The aftermath of September 11: what’s an epidemiologist to do?

Ezra Sussera and Mervyn Susserb

a Department of Epidemiology, School of Public Health, Columbia University, New York, NY, USA. Epidemiology of Brain Disorders at the New York State Psychiatric Institute.
b Gertrude H. Sergievsky Center Columbia University and Department of Epidemiology, Mailman School of Public Health, Columbia University.

Dr E Susser, Columbia University, Department of Epidemiology, 600 West 168th St, New York, NY 10032, USA. E-mail: ess8{at}columbia.edu

Since the terrorist attack of 11 September 2001, it is often said, we live in a different world. Perhaps not true in all endeavours, it is true in epidemiology and public health. Sudden and momentous change has shifted the focus and social role of our profession. Although epidemiologists are divided on how to respond to this change, as yet no published debate bears on the matter. We have elsewhere called upon epidemiologists to undertake a concerted effort to choose our future and choose it wisely.1,2 In accord with that stance, we seek to open a debate on what the change portends for our profession. The paper concentrates on the US but the issues are relevant to epidemiologists around the globe.

The attacks of September 11 and the anthrax cases in its aftermath provoked a re-examination of public health infrastructure in the US. For decades, public health had been a chronically under-funded human service. With the imminent threat of bioterrorism after September 11, public health suddenly became a central element in national defence. In quick response, the Federal government dramatically increased public health funding.3 Much of the money went to a narrowly focussed effort to invigorate infectious disease epidemiology. A large impact can be expected both on the detection of new pathogens and on the control of outbreaks of infectious diseases.

Some see this influx of funding for defence against bioterrorism as a mixed blessing for epidemiology and public health. The political threat of bioterrorism has overshadowed what is unquestionably the greatest public health crisis of our times, namely, the AIDS pandemic. Just prior to September 11, a global effort had been launched against AIDS,4 an effort seriously set back in the aftermath.

In addition, the increasingly close ties between public health and national defence are not welcome to all in our field. Through much of its history, public health has been associated with approaches involving a degree of coercion. These can be traced back to the forced quarantine practised by Italian cities in the 14th century.5 In the history of the US, they have included efforts to prevent the spread of epidemics in the late 19th century, by the forcible removal of infected individuals from urban communities;6 to protect US soldiers from venereal disease during World War I, by the virtual imprisonment of thousands of women thought to be infected with venereal disease in the American South;7 and to contain tuberculosis in the post-World War II years, by the detention and obligatory treatment of ‘recalcitrant’ patients.8 An element of coercion continued into recent decades, for example, in the successful international campaign to eradicate smallpox in the 1970s.9 Though justified for the broader community on the grounds of protection from an imminent threat, for individuals the policies were often harsh. The recent trend—accelerated especially by the response to human immunodeficiency virus (HIV) of well-educated, vocal and much afflicted gay communities—has been toward public health action that is less coercive and more participatory and respectful of individual rights. Tying public health to military imperatives may well reverse that trend, with adverse effects on the relationships between public health and the broader society.

Finally, a public health response impressive in its rapidity and magnitude has been diminished in effect by narrow scope and vision. Terrorism is in essence, as the label itself denotes, an assault on the mental state of a population. The spectacular attacks of September 11 and the insidious dissemination of anthrax in the aftermath were designed for maximum psychological impact. By this criterion they were highly successful. The World Trade Center attack precipitated an estimated half a million diagnosable mental disorders (mainly post-traumatic stress disorder and depression) in the New York region.10–12

It would seem obvious that public mental health should be a central element in any effective defence against terrorism. This opens the possibility for a long overdue advance in the public health field, which still is handicapped by its relative neglect of mental conditions. Yet, with few exceptions, the leading public health agencies have failed to take this opportunity, and have not integrated public mental health into the defence against terrorism.

In their responses to the change provoked by September 11 and its aftermath, epidemiologists are divided.13,14 Roughly, they fall into three broad groups, though these are not strict or mutually exclusive. One group emphasizes the positive benefits for epidemiology. In accord with the US government, they view defence against bioterrorism as the first public health priority of the present time, and applaud the new investment in pathogen detection and control. A second group recognizes some adverse effects on epidemiology, in particular, the diversion from other public health agendas. They point out, for example, that we face a far more devastating global health crisis in the AIDS pandemic, and decry the displacement of AIDS from centre stage. A third group sees the potential for positive consequences in the aftershock, depending upon how epidemiologists make use of the current situation. They believe in a coat-tail effect. If epidemiologists can take effective leadership in responding to a problem perceived as a top priority by government and much of society, then they will surely be able to garner more resources to achieve related but broader public health goals.

In choosing between these positions, we have found it useful to place the current scenario in historical perspective. September 11 was the first major event since World War II which tied public health directly to national defence. From a longer historical perspective, however, this was not unusual. In previous eras one can discern a similar pattern of funding for public health in response to a political or military threat. Going back to the origins of modern public health, the passage of the landmark Public Health Act of 1848 legislating sanitary reform for Britain was in response to the perception of an imminent political threat; the legislation was motivated in large part by the effort to stabilize the ‘condition of England’ and guided by the Benthamite theories of Edwin Chadwick.15 His idea was to minimize the threat of revolution and social disruption by preventing disease and consequently poverty (he considered disease to be one of the causes of destitution).

The pattern is especially clear in the 20th century experience of the US. At the beginning of the century the campaign against yellow fever in Cuba (begun in 1898) was explicitly undertaken to enhance the US military occupation of Cuba,16 and inaugurated an era of campaigns against ‘tropical’ diseases. In mid-century the Malaria Control in War Areas agency was created to control outbreaks of malaria among soldiers at home and abroad during World War II, and later metamorphosed into the Communicable Disease Center (the original name of the CDC).17 The elite Epidemiology Intelligence Corps of the CDC was founded in the 1950s by Alexander Langmuir to train a mobile corps of epidemiologists to respond to the threat of bioterrorism in the Pacific region;18 soon its functions were extended to general public health, with its officers playing a major role in fielding polio vaccine, and later in smallpox eradication. In all these instances, long-lasting institutions of epidemiology and public health were established in the context of a political threat. Although their creation was largely motivated by a political rather than a health agenda, the institutions often endured, and became vital platforms for public health research and action.

Most recently, the global AIDS crisis appears to be assuming a similar political mantle. The AIDS pandemic spun out of control with little response from the international community until Richard Holbrooke and others of the US State Department came to perceive the epidemic as a threat to global security and brought President Clinton to this view. The resulting global effort to combat AIDS is likely to create the precedent for other global campaigns, indeed, it has already been extended to malaria and tuberculosis.

With these examples in mind, we think a strong case can be made for the coat-tail effect. In terms of the health of populations, the threat of terrorism pales in comparison with the AIDS crisis. Nonetheless, epidemiologists can play a crucial role in legitimate defence against terrorism. We will thereby enhance the public perception of our profession, strengthen the institutions that support it, and make our calls for other actions more compelling. With respect to the AIDS crisis, in the effort to rejuvenate the global effort, we gain a stronger position from which to campaign.

This path, however, is hazardous, and the challenge daunting. To succeed, we will need to demonstrate effectiveness and leadership in response to the socially and politically defined priority of national defence, and to do so without losing sight of our own public health agenda. Thus, the choice is anything but simple. The thrust of our argument here is that we should make a considered choice, founded on an appreciation of the broad public health goals to which our discipline is tied. Epidemiologists need to debate these issues in a determined effort to shape our own future.

Acknowledgments

We thank Chelsea Morroni, Landon Myer and Nancy Stepan for their helpful comments.

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