Thoughts on economics and liberty

Author: Sanjeev Sabhlok

THE SEARCH FOR TRUTH BY MEANS OF THE NATURAL LIGHT – Descartes

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La Recherche de la Write par la lumiere naturelle

This light alone, without any help from religion or philosophy, determines what opinions a good man should hold on any matter that may occupy his thoughts, and penetrates into the secrets of the most recondite sciences.

A good man is not required to have read every book or diligently mastered everything taught in the Schools. It would, indeed, be a kind of defect in his education if he had spent too much time on hook-learning. Having many other things to do in the course of his life, he must judiciously measure out his time so as to reserve the better part of it for performing good actions — the actions which his own reason would have to teach him if he learned everything from it alone. But he came into the world in ignorance, and since the knowledge which he had as a child was based solely on the weak foundation of the senses and the authority of his teachers, it was virtually inevitable that his imagination should be filled with innumerable false thoughts before reason could guide his conduct. So later on he needs to have very great natural talent, or else the instruction of a wise teacher, in order to rid himself of the bad doctrines that have filled his mind, to lay the foundations for a solid science, and to discover all the ways in which he can raise his knowledge to the highest level that it can possibly attain.

I intend in this work to explain these matters. I shall bring to light the true riches of our souls, opening up to each of us the means whereby we can find within ourselves, without any help from anyone else, all the knowledge we may need for the conduct of life, and the means of using it in order to acquire all the most abstruse items of knowledge that human reason is capable of possessing.

But in case the grandeur of my plan should immediately fill your minds with so much wonder as to leave no room for belief, I must tell you that what I am undertaking is not so difficult as one might imagine. For the items of knowledge that lie within reach of the human mind are all linked together by a bond so marvellous, and can be derived from each other by means of inferences so necessary, that their discovery does not require much skill or intelligence — provided we begin with the simplest and know how to move stage by stage to the most sublime. In what follows I shall try to explain this by means of a chain of reasoning which is so clear and accessible to all that anybody who has not reached the same conclusions earlier will blame his failure to do so simply on the fact that he did not cast his eyes in the right direction and fix his thoughts on the matters that I considered. And I shall not deserve any more glory for having made these discoveries than a passer-by would deserve for having accidentally stumbled upon some rich treasure for which many persons had previously conducted a diligent but unsuccessful search.

I am surprised, indeed, that amongst so many exceptional minds, much better equipped than I to carry out this task, none have had the patience to pick their way through the difficulties. Instead they have nearly all acted like travellers who leave the main path to take a shortcut, only to find themselves lost amongst briars and precipices.

But I do not wish to consider what others have known or not known. I am content to observe that even if all the knowledge that can be desired were contained in books, the good things in them would be mingled with so many useless things, and scattered haphazardly through such a pile of massive tomes, that we should need more time for reading them than our present life allows, and more intelligence for picking out the useful material than would be required for discovering it on our own.

This makes me hope that you will be happy to find here an easier path. I hope too that the truths I set forth will not be any less well received for their not being derived from Aristotle or Plato, and that they will have currency in the world in the same way as money, whose value is no less when it comes from the purse of a peasant than when it comes from a bank. Moreover I have done my best to make these truths equally useful to everybody. I could find no style better suited to this end than that of a conversation in which several friends, frankly and without ceremony, disclose the best of their thoughts to each other. Thus let us imagine that Eudoxus, a man of moderate intellect but possessing a judgement which is not corrupted by any false beliefs and a reason which retains all the purity of its nature, is visited in his country home by two friends whose minds are among the most outstanding and inquiring of our time. One of them, Polyander, has never studied at all, while the other, Epistemon, has a detailed knowledge of everything that can be learned in the Schools. Leaving to your imagination their other conversations as well as their surroundings (from which, however, I shall frequently have them take examples in order to make their thoughts clearer), I shall now present them introducing the topic which will occupy them throughout these two books.

Polyander I consider you very fortunate to have found all those fine things in the Greek and Latin literature. Indeed, it seems to me that if I had studied as much as you, I should have been as different from my present self as the angels are from you. I cannot forgive the folly of my parents for believing that the pursuit of learning enfeebles the spirit, and for sending me to court and into the army at such an early age, and I shall regret my ignorance for the rest of my life if I do not learn anything through my association with you.

Epistemon The best thing I can tell you on this topic is that the desire for knowledge, which is common to all men, is an illness which cannot be cured, for curiosity grows with learning. But because the defects in the soul trouble a person only in so far as he becomes aware of them, you have an advantage over us in that, unlike us, you do not notice all the many things which you lack.

Eudoxus Is it possible, Epistemon, that you, with all your learning, are persuaded that nature can contain a malady so universal without also providing a remedy for it? For my part, just as I think that each land has enough fruits and rivers to satisfy the hunger and thirst of all its inhabitants, so too I think that enough truth can be known in each subject to satisfy amply the curiosity of orderly souls. The body of a person suffering from dropsy is no further removed from its proper condition than is the mind of someone who is perpetually tormented by an insatiable curiosity.

Epistemon I have, indeed, heard that our desire cannot naturally extend to matters which appear to us to be impossible, and that it ought not to extend to those which are evil or useless. But there are so many things to be known which seem to us possible and which are not only good and pleasant but also very necessary for the conduct of our actions; and I cannot believe that anyone ever knows so much that he cannot have good reasons to desire to know more.

Eudoxus What will you say of me, then, if I assure you that I no longer feel any passion to learn anything at all. I am as happy with what little knowledge I have as ever Diogenes was in his barrel, and this without having any need for his philosophy.[1] For my neighbours’ knowledge does not limit mine in the way that their fields form the boundaries of my small property. And my mind, having at its disposal all the truths it comes across, does not dream there are others to discover. Instead it enjoys the same tranquillity as would a king if his country were so isolated and cut off from others that he imagined there was nothing beyond his frontiers but infertile deserts and uninhabitable mountains.

Epistemon If anyone else were to speak to me in this manner, I should consider him to be very vain or else to be lacking in curiosity. But you escape the charge of vanity because you have chosen to retire to this remote place and because you are so unconcerned about being well known; and in view of the time you formerly spent in travelling, in associating with learned men, and in investigating all the most complex discoveries in every science, we can be sure that you do not lack curiosity. So all I can say is that I consider you extremely happy, and I am convinced that you must therefore be in possession of knowledge which is far more perfect than that enjoyed by others.

Eudoxus I thank you for the good opinion you hold of me. But I would not presume so much upon your courtesy as to expect you simply to take my word for what I have said. One must never advance propositions so soz remote from common opinion without at the same time being able to point out some of their consequences. That is why I invite you both to stay here this summer, so that I may have time to show you a part of what I know. For I venture to hope not only that you will admit that I have some reason for being content with my knowledge, but, in addition, that you for your part will be fully satisfied with the things you have learned.

Epistemon I have no hesitation in accepting a kindness which I was myself going to beg of you.

Polyander For my part, I shall be pleased to be present at this discussion, though I do not think myself capable of deriving any profit from it.

Eudoxus On the contrary, Polyander, I think it is you who will gain the greater benefit from it, since you are unprejudiced; and it will be far easier for me to set on the right track someone who is neutral than to guide Epistemon, who will often take up the opposite position. But to give you a more distinct conception of the sort of doctrine I propose to teach, I should like you to notice how the sciences differ from those simple forms of knowledge which can be acquired without any process of reasoning, such as languages, history, geography and in general any subject which rests on experience alone. I readily grant that one man could not live long enough to acquire first-hand experience of everything in the world; but I am no less convinced that it would be folly to desire 503 this. A good man is not required to know Greek or Latin any more than the languages of Switzerland or Brittany, or the history of the Empire any more than that of the smallest state in Europe. He ought simply to take care to employ his leisure in good and useful occupations, and equip his memory only with the most necessary knowledge. As to the sciences —which are simply a matter of our making reliable judgements on the basis of knowledge we already possess — some are drawn from ordinary facts about which everyone has heard, and others from observations which are unusual and highly contrived. I admit, too, that we could not possibly discuss each of the latter in detail. For we should need first of all to have examined all the herbs and stones that come from the Indies, to have beheld the Phoenix, and in short to have knowledge of all the marvels of nature. But I believe I shall adequately fulfil my promise if I explain to you the truths which can be deduced from the ordinary facts known to each of us, and so make you capable of discovering for yourselves all the others, when you care to take the trouble to look for them.

Polyander I think that this is all we can possibly desire. I should be happy if you would merely prove a certain number of propositions which are so well known that no one is ignorant of them, such as those concerning the Deity, the rational soul, the virtues and their rewards, etc. I compare these propositions to those ancient families which everyone recognizes as being very illustrious even though their titles to nobility lie buried in the ruins of antiquity. For I have no doubt at all that those who first brought mankind to believe these truths were able to prove them with very strong arguments. But ever since that time, these proofs have been repeated so rarely that no one knows them any longer. These truths are so important, however, that prudence obliges us to believe them blindly at the risk of being mistaken, rather than to wait until the next world in order to get clear about them.

Epistemon For my part, I am a little more curious, and I should like you to go on to clarify for me some special difficulties which I find in every science, and chiefly those concerning human contrivances, apparitions, illusions, and in short all the marvellous effects attributed to magic. For I think it is useful to know about them, not in order to make use of them, but in order to prevent our judgement from being beguiled by wonder at something of which it is ignorant.

Eudoxus I shall try to satisfy both of you. In order to establish an order that we can follow to the end, first of all, Polyander, I should like us to have a discussion, just the two of us, about all the things in the world, considering them as they are in themselves. I want Epistemon to interrupt as little as possible, because his objections would often force us to depart from our subject. Afterwards we shall all consider these things afresh, but under a different aspect, namely in so far as they are related to us and can be described as true or false, and good or bad. It is here that Epistemon will have a chance to set forth all the difficulties which will have occurred to him during the preceding conversations.

Polyander Tell us the order, then, that you will follow in your explanations.

Eudoxus We must begin with the rational soul, for ail our knowledge resides in it; and after considering its nature and effects, we shall proceed to its author. When we have come to know who he is, and how he has created all things that exist in the world, we shall be able to see what is most certain regarding the other creatures, and we shall examine in what way our senses receive their objects and how our thoughts are made true or false. Then I shall lay before your eyes the works of men involving corporeal things. After causing you to wonder at the most powerful machines, the most unusual automatons, the most impressive illusions and the most subtle tricks that human ingenuity can devise, I shall reveal to you the secrets behind them, which are so simple and straightforward that you will no longer have reason to wonder at anything made by the hands of men. I shall then pass to the works of nature, and after showing you the cause of all her changes, the variety of her qualities, and how the souls of plants and of animals differ from ours, I shall present for your 5o6 consideration the entire edifice of the things that are perceivable by the senses. After giving an account of celestial phenomena and what we can judge with certainty about them, I shall pass on to the soundest conjectures concerning matters which cannot be definitely settled by men, in order to explain the relation of things perceivable by the senses to things perceivable by the intellect, the relation of both sorts of things to the Creator, the immortality of his creatures, and their state of being after the end of time. Then we shall come to the second part of this discussion, where we deal with each science in particular, picking out the most solid elements in each of them and proposing the method for carrying them much further forward than has hitherto been achieved — a method which enables someone of average intelligence to discover for himself everything that the most subtle minds can devise. Having thus prepared our understanding to make perfect judgements about the truth, we must also learn to control our will by distinguishing good things from bad, and by observing the true difference between virtues and vices. That done, I trust that your passion for knowledge will not be so intense, and that it will seem to you that everything I have said has been satisfactorily proved —so much so that you will believe that a man with a good mind, even one brought up in a desert and never illuminated by any light but the light of nature, could not have opinions different from ours if he carefully weighed all the same reasons. Now, to enter upon this discussion, we must ask the following questions: What are the first things that people know? What part of the soul does this knowledge reside in? And why is it 507 so imperfect to begin with?

Epistemon It seems to me that all this can be explained very clearly if we compare the imagination of a child to a tabula rasa on which our ideas are to be traced, these ideas being like portraits drawn from nature. Our senses, inclinations, teachers and intellect are the different artists who may work at this task, and among them the least competent are the first to take part, namely our imperfect senses, blind instincts and foolish nurses. The most competent is the intellect, which comes last; and it must serve an apprenticeship of many years, following the example of its masters for a long time before daring to correct any of their errors. In my opinion, this is one of the chief causes of the difficulties we have in acquiring knowledge. For our senses see nothing beyond the more coarse and ordinary things and our natural inclinations are entirely corrupt; and as to our teachers, although undoubtedly you might find very perfect ones among them, they cannot force our judgement to accept their reasonings until our intellect has done the work (which only it can do) of examining them. But the intellect is like an excellent painter who is called upon to put the finishing touches to a bad picture sketched out by a young apprentice. It would be futile for him to employ the rules of his art in correcting the picture little by little, a bit here and a bit there, and in adding with his own hand all that is lacking in it, if, despite his best efforts, he could never remove every major fault, since the drawing was badly sketched from the beginning, the figures badly placed, and the proportions badly observed.

Eudoxus Your comparison nicely illustrates the first obstacle facing us; but you do not describe the means we must use if we wish to avoid it. Now it seems to me that your painter would do far better to make a fresh start on the picture; rather than wasting time in correcting all the lines he finds on the canvas, he should wipe them off it with a sponge. Similarly, as soon as a man reaches what we call the age of discretion he should resolve once and for all to remove from his imagination all traces of the imperfect ideas which have been engraved there up till that time. Then he should begin in earnest to form new ideas, applying all the strength of his intellect so effectively that if he does not bring these ideas to perfection, at least he will not be able to blame the weakness of the senses or the irregularities of nature.

Epistemon That would be an excellent remedy if it were easy to apply. But you are not ignorant of the fact that the opinions first received in our imagination remain so deeply imprinted there that our will cannot erase them on its own, but can do so only by calling on the assistance of powerful reasons.

Eudoxus I should like to try and impart some of these reasons to you. But if you wish to derive any profit from this conversation, you must now give me your attention, and let me converse a bit with Polyander; this will enable me to begin by overturning all the knowledge acquired up to the present. For, since this knowledge is not enough to satisfy him, it must be faulty: I would compare it to a badly constructed house, whose foundations are not firm. I know of no better way to repair it than to knock it all down, and build a new one in its place. For I do not wish to be one of those jobbing builders who devote themselves solely to refurbishing old buildings because they consider themselves incapable of undertaking the construction of new ones. But, Polyander, while engaged upon this work of demolition we can use the same method to dig the foundations which ought to serve our purpose, and to prepare the best and most solid materials which will be needed for building up these foundations. So please join me in considering which, of all the truths men can know, are the most certain and the easiest to become acquainted with.

