Public Health, Fall 1996

The Politics of Public Health

In 1981, the first cases of what is now known as AIDS were reported to the Centers for Disease Control and Prevention (CDC). At that time, James Curran, now dean of the Rollins School of Public Health, was chief of the CDC's research bran ch of sexually transmitted diseases. The CDC designated him to head a task force for three months to look into the problem. He did so, for the next 15 years.

During that time, Dean Curran dealt with many facets of public health, from laboratory research to prevention education to administration. In this interview, he addresses the major challenges, both epidemiological and political, that confront public he alth today.

Can you describe the historic role of public health in the United States and how that role has changed in the past 100 years? What is public health's charge now?

Public health's mission is to maintain and improve the health of populations throughout a society, a country, a city. Historically, public health has been involved with the surveillance of disease as well as evaluations of threats to the overall public health - whether those threats are diarrhea caused by contaminated water supplies or preventable outbreaks of infectious diseases.

Obviously, in the past 75 to 100 years, the public health threats have changed, as has our ability to deal with them. Safe water supplies, adequate housing, and advances in medical care - for example, the use of antibiotics and drugs such as insulin to prevent many of the early complications of diabetes - have greatly changed both the priorities of public health and our ability to deal with problems.

The attention-getting areas of public health usually involve the outbreak of a deadly infectious disease such as the Ebola virus or hantavirus. However, disease prevention is another important mission of public health. Is one area mor e important than the other?

In terms of public health in the United States and abroad, the most dramatic problems will always capture the public's attention because of the emergency of the event. This is true whether you're talking about the outbreak of an emerging virus su ch as hantavirus on Native American reservations in the Southwest, the contamination of Tylenol bottles with cyanide, or a concern about the spread of a potentially health-threatening toxic waste. It is extremely important for public health to be able res pond with adequate surveillance of the problem and to halt it as quickly as possible. It's important to determine whether we have a real or potential threat.

A recent example is the outbreak of Ebola virus in this country in imported monkeys from the Philippines, which, because of public health's rapid response capacity, was shown not to be a threat to humans. Being able to characterize and compare the viru s with those that do cause disease in humans was important, as was limiting and containing the virus threatening the animals.

Response capacity is also important for the sake of credibility. What is public health if we can't respond to emergencies of rare diseases about which our health care system has no specific knowledge?

On the other hand, larger threats to the public health of our population require a systematic look at how we might prevent heart disease, various forms of cancer, premature death from other diseases such AIDS, or unintentional injuries.

You've played a highly visible role in AIDS and HIV research. How do you judge the progress of research on these infections? What are the research strategies now?

Initially, when there were a small number of cases and the cases were apparently confined in the first year to only a few hundred gay men and a few dozen injecting drug users, it was easy for society and the government not to immediately and full y respond. We didn't comprehend the size of the problem and the magnitude of it. Its horizons appeared to be fairly small.

Response to the epidemic grew enormously and rapidly from about 1983 to about 1990, response from government, science, and society. People began to recognize the extent of the problem, both nationally and internationally, as a worldwide epidemic of a n ew disease. A disease that could be transmitted from person to person and for which there is no cure. A disease that had enormous social as well as physical implications for individuals, for families, and for populations. It received more attention during that time than problems that resulted in more deaths simply because it was a problem that could be spread from person to person, because there was no cure, and because there was no baseline research going on.

From a prevention point of view, AIDS forced us to come to grips with homosexuality, with sexuality in general, and to acknowledge our ignorance about sexual behavior and how to influence it to save lives. In general, science had more or less neglected these areas in terms of prevention of disease until AIDS came along. So there was a start-up cost.

I think what we've learned as we've watched the HIV epidemic is that just as research on cancer has assisted knowledge in HIV, now research in HIV - the treatment of opportunistic infections, for example - benefits many people who don't have HIV. It be nefits cancer patients. The basic research on the immune system, how to manage patients with damaged immune systems, has led to breakthroughs in other areas.

HIV has an impact beyond itself. It has had an impact on the epidemic of tuberculosis in the United States. It has had a dramatic impact on the improvement of the safety of the blood supply in this country.

