well, better. I just hope that we on the mainland don’t forget about our 51st State.

Like a Chicken With My Head Cut Off

One of the things that I admire about the people who I admire is their ability — real or perceived — to multitask. The best of them can do it effortlessly. They come up with stuff that they’ve done and I’m left wondering how they did it. I’ve been trying to match that kind of multitasking, but everyone who sees me trying to do so can tell that something is up.

Me, when my hands are full.

I’m going to let you in on another little secret: I’ve been asked to travel to Puerto Rico to aid in the response to the Zika outbreak there. I’ll be leaving sometime soon, and I have a ton of things to do until then. From scheduling and successfully completing my school-wide preliminary oral exams, to getting some stuff done on the Jeep, to everything else one needs to do before a “deployment,” I have a ton of stuff on my plate.

“So why are you blogging?” you seem to ask. More on that later.

Not only do I have to do all these things, I also have to keep up with my physical training and find out how to keep that up once I’m on the island.

It’s a small island.

I figure I’ll buy a cheap bicycle and ride it around the touristy areas. Then I’ll go to one of the many swim schools that cater to American universities but won’t get much business because of Zika concerns this year. And, finally, I’ll go for jogs around wherever I’m staying, or, if they’re putting me up at a hotel with a gym, I’ll work out there.

All the while spraying bug spray “liberally.”

Yes, there are concerns with what Zika can do to the human reproductive system, and it seems that men can carry the virus in their semen for up to six months after infection. But my wife and I have talked about it, and we’ve decided to take the appropriate precautions throughout this whole adventure. The needs of the many and whatnot.

Just the other day, someone asked me why I wrote so much (on this blog and that other one, and that other one that’s a well-known secret) and complained about not having enough time. I’m very tired of having to explain myself. Writing is what I do as a hobby, like painting or sculpting. It’s how I organize my thoughts.

In fact, while I’ve been writing this, I’ve shot off several emails, read two research papers, and confirmed some appointments. So it’s not like I sit down and write constantly. (Thank God for word processing and blogging software.) Just like some people knit, I get my best thinking done as I write. (And it’s not like I’m writing a full-on dissertation when I write a blog post. It’s 500 words, or thereabouts.)

Still, I wish I could multitask like a boss…

Like. A. Boss.

The 2016 Olympic Games in Rio Must Not Proceed

Here is some very thoughtful commentary from Dr. Amir Attaran published in Harvard Public Health Review.

Here’s the clincher from that opinion article:

“Which leads to a simple question: But for the Games, would anyone recommend sending an extra half a million visitors into Brazil right now? Of course not: mass migration into the heart of an outbreak is a public health no-brainer. And given the choice between accelerating a dangerous new disease or not—for it is impossible that Games will slow Zika down—the answer should be a no-brainer for the Olympic organizers too. Putting sentimentality aside, clearly the Rio 2016 Games must not proceed.”

I agree. Either Zika in South America and the Caribbean is a Public Health Emergency of International Concern, in which case the games must not proceed… Or it isn’t. It is, and the games should not be carried out because the danger is real of the virus being taken back home by athletes and visitors.

Zika, Zika, Zika! (An update)

Just a quick update on Zika:

A case-control study in French Polynesia has found a strong association between Zika infection and Guillain-Barré Syndrome (GBS). That is, the proportion of cases of GBS who had previous Zika infection (confirmed by serological analyses) was significantly larger than the proportion of people without GBS who had previous Zika infection. Of course, a case-control study is not definitive; it doesn’t prove causation. But it’s a strong relationship and the study is very sound.

A letter published in The Lancet talks about fetal brain damage and microcephaly in fetuses whose mothers were infected with Zika. The virus was detected in amniotic fluid and in the brain tissue of aborted fetuses. In fact, the brains of the fetuses (four fetuses) were not developing normally. Just like with the case-control study, these findings are not definitive, but they also continue to pile-on the evidence for a Zika-microcephaly link. (Still no connection between the “Monsanto Larvicide” and microcephaly, no matter how much people want to believe. Reality doesn’t care if you believe or not.)