Polyander Is there anyone who can doubt that things that are perceivable by the senses — by which I mean those which can be seen and touched — are much more certain than all the others? I for one would be quite astonished if you were to make me see just as clearly any of the things which are said about God or the soul.

Eudoxus That is just what I hope to do. I find it strange that men are so credulous as to base their knowledge on the certitude of the senses, when everyone knows that they are sometimes deceptive, and that we have good reason always to distrust those who have deceived us even once.

Polyander I am well aware that the senses are sometimes deceptive if they are in poor condition, as when all food seems bitter to a sick person; or if their objects are too far away, as when we look at the stars, which never appear so large to us as they really are; or, in general, whenever they do not act freely in accordance with their natural constitution. But such defects of the senses are all quite easy to recognize, and do not prevent me from being quite sure at present that I am seeing you, that we are walking in this garden, that the sun is shining on us, and in a word, that everything which ordinarily appears to my senses. is genuine.

Eudoxus So if I wish to make you fear that the senses are deceptive on  occasions when you are unaware of the deception, it is not enough for me to tell you that the senses deceive you on certain occasions when you perceive the deception. I shall have to go further, and ask if you have never seen one of those melancholic individuals who think themselves to be vases, or take some part of their body to be enormous; they will swear that what they see and touch is just as they imagine it to be. To be sure, a good man would be indignant if you told him that his beliefs cannot have any more rational basis than theirs, since he relies, like them, on what the senses and imagination represent to him. But you cannot take it amiss if I ask whether you are not, like all men, liable to fall asleep, and whether you cannot think, while asleep, that you are seeing me, that you are walking in this garden, that the sun is shining — in brief, all the things of which you now believe you are utterly certain. Have you never heard this expression of astonishment in comedies: ‘Am I awake or asleep?’ How can you be certain that your life is not a continuous dream, and that everything you think you learn through your senses is not false now, just as much as when you are asleep? In particular, how can you be certain of this when you have learned that you were created by a superior being who, being all-powerful, would have found it no more difficult to create us just as I am describing, than to create us as you think you are?

Polyander There, surely, we have arguments sufficient to overturn all the teachings of Epistemon, if he is reflective enough to give his attention to them. For myself, however, I fear that I should simply go wool gathering if I tried to consider such abstract matters, for I am a man who has never engaged in study or accustomed himself to turning his mind so far away from things that are perceivable by the senses.

Epistemon I agree that it is very dangerous to proceed too far in this line of thinking. Such general doubts would lead us straight into the ignorance of Socrates or the uncertainty of the Pyrrhonists.[2] These are deep waters, where I think we may lose our footing.

Eudoxus I confess that it would be dangerous for someone who does not know a ford to venture across it without a guide, and many have lost their lives in doing so. But you have nothing to fear if you follow me.

Indeed, just such fears have prevented most men of letters from acquiring a body of knowledge which was firm and certain enough to deserve the name ‘science’[3]. Supposing that there was no firmer basis for their opinions other than things perceivable by the senses, they have built upon sand instead of digging further down to find rock or clay. So we must not let the matter rest here, especially since even if you did not wish to give further consideration to the arguments I have stated, the arguments have already done what I desired: their chief effect has been to touch your imagination so as to make you fear them. For this indicates that your knowledge is not so infallible as to prevent your fearing that these arguments will undermine its foundations by making you doubt everything. Consequently it indicates that you already have these doubts, and so I have achieved my aim, which was to overturn all your learning by showing you its uncertainty. But in case you should now lack the courage to proceed any further, I would advise you that these doubts, which alarmed you at the start, are like phantoms and empty images which appear at night in the uncertain glimmer of a weak light: if you flee from them, your fear will follow you, but if you approach as if to touch them, you will find nothing but air and shadow and you will be more confident the next time such an encounter may occur.

Polyander I should like, then, to follow your suggestion and set forth these difficulties in the strongest form possible. I shall apply my mind to the task of doubting whether I have not been dreaming all my life, and whether all the ideas I thought capable of entering my mind only by way of the senses were not in fact formed by themselves, just as similar ideas are formed whenever I am asleep, and I know that my eyes are shut, my ears closed, and in short, that none of my senses help to form them. Thus I shall be uncertain not only about whether you are in the world and whether there is an earth or a sun; but also about whether I have eyes, ears, a body, and even whether I am speaking to you and you are speaking to me. In short, I shall doubt everything.[4]

Eudoxus There you are, all prepared, and at the very stage to which I had intended to bring you. The time has now come for you to consider closely the conclusions which I wish to draw at this point. Now, you see that you can reasonably have doubts about everything that you know only by means of the senses. But can you ever have doubts about your doubt, and remain doubtful whether you are doubting or not?

Polyander I must confess that your question strikes me with amazement. The modicum of insight I possess (which gives me a moderate amount of good sense) makes me see with some astonishment that I am forced to confess that I know nothing with any certainty, that I am doubtful about everything and certain of nothing. But what do you want to infer from this? I do not see that this universal amazement can be of any use, nor do I see how this sort of doubt can be a principle which gets us very far. For you arranged this conversation with quite the opposite end in view — to free us from our doubts and make clear to us truths which we should know and which even Epistemon, for all his learning, might not know.

Eudoxus Just give me your attention and I shall conduct you further than you think. For from this universal doubt, as from a fixed and immovable point, I propose to derive the knowledge of God, of yourself, and of everything in the universe.

Polyander You are promising a great deal indeed; and if things turn out as you promise, it will be worth our while to grant your initial demands. Keep your word and we shall be quite content to do so.

Eudoxus You cannot deny that you have such doubts; rather it is certain that you have them, so certain in fact that you cannot doubt your doubting. Therefore it is also true that you who are doubting exist; this is so true that you can no longer have any doubts about it.

Polyander I quite agree with you on that point, because if I did not exist, I would not be able to doubt.

Eudoxus You exist, therefore, and you know that you exist, and you know this just because you are doubting.

Polyander All of this is quite true.

Eudoxus But, so that you are not deflected from the course I suggested, let us proceed gradually, and as I said, you will find that you are making greater progress than you think. Let us go through the argument again. You exist, and you know that you exist, and you know this because you know that you are doubting. But what are you — you who have doubts about everything but cannot doubt that you yourself exist?

Polyander The answer to that is not at all difficult, and I can see perfectly well why you chose me rather than Epistemon to answer your questions: you did not want to ask anything which could not be answered very easily. So I shall say I am a man.

Eudoxus You are not paying attention to my question, and the reply you give me, however simple it may seem to you, would plunge you into very difficult and complicated problems, were I to press you even a little. If, for example, I were to ask even Epistemon himself what a man is, and he gave the stock reply of the scholastics, that a man is a ‘rational animal’, and if, in order to explain these two terms (which are just as obscure as the former), he were to take us further, through all the levels which are called ‘metaphysical’, we should be dragged into a maze from which it would be impossible to escape. For two other questions arise from this one. First, what is an animal? Second, what is rational? If, in order to explain what an animal is, he were to reply that it is a ‘living and sentient being’, that a living being is an ‘animate body’, and that a body is a ‘corporeal substance’, you see immediately that the questions, like the branches of a family tree, would rapidly increase and multiply. Quite clearly, the result of all these admirable questions would be pure verbiage, which would elucidate nothing and leave us in our original state of ignorance.

Epistemon I am sorry you despise the tree of Porphyry,[5] which the learned have always admired, and it annoys me that you would try to convey to Polyander what he is in a different way from the one which has long been universally accepted in the Schools. To this day no better or more appropriate way has been found for explaining what we are than displaying all the levels which make up our whole nature, for in this way, by passing up and down through all these levels, we can learn what our nature has in common with the natures of all other things, and in what respects it differs from them. And this is the highest point to which our knowledge can reach.

Eudoxus I have never had any intention of condemning the method of explanation ordinarily employed in the Schools, nor shall I ever wish to. For it is to that method that I owe the little I know, and my use of it has helped me to recognize the uncertainty of all the things I have learned there. So, even if my teachers taught me nothing that was certain, I owe them my thanks none the less, since it was due to their instruction that I came to realize this. Indeed, the fact that everything they taught me was quite doubtful gives me greater reason now to be thankful than would have been the case had their teaching been in closer accord with reason; for in the latter case I might have been content with the smattering of reason which I found in it, and that might have made me less conscientious in searching carefully for the truth. What I told Polyander serves not so much to point out to him the confusion and uncertainty into which his answer plunges you as to make him more attentive in future to my questions. Thus I am addressing my remarks to him; and to keep us from wandering any further from our path, I ask him once more what he is — he who can have doubts about everything but cannot have doubts about himself.

Polyander I thought I had satisfied you when I said that I am a man, but I quite see that I misread the situation: I can see that my answer does not satisfy you, and I must admit that it no longer seems adequate to me, especially when I think of the confusion and uncertainty into which, as you have shown me, it can plunge us if we want, to make the answer clearer and understand it better. Indeed, whatever Epistemon may say, it strikes me that there is a great deal of obscurity in these metaphysical levels. If, for example, we say that a body is a ‘corporeal substance’, without making clear what a corporeal substance is, these two words do not tell us any more than does the word ‘body’. In the same way, if we assert that to be living is to be an ‘animate body’, without first explaining what a body is and what it is to be animate — and likewise with all the other metaphysical levels — we are uttering words and putting them as it were in a certain order, but we are not really saying anything. The words do not convey anything that can be conceived, or form any distinct idea in our mind. When, in reply to your question, I said that I was a man, I was not actually thinking of all the scholastic entities which I knew nothing about and had never heard of, and which, so far as I am concerned, subsist only in the imagination of those who have invented them. I was thinking, rather, about the things we see, touch, perceive with our senses, and experience within ourselves — in a word, about things which even the most simple-minded of men know just as well as the greatest philosopher in the world. Undoubtedly I am a certain whole made up of two arms, two legs, one head, and all the other parts which make up what we call the human body, and which besides is nourished, walks, perceives by the senses, and thinks.

Eudoxus I saw at once from your answer that you had not properly understood my question, and that you answered more questions than I had asked. Now, in the list of things which you were doubting earlier on, you had already included arms, legs, head, and all the other parts which make up the mechanism of the human body. It was not my intention to question you about these things, the existence of which you are not certain of. Tell me, then, what you are, strictly speaking, in so far as you are doubting. This was the sole point on which I had decided to question you, because beyond this you can know nothing for certain.

Polyander I now see that I was mistaken in my answer, and that I went much further than was appropriate, since I did not quite grasp your intention. This will make me more careful in future, and it makes me marvel now at the precision of your method, as you guide us step by step along simple and easy paths towards knowledge of the things you want to teach us. But we have reason to say that it was a happy mistake I made, since, thanks to it, I know very well that what I am, in so far as I am doubting, is certainly not what I call my body. Indeed, I do not even know whether I have a body; you have shown me that it is possible to doubt it. I might add that I cannot deny absolutely that I have a body. Yet even if we keep all these suppositions intact, this will not prevent me from being certain that I exist. On the contrary, these suppositions simply strengthen the certainty of my conviction that I exist and am not a body. Otherwise, if I had doubts about my body, I would also have doubts about myself, and I cannot have doubts about that. I am absolutely convinced that I exist, so convinced that it is totally impossible for me to doubt it.

Eudoxus Splendidly put! So admirably are you acquitting yourself here that I could not put the point better myself. All I need do, I see, is to leave you to get on with the job on your own, after taking care to set you on your course. Provided we have proper direction, all we need for discovering the truth on the most difficult issues is, I think, common sense, to give it its ordinary name. Since, as I had hoped, you have a decent supply of that, I am simply going to point out to you the way you should take in future. Just keep going and, relying on your own resources, draw the conclusions which follow from that first principle.

Polyander This principle seems so fertile, and suggests to me so many things at once that I think I would have an enormous job arranging them in order. Just now you advised me to ponder on what I am, I who am doubting, and not to confuse this with what I once believed myself to be. This single piece of advice has flooded my mind with light and all at once scattered the darkness; so much so that by the light of this torch I see more sharply within myself that which is hidden within me, and I am more convinced that I possess something non-tangible than I ever was that I possessed a body.

Eudoxus I am quite delighted with this sudden enthusiasm, though Epistemon may not be quite so pleased. You have not freed him from his mistake, and you have not placed before his eyes a fraction of the things  you say are contained in this principle. So he will always be wondering why he should not believe or at any rate fear that everything which this light presents to you is like a will-o’-the-wisp which dies out and vanishes as soon as you try to get near it, and that you will soon slip back into the darkness you were in before, that is, into your original state of ignorance. It would certainly be an extraordinary occurrence if you, who have never spent much time studying or delving into the works of the philosophers, should so suddenly and so effortlessly end up a learned man. Therefore we should not be surprised that Epistemon thinks the way he does.

Epistemon I admit I took Polyander’s reaction to be a sort of burst of enthusiasm. Polyander has never given much thought to the grand truths which philosophy conveys, and I thought he was so transported by his reflection on the most insignificant of these truths that he could not refrain from displaying his intense excitement to you. But those who, like you,[6] have been plodding this path for a long time, expending much oil and effort in reading and re-reading the writings of the ancients, unravelling the thorniest knots in philosophy, are no longer surprised by such bursts of enthusiasm. They make no more of it than they do of the vain hopes of some who have just begun to learn mathematics. No sooner have such novices been given the line and the circle, and shown what a straight line is and what a curved, than they believe that they are going to discover how to square the circle and duplicate the cube.[7] But we have frequently refuted the views of the Pyrrhonists, and the fruits which they themselves have derived from their philosophical method have been so meagre that they have been wandering about aimlessly all their lives. Unable to free themselves from the doubts which they themselves introduced into philosophy, they have put their efforts exclusively into learning to doubt. So, with all due respect to Polyander, I doubt whether he himself can derive anything better from it.

Eudoxus I quite see that in directing your words to Polyander you want to spare me. Nevertheless it is perfectly obvious that your jests are directed at me. But let Polyander speak, and we shall then see which of us has the last laugh.

Polyander I shall do so gladly. But I fear that the dispute between you two will become heated, and that while you are pursuing the matter at all too exalted a level, I shall not understand any of it, and shall lose all the fruits I am going to reap (I promise myself) when I proceed to retrace my first steps. So I ask Epistemon to let me indulge this hope so long as it pleases Eudoxus to lead me by the hand along the path on which he set me.

