The Methodological Magic of Public Health

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Here’s another fascinating, sobering article in the Times tied to the COVID-19 outbreak. We know about the ongoing epidemic in China as well as new and fast-moving outbreaks in South Korea, Italy and Iran. So far there appears to be little if any domestic spread in the United States. This article looks beneath these headlines at the mix of federal authorities doing macro-planning, compiling lists of people returning from China and how they interact with a vast and decentralized array of local public health departments who are actually doing the monitoring.

I’m always struck by, amazed at how much of public health work involves not technology but methodicalness and record keeping. In purely technological terms much of it could have been done 100 years ago or, in outlines at least, 500 years ago. Phones and texts and emails obviously provide a critical new tool, allowing public health officials to remain in regular daily contact with hundreds or thousands of people currently self-quarantined across the country. But at its heart it’s an elementary process: find anyone who has tested positive for the infection, track down everyone with whom they had significant contact and get those people to isolate themselves (usually at home) from everyone else for 14 days.

In concept, that’s simple enough but the detective work is laborious. It’s inherently imperfect since inevitably some people won’t follow the rules, intentionally or not. Critically, at a certain point, if you start getting sustained transmission in country, it becomes impossible to scale such an effort.

As described in the Times article, the system is basically one in which federal authorities are generating lists of people in different areas who’ve recently been to China (or for other reasons should be monitored). Those are then relayed to local county and city health departments who do the actual monitoring. The budgetary impact of all this is potentially staggering and will quickly become a national issue. If the public health department in county X doesn’t have the budget to keep up with the monitoring, that’s obviously a threat that goes way beyond the borders of that county.

One important point to consider is that the most vulnerable populations are in countries with weak public health systems and limited state capacity. But two of the three moving outbreaks are in countries which should have state of the art capabilities: South Korea and Italy. South Korea may have a certain logic because of proximity to China and what I assume are heavy travel flows. Italy is harder to figure. The daunting possibility is that these outbreaks are inevitable and it’s only in these country’s with advanced public health systems that the outbreaks have even been detected.

Scary stuff.

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