Public Health or Transplant Surgeons

Most people, from every stratum of society, could give a description of what a surgeon, a cardiologist or a plastic surgeon does. Most will probably know when they need a referral to a rheumatologist or a nephrologist. But very few people have ever been referred to an epidemiologist. Epidemiologists deal with populations, where they lurk behind the curtains of familiar medical environments. Even many clinicians will stumble when trying to define the field of public health, the stomping ground of epidemiologists.

Public health is defined as “the science of protecting the safety and improving the health of communities through education, policy making and research for disease and injury prevention.” Many professions are involved today in public health, including nursing, social workers, economists, statisticians and mathematicians, nutritionists and many more. As a student in medical school during the apartheid era in South Africa, Public Health involved a short series of lectures during the clinical years. The textbook was written by a figure in South African medicine whom we had never heard of, and the thing most of us remembered years later about our course, was the chapter which defined how many cubic feet of air was assigned to each black mine worker in the crowded hostels where they slept. This chapter, together with the rest of the book, was looked on as a joke, with little relevance regarding our future careers in medicine.

My early years as a pediatrician involved setting up an academic teaching program in community pediatrics in a small town built to receive immigrants after the establishment of the state of Israel. These “development towns” housed mostly people from the low socio-economic level, with much of the morbidity related to the poor living conditions. At one stage, a sudden wave of children with severe diarrhea and high fevers appeared in the clinic. The results of stool cultures showed that Shigella, a bacteria which could produce severe and even life-threatening disease was responsible. Almost all cases came from an ultra-Orthodox community living in a nearby settlement. Further questioning of the families involved pinpointed the outbreak originating in vegetables purchased from a market in the nearby Gaza strip. The explanation was that this was a year of shmita, when according to Jewish law, during this time which occurs every seven years, observant Jews should leave their fields fallow, and purchase from other sources. The religious community obediently purchased all their vegetables from in the nearby Gaza strip, where the irrigation of the crops probably included human sewage. I had managed to use my newly acquired knowledge accrued from a Master in Public Health degree to solve an interesting riddle in the community I served.

I have subsequently been involved with various roles with the SARS and other serious disease outbreaks. But until January 2020, public health and epidemiology were just an addition to my medical education. Then the COVID-19 tsunami arrived. The stars of this pandemic were the silent warriors of the past. The high- profile spokespeople of the medical world were now not heart transplant surgeons or emergency medicine heroes. Experts in public health and infectious diseases appeared throughout the day on all the media. The previously unknown quiet spoken director general of the Ministry of Health, an economist by training, and his deputy, a public health specialist, became prime time heroes and were parodied on comic reality television. Just as Trump battled to steal the limelight from Fauci, a wise and experienced specialist in infectious diseases and epidemics, our prime minister found time between fighting off charges of corruption and forming a new government, to keep the Corona footlights shining on him each night.

It was easy to get confused, as we found ourselves in the midst of a pandemic which caught most of the world with their pants (or skirts), down. The media produced experts in a steady stream, each trying to explain the management of the epidemic, either defending government policy or, attacking current actions. Experts confidently predicting the future of the epidemic included hospital directors, a Nobel Prize winner with a background in biophysics and biostatistics, high ranking army personnel and various other soothsayers. One remembered the definition of an expert – a specialist who knows everything about something, and nothing about anything else.

The problem with the lockdown, the cordon sanitaire, was that it was clumsy, a sledgehammer. It arrived too late and broke down the fundamental element of public health, information. This was the response of the Chinese government at the outset. It differed from the norms of public health, which have developed since the plague years, which stress case findings of individuals, then tracing and isolation. Now, four months after Corona became a household word throughout the world, we are starting to see the experts struggling to put all the information into perspective. The need is urgent, because among all the hubris, there is agreement that a second wave has arrived. This, when we are not yet ready to say that the first wave is over. Some hard questions need speedy answers. Do children spread the disease to the at -risk elderly? How serious is the risk of surface contact compared to droplet spread? Should we keep people at work and save the economy, while risking a dramatic rise in mortality among the elderly? Do we keep schools open at all costs?

The system has learned important lessons regarding “next time”, such as the need to be ready with enough PPE and ventilators, and how to identify the seriously ill at an earlier stage through monitoring oxygen saturation and preventing prolonged artificial ventilation in intensive care. But this sub-microscopic virus has shown society that medical issues in a pandemic situation, stand alongside issues of education, economy and ethics. The public health specialists should be setting the stage for discussion between “the experts” in health care and education, the academicians and the philosophers, in preparing for the inevitable continuation of Corona and future epidemics. We have applauded the first surgeon to perform a heart transplant and the drama of separation of Siamese twins. We must now be ready to applaud the team of professionals who find the way to guide humanity wisely through COVID-20, and the epidemics that will follow.And must be ready to face the consequences if we let the politicians replace the professionals.