Epidemics in the United States: Public Policy Responses and the Lessons to be Learned

The U.S. media have begun informing the public about the impending avian flu epidemic, which most scientists agree is a matter of "when" rather than "if." The Wilson Center's Division of U.S. Studies, Environmental Change and Security Program, and Global Health Initiative brought together four public health historians to discuss the "politics of disease" – the social and moral factors that have influenced the U.S. public policy responses to epidemics – as well as to suggest lessons for better preparedness in future epidemics.

Pellagra was "a disease of ignorance, a disease of poverty," Prof. Alan Kraut declared in his discussion of the conditions that enabled the disease to kill 40,000 Americans between 1906 and 1940. Dr. Joseph Goldberger, the Public Health Service physician who began his investigation of pellagra in the South in 1914, was virtually alone in hypothesizing that it not an infectious disease but, rather, the result of a nutritional deficiency. Determined to prove his thesis, he undertook radical experiments that extended as far as injecting himself, his wife, and his co-workers with blood drawn from pellagra sufferers. When the price of cotton fell in the 1920s, impoverishing many Southern workers and their families, a pellagra epidemic ensued – as Goldberger had predicted it would. Responding to his pleas, President Harding authorized food programs to supplement the diet of the poor, who could not otherwise maintain a balanced diet. The programs, however, ran afoul of southern politicians, who refused to acknowledge the rampant poverty that existed in their states and preferred to believe that pellagra was germ-based. What Goldberger discovered, Kraut said, was that public intransigence and ignorance can be as important as germs in spreading disease. The missing nutrient that can cause pellagra, subsequently identified by scientists as niacin, is now widely available in fortified foods.

Unlike pellagra, influenza is a highly infectious disorder. As Prof. John Barry noted, it killed between 50 to 100 million people worldwide during the pandemic of 1918. History has shown that influenza is not only a lethal pandemic but also a recurring one. There have been three to five pandemics a century as far back as we know, with three occurring in the twentieth century. The scientific community is therefore certain that there will soon be another one, originating – as all flu pandemics do – from a strain of avian influenza. It is nonetheless difficult to know exactly which strain of influenza to expect because, Barry explained, the influenza virus is close to the fastest mutating virus in existence. Federal government officials responded to the 1918 epidemic by suppressing reports of the disease and assuring the public that there was no problem. That tactic, which created understandable cynicism in a public that watched people die of the disease within 24 hours of contracting it, resulted in public panic and caused many cities in the United States to cease functioning effectively. Fighting the trend, San Francisco was honest with its residents and prepared them for the worst. There, the virtual breakdown of society found in other major U.S. cities was avoided.

Venereal disease (VD), which affected the military, became a particular concern of the federal government during World War I. Dr. John Parascandola found that 13 percent of the draftees had either syphilis or gonorrhea. Congress reacted by providing funding for an anti-VD campaign and a venereal disease division was established within the Public Health Service (PHS). Federal policies, however, were constrained by the socio-political and religious considerations of the times, and the result was that methods of social control took precedence over public education. Most importantly, a decision was made not to distribute condoms to troops but, instead, to try and suppress prostitution around military camps. As a result, approximately 20,000 women were quarantined; others were jailed. Dr. Thomas Parran, who became head of the VD division of PHS after World War I, was determined to treat VD as a public health issue and sought to begin a campaign of public education. Backlash from socio-political forces, however, forced the PHS to emphasize morality in its educational materials, rather than to equip the public with knowledge of the best measures for protection from VD.

Socio-political factors affected the public's reaction to other epidemics, as Dr. Victoria Harden noted in recounting the response of the scientific and government communities to two twentieth century epidemics: Rocky Mountain Spotted Fever (RMSF) and AIDS. RMSF, first identified in the Bitterroot Valley of Montana in 1902, was caused by a bacterium transmitted through the bite of an infected tick. The first response was to treat cattle in an attempt to kill ticks. As only five percent of the tick population was infected, the response was far from the most efficient one possible. In 1924 a vaccine that did not prevent contraction of the disease but did prevent death was developed, and the Montana authorities were wise enough to embrace it and provide it to residents free of charge. Antibiotics developed in 1948 cured the disease, and by the 1970s RMSF resulted in fewer than 30 deaths a year.

The response to AIDS, by contrast, constituted a public health disaster. The first description of AIDS was published in 1981. By 1982, scientists understood that the disease spread through blood transmission and unprotected sex. Because the highest initial incidences of the disease occurred among stigmatized groups such as homosexuals and drug users, the governmental response was to ignore it. Some other countries responded to AIDS as a medical matter rather than as one of morality in the 1980s, undertaking a massive educational effort, but the U.S. Surgeon General did not authorize such a campaign until 1988. Even then, insistence on treating AIDS as a matter of morality rather health led – and continues to lead – to the restriction of public health measures such as condom distribution. The disease has proven impossible to inoculate against or to cure, largely because HIV (human immunodeficiency virus), which causes the disease, mutates 1,000 times faster than the flu virus. The best that the scientific community has been able to do is develop anti-retroviral drugs, which are extremely costly and have substantial side effects, to suppress the symptoms. The policy lessons, Dr. Harden concluded, include the importance of funding medical research between epidemics, so that the scientific community can do its best to meet the challenge of new diseases. In addition, the health establishment must be reorganized so that internecine rivalries do not impede public health efforts. Perhaps most importantly, Harden cautioned, it should never be assumed that any disease has been conquered.

Drawing on the histories of past epidemics, the panelists emphasized that the country cannot afford to permit the moral qualms of some to trump the need to treat future epidemics as a public health matter. It is crucial for the government to tell the nation the truth; public education is an important component of the fight. So is planning, with all levels of government coordinating the effort. As Prof. Barry noted, this nation is now more vulnerable than ever to a flu epidemic, because of factors such as the ease of travel, our reliance on foodstuffs from abroad, and the lack of stockpiled food supplies. "Every disease has a politics connected to it," the panelists warned; we have yet to see what the politics connected to the coming flu epidemic will be.

Drafted by Acacia Reed.