Eudoxus Very well; when you consider yourself simply in so far as you are doubting, you realize that you are not a body, and that so considered, none of the parts which make up the mechanism of the human body are to be found within you, that is, you have no arms, legs, head, eyes, ears or any sense organs. But see whether you can reject in the same way all the other things which you previously understood to be implied in your former notion of a man. As you rightly remarked, it was a fortunate error you made when your answer went beyond the bounds of my question. For it makes it easy for you to get to know what you are: all you need do is to separate from yourself and reject everything which you clearly see does not belong to you, and admit only what necessarily belongs to you —so necessarily that you are as certain and convinced of it as you are of your existing and doubting.

Polyander I am grateful to you for setting me on my way in the manner you did; for I no longer knew where I was. I said previously that I was a whole put together with arms, legs, a head and all the parts which make up what is called ‘the human body’, and in addition that I walk, am nourished, perceive by the senses, and think. In order to think of myself simply as I know myself to be, it was also necessary for me to set aside all the parts or components which make up the mechanism of the human body, that is, to think of myself as lacking arms, legs, head — in a word, as lacking a body. And yet it is true that whatever it is within me that is doubting, it is not what I call my body. Therefore it is also true that I, in so far as I am doubting, am not that which is nourished or walks; for neither of these actions can be performed without a body. I cannot even say that I, in so far as I am doubting, am capable of perceiving by the senses. For as feet are needed for walking, so eyes are needed for seeing, and ears for hearing; yet since I have none of these organs — because I have no body — I cannot say I perceive by the senses. Furthermore, in the past I have thought while dreaming that I perceived by the senses many things which I did not really perceive. And since I have decided to admit nothing here unless its truth is such that I can have no doubts about it, I cannot say that I am a sentient being, i.e. one which sees with its eyes and hears with its ears. For it is possible in the way just described that I believe I am perceiving by the senses, even though I have no senses.

Eudoxus I cannot but stop you here, not to lead you off the road but to encourage you and make you consider what good sense can achieve if given proper direction. For is there anything in what you have said which is not exact, which is not validly argued, which is not correctly deduced from what has gone before? All these points have been stated and worked out not by means of logic, or a rule or pattern of argument, but simply by the light of reason and good sense. When this light operates on its own, it is less liable to go wrong than when it anxiously strives to follow the numerous different rules, the inventions of human ingenuity and idleness, which serve more to corrupt it than render it more perfect. Epistemon himself seems to agree with us on this point; for his silence indicates that he agrees entirely with what you have been saying. Go on, then, Polyander, and show him how far we can get with good sense, and also what conclusions can be derived from our first principle.

Polyander Of all the attributes I once claimed as my own there is only one left worth examining, and that is thought. I find that it alone is such that I cannot detach it from myself. For if it is true that I am doubting (I cannot doubt that), it is equally true that I am thinking, for what is doubting if not thinking in a certain kind of way? Indeed, if I did not think at all, I could not know whether I doubted or even existed. But I exist, and I know what I am, and I know these facts because I am doubting, i.e. because I am thinking. It could even happen that, if I were to cease thinking for a moment, I would also completely cease to exist. So the one thing which I cannot separate from myself, and which I know for certain that I am, and which I can now assert with certainty without fear of being mistaken, that one thing, I say, is that I am a thinking thing.

Eudoxus Epistemon, what do you think of what Polyander has just been saying? Do you find, anything in his whole argument which is defective, or anything inconsistent? Would you have thought that an uneducated man who had never bothered to study could reason with such precision, and be so consistent in all his arguments? If I am not mistaken, you must, as a result of this, begin to see that if you simply know how to make proper use of your own doubt, you can use it to deduce facts which are known with complete certainty — facts which are even more certain and more useful than those which we commonly build upon that great principle, as the basis to which they are all reduced, the fixed point on which they all terminate, namely, ‘It is impossible that one and the same thing should exist and at the same time not exist.’ Perhaps I shall have occasion to demonstrate the usefulness of doubt to you. But let us not interrupt the thread of Polyander’s remarks, or stray from the argument. So see whether you have anything to say or any objection to make.

Epistemon Since you are asking me, even needling me, to take sides, I am going to show you what Logic can do when roused, and I shall raise such stiff obstacles that not only Polyander but even you will find it exceedingly difficult to get round them. So rather than going any further, let us stop here and take the trouble to make a rigorous examination of your fundamental principles and conclusions. With the aid of the true Logic and on the basis of your own principles, I shall demonstrate that nothing Polyander has said has a legitimate basis or leads to any firm conclusions. You say that you exist and you know you exist, and you know this because you are doubting and because you are thinking. But do you really know what doubting or what thinking is? Since you do not want to admit anything about which you are not certain or of which you do not have perfect knowledge, how can you be so sure that you exist, on the slender basis of such obscure facts as these? You should really have taught Polyander first of all what doubt is, what thought is, what existence is, so that his reasoning might have the strength of a demonstration, and that he might understand himself before trying to make himself intelligible to others.

Polyander That is quite beyond me; so I shall give up the struggle and leave you and Epistemon to unravel this knot together.

Eudoxus I shall undertake the task with pleasure on this occasion, but only on condition that you act as judge in our dispute, for I dare not hope that Epistemon will give in to my arguments. Someone who, like him, is stuffed full of opinions and taken up with any number of preconceptions finds it difficult to submit himself exclusively to the natural light, for he has long been in the habit of yielding to authority rather than lending his ear to the dictates of his own reason. He would rather question others and ponder on what the ancients have written than consult his own thoughts about what judgement he should make. From childhood he has taken for reason what rested only on the authority of his teachers; so now he puts forward his own authority as reason, and is anxious that others should submit to him in the way that he himself once submitted to others. But I shall have cause to be content, and shall regard myself as having more than adequately answered the objections which Epistemon put to you, if only you agree with what I shall say, and your own reason convinces you of it.

Epistemon I am not so pigheaded or so difficult to persuade and satisfy as you think. And although I had reason to lack confidence in Polyander, I am positively eager to submit our dispute to his arbitration. As soon as he comes down on your side, I promise to admit defeat. But he must take care not to let himself be deceived or to make the mistake for which he reproaches[8] others, i.e. to regard his esteem for you as a convincing reason for believing what you say.

Eudoxus If he relied on such a feeble basis for belief, he would surely be neglecting his own interests, and, I vouch, he will look after himself in this matter. But let us get back to our subject. I quite share your view, Epistemon, that we must know what doubt is, what thought is, what existence is, before being convinced of the truth of this inference, ‘I am doubting, therefore I exist’, or what amounts to the same thing, ‘I am thinking, therefore I exist’. But do not imagine that in order to know what these are, we have to rack our brains trying to find the ‘proximate genus’ and the ‘essential differentia’ which go to make up their true definition. We can leave that to someone who wants to be a professor or to debate in the Schools. But someone who wants to examine things for himself, and to base his judgements about them on his own conceptions, must surely have enough mental capacity to have adequate knowledge of what doubt, thought and existence are, whenever he attends to the question, without having to be taught the difference between them. Besides, there are, in my view, some things which are made more obscure by our attempts to define them: since they are very simple and clear, they are perceived and known just on their own, and there is no better way of knowing and perceiving them. Perhaps some of the most serious errors in the sciences are those committed by those who try to define what should only be conceived, and who cannot distinguish between what is clear and what is obscure, nor tell the difference between something which needs and merits a definition if it is to be known and something which is best known just on its own. But doubt, thought and existence can be regarded as belonging to the class of things which have this sort of clarity and which are known just on their own.

I would never have believed that there has ever existed anyone so dull that he had to be told what existence is before being able to conclude and assert that he exists. The same applies to doubt and thought. Furthermore, the only way we can learn such things is by ourselves: what convinces us of them is simply our own experience or awareness — that awareness or internal testimony which everyone experiences within himself when he ponders on such matters. Thus it would be pointless trying to define, for someone totally blind, what it is to be white: in order to know what that is, all that is needed is to have one’s eyes open and to see white. In the same way, in order to know what doubt and thought are, all one need do is to doubt or to think. That tells us all it is possible to know about them, and explains more about them than even the most precise definitions. So it is true that Polyander must have known these things before being able to draw the conclusions which he did. But, since we chose him as judge, let us ask him if he has ever been ignorant of what doubt or thought or existence is.

Polyander I am quite delighted, I must admit, to hear you arguing about something which you could learn only from me. I am pleased to see that on this occasion at any rate you must acknowledge me as your teacher and regard yourselves as my pupils. So to put both of you out of your misery, I shall solve your problem at a stroke (it is totally unexpected events which we say happen ‘at a stroke’). I can say for sure that I have never doubted what doubt is, though I only began to recognize it, or rather to give my attention to it, when Epistemon tried to cast doubt on it. As soon as you showed me what little certainty we can have in the existence of things which we can know only by means of the senses, I began to doubt them. This was enough to bring my doubt home to me and to make me certain of it. Thus I can state that as soon as I began to doubt, I began to have knowledge which was certain. But my doubt and my certainty did not relate to the same objects: my doubt applied only to things which existed outside me, whereas my certainty related to myself and my doubting. So Eudoxus was right when he said that there are things we cannot know about unless we see them. In order, then, to know what doubt and thought are, all we need do is to doubt and to think. The same applies to existence: to know what that is, all we need do is to understand the meaning of the word, for that tells us at once what the thing is which the word stands for, in so far as we can know it. There is no need here for a definition, which would confuse rather than clarify the issue.

Epistemon Since Polyander is satisfied, I too shall agree, and I shall not press the argument any further. But, after two hours of discussion, I cannot see that he has made much progress. All Polyander has learnt with the aid of this marvellous method which you are making such a song about is the fact that he is doubting, that he is thinking, and that he is a thinking thing. Marvellous indeed! So many words for such a meagre result. Four words could have done the trick, and we should all have agreed about it. As for myself, if I were required to spend so much time and engage in such a long discussion in order to learn such an insignificant fact, I would be very reluctant to make the effort. Our teachers have so much more to tell us, and they do so with much more assurance. Nothing holds them back; they deal with everything themselves, and decide each point. Nothing deflects them from their purpose; nothing takes them by surprise. When they feel themselves pressed too hard on some point, an equivocation or a distinction gets them out of their difficulties. You can be sure that their method will always be preferred to yours, which casts doubt on everything, and has such a fear of tripping up that it is constantly dithering and making no headway.

Eudoxus It was never my intention to prescribe to anyone the method which he should follow in his search for truth, but simply to describe the method which I used myself: if it should be thought to be defective, it would be rejected; if good and useful, others would use it too. I left it up to each individual to use it or reject it entirely as he saw fit. If someone should now say that it has not got me very far, this is a matter for experience to determine. Provided you continue to give me your attention, I am sure you will admit that we cannot be too careful in establishing our first principles, and that once these are established, the consequences will be able to be deduced more easily, and will take us further, than we dared hope was possible. All the mistakes made in the sciences happen, in my view, simply because at the beginning we make judgements too hastily, and accept as our first principles matters which are obscure and of which we do not have a clear and distinct notion. That this is true is shown by the slight progress we have made in the sciences whose first principles are certain and known by everyone. By contrast, in the case of sciences, whose principles are obscure and uncertain, those who are prepared to state their views honestly must admit that, for all the time they have spent reading many a vast tome; they have ended up realizing that they know nothing and have learnt nothing. So, my dear Epistemon, you should not be surprised that I wish to lead Polyander along a more certain path than the one I was led along myself, and that I am so careful and precise as to take nothing to be true if I am not as sure of it as I am of the certain fact that I exist, and am thinking, and am a thinking thing.

Epistemon You seem to me to be like an acrobat who always lands on his feet, so constantly do you go back to your ‘first principle’. But if you go on in this way, your progress will be slow and limited. How are we always to find truths such that we can he as firmly convinced of them as we are of our own existence?

Eudoxus That is not as difficult as you think. For all truths follow logically from one another, and are mutually interconnected. The whole secret is to begin with the first and simplest truths, and then to proceed gradually and as it were step by step to the most remote and most complex truths. Now can anyone doubt that what I have laid down as the first principle is the first of all the facts we can get to know if we proceed more methodically? It is certain that we cannot doubt this, even if we doubt the truth of everything in the universe. Since, then, we are sure that we have made the right beginning, we must see to it that we do not go wrong from now on. We must take great care to admit as true nothing which is open to even the slightest doubt. With this in view, I say we should let Polyander speak on his own. The only master he follows is common sense, and his reason has not been marred by any false preconceptions. So it is hardly likely that he will be deceived; if he were, he would soon realize it, and would have no trouble getting back onto the road. So let us hear what he has to say; let him tell us about the things which, so he told us, he saw to be contained in our[9] first principle.

Polyander So many things are contained in the idea of a thinking thing that it would take whole days to unfold them. We shall be dealing for the moment only with the most important things, and with those which help to make the notion of a thinking thing more distinct, and which will help us to avoid confusing it with notions which have nothing to do with it. By a ‘thinking thing’ I mean…[10]

[1] Diogenes of Sinope (fourth cent. B.C.), one of the founders of the Cynic school of philosophy, was celebrated in antiquity for residing in a large earthenware tub.

[2] Socrates attributed his reputation as the wisest man in Athens to the fact that he alone recognized that he knew nothing. Pyrrhonism was a strong version of scepticism which advocated complete suspension of judgement (named after Pyrrhon of Elis, born c. 365 B.C.).

[3] Cf. above p. 101.

[4] Here the French manuscript ends; what follows is translated from the Latin of the Amsterdam edition (1701).

[5] Porphyry, one of the founders of Neoplatonism (born c. 237 A.D.), proposed a ‘family tree’ of genera and species under which things may be classified. Thus the genus, substance (the ‘trunk’ of the tree), branches into the two species, corporeal and incorporeal, each of which divides into a further pair, etc. — for example, corporeal into living and non-living, living into sentient and non-sentient, etc. Cf. above p. 344.

[6] AT suggest that ‘you’ (tut) is a misprint for ‘me’ (mei).

[7] Two of the problems of Greek mathematics — both unsolvable: the former, to construct a circle with the same area as a given square; the latter, to construct a cube which is twice the volume of a given cube.

[8] Lat. exprobat (‘he reproaches’) may be a misprint for exprobras (‘you reproach’).

[9] The Amsterdam edition (1701) has ‘your’ (vestro), but the sense requires ‘our’ (nostro). One might, alternatively, give this sentence to Epistemon.

[10] The Amsterdam edition inserts here the sentence, ‘The rest is missing.’

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The Doctrine of Specific Etiology by Rene Dubos

Extracted from Mirage of Health (1959)

Until late in the nineteenth century disease had been regarded as resulting from a lack of harmony between the sick person and his environment; as an upset of the proper balance between the yin and the yang, according to the Chinese, or among the four humors, according to Hippocrates. Louis Pasteur, Robert Koch, and their followers took a far simpler and more direct view of the problem. They showed by laboratory experiments that disease could be prouced at will by the mere artifice of introducing a single specific factor—a virulent microorganism—into a healthy animal.

