Saturday, July 11, 2020

Top Public Health Interventions

A list of the top public health interventions in history...

  • Sewer pipes (Mesopotamia 4000 BC)
  • Soap (for washing hands circa 2800 BC)
  • Emperor Shennong of China mandating drinking boiled tea (2737 BC)
  • Mosquito nets (from Cleopatra's time through present)
  • Vaccination (Jenner 1796, Pasteur 1880)
  • Pasteurization (Pasteur 1864)
  • Antibiotics (pace Fleming's penicillin 1928 onward)
  • Existence of unions (1827 onward)
  • Child labor laws (starting with the Cotton Factories Regulation Act of 1819 in England to present)
  • Birth control pills (Djerassi 1951, and Pincus and Rock producing Enovid, the first birth control pill approved in 1957)
  • Tobacco control (1952 to present, from the 1964 US Surgeon General report through the Tobacco Control Act of 2009)
  • Seat belts (1955 to present, the crucial milestone was 1966 with the National Traffic and Motor Vehicle Safety Act in the USA)
  • Occupational safety regulations (kicked into high gear in the US with Occupational Safety and Health Act of 1970)
  • Water fluoridation (widespread after 1945)
  • Iodized salt (1924 onward)
  • Ban on use of lead in gasoline (regulation starting 1973 - banned in US with Clean Air act in 1996)
  • Antiretrovirals, especially in African countries to manage HIV (1996 onward)
  • Board certification for doctors (1917 onward)
  • FDA approval for food and medicine (onset with Food and Drug Act in USA 1906, effective after 1938's Food, Drug, and Cosmetic Act )
  • Helmets (although a 1600 BC invention, their public health application came in sports after 1896 for American football and transportation circa 1914 with the motorcycle helmet)
  • Gun control (in most countries almost immediately after its invention circa 1000 AD with Yemen and the USA as modern day outliers)
  • Alcohol control (an ongoing and uneasy spectrum of regulations even to the extent of prohibition with religion even weighing in)
  • Oral rehydration therapy (1940s, popularized with ORS sachets especially after the refugees successfully treated during cholera epidemic of cholera after the Bangladeshi Liberation War)
  • Facial masks and shields (briefly after the influenza pandemic of 1918, in East Asia after the SARS pandemic of 2003, in China, Taiwan, South Korea, Vietnam, Mongolia, Japan and the Czech Republic memorably immediately after the start of the novel coronavirus SARS-CoV-2 pandemic January-April 2020, and the rest of the world circa March - June 2020, with notable American exceptionalism - in most enlightened states in the US. The N95 respiratory mask, conceived in 1992, remains a milestone although cloth masks have long had their uses. Whither my Texas neighbors you may ask? The neighbor who was overheard just a month ago, after The Grand Reopening of Texas, shouting "There is no virus" remains under the relentless grip of the Positivity of The Governors even after their July 2020 pivot. My best guess is that it will take 9 months, or perhaps personal experience, for the aversion to evidence and public health to penetrate consciousness. On the other hand, norms can change quickly, as evidenced in other countries, but I won't hold out hope for the year 2020 in the USA at large, I think it's a Vision 2021 project despite the rising body count)

This became a collaborative list with crucial additions from friends and The Wife, whose pointed comment about the birth control pill prompted me to add It's a Man's Man's Man's World by James Brown to the playlist I was conjuring for this list. Indeed oral contraceptives have probably positively affected the greatest numbers of humans lives outside of soap and sewers.

A twitter follower also challenged me that it was Emperor Shennong's courtiers, not the Emperor himself, who mandated boiling tea - that the Emperor just preferred his tea boiled. This again speaks to the Princpal-Agent relationship, and posits that there is a difference between the wishes of the Emperor and those surrounding him. The suggestion is that "Who will boil me this tea?" is the antecedent to "Who will rid me of this meddlesome priest?". I dodged the question as is my wont because, in any case, it was fortuitous that boiling water, with its side effect of killing germs and other beastly organisms, became an integral part of humanity's public health arsenal.

There was some controversy about my inclusion of child labor and the existence of unions, enough that I was even moved to play Devil's advocate

Think about it, would we have Dickens without child labour? What paradise have we lost when the youth of Bangladesh, or Ghana are no longer doing shifts in the textile factory, or planting yams and pineapples in the hills of Aburi? Our modern day Oliver Twists and Little Annie's no longer have the hard knock life, coddled as they are with this modernity, they have school not farms, and they are constantly demanding fondleslabs of mobile entertainment.

