Public health has come a long way since the 14th century when it consisted almost solely of painting a cross on the door of houses where the plague had struck. Indeed, Monty Python’s wheelbarrow-pusher crying out “”Bring out your dead” grossly over-stated the extent of public health those days. People had to deal with their own. Since then, we have fixed the sewers and water supply and immunised kids against the major killers so public health is a lesser issue, and the health debate can concentrate on hospitals and hi-tech gadgetry and how much of it should be paid by Medicare and private health. Or maybe not.
The past fortnight has seen a confluence of events that illustrates public health’s re-emergence. Some more serious cases from poisoned mettwurst were reported; we had warnings about the worse of two versions of HIV taking over and we heard some Canberra residents going public over arsenic poison on their property. The three are good illustrations of the main new sources of public-health concern: long food-processing and food-delivery chains; increased resistance of bacteria and viruses to anti-biotics; and more poisonous chemicals in the environment. Humans being humans, all three carry a certain amount of emotion and even hysteria. And the emotion and hysteria is never qualified by the extent of the risk. Mention asbestos, arsenic, legionella or the death of a child from food poisoning and the over-reaction is astounding. This leaves the public-health official in a bind. What should the public be told about particular risks? How do you balance the avoidance of individual medical harm with the social damage done by the hysteria and irrational action that can follow general disclosure? Some of these questions are being considered at a conference in Melbourne next week. (For details ring the Australasian Faculty of Public Health Medicine Sydney 02 2565404) The arsenic and mettwurst cases are good examples. Arsenic at levels greater than the public-health action levels which was left over from old sheep dips has been found on several residential blocks at Theodore.
It poses a small risk, especially to children playing in the dirt. What information should be given out? Does the public health official quietly tell the affected residents? Or those residents and their neighbours? Letter-box the suburb? Issue a media statement to the world? Slowly allow the information out so emotion does not run high? It is not easy stuff. You can wipe tens of thousands off property values depending on how the information is put out. That then itself can become a public-health issue with the resulting stress from mortgage foreclosures or inability to sell. Indeed this has happened. The public-health issue can be further confused by questions of legal-liability. “”You knew there was arsenic at Theodore; I bought a house there and have lost thousands.” With mettwurst there was a threat to life, so general information was imperative.
It over-rode the manufacturer’s economic interest, and the interest of the smallgoods industry in general. But even in that case, there is a public health balance. Many people may lose their jobs in the smallgoods industry, which has suffered greatly in the wake of the crisis. One or two people may commit suicide or do other socially damaging things. In such an inter-connected society, the public health official has to be more a social scientist than a medical one. On a smaller scale, take the local pizza shop. After a complaint from a customer an environmental health officer finds it has rats and cockroaches. The shop agrees to a thorough clean and fumigation. Does the inspector tell the world, or should authorities let the owner put up a “”closed for repairs” sign and quietly do the job?
The acting general manager of the public health division of ACT Health, Alec Percival, says it is a question of balance. He has a cautious sympathy for the journalists’ cry of “”the public’s right to know”, but he cites cases of where he would say it is not in the public interest for the public to know. That sort of talk raises the hackles of the civil libertarian and journalist. How can it be in the public interest for the public not to know. Percival argues that in the pizza-shop case what damage there is has been done and any future risk has been averted because the pizza-shop owner now knows he will be under closer scrutiny. If authorities make a general announcement that theplace was closed because of rats, the pizza-shop business will be ruined. Perhaps four or five people might be put out of work with all the health stress on those families.
It is not purely a health-v-economics equation. Public-health officials have to deal with the fact of the irrationality of the human response and have to weigh up the damage that might do against the general principle of free information. For example, Canberra has an occasional typhoid case _ picked up overseas. Should neighbours be told? Should the world be told? Percival argues no, because there is a privacy issue. The hysterical response and associated stigma are more harmful than the risk warrants in a well-sewered and watered place like Canberra. But he would quietly tell ACT Electricity and Water that there is a typhoid case in suburb X and not to do work there without checking to see if the precise location is clear. Balancing the harm against the possibility of informing only as widely as the risk warrants is a question of judgment and balance. Inevitably, it can go wrong but maybe not as wrong as general principle of publish everythign and be damned. The ACT does not have any specific guidelines, but works case by case. Sometimes questions of legal liability will conflict with public-health concerns.
The tendency for legal advice to avoid anything that might be an admission of liability can hinder public health on two fronts. First, it may prevent necessary publicity for fear of defamation or admission of liability. Second it may prevent the quick and quiet dealing with an issue as affected people seek reassurance. The Theodore arsenic cases are classic. It is perhaps more difficult in Canberra, where an articulate community can give people in power a very hard time. The asbestos issue probably got out of hand and caused more harm than it saved. In Queanbeyan they left it in the roofs. In the ACT they took it out. In doing so they probably caused injuries (broken legs etc by roof workers) and possibly exposure to loose asbestos that would outweigh the mesothelioma risk to residents.
Worse still on the public health scale, the $50 million spent removing it would have certainly saved more lives and relieved more suffering if it had been spent cutting waiting queues at Woden Valley Hospital. That’s hysteria for you. Ultimately, the answer is more information, education and greater nderstanding. Even so, it is very difficult to say to an individual householder: “”You have a minor risk with asbestos in the roof that might treble your risk of getting deadly mesothelioma from one in 300,000 to one in 100,000, but we are not going to do anything about it because we will do better spending the money screening for lung cancer at Woden”. Private, group and public rights are pitted against each other. In that context information and how it is used can be critical in determining how the money is spent. In particular, the use of the media _ always good for perpetrating a bit of hysteria _ can affect the outcome. Modern communications and travel and a more critical society make some public-health matters worse. On the other hand, they can help after they arise. Information technology is helping target the need-to-know groups more easily.
Databases of children’s immunisation status, for example, mean that children who have not been immunised can be more quickly identified and notified. It means religious groups who oppose immunisation do not get excluded from schools because they are not immunised; they only get told not to come to school in a risk period. Similarly, bar-coding in supermarkets, wholesalers databases and health-departments databases enable quick extraction and notification in cases of suspect food in a way that was not possible before widespread computerisation. But it will never overcome the hysteria caused by lack of understanding of information and by emotion. Nor will it overcome plain, justified fear. Human nature is such that there will always be a certain amount of painting an X on the door.