From the field of infection the doctrine of specific etiology spread rapidly to other areas of medicine; a large variety of well-defined disease states could be produced experimentally by creating in the body specific biochemical or physiological lesions. Microbial agents, disturbances in essential metabolic processes, deficiencies in growth factors or in hormones, and physiological stresses are now regarded as specific causes of disease. The ancient concept of disharmony between the sick person and his environment seems very primitive and obscure indeed when compared with the precise terminology and explanations of modern medical science.

Unquestionably the doctrine of specific etiology has been the most constructive force in medical research for almost a century and the theoretical and practical achievements to which it has led constitute the bulk of modern medicine. Yet few are the cases in which it has provided a complete account of the causation of disease. Despite frantic efforts, the causes of cancer, of arteriosclerosis, of mental disorders, and of the other great medical problems of our times remain undiscovered. It is generally assumed that these failures are due to technical difficulties and that the cause of all diseases can and will be found in due time by bringing the big guns of science to bear on the problems. In reality, however, search for the cause may be a hopeless pursuit because most disease states are the indirect outcome of a constellation of circumstances rather than the direct result of single determinant factors.

It is true that in a few cases—far less common than usually believed—the search for the cause has led to effective measures of control. But it does not follow that these measures provide information as to the nature of the trouble that they correct. While drenching with water may help in putting out al blaze, few are the cases in which fire has its origin in a lack of water. The story of insulin and diabetes well illustrates that the discovery of a therapeutic agent does not necessarily solve the problem of disease causation.

Diabetes was first produced in experimental animals by interfering with pancreatic secretion, and this discovery led to the preparation from pancreas of a substance, insulin, which plays an important role in the metabolism of sugar. Insulin was then shown to be highly effective in the treatment of diabetes in man. This therapeutic triumph is probably the most elegant and spectacular achievement of medical science, but its bearing on the etiology of diabetes is far from clear. While diabetes can be produced in experimental animals by injuring the pancreas and thus interfering with the production of insulin, the disease as it occurs in man is a general metabolic dysfunction affecting the metabolism of protein, fat, and mineral, as well as of sugar. The primary disturbance may be in some part of the body quite remote from the pancreas and the deficiency of insulin may be secondary to it. Treatment with insulin corrects the manifestations of diabetes but it has no effect on the primary lesion of the disease, which remains unknown in many cases. Likewise, cortisone is highly effective against many inflammatory states which do not originate from a lack of this hormone in the patient, just as aspirin, which is a synthetic drug foreign to the body, can alleviate pains and headaches.

Thus, effective therapies do not constitute evidence for the doctrine of specific etiology, and there are many cases in which a given disease can be controlled by several unrelated procedures. The incidence of malaria in a community can be reduced by drugs that attack the parasite, by procedures that prevent mosquitoes from biting man, by insecticides that poison the mosquitoes, or by agricultural practices that interfere with their breeding. The difficulties inherent in the concept of causation of disease are now apparent even with regard to tuberculosis, long thought to have provided the most spectacular demonstration of the doctrine of specific etiology. All textbooks dealing with infectious diseases consider the discovery of the tubercle bacillus as the highest peak of the science of medical micro  biology. The circumstances were indeed dramatic. At that time tuberculosis was by far the most important disease in the Western world. The tubercle bacillus was difficult to visualize by microscopic techniques, and even more difficult to cultivate in vitro. Yet Robert Koch succeeded in demonstrating its presence in all tuberculous tissue that he studied and in producing at will experimental tuberculosis by injecting small amounts of cultures of the bacillus into guinea pigs, rabbits, and mice. flow could one doubt, after these spectacular achievements, that the bacillus isolated by Koch was the cause of tuberculosis? There was, however, another aspect of the problem that had remained hidden from Koch. It can be stated with great assurance that most of the persons present in the very room where he read his epoch-making paper in 1882 had been at some time infected with tubercle bacilli and probably still carried virulent infection in their bodies. At that time, in Europe, practically all city dwellers were infected, even   though only a relatively small percentage of them developed tuberculosis or suffered in any way from their infection. Koch himself was infected. When he injected tuberculin into his own arm in 1890 he suffered one of the most violent allergic reactions on record, evidence of the fact that the tubercle bacillus had at some earlier time multiplied in his body. But Koch did not have clinical tuberculosis, and he remained a vigorous man until he died of cerebral hemorrhage.

Many other well-documented examples could be quoted to demonstrate that multiplication of a virulent microorganism in the body rarely expresses itself in the manifestations of disease. Around 1900 Pettenkoffer in Germany and Metchnikoff in France, with several of their associates, drank tumblerfuls of cultures isolated from fatal cases of cholera. Enormous numbers of cholera vibrios could be recovered from their stools; some of the self-infected experimenters developed mild diarrhea, but the infection did not result in true cholera. More recently human volunteers were made to ingest billions of dysentery bacilli under conditions assumed to be optimal for the establishment of infection. Enteric capsules full of feces obtained directly from acute cases of bacillary dysentery in man were used as additional experimental refinements to increase the chances of establishing the disease. Yet only a few of the volunteers developed symptoms referable to dysentery and most of them remained unaffected by the experimental infection.

The ease and predictability with which Pasteur, Koch, and their followers produced disease at will in experimental animals seem miraculous in view of the difficulties that have so often been encountered in subsequent attempts to produce disease in man. Their success seems incompatible with the course of natural events. The fact of the matter is that Pasteur and Koch did not deal with natural events, but with experimental artifacts. The experimenter does not re-produce nature in the laboratory. He could not if he tried, for the experiment imposes limiting conditions on nature; its aims are to force nature to give answers to questions devised by man. Every answer of nature is therefore more or less influenced by the kind of questions asked.

The art of the experimenter is to create models in which he can observe some properties and activities of a factor in which he happens to be interested. Koch and Pasteur wanted to show that microorganisms could cause certain manifestations of disease. Their genius was to devise experimental situations that lent themselves to an unequivocal illustration of their hypothesis—situations in which it was sufficient to bring the host and the parasite together to reproduce the disease. By trial and error, they selected the species of animals, the dose of infectious agent, and the route of inoculation, which permitted the infection to evolve without fail into progressive disease. Guinea pigs always develop tuberculosis if tubercle bacilli are injected into them under the proper conditions; introduction of sufficient rabies virus under the dura of dogs always gives rise to paralytic symptoms. Thus, by the skillful selection of experimental systems, Pasteur, Koch, and their followers succeeded in minimizing in their tests the influence of factors that might have obscured the activity of the infectious agents they wanted to study. This experimental approach has been extremely effective for the discovery of agents of disease and for the study of some of their properties. But it has led by necessity to the neglect, and indeed has often delayed the recognition, of the many other factors that play a part in the causation of disease under conditions prevailing in the natural world—for example, the physiological status of the infected individual and the impact of the environment in which he lives.

Since several distinct determinants usually play a part in the causation of disease processes, it is customary to consider that there are several categories of causes with different levels of importance. Textbooks contrast “initiating,” “exciting,” or “immediate” causes with “contributory” causes, which play their part merely by bringing the patient under the influence of the initiating causal agent. Simpler and more useful, perhaps, is the recognition of predisposing causes, precipitating causes, perpetuating causes. However, the qualificative appended to a cause is to a large extent a reflection of the present state of knowledge and of prevailing interest. While these differentiations are of help in teaching, they often paralyze thought, and they rarely constitute useful guides for action.

Consider, for example, the evolution of the knowledge of cholera during the past hundred years. John Snow achieved fame for recognizing that an outbreak of cholera in London affected only persons using the water supplied by one particular public pump located on Broad Street. He concluded that cholera was water-borne and he controlled the outbreak by the mere artifice of removing the handle from the pump. Bad, impure water was for John Snow the initiating, precipitating cause of cholera. It is now known that those who used the Broad Street pump contracted cholera because the water that they obtained from it contained cholera vibrios. As a result, the vibrio is presently considered the cause of the disease. But this statement is not so meaningful as appears on first sight since, as already mentioned, vibrios can be ingested in enormous numbers and persist in the stools without seriously inconveniencing the infected person.

The most that can be said, therefore, is that, once the vibrios have become established in the intestinal tract, some other factor can convert the infection into disease. There is still mystery concerning the circumstances which transform cholera from the minor nuisance of the bazaar into a raging pestilence or concerning the factors which bring about the spontaneous termination of catastrophic outbreaks. But, while knowledge of the cholera vibrio has not yet proved very helpful in the understanding of epidemics, much progress has been made in the treatment of the cholera patient. Effective therapy has followed recognition of the fact that the most important symptoms of the disease are due to the loss of fluid and electrolytes from the intestinal tract. Cholera can be successfully treated merely by replacing fluid and electrolyte, without any serum or antimicrobial drug to combat the infection. Thus, the mechanisms which increase permeability of the gut might be regarded as the real cause of the disease since they account for its symptomatology and since treatment of the effects usually results in cure.

The complexity of most ecological systems renders it difficult to single out any one particular component of the system as playing a role of unique importance in the causation of disease. Until 1940 all medical textbooks agreed that the green streptococcus was by far the most frequent cause of subacute bacterial endocarditis. And indeed it was shown around 1945 that this otherwise fatal disease could often be arrested with doses of penicillin large enough to inhibit the streptococcus. Unfortunately it was soon recognized that disappearance of the streptococcus was not uncommonly followed by infection of the heart valves with other kinds of bacteria normally present in the intestinal or respiratory tract, which penetrate sporadically into the blood stream and settle wherever conditions are favorable for them. Thus, both the initial organic lesions on the heart valve and the various kinds of bacteria that can proliferate on them in succession can be properly regarded as causes of subacute bacterial endocarditis.

The same difficulty is met in trying to determine the cause of deaths during and after episodes of smog. During the winter of 1952 a few days of smog in London resulted in the death of some 5,000 persons, and likewise recent episodes of smog over the Meuse Valley in France or in Donora, Pennsylvania, greatly increased mortality. In general, the deaths that occur during or immediately after a smog are listed in official records as being due to cardiac accidents and bronchitis. On the other hand, there is no doubt that heart disease is extremely widespread and has many different origins, and that bronchitis is associated with the activity of viruses and bacteria ubiquitous in all human communities. What, then, are the causes of deaths that follow smogs? The vascular lesions which are so common in modem man? The bacteria and viruses which almost everyone carries in his respiratory tract? or the poisonous substances in the air which reach everybody but kill only a few?

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Transcript: The 2009 H1N1 Experience: Policy Implications for Future Infectious Disease Emergencies

March 5, 2010 conference in Washington: Role of Disease Containment in Control of Epidemics

Source video

The panel was made up of Jennifer Nuzzo, Center for Biosecurity of UPMC (University of Pittsburgh Medical Center?), Moderator; Jeffrey Levi, Trust for America’s Health; D.A. Henderson, Center for Biosecurity of UPMC; Ronald St. John, Public Health Agency of Canada; Marcelle Layton, NYC Department of Health and Mental Hygiene; James Blumenstock, Association of State and Territorial Health Officials.

JENNIFER NUZZO

Well, I’m very pleased to be moderating this panel on the public health response to emerging infectious disease. Just like the last panel, in this one we’re also going to use a scenario to sort of limit our conversation. But in this panel we’re going to discuss what specific measures we would take to respond to a new contagious virus for which there are no medicines, vaccines available now or on the horizon.

As we all know, in the early phases of the H1N1 pandemic, many countries employed measures to either slow or to stop the spread of influenza. The measures we’re talking about, you know, some closed schools, others isolated sick people. Others pursued even more intensive strategies, like implementing travel restrictions, installing fever screens in airports, quarantining people who are not yet sick but who had arrived from affected areas.

Some countries continued some of these measures throughout the pandemic and in some cases against the recommendations of the WHO. Whether or not these interventions significantly delayed, stopped, or reduced the number of cases is unknown, and it’s probably up for debate among experts. These are the measures we’re going to talk about today. And so we don’t necessarily expect that we will come to any closure on which specific measure we would use. But we are interested in understanding what the decision-making process would be for which measures we would use under what circumstances.

So to set up this discussion, we have asked our panelists to put themselves in the role of state health officer. For some it’s not a real stretch. For others, they might have to remember back to the days when. And to imagine what they would do if faced with the job of trying to control the spread of a new virus, one that’s causing significant sickness and death, that’s occurring in small clusters in the United States as well as in multiple locations abroad. And as with SARS in our scenario today, we’re going to assume that there are no medicines or vaccines or rapid diagnostic tests available.

And we’d like to hear which measures our panelists would consider using to limit the spread of this new virus and why. For our panel today, we will give each of our panelists an opportunity to make introductory remarks followed by a moderated discussion. And then we’ll open it up for questions from the audience.

So today we are lucky to be joined by five esteemed individuals. First we’ll hear from Ron St. John, who you met in the Q&A session before. Ron has a longer than 35-year career in public health and infectious disease control. As he mentioned, he served the Public Health Agency of Canada as the first director general of the Center for Emergency Preparedness and Response. And he led the agency’s response to the aftermath of September 11th and SARS. He also led policy and planning efforts for Health Canada on issues related to counterterrorism, quarantine, and migration and travel health. Since retiring from government service in 2007, Ron continues to consult in the realm of infectious disease control.

Then we’ll hear from Jim Blumenstock. Jim is the chief program officer for public health practice for the Association of State and Territorial Health Officials. He works on behalf of state public health agencies on issues related to infectious and emerging diseases, immunization, environmental health, and public health preparedness. And before joining ASTHO, Jim was a deputy commissioner for health in the New Jersey Department of Health and Senior Services, which he held for an impressive 32 years. In New Jersey government, that’s very impressive.

And then we’ll hear from D.A. Henderson. D.A. is a distinguished scholar and founding member of the Center for Biosecurity of UPMC. He held several senior-level positions in the U.S. government, including director of the Office of Public Health Emergency Preparedness at the U.S. Department of Health and Human Services. And as many of you know, he also led the World Health Organization’s successful campaign to eradicate smallpox, a job for which he has received top honors from governments across the world.

We’ll then hear remarks from Jeff Levy. Jeff is executive director of Trust for America’s Health, where he leads the organization’s advocacy efforts on behalf of a modernized public health system. Jeff oversees TIFA’s work on a number of public health policy issues, including their annual assessments of the nation’s public health preparedness. And he and his colleagues have written extensively and spoken extensively about pandemic preparedness, including U.S. response to H1N1.