Of course, it was facetious to posit a world without Dickens, there was more than enough outrage in 19th century England and the world for Charles Dickens to get novelistic material. The little street urchins and cannon fodder for the worst excesses of capitalism might make the headlines but the the vast majority of capitalism's operation is a mundane grind, a rigged shell game on a tilted playing field - pick your metaphor. Call them the underlying conditions and risk factors that favour capital over labour. The notion of "the weekend", far from being divinely prescribed as days of rest, was in actuality a hard fought victory of labor and trade unions, as were occupational safety regulations. Social welfare and the advances in communal living have had considerable impact beyond the economic sphere and have public health effects.

Looking over the list, the human species has gotten away with much faulty biology and superstition. I suppose that belief in unseen things is what makes the Gospel of Germs such a hard sell that it requires constant marketing and reinforcement. Hilaire Belloc would satirize late 19th century popular conceptions of The Microbe in The Bad Child's Book of Beasts and More Beasts (For Worse Children). Things are not much changed in 2020 than in 1897.

The Microbe by Hilaire Belloc

The Microbe is so very small
You cannot make him out at all,
But many sanguine people hope
To see him through a microscope.
His jointed tongue that lies beneath
A hundred curious rows of teeth;
His seven tufted tails with lots
Of lovely pink and purple spots
The Microbe by Hilaire Belloc 2

On each of which a pattern stands,
Composed of forty separate bands;
His eyebrows of a tender green;
All these have never yet been seen -
But Scientist, who ought to know,
Assure us that they must be so...
Oh! let us never, never doubt
What nobody is sure about.

It is interesting that the tiny clumps of viral RNA that are driving our current covidious predicament fit much the same description.

the novel coronavirus SARS-CoV-2

The inverse list is also interesting, and we have a great candidate in Thomas Midgley for the most catastrophic intervention. Midgley invented both leaded petrol, and the CFCs (chlorinated fluorocarbon) used in refrigerators. The collateral damage, and body count, of these two inventions are world historic. Still, knowledge about their effects on the environment was not well known in his lifetime, unlike the inventors of gunpowder or the nuclear bomb. Midgley didn't have an Alfred Nobel come-to-Jesus moment and continued tinkering until his death.

I think we have real time candidates for the negative list either with neglect or by wilful policy decision making. It's slightly morbid to follow the implications of that thought because it gets to valuing abstraction over of flesh and blood. What is the value of a human life? And who gets to coldly decide that on the golf course or hastily fortified bunker?

Back to Basics

Covid-19 is a funny disease as my doctor uncles and aunts put it. It's forcing humanity to go back to basics and causing us all to change our way of life. If you take a look at the coronavirus superspreading timeline, you quickly get a sense of the activities that are now to be avoided, they involve crowds, and places with poor ventilation and sanitation, and where we sing or chant. We basically shouldn't touch or breathe on each other. And these are hard lessons to teach and follow, as I've found even after months of self isolation. The 7 and 9 year olds in my household are not the only ones that need constant reminders about the best practices for survival, frequently washing hands is not obvious despite our best efforts to make it a habit. It's hard to be a good neighbor when you can't do small talk and even conversations over the fence are fraught and wary episodes.

All communal gatherings have the potential for risky distribution of disease even as they might give comfort and social and economic utility. Paradoxically, we need to draw on social living for comfort and resilience, yet in our present, it is social distancing and enforced absence and the foregoing of our rituals and traditions that is our best chance of survival.

We are all in this together and it pays to learn the lessons of The Mosquito Principle, for these clumps of viral RNA, like our close and longstanding companions, mosquitos, don't discriminate. While we wait for a vaccine or effective treatment for Covid-19, our mantra has got to be: stay home if at all possible, maintain social distancing, and wash hands with soap frequently, wear masks when outside and perhaps even indoors when there is poor ventilation or if in the company of others beyond one's core living unit.

Optional: pray.

For faith healing is always an option; epidemiologists will forever be fighting a rearguard action against the placebo effect of faith. The other alternative is the very human hope that you will be saved, a deus ex machina is always a possibility - vaccines do get developed. Indeed this wishful thinking is firmly embedded in American mythology and culture.

And yesterday was the day of our cinema heroes
Riding to the rescue at the last possible moment
The day of the man in the white hat or the man on the white horse
Or, the man who always came to save America at the last moment

Someone always came to save America at the last moment
Especially in B-movies

B-movie by Gil Scott-Heron

In lieu of herd immunity, researchers at the Center for Disease Control (CDC), or perhaps the Surgeon General, would do well to issue the following public warning:

Nostalgia can be a fatal disease.

Observers are worried

chief zaachi physical and spiritual center

A Public Health Playlist

As always, a soundtrack for this note. (spotify version)

Suffice to say that I prefer public health interventions to faith healing, as always there is the fine print: your mileage may vary

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