Assessing Threats to Health
By: Stephen CollierOne last thing that I have been sitting on for a while: The journal Biosecurity and Bioterrorism published in late 2007 an interesting exchange between Lynn Glotz, (her piece is called “Casting a Wider Net for Countermeasure R&D Funding Decisions“) and Gerald Epstein (his response: “Security is More than Public Health.”). Klotz is basically arguing, on c0st-benefit grounds, that the U.S. has been dramatically mis-allocating its counter-measure funding, placing too much focus on bioweapons agents like anthrax and smallpox, and too little focus on other infectious disease, like AIDS and flu. She backs this up by a cost-benefit analysis that looks at likely annual deaths from each, and, thus, the relative priority that should be assigned to each in funding decisions. It is a classic effort at “budgetary rationalization” of the type I analyze in “Enacting Catastrophe.”
Epstein responds, as might be surmised from his title, that “security” cannot be reduced to the number of deaths. A weapon like smallpox, he argues, poses a potentially “existential” threat in the sense that an attack may compromise the U.S. Government’s ability to continue operations in the face of mass panic and total uncertainty about further attacks.
So this debate is a very distilled example of something that lots of us have been working on for quite some time (I am thinking particularly of Lyle and Dale’s work, which Andy and I have been thinking about recently in writing the introduction to Biosecurity Interventions). On the one hand, you have a cost-benefit approach from public health; on the other hand, a national defense view of the world, which is used to thinking about — and acting on — uncertain but potentially catastrophic events. The experts do not agree. Worth a few minutes to read the articles over.
March 2nd, 2008 at 2:36 pm
Keep in mind that a couple of years ago, most public health experts agreed that a bioterror event is likely to happen in the next few years and that we should prepare for it. At that time, no cost-benefit arguments were made.
I think a lot of the disagreement between the public health people and the national security people has to do with the smallpox vaccination program. It is hard to underestimate the traumatic effect of the SVP on the public health community. The trauma itself was not caused by the fact that two different rationalities clashed (although that certainly played an important role, but its not the whole story - there can be a mediation for the most fundamental dichotomy). The public health community was not a priori opposed to the SVP, but what really annoyed them was the way it was managed by the federal government. I think this traumatic experience is really essential to understand what happened next.
When public health experts refer to specific rationalities, like cost-benefit, etc. they are right to do so. But I think that in some contexts these rationalities are means to rationalize something quite different.
March 2nd, 2008 at 6:53 pm
This is interesting Carlo. But I wonder where it takes us. One possibility is that it implies that what is “really” going on here is power dynamics. Public health folks were pissed that a biosecurity program got implemented in a manner that failed to incorporate their concerns, input, and so on. But it is also likely the case, I would think, that their concerns and input would have included more attention to the question of costs and benefits for public health departments and individual workers. It may be true, as you say, that when people talked about bioterrorism they didn’t talk about cost benefit. But what at least some of the case studies people have done seem to suggest is that when any concrete measures are actually proposed that violate an underlying norm of risk assessment then things get stickier. No?
March 2nd, 2008 at 7:50 pm
I guess what I wanted to point out is, first, that the public health people were not fundamentally opposed to bioterrorism preparedness. Second, the svp changed the dynamic quite a bit and I think that’s important to keep in mind. I think bioterrorism simply looked differently for the public health people after their troubling experience with the svp. (Dale: please come to my rescue here!).
What happened after 2003 is basically the dual use story. Public health folks tried to re-direct bioterrorism funds into more general preparedness efforts and public health infrastructure (partly because of the svp experience and the way they were treated by the administration, partly because there are other emergencies that urgently require attention, partly because of the cost-benefit argument, etc.). Things like “syndromic surveillance” were promoted: useful for both bioterrorism as well as for other stuff, like influenza (Mediation: the public health folks increasingly wanted to prepare for a pandemic, the federal government primarily made money available for bioterrorism preparedness). Lyle’s argument, as far as I remember, was that syndromic surveillance might indeed be useful (despite the fact that it produces too many signals), but that you then need on-the-ground epidemiologists, who follow things up.
Another problem with the dual-use argument is that bioterrorism funds have gone mainly to large urban areas. But what if there is a pandemic flu outbreak in Kansas due to a reassortment event in a swine? They are still reporting disease outbreaks on paper and have not yet made it into the computer age. Welcome in America!
This leads us to another point: There has been too much focus on invention rather than consolidation and implementation. There are enough smart technologies out there. I don’t know how many incredibly smart simulation-detection-early/warning/systems etc. I’ve seen. They are all perfect! But the most likely thing that will happen is that none of them will be implemented across the country.
Stephen: I don’t understand your last point.
As to risk assessment: As you know, there is no way of deciding if a bioterror event is more likely than a pandemic. H5N1 is now around for more than 10 years.
Laurie Garrett correctly pointed out that there is hardly a lack of attention on AIDS (and, I would add, pandemic flu).
There are larger reconfigurations between public health and national security occurring today around infectious diseases more generally.
March 4th, 2008 at 7:40 pm
Okay Carlo, okay Stephen. I’ll enter this dialogue with a few points. Point 1: I don’t see how what the two of you are saying necessarily conflicts or contradicts one another. Different rationalities were entering into the field of play (which Carlo concedes), and the two institutions in focus here (the state and the public health ‘establishment’) were the object of shall we say an interesting and an occasionally lopsided power differential (which I think Stephen did/would concede). Point 2: Carlo, Stephen’s last point touched on a conclusion I drew from my case study. The long and short of it is: at the 2002-2003 juncture, the public health folks *literally* were at a loss to figure out how to think about smallpox vaccination utilizing cost-benefit techniques. Half the equation was missing. A whole series of creative discussions, arguments and even techniques therefore had to be elaborated and brought to bear on the thing, thereby formulating it as a different kind of problem. Point 3, and perhaps the thing I’m most interested in lately, is: what is/are the rationales (in the sense of the reasons or justifications) to be prepared these days? What’s the goal? Increasingly, as we have discussed in this and other forums, is the notion of resilience. Increasingly we’re seeing resilience creep into more and more aspects of disaster preparedness - and I suspect public health will soon follow. Certainly, continuity of operations - a VERY fascinating technique with roots in finance and information technology, among other domains - must be viewed in the context of resilience as well as organizational (not to mention governmental/societal!) preparedness. What’s my point? That linkages between security -with its way of assessing and understanding danger - and resilience (with its own techniques rising increasingly to prominence) can prove productive in understanding how and why public health and national security select certain objects as potentially catastrophic - and how and why certain techniques are seen to provide the way forward.