Howard Markel, MD, PhD

Disclosures

December 21, 2005

Fans of the film "Dr. Strangelove" are well acquainted with a basic principle of controlling contagious diseases in the 21st century. As articulated by the maniacal General Jack D. Ripper (played to perfection by the late George C. Scott), democracy requires uncorrupted body fluids.

Or, as historian Peter Baldwin recounts in his recently published scholarly treatise, Disease and Democracy: The Industrialized World Faces AIDS, "bodily fluids are the sap of the body politic."[1]

After all, we live in a world that, although physically the same size as that of our predecessors, appears to be constantly shrinking. This is due to a burgeoning global marketplace and its insatiable hunger for the flow of goods and people, rapid travel, vague international borders, reemerging and newly emerging deadly infections, financially strapped public health agencies, and the profound amnesia many people exhibit once an epidemic threat has subsided.

Public health experts, of course, have emphasized these critical points for, at least, the last 2 centuries. Activities such as the International Sanitary conferences held in the mid-19th century in responses to cholera, bubonic plague, and yellow fever; the development of the World Health Organization in 1948 to combat threats to international public health; and recent studies focused on the spread of infection are all examples of efforts to prevent or control epidemics that have used an application of modern technology and science, guided by an understanding of the world as interconnected, to mount the battles against epidemics of past eras.[2]

In fact, the last few decades were hardly pacific. Numerous public health officials repeatedly warned about potential microbiologic attacks of a sexually transmitted disease such as AIDS, not to mention the more familiar killers such as tuberculosis and influenza. The problem was that too few of us were listening, let alone acting.

As Professor Baldwin noted in his articulate and comprehensive social historical analysis, different nations adopt different approaches to solving similar social dilemmas. Contemporary approaches to AIDS around the world, he explains, have ranged from voluntary, consensual tactics such as educational campaigns directed at changing behavior and practices in some nations, to more coercive methods such as restriction of civil rights of HIV-positive people or of those at risk of contracting the infection and the often misapplied institution of quarantine in others.

Last year, I attended an international conference on emerging infectious diseases. Because the memory of severe acute respiratory syndrome (SARS) was still fresh in all of our minds, many crowded into an overheated hotel ballroom to listen to a series of lectures on that epidemic by the quarantine officers of Canada, China, Hong Kong, Singapore, and Vietnam. Each nation mounted a different response to the same infectious crisis. But what was most remarkable about this seminar was that those nations least respectful of civil liberties were most successful in containing the epidemic.

Singapore and Vietnam ordered immediate, strict quarantines and quickly turned the tide of SARS. China, once it got over the misguided secrecy that marred its initial clumsy responses to the virus and clamped down on their citizens' travel plans, soon followed suit. It was Hong Kong, and to a greater extent, Canada, that best honored its citizens' individual rights and had a much harder time interrupting the spread of the virus.

I bring this up not in advocacy of harsher public health laws but, instead, as a troubling observation that open democracy has the potential to impede rapid responses to epidemic disease. Early failures to develop case tracing programs for HIV-positive people and their contacts or to close gay bathhouses in the United States during the 1980s may have admirably protected the individual's civil rights, but there was a huge price to pay in terms of the public's health.

If there is a lesson to be derived from the AIDS crisis -- or any epidemic, for that matter -- it is that in a global community, no nation can afford to consider itself unique in its management of epidemics. Democracy – and, more cogently, the global marketplace -- encourages the vast intermingling of ideas, technologies, goods, services, people, and, like it or not, deadly germs. Indeed, the only real chance we have as we continue to wage the constant battle against microbes in the 21st century is to develop public health mechanisms that are followed by every nation of the world and well funded by those of us fortunate to be living in the wealthier ones.

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