And then finally, we’ll hear from Marcy Layton. Marcy is the assistant commissioner for the Bureau of Communicable Disease at New York City Department of Health and Mental Hygiene. And it’s difficult to sum up everything that she’s done there, except that I think I at one point saw a figure that she’s led more than 1,000 outbreak investigations. That figure is a few years old, so maybe it’s tripled by now. But anyway, and countless other health crises, including September 11th attacks, anthrax attacks, global SARS epidemic, and the first cases of West Nile virus in this hemisphere.

So now that you’ve met our panelists, I will let Ron start with his remarks.

RON ST JOHN

Thank you very much, Jennifer. And thank you very much to the organizers for the invitation. And to maybe present a little bit of Canada here today.

First of all, a bit of a disclaimer, like my colleague from Minnesota, who said many of you represent your organizations. I am the former director general of the Center for Emergency Preparedness Responses, you’ve heard. So I want to make it clear I do not repreesnt the center, and I do not represent the public health agency, and I do not represent Health Canada. And that means that I can say whatever the hell I want to say. Without political spin.

I’m going to spin off of this scenario a little bit. I never was a state health commissioner, nor was I a provincial chief medical officer of health in Canada. I’ve always been a Fed, and I have a certain bias inherent in that.

But I’ll spin off this scenario. And the scenario says this is a significant disease. And that means to me that it sits somewhere on that continuum between a mild disease and a severe disease. And, you know, where does it fit? That will drive a lot of the decisions that governments will make in response to the threat. And I’d like to say that, in my opinion, my experience, the biggest driver of that decision-making process will be fear of death.     [Sanjeev: This is great stuff – that an experienced PH professional admits that everything in such situations is driven by fear.] And fear of death is obviously a human thing, and that is a major driver. And we tend not to think about that too much, but mortality is a critical driver. And the overestimation of mortality in Mexico was a major driver in the early days of response and concern.

So let me deal quickly with the significant disease scenario and assume that this is really a highly lethal disease, and maybe even it’s even the highly transmissible avian influenza virus with its 50 to 70 percent mortality rate with no treatment available. And I would postulate that the responses of governments would be radical. If I were in Canada and there was a cluster like this in the United States or France, somewhere like that, this would be the close-the-border situation.

CLOSURE OF BORDER

This would be the question put, do we close the borders? And I asked myself, and this has come up, can this be done? Not should it be done, but can it be done? And the answer is, yes, it can be done. In fact, we did it. We did it in 2001. We closed the airspace in Canada and the USA within hours, within hours. So, yes, it can be done.

But then, no, it can’t, because a lot of people between Canada and the United States, a lot of people don’t realize there are 1,300 border crossings that have people on them. Now, somewhere up in Minnesota, and I may be corrected by my colleague from Minnesota, there’s a lake, and somewhere the border runs through the middle of that lake, and there are canoes going back and forth. And I know that somewhere out in Montana there’s a dusty road that goes north, and there’s a sign along that road that says, Welcome to Canada. Will you please stop 50 miles up the road at that house on the right and let us know you’re here? That’s our border between our countries. So can it be closed? In one sense, yes. Can it not be closed? In another sense, it cannot be closed.

DOMINO EFFECTS

But there were huge domino effects, and there were huge unanswered questions about closing the border.

For example, there were planes in the air at the time of the closure, planes that had passed the no return point. They can’t go back. Where do they go? Do we let them crash? If they have asymptomatic people on board that might be infected? Well, we didn’t let them crash. They landed in Halifax, and they landed in Nova Scotia and Newfoundland. We had planes bumper to bumper, wingtip to wingtip, and we had about 20,000 to 40,000 people stranded during the 2001 episode.

Then there are other considerations like stranded citizens in other countries. During the SARS, I was asked by the Department of Foreign Affairs, Ron, what are we going to do if all the Chinese Canadians holding Canadian passports in Hong Kong want to come home? I said, well, how many are there? And they said 200,000. And I said, I’m not going to think about that because I really don’t have an answer for that. And fortunately, they didn’t elect to come home. But there are questions like, what do you do with your citizens when you close your borders?

And then there’s the economic loss from the border closure versus mortality losses, and how do you measure that? Every day between Canada and the United States, one and a half billion dollars of goods cross the border every day, every single day. And Canada is the biggest supplier of oil to the United States. And we in Canada have only a three-day supply of perishable foods in the country. So border closure is not a particularly good idea.

What about border? I just don’t know. Because the political decisions and the fears may overwhelm any rationality. [Sanjeev: Another great point] But it’s clear that it’s an extremely complex issue.

And from a public health point of view, I feel like it should never happen.

But let me deal with the less severe situations. The things we’ve done so far in SARS and H1N1 that don’t seem to be too impressive.

OTHER TOOLS

Besides close the border, there are about five tools that we have.

a) TRAVEL ADVISORIES
We have travel advisories and restrictions, and I’ll deal with that real quick. Unless the restriction is you can’t get there from here, there’s not much impact that that can have. We used to advise, we still advise Canadians about non-essential travel. Don’t avoid non-essential travel to place X or Y. What’s non-essential travel? Well, if my uncle just died and I have to go to the funeral, that’s non-essential for me. If I’m closing a $4 million deal in China, that’s pretty essential travel for me.

And it becomes so subjective, we couldn’t define it. So I’m not too impressed, unless it’s a total restriction, which is close to closing the border.

b) STOPPING SELECTED FLIGHTS

Stopping selected flights. Well, there are over 5,000 major international airports in the world. And Argentina, in a few days after the episode began in Canada, Mexico, and the United States, canceled all flights from Mexico, Canada, and the United States into Buenos Aires. Yet you can fly from Toronto to Sao Paulo, Brazil, and from Sao Paulo, Brazil to Buenos Aires, which would have been permitted. So the permutations make it rather silly to think about stopping selected flights.

c) QUESTIONNAIRES

What about questionnaires? During SARS, we distributed over a million questionnaires to inbound passengers. And we had three questions: Do you have a cough? Do you have a fever? Have you been in contact with someone with SARS?

I was always impressed by how many people were honest and said yes. I smoke three packs a day and I have a cough. But whenever you set up a screening, you have to deal with the false positives. And we had over 2,800 people that said yes to one of the questions. So we had to set up a $17 million system of nurses and secondary screening to make sure that they did or did not have SARS, and none of them had SARS.

d) THERMAL SCANNERS

We had thermal scanners and we scanned over 970,000 people. And in spite of the technical challenges for setting those things up, we had 373 positive results and no SARS.

The problem there is prevalence. The prevalence of disease, prevalence of SARS in travelers was so low, it was searching for a needle in a haystack. So the positive predictive value of any positive test was nil. Now, in a highly infectious disease, the prevalence would change and maybe those measures might be useful. [Sanjeev: THAT IS BEING TOTALLY STUPID – since infectious disease would transmit asymptomatically, making even true positives worthless, since most disease would go undetected, anyway.]

e) QUARANTINE

Finally, quarantine, the fifth measure. We have probably, I think, the only modern day quarantine experience for SARS in Toronto. We quarantined between 20,000 and 25,000 people. On any given day, there were 7,000 to 8,000 people in a self-imposed quarantine.

Now, what were the problems? They were unanticipated.

i) Number one, compensation. How do you compensate people? Who’s going to compensate the people who stay home in their self-imposed quarantine because we asked them to go into quarantine?

ii) There were the other fallout dominoes, I call them. We had telephone calls like, you know, “I just got to go down to the local bank machine, get 20 bucks, can I go out for half an hour, and I’ll be right back”. “Baby’s out of diapers, can I run down to the supermarket, get some diapers, I’ll be right back”. And the social support that is necessary for quarantine is not there, was not there, still isn’t there, if you were thinking about quarantining large numbers of people.

iii) And then finally, the logistics are huge. We talked about, well, what do we do with… [Sanjeev: the sheer size of quarantine]

We were thinking H1N1 was going to come from Southeast Asia. The first plane comes into Vancouver, great, there’s 173 people on board, we put them over there. Holy smokes, two hours later, three hours later, there’s another plane from Hong Kong. There’s another 170, 180 people, 200 people, we put them over there. By the end of day one, we’d exhausted where we’re going to put people.

And then how are you going to support those people?

Well, you wait to see whether they get sick or don’t get sick. We decided that if it were to happen and we had any advance notice, anybody who was sick, we’d send them home. Please stay home. And we’ll try to look after you at home.

So quarantine in a modern global world with intense movement of people is not a particularly attractive proposition, especially from a logistical point of view. Yet the public will demand responses from the government, and the government will put these measures in place, one, more, or all, thinking that they can gain the public trust.

And it’s a two-edged sword, because if you oversell it and tell the public this is going to keep the disease out, and it won’t, then you’ve lost the public trust. So you’re on a difficult two-edged sword as to how you sell these things to the public. [Sanjeev: THE STUDPIDITY LIES IN TRYING TO “SELL” THESE TO THE PUBLIC]

So finally, just to close, I think the real challenge is not so much trying to figure out how to use these tools. They WILL be used one way or the other.

But the real challenge is to prepare to deal with the problem when it arrives, because it will arrive.

In Canada we kept saying over and over again that the new border for infectious disease is the door of our hospital, because that’s where people who are sick will come, and you have to be prepared to consider what you’re going to do with people who turn up with serious disease.

We used to tell our physicians, my closing remark is, there are two questions you need to ask your patients that come in with fever or indications of an infectious disease. And that question was, have you traveled anywhere? We learned from SARS that you have to ask a second question. Has anybody in your family traveled somewhere? Because the first case was a Chinese grandmother who died at home.  he case that showed up in the hospital was her son. And he said, I haven’t traveled. And nobody thought to consider the second question.

Thank you.

JENNIFER

Thank you very much. I think there’s a lot of points there that we’ll probably come back to at the end. So, Jim?

JIM (James Blumenstock)

Great. Jennifer, thank you. Good afternoon, everyone.

I certainly will do my very best to complement the points that Ron made and anticipate the comments that the other panelists will provide and hopefully set you up very nicely.

But before I do, I wanted to reflect on Admiral Lurie’s presentation earlier today where she shared a personal reflection. She disclosed her love for folk music, and I think she did an excellent job, sort of connecting that, to the H1N1 experience in a way or a process to transfer lessons learned to the following generations.

Well, I’m going to follow that lead and disclose something personal with you all as well. I, too, love music, but I’m a country music fan, which is pretty weird for a guy from New Jersey when we were born and raised on Springsteen, Bon Jovi, Frankie Valli, and Frank Sinatra. But there’s the point that I want to get to here.

So, for those of you who have any familiarity with country music, you can appreciate there’s usually four major themes or components that are in any country music song. Number one, the cowboy loses his job. Secondly, his lady leaves him. His pickup truck breaks down, and his dog usually dies.

So what is the connectivity between those four themes and social distancing laws and other types of restrictions of movement?

Well, as you can imagine, the cowboy’s life was turned upside down, and he’s experiencing significant disruption. Well, clearly, in considering the issues of isolation, quarantine, border closings, and other types of restriction of movement, you could only imagine the disruption of society that that would turn into.

So the point here really is that in this topic, where we’re talking about isolation, quarantine, movement restrictions, these are very, very powerful legal public health tools that our profession has. And I believe we were very fortunate that we did not need to use many of them, if any of them, and if so, sort of in a very isolated, modest fashion during the recent H1N1 experience. So because of that, there’s not much material to work with as far as connecting the last six or eight months with a more catastrophic or severe event.

But there are a few that I would sort of like to touch upon.

First, clearly, they are serious actions that can be taken, and they do have some degree of utility and value. But a lot of times, when you talk about isolation, quarantine, and travel restriction, they’re sort of talked about as a suite of mitigative actions. But they really are all very different. They have different triggers, different outcomes, and different ramifications. And I think that’s a point that needs to be accentuated.

Secondly, the key here is I believe that making those decisions probably will be one of the most difficult decisions a public health officer will have to make when they’re in a command-and-control environment managing a response to an infectious disease activity.

When you look at the H1N1 experience – and I want to link two experiences that weren’t specific to this type of community mitigation but I think they’re good illustrations. One is the issue of standardization and consistency and how the public will perceive triggers and decisions that are made across the country.

There are two examples that come to mind. One was the school closings in the spring, and second was the vaccination priority groups and how different jurisdictions at different times were vaccinating different groups. If we thought that that was a significant communications and public relations issue, dealing with those two fairly limited and well-defined issues, you could only imagine the public reaction, questioning of trust, and possibly chaos as if we move forward in a nation that has varying degrees of those triggers for isolation, quarantine, and restriction of movement, including closing of borders.

So as a public health official – and I’m sure the other three panelists will really delve into that as far as the triggers in the real-world examples – the first thing that I would want to make sure [is] that while I know I will need to make those decisions in the future, but the first thing that has to be put in place is I have to have the assurance that I have the legal authority and the capabilities to make those decisions and take those actions.

So I wanted to take this opportunity to share with you what CDC and a lot of the other practice partner associations have done to support decision-makers at a state and local level to ensure that they are capable of at least making the legal decision and having the necessary support should those significant actions take place.

What we have done is we’ve created a legal sufficiency template on all social distancing law legal interventions that a state or a local health official could possibly contemplate in protecting their community. Such things as restriction of movement of persons, inter-jurisdictional coordination, closure of public places, school dismissal, and cancellation of mass gatherings.

So it provided a standardized assessment tool drilling down to no less than 100 features to assess whether or not that jurisdiction has legal sufficiency, to create a table of authorities so that if it has to be referred to in a quick fashion, it’s at their fingertips, and as part of it, it also required a legal consultation meeting between the sectors of public health, law enforcement, and the judiciary to make sure that they were all very familiar with the laws and had a decent playbook to follow should those types of community mitigation legal strategies need to be played out.

Another benefit of this activity was to ensure that the judiciary had a bench book, that they basically were very familiar with these public law legal interventions if in fact it was necessary.

Because as Ron had mentioned, these are not everyday decisions and actions, and whether it be a municipal, county, or state judge, they very rarely have had the opportunity to make any decisions on this. And if it was, it was probably just on an isolated, non-compliant TB patient. And quite frankly, when they talk about quarantine to them, it’s usually a municipal court whose dog owners refuse to follow a public board of health order on quarantining an animal.

So that was clearly a significant learning opportunity to ensure that the judiciary was up to speed on that particular issue. So, tying H1N1 to a more serious infectious disease response.

The four takeaway messages I’d like to share before I turn it over to D.A.

a) RESOURCES

First is the issue of resources.

I counted no less than 14 times this morning reference to the need of a public health infrastructure with significant resources to effectuate an appropriate response. If you all agree that isolation, quarantine, restriction of movement was not really a major feature in H1N1, what would it look like from a resource drain if it was?