You had a long career at the CDC. Currently, parts of that agency are embroiled in political controversy, particularly the National Center for Injury Control and Prevention. What happens when public health issues become political?

The job of a public health leader is to continually redefine the unacceptable. Public health practitioners and leaders should be looking at the most important threats to health in a society and what might be done to avert those threats. And we sh ould do that in a politically blind fashion. We should not be influenced either positively or negatively by partisan politics or by interest groups, but have an unbiased interest in those most important public health problems about which we can do somethi ng.

When I talk about politics, I would like to distinguish between a partisan "p" and a nonpartisan "p." Obviously public health deals with improving and understanding the health of populations. Understanding public health problems and finding solutions t o them necessitate getting communities involved. You cannot do surveys of the immunization levels of children in inner-city Atlanta, rural south Georgia, or suburban Alpharetta without the approval and understanding of people who live in those areas as we ll as their political and community leaders. So almost every understanding and solution to public health problems involves political approval and consensus building.

What is particularly harmful to public health is when the strictly partisan aspects of politics invade public health issues. For example, a particular lobbying group - let's say tobacco companies - could put pressure on an elected official to distort t he truth about the adverse ill effects of tobacco. It's important that at one point elected officials take into account the public health facts. I'm not saying public health leaders should be making all the decisions affecting the economy of North Carolin a, but it is important that the public health facts stand by themselves and that influences are recognized openly and honestly.

It is naive, however, to think that you can stay away from politics in public health.

Will the fate of the National Center for Injury Control and Prevention have an impact on the Center for Injury Control and Prevention at the Rollins School of Public Health?

Art Kellermann is the director of our center for injury control and has been a national leader in looking at ways to prevent injury, including bicycle injuries as well as those caused by handguns. As such, he often has been the target for people who are vehemently opposed to gun control, particularly the National Rifle Association. To the extent that the CDC's budget for its National Center for Injury Control or its credibility is damaged by the controversies, it could have an impact on all peopl e who conduct research in this area and all of us concerned about the epidemic of violence-related injury and death.

This is an example, I think, of changing and redefining the unacceptable, looking around the world and asking, why does the United States have so much morbidity and mortality due to handguns? Is ours a more violent society than others? Or are we equall y violent with tools that cause death instead of tools that cause bruises?

How can a government agency such as the CDC and a school such as the Rollins School of Public Health work together to complement each other's initiatives in public health?

We are really fortunate to be right next to the CDC. That was part of Robert Woodruff's vision when he obtained the land for Emory to donate to the CDC, that this would be an important partnership. With the formation of the Rollins School of Publ ic Health, Emory has taken an important step forward in being able to contribute to that partnership.

I often say that Atlanta is the public health capital of the world because of the presence of the Robert W. Woodruff Health Sciences Center, the CDC, the American Cancer Society, Care International, and the Carter Center. We feel fortunate to have a fi ne school of public health to participate in this capital.

We have some advantages to bring to partnerships at the CDC in the area of teaching and training. We have more than 700 full- or part-time graduate students in the masters and doctoral programs who can work very closely with programs at the CDC. We hav e more than 100 CDC professionals who serve as adjunct faculty at the Rollins School of Public Health, and many of our faculty work part time at the CDC in joint programs.

What are your priorities and goals for this school?

I think the priorities and goals can be listed along the areas of teaching, research, and service. We had a 30% increase in our applications this year. We've not only had more applicants but also stronger applicants while retaining a very diverse group. To maintain this diversity and the quality of our applicant pool, we have to continue our emphasis on teaching. We also need to greatly improve our ability to give scholarship support based on need and merit.

In research, we want to strengthen and increase our capacity to conduct funded research and increase the research capacity and productivity of the school.

The third area is service. We are the major school of public health in the state of Georgia and the city of Atlanta, and we have an obligation as well as an opportunity to play a major role with the state health department and with district, city, and county health departments to contribute to public health in the state of Georgia.

Fall 1996 Issue | When Women Use Drugs | The Politics of Public Health
The Road to Reform | Crossroads
Class Notes

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