So now we have evidence of neurological disorders associated with Zika infection outside of Brazil, which throws a wrench in the theory that it’s Zika plus some other thing (e.g. Dengue infection). It also throws a wrench in the larvicide theory. It even throws a wrench in the Reptilian Overlords and OMG! Zombies! theories.

This is how science works, by the way. You get a case report or an outbreak, and you work from there. You don’t make enormous leaps to things that are not biologically plausible. You eliminate all the biologically and scientifically plausible things before you move into the really weird stuff. In other words, when you hear hoofbeats, think horses, not zebras. Leave the zebra preparations to the experts. 😉

Six things you need to know about Zika right now

The Zika virus situation is this year’s Ebola. Like with Ebola, a lot of doom and gloom is floating around, and a lot of outright lies are being put forth by people who have no clue of what is going on. They are relying on fears and speculation to drive up visits to their websites or blogs because clicks pay in today’s internet economy.

Not on this blog. If you look around, you’ll see that I am not selling you anything. I’m not advertising for anyone, and I will resist every urge to do so. If I were in the business of making money, I wouldn’t be in Public Health. My profession is notorious for under-paying people in it, unless you manage to land some big-time consultancy or an academic position.

With that in mind, I want to tell you some things you need to know about Zika right now, and some things you need to keep in mind as we move into the warmer months of the year here in the United States, or if you’re traveling abroad. Just like with all emergencies, be informed and act, but don’t get consumed by it all. Most of all, don’t panic.

  1. Zika is a viral infection caused by — you guessed it — the Zika virus. The Zika virus (or ZIKV as some are calling it) is a relative of Yellow Fever, Dengue, and West Nile Virus. Like its cousins, Zika is transmitted by mosquitoes.
  2. The species of mosquito that is primarily distributing Zika around the world is the Aedes species of mosquito. Currently, in South America, it is the Aedes aegypti mosquito that is doing most of the transmission. This Aedes species also transmits Chikungunya and Dengue. In the United States, we have the Aedes albopictus species more than A. aegypti. That doesn’t put us in the clear, however, as A. albopictus has been associated with Zika outbreaks in the past.
  3. It is generally a good idea to avoid being bitten by mosquitoes, whether here in the United States or in a tropical area, or in Europe. It doesn’t matter. Avoid being bitten by mosquitoes, flies, ticks, and other insects/arthropods to maximize your chances of avoiding Zika and other arthropod-borne infections. Avoid areas where there are a lot of mosquitoes, wear long sleeves and long pants if you must go to those areas, wear repellents, drain any standing water near or inside your home, etc. Do what you need to do to prevent mosquito bites and control their population. But be smart about it. Don’t think that because your town government fogged for mosquitoes that somehow you’re protected. You might not be.
  4. As of today, Wednesday, February 17, 2016, there has been no causal link between microcephaly (a reduced size of the head at birth) and Zika virus infection during pregnancy, but there is compelling evidence that there is a link in there somewhere. A few days ago, an activist group from South America came out with a position that it was a larvicide (a chemical added to water to prevent mosquito larvae from maturing) that was causing the microcephaly seen in places where there is heavy Zika infection rates. This is nothing more than a conspiracy theory at this point. In fact, the evidence against the larvicidal is flimsier than the evidence for Zika causing microcephaly. That is, if we are to believe it’s Monsanto and the evil corporations causing microcephaly, then we must accept that it’s Zika because the evidence for Zika causing it is more coherent.
  5. There is a lot yet to learn about Zika, shamefully. And I write “shamefully” because Zika has been hitting places far from the United States for a while now, and it is only now that it is at our doorstep that we are panicking into doing something about it. We really are panicking. You see the panic in politicians who are, like they did with Ebola, calling for strict quarantines of people traveling to places where Zika is being actively transmitted. (As if mosquitoes can be quarantined.) And you see the panic in the increased response from the Centers for Disease Control (CDC). They are pulling a lot of resources from a lot of places, yet duplicating a lot of the work that has already been done by public health agencies in other countries. (It’s not good enough until Americans do it, I guess.) Had we done all this when French Polynesia got hit in 2013, we might have avoided Zika from reaching Brazil. Had we done it before that, we might have contained it SE Asia.
  6. So stay informed on the situation by frequenting the WHO News/Media Center or the CDC Zika Web Page. If you want opinion, you can come to this blog, or Orac’s, or the Public Library of Science’s Neglected Tropical Diseases page, or the Virology Blog. Don’t panic. You’re going to be okay. We all are.