The numbers that were shared by Dr. Frieden and others earlier, $1.4 billion could grow to $1.9 billion between now and June to the state and local public health. That funding (unpublished data suggests that that funding alone) can be attributed to 15,000 response jobs, whether they’re full-time, part-time, contract employees, term-limited employees to help support the public health response, all of which won’t exist come July 30th of this year. Again, that surge, throwing money at an emergency. If we had to effectuate these types of community mitigation strategies, what additional resources would that lay on top of that?

Secondly is the issue of community-trusted agents. A lot of examples today about how folks in the community made the difference in reaching hard, disenfranchised, at-risk individuals. We could clearly imagine the level of potential distrust, societal or social justice issues if we were to launch an isolation, quarantine, or restriction of movement activity. Those local agents that could be your best representatives in helping the public understand those types of decisions is critical.

The third is regional coordination. There’s no doubt in my mind that H1N1 further galvanized the ability for jurisdictions to work together in harmony in a regional basis. Many great examples of not only state and local improved coordination, but also state to state, because clearly they built upon each other’s experiences. They basically joined in making command decisions, and certainly with the issue of isolation, quarantine, and restriction of movement, the issue of variance from jurisdiction to jurisdiction, or why one town or state is doing it and why others are not, will be a significant policy and public relations issue.

The last one is an endgame strategy. Whenever you turn something on, you need to know when to turn it off and what’s going to give you those indicators that time is right and the way to do it. As soon as you have a decision point to initiate any one of these mitigation activities, you should immediately start developing your exit strategy or your endgame strategy, because it will be as challenging to demobilize and suspend a decision as it was when you had to make the decision in the first place.

Thank you.

JENNIFER

DA?

DONALD HENDERSON

I think Jim and Ron have given you quite a summary of what is possible to do when you don’t know the agent and you’ve got a mysterious disease here.

But I’ve been in a lot of epidemics over my past 30, 40 years, and they have a remarkable consistency. One is the first thing that happens is a chief politician goes before the public and assures the public that the government is in full control of the problem and don’t worry about it. This is patently false. Everybody knows it.

But he announces then that the government is taking prompt action, and he’s never quite sure what prompt action he could take, so he looks for a border to close, an international border or a state border. In fact, at one time I had to stop our government from closing the border with Canada when Canada had one case of smallpox in 1962, which had passed through the United States, and he developed a rash in Canada, and they wanted to close the border. And we solved the problem because I was able to persuade them that the Canadians would do just about the same as well as maybe they would do in Pennsylvania or Ohio. We wouldn’t close the border there, and they agreed. So I happily called the Canadians and said, “Well, we’ve decided Canada is a 51st state, so we’re taking no action”. And that seemed to make everybody quite happy.

And the third thing that happens, and I’ve had this happen with me on several outbreaks arriving, and the chief health officer has promptly vanished from public sight and leaving it to one of us to fill in and keep the press informed. I think it was here in Washington, as a matter of fact, that the chief health officer liked to play tennis, and we’d have a 7 o’clock meeting, and he was gone for the rest of the day, and we handled it from there on. That, too, was a suspect smallpox importation.

Well, the question is, what could you do? And it is a problem. I guess what one would be inclined to do is to talk to the public and tell them what you know, be honest about it, talk about calling a meeting of hospital people and trying to figure out what we’re going to do about taking care of a lot of people. And then you really want the public to do something, so a harmless thing is to tell them to wash their hands, and if they have a cough, cough into their sleeve.

It doesn’t hurt, and it might be something they could do. And finally, you’d have to look at the question of isolation. And here, I think this would be important. It’s an accepted thing to isolate cases, infectious cases. Well accepted. It’s humanitarian. It makes sense and may mitigate the effects of the epidemic. And in some cases, even mandatory isolation may be necessary. I don’t think that happens very often, although it has in recent years, but we should have the necessary authority to do that.

Well, the question comes up, but what about stopping a disease from entering a country? And I think we’re indebted to Howard Markle and his colleagues who documented the experiences with 1918 influenza and how successful were countries in keeping out the [Spanish] flu. And they were successful. American Samoa never had 1918 flu. They interrupted all travel. I mean, there were no boats allowed to land for about six months, and they missed the 1918 flu.

And there’s another example. I think it’s Gunniston, Colorado, if I remember correctly. They put up a posse, an armed posse, and they had a single road that went up to Gunniston, and the armed posse got there and simply staved off anybody coming up.

Now, somehow or other, that didn’t seem terribly applicable in today’s day, and that was about 1918, so it is different.

FAILURE OF BORDER SCREENINGS EVEN FOR SMALLPOX

Now, in the smallpox program, there was a question, what do we do about screening people? And this was something we were really deeply concerned about with smallpox. And so we went into the records rather thoroughly since about 1945, and there were about just under 50 importations of smallpox that could be well-documented. And the question is, how many might we have intercepted who might have had just fever or rash? And the fact was, none.

So anything we were doing at a border crossing to try to interrupt smallpox coming across the border would have been quite futile. I then had some discussions with our CDC colleagues and the quarantine group down there and thought about this. I thought, you know, as I said to them, CDC investigates a lot of different outbreaks, and many of these you can tell which is the first case and so forth, and it would be interesting to see how many instances we could identify in which that first individual might have been intercepted coming into the country. And I’m still waiting for one example so far.

So I think the point is that this idea that in this day and age, one is going to intercept people coming across the border and you’re going to stop the spread of the disease is a concept that was antiquated a very long time ago. Nevertheless, during the course of this outbreak, I had an argument with one of our colleagues and said, what do we do if we have a 747 about to land in New York and it has – and this was well, I guess, before the H1N1 – and it has a case of H5N1 influenza aboard? What are you going to do? [He said] “We have to isolate them after arriving”.

HUMAN FAILURE OF QUARANTINE

Well, first of all, I didn’t know how many 747s were carrying diagnostic kits aboard and could make that diagnosis in the first place. But then if they did land, then what? Are you going to house these people and quarantine them as a group? Now, here you’re dealing with quarantine. People are perfectly well, and quarantine means housing or isolating those who are perfectly well.

You would have to keep each of them in a separate room because if you’re assuming that one might infect another and therefore if they’re milling around, you’re really condemning everybody else to possibly getting infected. So you’d have to have separate rooms.

So you’ve got one 747 coming in and everybody in separate rooms for a proposed at that time 10-day isolation, and how many planes are going to come in with people with respiratory disease aboard and how many planes are really going to have to be – plane loads of people – isolated in how many rooms? Well, you didn’t want to look for a reservation in New York at a hotel if we really adopted that. [Sanjeev: Henderson anticipated the farcical “hotel quarantine” of Melbourne in 2020] But that seriously was being discussed as recently as even the H1N1. So I think there are concerns here that we really have to be quite clear, and I think there’s a tendency to overreact and not to realize what the problems are.  [Sanjeev:  Correct. THE PROBLEM OF HUMAN FACTORS IS COMPLETELY IGNORED BY PUBLIC HEALTH]

And then go on, lastly, finally, to quarantine. That, of course, goes back hundreds of years, and quarantine was really quite effective in times when we had yellow fever, in times, let’s say, in the 19th century, even into the 20th century. Smallpox was virtually kept out of Australia because of being able to block ships coming in. [Sanjeev: Henderson is COMPLETELY WRONG HERE!]

So far as further elements of quarantine, the question is, what do we do? Now, in the smallpox program, we looked at this, and what we found very quickly was that if you tried to quarantine whole families, you quickly found that people were hiding cases. You immediately, everywhere you went, they hid the cases because they didn’t want to be in quarantine. If you’re going to take them away to a quarantine camp, they certainly didn’t want that. So you quickly lost all control of the outbreak very quickly.

And I think this is what we could anticipate at this time if we were to think in terms seriously of quarantine as an element. So we’re really looking at the question of, yes, isolation of patients, but quarantine I have trouble with.

And I’ve tried to look at the situation not too long ago as we were thinking about this. When in the last 50 years have we really used quarantine, and it was effective? Well, Toronto provided us the great experience here in trying to quarantine what they did in regard to SARS, and talking with the chief health officer, I think at that time, mit was an absolute nightare. And, in fact, one of the chief physicians in the hospital who felt he played a key role, and he was talking to me, and he said there was one day when he had a slight fever and he coughed, and I said, what did you do? He said, “I was too critical. I couldn’t be quarantined. I was isolated at this point. I had to work.”

And so I think the concept of quarantine is something that, I would say at this point in time, this was prevalent in the 20th century and probably sort of faded around 1950, 60 in terms of significance. I’m a little surprised we have a unit actually still at CDC or newly formed at CDC on quarantine, which I don’t really see where we’re using it, and I don’t see the utility of it at this point in time as little as I see the utility of blocking borders. So I think we’ve learned something about epidemiology and microbiology over recent years, and I think we need to apply these intelligently and not revert to earlier times when we didn’t understand the spread of disease.

So with that, let me conclude.

JENNIFER

Jeff?

JEFF (Jeffrey Levi)

Well, I think my colleagues have done a good job of sort of successfully destroying any suggestion of using some of these measures. But I think in any situation we’re going to need to come up with some sort of response and probably we’ll come up with some sort of recommendations around social distancing of some kind.

And so it may not be quarantine, it may not be closing the borders, but part of it is policymakers aren’t going to want to be able to say we’re doing something, and part of it is because there may be instances where it makes sense. So rather than talking about specific measures, what I’d like to talk about is what needs to be in place before the event happens. So how are we going to, in any of these situations, whether relatively minimal or very stringent, these will only work if we have the cooperation of the public. We don’t have enough law enforcement officials to make these things happen unless there’s some level of compliance, voluntary compliance.

And so what are the things that we need to have in place or have done in advance? I think there are a number of things. First, and some of this is going to be very obvious, but first is we do have to communicate and engage and educate the public about what the risks may be and what the interventions are, why they might work, why they might not work.

The public is far more educable if you truly engage them rather than lecture to them, is truly can be reached if there is good community engagement. We saw that, I think, with the vaccine prioritization. We heard that earlier today about, in some instances, the public was in the right place before handed down public health wisdom was able to reach where the public was in terms of prioritization. So I think with the right effort, the public can understand this kind of complexity.

And I think we want them to understand this complexity for two reasons. It can cut really in both ways. We don’t want them to be so afraid that they demand some kind of action. Don’t just sit there and do something, even if that action is unwarranted. Or when it is time to do something, we don’t want them to be resisting that simply because they don’t understand it, because we ultimately will need voluntary compliance.

The second thing is, to be very blunt, the faces and the voices communicating about these issues have to look different than they do on this panel. We need to make sure that there is true community involvement and that every part of our very diverse country is being heard and understands and that we are giving meaningful leadership roles to everyone.

And finally, the term that we all throw around but don’t spend a whole lot of time defining how we’re going to go about building, is we need community resilience, so that people can actually comply with what we ask them to do, because if we don’t give them that capacity, they won’t do it regardless of the law.

We heard some of that today. The most obvious is the one about sick leave. And we actually have some good anecdotes, if not fully documented evidence, of people with H1N1 going to work, even though they knew they shouldn’t, because they had no choice. [Sanjeev: This is just one of the infinity of human factors] They had no sick leave. We are the only developed country that does not mandate sick leave for employees.

We also need to make meaningful the steps that we ask people to do, whether it’s stockpile food, stockpile supplies. Government hasn’t issued an extra 20% of a food stamp allocation once a year for people to replenish their stockpiles of whatever food and water they’re supposed to be keeping on hand, assuming they have a place to do it. If you live in a New York apartment, your apartment is about as big as this table. Where are you stockpiling your food and resources? It can be a practical issue.

But we also need to think about if we’re going to ask people to stay home when they are sick and not go to the grocery store when they run out of diapers or go to the ATM, then we need to provide the social support services that can provide those services and that kind of support. [Sanjeev: RIDICULOUS SUGGESTION:  the devil is in the detail] Those things aren’t cheap to do, but those are quite practical.

I think probably the more important thing is that we need to be establishing the credibility of public health in working with everyone and in showing and demonstrating concern about people’s health throughout the year at all times, not just in response to an emergency.

That’s where I think we fall into a little trap in setting up this competition, for example, between fighting chronic diseases and preparedness, or any kind of public health intervention and preparedness. We’ve come to recognize in the chronic disease world, and I’m hoping soon, and also in the traditional infectious disease world, that community prevention is an important thing, and building stronger communities and dealing with structural impediments to people making healthy choices, getting a better understanding of why people take risks and what we can do to mitigate that risk-taking. If we do that well throughout the year or in the normal course of activities, then we will have, (A), established good relationships with folks, and (B), made them healthier and stronger to begin with, to have their own capacity to respond to these challenges. So if we think about reducing risk throughout our life, then it crosses from preparedness for emergencies all the way to whether I exercise or eat well.

The other part of preparedness is preparing policymakers, preparing those politicians who want to be able to get up and say, I’m doing something, I’m responding. I actually found Rich Besser’s story about Rahm Emanuel sitting in a corner wanting to rewrite the guidelines, in some respects reassuring, because it’s important for public health not to be questioned, not to be challenged, and not for us to assume that just because this is the perceived wisdom and the conclusion of our evidence-based analysis within the closed world of public health, that that’s necessarily the right answer. We have too many examples of public health being wrong to be that arrogant and to be challenged, but challenged in an appropriate way, because that story ended the right way. So there was a challenge, there was a pullback from the political folks in saying, oh yeah, well we’re not completely interfering, but you really need to think about it this way. And ultimately, the reality, ultimately the public health guidance reflecting the reality that the political people were articulating to them.

That interaction is incredibly important, but for that interaction to work well, there has to be a good, established, ongoing relationship between the political people and the public health policy people, because that relationship, when you’re trying to make these very difficult decisions, you can’t just be introducing yourselves to one another. Now, that was one of the challenges of responding to H1N1 in the middle of a transition, but I would argue that some of the key people who were involved in that transition were people who were coming back, who actually had long-term relationships with some of the public health officials, and that was a good thing about what we experienced in the transition.

Finally, whatever is decided, there needs to be consistency across the country, and I think Jim spoke to some of that, but others have spoken to it today. Yes, we are a diverse country with very diverse capacities and approaches in local health departments, but as someone who lives here in Washington, D.C., where you have the D.C. Health Department, Prince George’s County, Montgomery County, Arlington, Alexandria, all surrounding us, and each jurisdiction managed to take the same prioritization list for H1N1 vaccines and implement them differently. And so people who were not able – I know of cases of people who somehow didn’t make it into that first tier in D.C., – walked over to Prince, or drove over to Prince George’s County and got their vaccine, and vice versa. And there was no coordinated mechanism among the metropolitan governments, even though there is allegedly a coordinating mechanism, to articulate either why they are different or try to resolve those differences.

