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Anatomy of an Epidemic (cont.)

Lesson 1

It really is a small world after all
“One thing is clear—the 747 is a great incubator.” That isn’t a revelation to David Celentano, or to anyone else who logs 100,000 miles a year on airplanes. As the Hopkins epidemiologist tracked early SARS numbers on his office computer in April, he found himself remembering all the colds he’d caught over the years from fellow air travelers. Then he canceled a planned trip to Asia.

Air travel has long been regarded as a potential public health risk. With SARS, that risk became deadly reality—a new infection made its way from a remote corner of China to the Hong Kong airport. From there, it traveled throughout the Asian continent and halfway around the world, all before it even had a name.

“Fifty years ago, an outbreak like this might well have burned itself out locally,” notes Kenrad Nelson, MD, professor of Epidemiology and a former Epidemic Intelligence Service officer. “Disease is global today. So public health has to be global.”

This new reality means that tomorrow's practitioners need to be prepared for all sorts of maddening complications in the fight against infectious disease.

Witness the initial dissembling about SARS numbers by some Chinese authorities. Witness the bureaucratic brouhaha over how—or even whether—the international community could assist Taiwan, a country most of the world doesn't formally recognize. Air travel might make the world a smaller place, but it doesn’t make it any less messy.

“Local, national, WHO: All three need to be working, and they need to be working in unison and without defensiveness,” says Ron Brookmeyer, PhD, chair of the School’s MPH program. “A lot needs to be done to improve the chances that that’s going to happen when it needs to happen.”

Getting there will require years of grunt work: building relationships, opening communication lines, and expanding cooperative capabilities.

“Fifty years ago, an outbreak like this might well have burned itself out locally,” says Kenrad Nelson, MD. “Disease is global today. So public health has to be global.”

That’s the kind of work alumnus Scott Dowell, MD, MPH '90, was doing in Thailand when SARS erupted. The first of its kind in the world, his program lends CDC expertise to nations establishing programs to better detect and control outbreaks of infectious disease. Its mission encompasses training programs, surveillance strategies, and capacity building—the kind of work that more Asian countries are doing in the wake of SARS.

“Public health has suddenly been elevated to a much more important position in many of these places,” Dowell says. “I hope that gives us a push toward strengthening international collaborations so we can put quality public health teams into places where these outbreaks can happen.”

For some School faculty, the urgency of the task raises questions even about domestic spending here in the United States, where many experts have long decried the “dismantling” of the public health infrastructure. The field received 10 percent of health care spending in the 1940s; that's down to 1 percent today, even after a recent boost spurred by fears of bioterrorism.

“But compared to other countries, we’re still in pretty good shape,” says Kenrad Nelson. “What SARS says to me is that we have to be concerned about places all over the world that don’t have good public health systems.”

“We here in the United States need to think seriously about investing in these other countries,” agrees Robert Bollinger, MD, MPH ’88, associate professor of International Health. “Their ability to deal with problems is going to be critical for us as well as for them in the future.”

The international community, on the other hand, needs to beef up WHO’s capabilities. Among School faculty, there is broad agreement that WHO performed commendably in the face of SARS. Its forceful early travel advisory and aggressive surveillance strategies helped stem the spread of an infectious agent that might otherwise have killed many thousands instead of less than 800.

But WHO’s success should not imply that it has all the resources and expertise it needs, warns Neal Halsey. “What’s happened with SARS is such a powerful argument for strengthening the WHO,” he says. “Look at what they accomplished, and then look at their extremely limited resources. It was just nine people doing almost all of what they did out there.”

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