What is a “handful”?

Everyone is getting all caught-up in the fever over Zika in the Americas. So I was pleasantly surprised to see an article in a blog I frequent titled: Your Non-Alarmist Guide to the Zika Virus. Unfortunately, it only took one sentence for the whole post to be derailed for me:

“Zika virus, a previously obscure disease that had only caused a handful of cases in Africa and some island nations, is now a major global health concern.”

I thought to myself, “Only a handful?”

Now, I’m not a native English speaker, so there are those times when a phrase or colloquialism evades me. The word “handful” represents “very few” to me, like, five or less. I’d even go with ten or less if you push me. When I look up the word “handful,” I get definitions like “a quantity that fills the hand.” That, to me, is a handful.

From everything I’ve been reading about Zika, there have been thousands of cases of it in Africa and the South Pacific before it hit Brazil last year. Thousands, to me, are not a handful. That’s more like a motherlode or even a shipload. It’s a lot, and not a handful.

Maybe I’m caught up in the word for no reason, and maybe the real message to be learned from the article is that we all need to chill out over Zika and not make asses of ourselves like we did with Ebola. There shouldn’t be a rush to quarantine people willy-nilly because they are coming back from a place in the world that scares us. And we should let the science (especially the epidemiology) guide the response.

But we humans understand risk based on numbers. If you tell me that there are 20 cases of measles in the United States right now, I probably wouldn’t worry because I know that you know that I know that you know that measles is on the rise. Twenty cases, while an embarrassment for the most powerful nation in the world with wide access to vaccines, is not a big deal. On the other hand, if you tell me that all twenty are in my community, then the game changes a little bit. It changes even more if those 20 occurred in the last week. Time and space, you see, make numbers look different… A sort of epidemiological relativity.

So when the author of the post writes right off the bat that there have only been a handful of cases “over there,” the reader may reasonably assume that Zika has not been a big deal to humanity, and that maybe it won’t be this time around either. However, if you look at the field reports and published papers from the outbreaks “over there,” you come to find out that the outbreaks occurred explosively, involved thousands of cases, and were hard to bring under control. Add to that the fact that the microcephaly association may have been missed because of inappropriate surveillance “over there,” and the problem becomes a little bit clearer and a little bit scarier.

I don’t think that it was the author’s intent to undermine the number of cases or the impact of Zika to those countries “over there”. However, I do wish that she would have quantified them a little bit better than just writing “a handful.” A simple literature search for Zika reveals that there were about 20,000 cases in French Polynesia in 2013 during their outbreak. Before that, about 75% of the inhabitants of Yap Island (population ~7,000) came down with it in their outbreak. Going back even further, you see field reports from Africa in which hundreds or thousands of cases are noted in different outbreaks.

Unfortunately, I see the same mistake from other writers trying to convey the magnitude of what is happening in the Americas. Likewise, the people who are easy to panic are making it out to be like everyone and their sister is getting Zika in “those countries.” All this when the answer is somewhere in the middle and the truth is busy trying to catch up to rumors and speculation.

Where do you begin to understand Zika?

It’s all the rage these days to get worked-up about Zika. Just like last year with Ebola, this year we’re freaking out over a disease from “over there” coming “over here” and hurting Americans. Also, the observed association between Zika infection in pregnancy and microcephaly is scaring the crap out of people. (It’s really scaring the far-right, anti-abortion people because women will start thinking of abortions as an alternative to having a microcephalic or anencephalic child.)