And each decision was individually justifiable, but it created incredible confusion among the public, and we need to make sure that we are a good deal more consistent. The more extreme the measures we take, the more consistent they have to be, because otherwise it will be even more undermining and evasion, and ultimately it will be ineffective.

Thank you. [Sanjeev: I FOUND THIS TO BE ENTIRELY NONSENSICAL, since he didn’t even try to address the points raised by Henderson. We are NOT interested in implementing something that will fail, and cause harm]

JENNIFER

Marcy?

MARCY (Marcelle Layton)

Thanks. I guess I have the privilege or challenge of being the last speaker on the last panel.

And I just was reflecting, listening to D.A. talk, that the last time I followed D.A. was, I think, back in 1998 at the first International Conference of Emerging Infectious Diseases, when he gave his first keynote address on bioterrorism. And I probably stupidly agreed to be on a panel to talk about the local capacity to respond to bioterrorism that became a headline story in New York City. I think I gave a Rich Besser-like honest assessment of what our capabilities were and almost got fired. For better or for worse, I guess I survived that. Hopefully it won’t be so challenging today.

Anyway, I decided to focus my remarks on quarantine, which, to be honest, is probably one of the more difficult issues that I’ve been involved in numerous discussions, both in New York City and at national meetings over the years, about if and if so when to consider using quarantine as an outbreak control measure.

QUARANTINE

And I think, you know, from a purely scientific perspective or theoretical perspective, it almost sounds like there’s no question. It seems obvious that if you have people who’ve been exposed to a life-threatening contagious illness, especially one that you don’t have any countermeasures for, that you should separate them until they develop illness, in which case you would isolate them, or if they remain asymptomatic through the incubation period, it’s okay to let them go.

So on the surface it seems obvious, but obviously, as everyone else has alluded to, to actually put this in place is much harder. The practicalities of doing this in a place like New York City, I can just amplify on all the comments that have been said. The logistics of housing, feeding, monitoring, and otherwise caring for people, whether they’re at home or in a quarantine facility, and all the unintended consequences, personal, social, political, and economic.  So in New York City, you know, we recognize that it’s probably a very rare scenario. I can probably think of one or two examples where we might implement it and where containment we actually think is possible. We don’t want to do it unless we think it actually is going to succeed.

We’ve done a number of things in New York City to prepare for it. Just to give you some examples, as I think Jim said, we actually did critically look at our existing public health laws about, I want to say almost ten years ago, and looked at what we needed to strengthen to give ourselves both the authority and the flexibility to implement both isolation, but as importantly quarantine, if we thought they were needed. And the criteria that we’ve established for when we would implement a larger scale quarantine include a number of factors.

One, obviously, like the scenario that it was a potentially contagious disease that may pose an imminent and significant threat to the public health with significant morbidity and obviously high mortality. It has to be a disease that’s not already out there in New York City circulating in the general population. We have to think that if we implement quarantine, that there’s the possibility of either preventing introduction or delaying the introduction and community transmission in the city. [Sanjeev: THESE STUPID PEOPLE HAVE NO THEORY OF CONTAGION/ ISOLATION – and just because a disease might lead to significant mortality doesn’t mean any thing about whether isolation is suitable, let alone quarantine. See my TOI piece and PH textbook]

And then most importantly, we need to convince ourselves that less restrictive measures aren’t potentially viable or effective alternatives to preventing or delaying the spread of the disease among the city’s population.

Small scale quarantine in New York

In addition to strengthening our laws, we’ve actually done some real logistical operational planning about where we would put people. We’ve actually funded two New York City hospitals to develop quarantine facilities for a smaller scale event, and we’ve done a lot of work with the staff there to plan for and exercise the medical, social, psychological, and basic support needs that we would need to put in place if we had to activate either or both of these units.

And then we’ve done a lot of planning on these bigger picture issues, both policy, legal, and operational, of how we would do a larger scale quarantine, whether it’s the voluntary home quarantine that was done in Toronto or a more restrictive quarantine in a dedicated facility.  Our decisions on whether we would implement quarantine would obviously need to be based on, first off, science, the clinical and epidemiologic characteristics of the disease, if they’re known, and the sort of things we would weigh in, or whether people are contagious prior to or early on after illness onset. Obviously, if they’re contagious while they’re asymptomatic, it’s almost impossible for quarantine to be effective. [Sanjeev: Here she’s getting more sensible]

How effectively the disease is transmitted, the route of transmission and the efficacy of that, the length of the incubation period, and how extensively the disease is spread, both worldwide and in the United States, at the time the first cases or contacts are detected in New York City.

And obviously, all of these factors would be really difficult to determine if it’s a new disease that has just emerged, whether it’s elsewhere or in New York City.

That’s really what we faced in the spring when very little was known yet about H1N1. And I’ve been struck by how long it takes and how hard it is to determine those factors in close to real time. I think for SARS, it took a very long time for us to fully understand incubation period and generation time and secondary attack rates, and the same was true for H1N1.

The other issue is, obviously, we don’t want to do it unless we think we can do it successfully, so all the capacity and resource issues that would need to be in place, especially for an involuntary quarantine, we would need to be able to enforce it with our law enforcement partners as well as afford the due process rights of those that we’re detaining and promote their safety, well-being, and compliance.

In New York City, we actually did not need, fortunately, to implement quarantine for any event that I’ve been involved in during the SARS outbreak in 2003. We only focused on isolating cases and actively monitoring their contacts, but not restricting their movement. None of our suspect cases ended up being confirmed, so whether that would have been successful if we had true cases, obviously, it’s hard to say.

And in the spring of 2009, when we were one of the first, as Tom Frieden said earlier today, and definitely for the spring, more severely impacted cities during the initial wave of the H1N1 pandemic, we again focused on isolating ill cases, either voluntarily at home or using infection control precautions in the hospital, but we never considered quarantine given what we knew about the epidemiology of influenza.

We made the assumption, and I think it was mostly borne out by later studies, that the spread of flu, H1N1, would be similar to what we knew about influenza in general, and also given that it was clear even by the time we detected the school outbreak in New York City that we were hearing about sporadic cases elsewhere in the U.S. and eventually in the world, so we knew we wouldn’t be able to contain it, so similar to what Rich Besser said earlier. [Sanjeev: this is an important para which suggestst that there were sensible people in USA during the swine flu. Maybe the term “flu” was helpful. But the fact that they realised they couldn’t contain it, was a crucial scientific insight]

My last point was going to echo what Jeff just said about the importance of public engagement, that even if we ever did face a situation where we decided we want to implement quarantine, it’s only going to be as effective as we can gain the public and community and political leaders’ cooperation in our doing so, and that will really require explaining why and how we are planning to implement quarantine and quarantine measures and getting their acceptance and cooperation.

JENNIFER

Great. Thank you. Well, we had a number of strong opinions on this panel, so I’m wondering if any of the panelists want to respond to anything that’s been said.

Q&A FROM PANEL

RON

A comment, a small argument with DA, and a question for Jim.

A comment. Intercepting disease at the border, just to let you know, there were five SARS cases in Toronto that were international travelers. None could have been detected at the border. They all were asymptomatic when they came. They all got sick in Canada, so I also don’t think you can intercept disease at the border.

The little argument with DA, and it’s about the need for a quarantine service. I grudgingly got to the point where I thought, yeah, Canada needed to have a quarantine service, and the reasons were twofold.

First of all, some of you may remember in 1995 there was a pneumonic plague outbreak in the city of Surat in India. I happened to be sitting in my office with a television set, watching CNN broadcast pictures of Indians fleeing the city of Surat, and I thought, well, isn’t that interesting? And, of course, that’s a long way from Ottawa. One hour later I got a call from Toronto Pearson Airport.

It said, Dr. St. John, there’s an Air India flight arriving nonstop from New Delhi, not Surat, New Delhi, and it’ll be arriving here in about three hours, and everybody at the Toronto Pearson Airport is going to walk off the job because they think there might be plague on the plane. There are 30,000 people that work at Toronto Pearson Airport. It was not trivial, and the person said, do something.

At that time, Canada had effectively dismantled its quarantine service, and there were four quarantine officers all in Ottawa for the whole country who hadn’t responded to anything in about 10 years. I sent one of them on a plane to get to Toronto before the Air India flight. He got there 20 minutes before the Air India flight, and that big 747 parked not up to the ramp, but just not quite there.

And he was the one that went out and climbed a ladder, opened the big bay, looked inside and said, there are no rats and no fleas in here. It’s okay. That is a true story, but it was a wake-up call.

And it was a wake-up call that you need somebody who will make people feel comfortable when they all know that now disease is traveling by airplanes. And so we rebuilt a quarantine service, minimal, small, relatively small, in the six international airports, big international airports we have. And it’s their presence that makes everybody happy.

Not that they’re stopping disease. Once a week, about once a week, one of them boards a plane because the captain has read it ahead and said there’s somebody sick on the plane who drank too much. But the fact that there’s somebody there that is an authority and knows something about health and public health and infectious disease can go on that airplane, everybody is really happy.

And the only other argument in favor of it, but that is important. The presence is important. The only other argument is if you’re going to have a law about quarantine, then you should have an enforcing agent. Because if you did need, if there was no quarantine officer and you did need to stop somebody for whatever reason, there’d be nobody there to enforce it. So I grudgingly had to admit that we needed a quarantine service. [Sanjeev: These are good points, but the main reason you need a quarantine service is that you need people whose whole life is about studying quarantine and who can explain to the public about how it DOESN’T WORK.]

And finally, the question for Jim.

Jim, how long do you think it took for me to discontinue thermal scanning after the last case of SARS in the world was reported?

JIM
Probably longer than you wanted it to take.

RON

It took six months before I could convince the minister to stop thermal scanning. And why, she said, we need the public’s trust that we’re doing something. [Sanjeev: THIS IS WHERE PANIC COMES INTO POLICY MAKING, and it is crucially important to educate the public IN ADVANCE why these measures can’t work]

JIM

If I could just add to it, and I know Jeff and others touched upon it, and it was raised several times today, is the whole issue of trying to reconcile the issue of national consistency and standardization with sort of the tenet that local conditions drive local decisions. And I don’t have a magic fix to that other than to say, over time I think the delta is getting smaller, but it still exists. So the issue here is when, for all good reasons, it happens, how best to convey that message so that the public and the policymakers and anybody who has the potential to be a second guesser can appreciate and possibly respect or at least tolerate that type of circumstances.

That being said, I think even when we’ve done the interim in-progress reviews for H1N1, the state and local public health community has verbalized that maybe we should have been a little bit more prescriptive in the way we would do things. Again, not encouraging the U.S. government to dictate the public health response, but maybe being more willing to accept stronger, more forceful guidance and direction. So that was sort of a retrospective from the state and local public health perspective.

Not that anyone is willing to surrender local home rule or local authority or also realizing that at a local level there’s a lot of influencing factors that go into decision-making, but I think overall it is much, much better in my career – as far as an honest and sincere effort – to basically have as much consistency and conformity as possible.

JENNIFER

I’d like to actually follow up on that point. We’ve heard about it all day long.

We hear this tension between wanting consistency and also wanting flexibility at the local level.

JIM

And there’s a sweet spot somewhere in there that we just haven’t found it yet.

JENNIFER

So I’m going to push the panelists a little bit, and I’m going to suspend you temporarily from your duties as state health officers to ask the question, who should be making decisions? At what level in the government should we be making decisions about using these measures? Because clearly the actions taken by one state could affect the trade and travel of another state.

So who should be making these decisions? Where should the decision-making happen? And then also, given what we heard earlier today about it’s both a scientific and yet also a political decision, where does that, you know, who has the authority? I mean, we understand who has the legal authority, potentially, maybe not as clear, but who has the legal authority to make decisions. But where should that decision-making happen? And do we have the right process for that? So I’ll ask any panelists that would like to respond. Hopefully someone will give us an answer.

JEFF

I don’t have an answer, but I think I want to tell a story about why it can be so important. And it’s not just consistent between the federal level and the state level, but also within the federal government. The second worst hearing of my – congressional hearing of my life – first was involved with Strom Thurmond, and it was many years ago, was a very recent one on H1N1 that was essentially taking TSA to task, Transportation Security Administration, for not, quote, protecting inspectors at the airports.

And what it all really came down to was at some airports, people were being told that they should wear gloves and masks, and others they were forbidden from wearing gloves or masks. And there was not, there didn’t appear to be a consistent way within the federal government for there to be a clear communication about what sort of protection should be taken and what should not. And so when you have that kind of, so you had CDC saying one thing, DHS as an agency saying another, TSA as part of DHS saying a third, and then it being implemented a fourth way, well, forget the state and local thing, this is a real problem.

And created this real opening for a member of Congress to, you know, to demagogue the issue, and essentially say no one knows what they’re doing, you don’t care about the workers. So I’m just saying it’s important for someone to decide. And I think it ultimately needs, you know, I would argue that these sorts of things, there needs to be a single standard and it needs to come out of HHS, it needs to be a public health position.

MARCY

Thank you. I’ll grab it, I’m not sure why. I think it really depends on what the decision is.

There’s no one answer to that question. I think things like interstate travel or obviously international travel that relies at the federal level, I think when you, I mean, I think it’s important to realize, especially for a new disease that’s emerging where you don’t really understand everything yet. And I can’t emphasize enough how long it takes to get enough information to truly understand it, that it’s really hard for anyone to come up with a clear decision that makes sense for everyone to stick with no matter what.

And I think there does need to be some flexibility. And I thought the way that Rich presented how they acknowledged it around school closures is that these are our guidance, they were guidances, and that different places will need to implement them differently or may decide to implement them differently based on their local circumstances. There are some decisions where that makes sense, there are others where it doesn’t. [Sanjeev: THIS WOMAN IS DEEPLY CONFUSED – that’s because there is no standard science in PH, everyone cooks up their own “science”. This is a priesthood, not a scientific profession. How does this kind of GOBBLEDYGOOK solve the problem of some TSA agents wearing masks and others not? There is a SCIENCE behind this and that’s what this CONFUSED WOMAN doesn’t understand. ]

So I think it really depends on what issue is being decided, and both the regulatory issue and how much data there is to make that decision, and if there isn’t much, acknowledging the flexibility that may be needed to implement it.

JIM

Just to add quickly, a lot of this, all of this discussion has been on a governmental agency making a decision to do something. But there’s another dimension to that, and that’s sort of the spontaneous decision or action of a citizen, a business, a school, to take their own action, even if it’s sort of in a very authoritative sense, and having a local official reverse that because it wasn’t consistent with the agency’s policy and practice and it was unwarranted. [Sanjeev: this is why there needs to be widespread understanding of the actual science in the community. Currently, PH textbooks are a dog’s breakfast – or worse: recipes for mass murder]

And that itself has a whole suite of complications and public relations issues too, so we can’t lose sight of that.

