My friend Allen Perkins received a text from his
college-student daughter asking if she should be worried about the Ebola virus.
His reply, discussed in “Ebola
virus and the dread factor” in his excellent blog, “Training Family
Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice,
based upon an understanding of the epidemiology of disease. While is it obviously
a serious problem in West Africa (particularly Liberia, Sierra Leone, and
Guinea), it is not in the United States. Many other things are much more of a
threat in the US, including, as Allen points out, “death from bee stings” (100
per year in the US).
Ebola might someday
become a significant problem in the US, but it is unlikely and is not now. Many
other health problems are. College students like Allen’s daughter should be
sure that they have all their recommended immunizations for diseases that can
be prevented by vaccine, including HPV and meningococcus, a very serious and
often deadly cause of meningitis that can become epidemic where young people
live together in close quarters, like college dormitories (and army bases).
Yet, many do not receive these immunizations for reasons that range from
passively not getting it done (less of a problem in schools where it is
required) to having beliefs, or having parents who have beliefs, that vaccines
are dangerous and should be avoided (in some cases this can trump school
requirements). They are, by the way, wrong. The net benefit far outstrips the
risk. Having your child get meningococcal meningitis and die or have serious brain
damage, or get cervical cancer, is not something you want.
But focusing on conditions over which we have
little or no control, rather than the ones we do, is fairly epidemic in this
country (and likely others). Dr. Perkins focuses on the “dread factor”, about
how news reports (not to mention thriller movies) whip up fear about these
diseases. On the other hand, mostly what we can do is fear them, while the
diseases which we individually might be able to have an impact on would require
us to have to maybe do something hard: change our diet, start exercising, stop
smoking, not drink so much or at the wrong times. I have written in the past
about a patient who had a terror of breast cancer, a disease for which she was
not at an increased risk based both on her youth and lack of family history. On
the other hand, she did not seem particularly worried about the health risks of
her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or
having unprotected sex with several different men.
Most of us can see
that this is not logical, and maybe even snicker a little about her poor
decision making. But it is only a little extreme. Many, perhaps most, of us,
could do a better job of eating right, of exercising, of not smoking or
drinking excessively (which for many people is “at all”). If not Allen’s
daughter, many of her classmates are at much greater risk from going out and
getting drunk on a weekend night, increasing their risk of motor vehicle
accidents, sexual assault, poor judgment in choosing voluntary sexual encounters,
and long term habituation for those with a predilection for or family history
of alcoholism, just for starters. But taking action to prevent such bad outcomes
is hard, requires effort, and often means not doing things we like in the short
term, such as eating tasty-but-unhealthful foods, drinking with friends,
smoking when we are addicted to nicotine, driving when we (or the driver) is
only a “little drunk”, or having to do unpleasant exercise. Or it can conflict
with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing
things that our friends are doing. Worrying about things that we can do nothing
about, like breast cancer or Ebola, may be a little irrational, but it is in
some way comforting because if the bad thing happens we are an innocent victim.
In addition, there are actions a society can take, that could make even
more of a difference from a public health, population health, point of view,
saving more lives, but these require political will. Sadly, this is often more
lacking than individual will. Guns are the prime example; many state legislatures
and legislators make it a point of personal pride to advocate for there being
no restrictions at all on what kind of guns (e.g., automatic weapons) and
ammunition (e.g., armor piercing bullets) people can have or where they can
carry them (everywhere, open or concealed). Helmets and alcohol regulation are other
areas where opportunity for prevention is often missed. Car safety has been
increased by car and highway redesign and tobacco has been increasingly
regulated (against the opposition of the industry, it should be noted, in both
cases) for the benefit of public health, but many opportunities remain.
Indeed, expanding health coverage to all those below 133% of poverty by
Medicaid expansion continues to be opposed by those who want to be seen as
against Obamacare. This may be irrational from a public health point of view,
but in many states it is rational, if offensive, for being re-elected. The most
unjust and inequitable part of it all is how the effects of poor public health
policies most affect the most vulnerable, poorest, least empowered people in
our society, or indeed any society. Public health education campaigns tend to
focus on diseases that have well-funded advocacy groups and affect the majority
population; a recent qualitative study of African-American women found that
they were very aware of the threat of breast cancer, but hardly at all of
stroke – a disease statistically more likely to affect them.
Speaking of public health, it is gratifying to see some newspaper
coverage of Ebola that is not sensationalist or scary. “U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak
Up”, by Richard
Pérez-Peña in the NY Times, August
30, 2014, addresses the small but real risk that may affect colleges from
students who have (unlike Allen’s daughter) actually traveled to West Africa.
Even better is “Leadership and Calm Are Urged in Ebola
Outbreak” by Donald G.
McNeil, Jr., which presents a
rational, thoughtful, public health approach, and discusses public health
strategies which have been used in the past in major crises and are beginning
to be implemented in West Africa. These strategies center around the use of
local, respected experts who can effectively communicate with the people in
their countries, rather than international aid agencies. The goal is to help
people to utilize appropriate prevention and protection measures rather than
panic. Again, as in the case of the other personal behaviors described above,
this can be hard for people, especially when it contradicts cultural and
religious values (such as how the dead are buried). But having voices who are
local, who understand the culture, and have both medical/public health
credentials and individual credibility, is extremely important. Of course,
unlike the Ebola “scare” articles, these were both on page 8 of the newspaper,
but have a more prominent position on that day’s Times homepage.
So what are the lessons? Understanding risk is not always easy,
especially when an epidemic with a hugely high mortality rate threatens. Doing something is harder than not doing
anything, and it can thus be tempting to worry more about the things that we
can’t do anything about rather than those we could reasonably take action on.
The same is true for public health issues that need to be addressed at a
And, of course, it is always the most vulnerable who suffer the most.