A letter went out to students and faculty at the school the other day asking for students to help do research to pin down the incubation period of Zika. The incubation period is the time from initial exposure/infection to the time of initial symptoms. It’s somewhat hard to pin down this time with Zika because it is transmitted primarily by mosquitoes. If you go to a place teeming with mosquitoes, it’s hard to figure out if yesterday’s exposure lead to infection, or the one from last week.

This problem is the same one we see with foodborne diseases. We eat a few times a day, so out opportunities for exposure are many, and they are continuous. But we figure out the likely culprit when different people start reporting the same exposure, e.g. eating the same food at the same event or from the same restaurant. So what do you do when the exposure is mosquito bites all the time, every day, all over the place?

For those, you look at people who travel into and then out of the areas with heavy mosquito presence and then got sick. You determine when the last day they were there was and count from there to get the soonest incubation time, then you determine when they arrived at the endemic area and get the latest incubation time. You this over and over again with as many travelers as possible, and then you figure it out.

As it turns out, Africa, Asian and South American researchers have done this. Even some European scientists who responded to a large outbreak in French Polynesia in the South Pacific have come out with a good estimate of the incubation period. They all agree that it’s between 5 days and two weeks, and that the disease lasts about one week (as long as two weeks). However, for some reason, the school is recruiting students to do a literature review to figure this out. (I cheated. I contacted tropical disease epidemiologists who’ve already done the work.)

And this is the thing about epidemiology education in the United States. As I mentioned before in “The Two Kinds of Epidemiologists“:

“The research and academic epidemiologist looks at a public health problem and designs a study to better understand it. He or she makes sure that the measurements are valid and that the information collected from the study is reliable. They take good care to choose the subjects carefully so as to not introduce bias into the study. With data in hand, they test several hypotheses about the mechanisms that cause whatever disease or condition that they’re studying. They use the “dark arts” — as one frequent reader/commenter has called biostatistics — to make sure that their observations are not due just by chance, or that they’re not being influenced by things seen or unseen. Finally, they put all of their findings in a research article and get it published at one of many reputable scientific journals.”

And then all that information sits in a journal, waiting to be used. Take, for example, the story of Brian Foy. From the Washington Post:

“Brian Foy, a researcher who studies mosquito-borne diseases, said in a 2011 paper that he had found likely evidence of a little-known virus spreading through sex. If true, it would be the world’s first documented case of sexual transmission of the virus, he said at the time.

Foy wanted to study it further, but no one would give him the funding he needed: He had found just one example, and the virus — known as Zika — was too obscure, he was told.”

I read that the other day, and my head exploded.

She gets me.

My head exploded because it was yet another example of how public health is failing to take all that knowledge into action. In 2010, two researchers published a really good paper on “Present and Future Arboviral Threats.” (Arboviruses are viruses transmitted by arthrobods. ARthropods + BOrne + VIRUS, get it?) They wrote:

“Perhaps the greatest health risk of arboviral emergence comes from extensive tropical urbanization and the colonization of this expanding habitat by the highly anthropophilic (attracted to humans) mosquito, Aedes aegypti. These factors led to the emergence of permanent endemic cycles of urban DENV and chikungunya virus (CHIKV), as well as seasonal interhuman transmission of yellow fever and Zika viruses.”

Had I been sitting at the White House and read that paper, I would have convened a panel from CDC, NIH, etc., to come up with an immediate plan to survey for these infections the world over and both track them and combat them… Years before they came to the United States.

But that’s the thing. There are plenty of us doing research and writing papers, and few of us working to put that knowledge into action. What is worse is that those of us who are working on it are not communicating well with each other. We either want to be protective of our work, or we just plain don’t know how to communicate our work. (Look at how we fail miserable to communicate the importance of vaccination in, say, Orange County, California. Effective communication would make anti-vaccine advocates be no more credible by the general public than people who believe the Earth is flat.)

We desperately need a Neil deGrasse Tyson of Public Health.

So the answer to the question I posed in the title is not “in the literature,” to be honest. The answer is “from each other… And now, before the next thing comes.”

“This is the time when things must be done before their time.” – 1949, Vol 5. No II of the Bulletin of the Atomic Scientists.