RON

Just to share some of the idiosyncrasies of Canada, it’s pretty clear that these measures, travel advisories, quarantine, all this kind of stuff, for anything at the border is a federal decision. Anything within a province is a provincial decision, and nobody has any authority between provinces. So if you wish to move or move yourself from Manitoba to Ontario, nobody has any authority to stop or impede or do anything.

DONALD

Well, effectively, this is true, I think, for the United States too. There are state authorities here who prevail over a lot of different things.

But I think, in fact, what we’re looking for is, and the way things generally work, is an authoritative site which gains sufficient in the way of recognition that what they’re advising and what have you are generally accepted as a result of that. And there are various advisory committees feeding into it. Much of what we do in immunization practice goes through the advisory committee in immunization practice.

But that’s an advisory committee. It is not making a decision. It is an advisory committee to the secretary.

So that I think it’s kind of a muddy area, but I think you muddle through. And trying to draw, I think, strict lines here, you get into trouble with it, I think. [Sanjeev: This is weird stuff, coming from Donald. The focus of PH should be to document and disseminate the actual science, not to further muddle the already muddled situation]

JENNIFER

We heard throughout the day that states, and I think, Jim, you spoke to this, that more specific guidance was a number of states and localities wanted it.

But then on this point again about the flexibility of where decisions get made, you can imagine the folks in the federal government possibly feel like that’s a bit of a catch-22. So I guess if you were to give them advice regarding the kinds of guidance that you’re looking for, what would it be? I mean, we have an opportunity now in the inter-pandemic period or at least this relative quiet to try to figure out what to do next time.

JIM

Yeah. Well, I guess, you know, my takeaways on this was, number one, overall the quality of guidance from the federal government was outstanding to state and local practitioners and extremely helpful. That’s a fact. Number two, in large part, the U.S. government was very respectful of local and state decision-making, home rule, and that whole issue of local conditions.

So where does that leave us? The issue of maybe shrinking the four corners a little bit more on the range of guidances and options is one possible, or maybe being a little bit more directive or forceful in nudging decision-making in one direction without mandating it. I mean, those are other techniques and strategies without sort of violating those tenets. But I think the key here is that there is general recognition that there should have been a little bit more consistency in a national response.

And the issue now is for individuals to figure out how, through an after-action process, to answer your question, how to get to that point. And I personally don’t know the magic to that other than the recognition that people feel that we would definitely be in a better place if we were in that situation.

DONALD

I think in recent years, and watching it evolve, that HHS has been issuing consistently advice, I now see DHS sort of intruding with advice in various ways. I won’t comment on it. Some of this is contradictory.

I think where I’m a little concerned, and I think a number of us are, that, for example, we don’t have anyone from medicine or public health in the Office of Science and Technology Policy or in the higher levels of government in the White House.

I mean, this has been a very dearth of people with a public health background who understand many of the issues. And, in fact, this has been true, I think through the Clinton administration, it was scarce. And, certainly, I think it’s not been improved.

We did have, I think, in public medicine and public health, I think more in the way of input into Bush I, and the Office of Science and Technology Policy was playing a fairly prominent role. But that office is up and down, and various other offices are kind of up and down depending on the president. And, at this point in time, I think we’ve got a dearth of public health and medical experience at the highest levels of government, and I would hope we’d see that change.

In fact, we don’t have, we have an office for international health in the Department of Health and Human Services. That job hasn’t been filled yet. No one has been nominated, to the best of my knowledge.

JEFF

I guess the thought that I want to add is – I mean, I agree that there isn’t a cut-and-dried answer as to should it be the federal government setting all the standards and locals just follow, and, obviously, things have to be adapted to the local level.

But I also think that we have not addressed, and need to, the tremendous varied capacity of local health departments across the country. With almost 3,000 local health departments, there is no consistency.

If every local health department were like New York City, I’d have no problem with leaving those decisions at the local level. But we are leaving a lot of people essentially poorly protected because we have such a variety of capacity, and we have not figured out a way to address that.

We give out a lot of money to state and local health departments. It may not be enough, Jim, but we do give a lot. And it’s very hard, but that has been money that has not been attached to setting a minimum standard of capacity. That needs to be achieved, and we actually don’t give the money out based on how much additional capacity people need to develop. [Sanjeev: WHAT IS THIS MINIMUM STANDARD OF CAPACITY? No one has a clear understanding of the actual science, and everyone is running around like headless chooks. Fauci was not an exception but the rule. Constantly flipping from one to another position, not following his own advice, etc. THAT is the real problem with PH – the complete absence of a SCIENTIFIC UNDERSTANDING OF CONTAGION]

If we’re going to give a lot of discretion to local health departments, then we need to make sure that they have the knowledge and the resources to actually exercise that discretion.

JENNIFER

At this point, if folks want to come up to the microphone to ask questions, you’re welcome to do so. I’m going to continue with the panelists.

Marcia, you articulated some of the key points. Very specific information that goes into making decisions about which measures to use. You also acknowledge that decisions have to be made in the face of uncertainty. We’ve heard throughout the day about how it was excellent to maintain flexibility during H1N1, particularly as the situation evolved.

I guess, have we put into place since H1N1, or is there an ongoing effort in your mind, adequate to try to address, get a better handle on information earlier? Are we putting systems into place that can try to close the gaps in terms of the information we need to make critical decisions?

MARCY

I think many of us, as we were planning for how we would respond during a pandemic – there’s no question local and state health departments were planning for, and probably some easier than others – put in systems to count cases. We count hospitalized cases mostly, and we count deaths, and we can estimate milder infections.

There were two critical issues that struck me when I went back and looked at our 2006 pandemic plan, several weeks into the spring outbreak, that I really hadn’t thought about.

One is I thought I’d have more warning, and unfortunately, I didn’t have that.

The other is how hard it was. The decisions about community measures were always going to be based on severity of illness. As somebody else alluded to, Mexico initially, I was on a conference call with CDC that Thursday before we recognized our school outbreak the next day on Friday, when I first heard about Mexico, but it was a rumor. It wasn’t confirmed yet. It was confirmed actually the next morning that I heard it was the same virus as those several cases in California. To me, that was, oh no, this is a potential pandemic, and I had an outbreak of what sounded like fever and sore throat and flu-like illness literally the same day that morning that I heard about it.

In Mexico, initially, it was supposedly very severe, and I think it’s because you’re looking at the tip of the iceberg. Something that really struck us in the midst of – unlike SARS, where I got to watch it from afar and be frustrated by the fact that there’s all this data being collected, and I wasn’t privy to it or the details of it, it takes weeks or months for it to become published – I was in that same position in some ways in the spring, so we really tried to prioritize what are the things we need to know to estimate things we hadn’t really thought about in retrospect getting in near real time. Things like case fatality rate requires knowing how many people were infected, and though it’s relatively easy to count 1,000 or so hospitalizations, it’s really hard to estimate the number of infected, especially for a disease like influenza.

And then transmission factors. We were lucky that the initial outbreak in New York City occurred in a relatively contained environment of this school, so we did prioritize very quickly doing some epi studies at that school, but it took time for that data to be available to analyze even as quickly as we did it. We made some estimates early on that, to be honest, ended up being good estimates based on some quick surveys that we did with the school. So I think in retrospect what I hope to have engaged the CDC influenza folks in as things are calming down and we have time to think is let’s think about what we need to put in place to answer these sort of questions quickly the next time: So how severe is it and how easily is it spread? Because those two factors are the two factors I’m going to weigh in, or not I, but I’ll be advising leadership as far as how restrictive we should be with community measures.

RON

Marcy, a question about that. Counting the cases is one thing. I think we find that rather easier to do. But then you also have the question of the contacts of the cases. And that can quickly mushroom, as you know, into large numbers. And that requires personnel to go out and find them, talk to them, all that kind of stuff. How did you manage, did you find problems with recruiting enough people to start to pursue that investigation out to the fringes?

MARCY

Again, I think something I hadn’t thought as clearly about when I wrote the surveillance section of our pandemic plan that we had to think about at the time and then for the fall was we don’t need to count every case. We almost get caught up in the media gets caught up in how many cases, how many deaths. The things that I needed to know were how severe it was and how is it spreading. And you can do that in a more focused way if you’re not expending resources trying to contact or find every case. We never attempted to identify and track every contact in the spring.

We knew, you know, for the same reason we never thought about implementing quarantine. We had thought about how we might do that for smallpox because of the concern about needing to not just find them but vaccinate them in the event that we were able to contain a small intentional introduction into the city. I mean, that is probably the one scenario where we would consider a strict quarantine if it was introduced in small numbers intentionally and we had the chance to contain it.

So, you know, I think the strategy is really thinking through, you know, what is the information you need to know and what is the most efficient way to get it? You know, in the spring we did count every hospitalized case, but we also and we tried very actively to count every death working very closely with our medical examiner’s office and we estimated infection rates by very quickly putting in place these population-based surveys. And then at the school we did a focused epi study to look at transmission factors, again, because we were lucky in that that’s the setting that the outbreak emerged in. So we were able to do it.

And, you know, we thought about for the fall the need to recognize if the virus changed, but I didn’t feel as responsible for being the one, you know, by the time the fall came around, you know, there were many opportunities for many people to be looking at changes in the virus. But thinking through how the place where it’s first recognized or one of the first places that it’s recognized, how important it is to find a way to collect that information quickly. And we tried to get that information up quickly on our web and through our alert systems, you know, and we’re still struggling to publish what we did, but most of the information that we found we got out as quickly as we could both in forums like this and through the web.

General audience Q&A

JENNIFER

Eric?

ERIC

Yeah, this week is the seventh anniversary of the eruption of SARS out of China. And so the recognition of the lack of utility of the kinds of things that we’ve been discussing, quarantine, travel restrictions, were pretty clear not only in Canada but in Hong Kong and elsewhere. And there’s great agreement among the panel that these measures are of limited utility at best.

So why during the pandemic did such advanced countries as China, Great Britain, Mexico, and others implement travel screening, travel restrictions, and quarantine? Is it just public health responding to political pressure? And if so, is that right?

RON

In Argentina, for that winter epidemic that they had last summer, they had a scientific advisory committee for the Minister of Health and the President. The scientific advisory committee recommended against any quarantine, against stopping flights, basically said, let’s prepare, it’s going to come. They were overruled by the highest political level, and orders were issued to stop the flights. And a military hospital was sent to the airport and a few other silly things.

I go back to some of the SARS experience in which the public, the political level, the political leadership felt enormous pressure to be seen as being proactive and be, quote unquote, doing something. And what are the available tools? Well, there are only about five or six. So, you know, do something.

And I think that is the primary pressure. That they’re under.

DONALD HENDERSON

Yeah, I would agree with this. I think the political pressure is there. And as an official, you want to respond and tell the public we’re doing something to mitigate this or do something positive. And it’s pretty hard to identify what is going to make a difference.

I think in the folders is the 1957 epidemic, which I lived through as head of the influenza surveillance unit for the time, as a matter of fact. And we were grasping at straws trying to figure out what did we do. And the one thing we found as a measure, one of the most best ones we had was actually elementary school absenteeism. That went up first, and you could pick that up quickly at various places. But then that would tell us where it was, but how many cases there were, goodness knows. Fortunately, at that time, we weren’t pressed to have a number. And I think one of the problems that we did get very much absorbed with was how many confirmed cases do we have. And this, I think, just the publicity of it, getting a count, getting the number of deaths, is a problem. And I didn’t really have a very good alternative during the time. But if we’d been pressed back in 1957, I have no idea what we’d do to come up with a number. It would be just purely a guess.

So we were using basically very crude data and surveys and what have you. But I don’t know what you do, actually, in terms of what do you do to assure the public you’re doing something. And what is it you decide?

And I would note in Asia, it’s very common to put on face masks, as you may know. I mean, it’s certainly very common, which is something you could do. And did we recommend face masks? Well, we chose not to recommend face masks. And I think the feeling is they wouldn’t make very much difference.

But if we then look to the data we have on hand washing and what difference does that make and how good is our data on that, frankly, it’s not very good.

And what does it do when you’re stifling your sneeze in your sleeve? You think it would do some good. I mean, intuitively it would make sense, but does it? And how much do we mitigate by isolating the patients and what way and for how long? This is a very hard disease, I think, to get quantitative data. And we looked at this in every possible way trying to get studies that we could quantitate things. And in 1957 we did do a huge study in Louisiana, the earliest cases. And this was a detailed survey and serologic studies were done. And we got a lot of data, but it doesn’t help you in many of the other places.

So this is a very nasty disease to deal with.

With smallpox, we knew when a smallpox case was there. They had a big, beautiful rash on every case and had no trouble. It was an epidemiologist’s dream. But with influenza, you don’t really have that.

JENNIFER

Monica.

MONICA

This is for Jim and Marcy. There’s been a theme today that an informed and involved citizenry is a critical asset in managing any epidemic. But to follow up something that Jeff brought up, I mean, what capacity exists at the state and local level to effectively interact with the public so that they trust us when we say, you know, it’s going to be disruptive, but the social distancing is a value to you? You know, this countermeasure is new, but we think it’s what is going to be what is necessary now. And then what can the Feds do to improve that capacity?

JIM

Sure. I mean, in general terms, I think certainly in the last year or so, we have made significant progress in cultivating better relationships with community organizations, grassroots, faith-based organizations, those that really represent the best interests of those at risk, vulnerable, and in many cases disenfranchised. It doesn’t mean that we have a perfect or a full relationship, but I think clearly H1N1 has brought us to a higher or better place in that regard. I believe Dr. Frieden said earlier today that probably in general populations, we did a much better job than we did in some of the possibly minority sectors, and there are still significant legacy concerns and issues that we need to overcome.

But, I mean, I think that’s clearly a focal point of state and local public health going forward, where we really need to invest our time and efforts on, because that is what’s going to make the difference at the end of the day.

MARCY

I’ll just echo that, that it’s not just talking to the public through the media, it’s actually trying to engage them directly in many different ways, both local political leadership as well as community groups, faith-based groups, et cetera.

And I think something that was eye-opening to me, there was a project that we got funded for by CDC to look at how we do essential medical services during a pandemic that had been funded for several years, and we were finishing it up. And the last thing that we were doing with that group was around risk communication issues, around how we would address some of the challenging issues around limited scarce resources, et cetera. And we used some of those focus groups to actually look at how the messages we were getting out in New York City at the time were being received by specific vulnerable groups, whether they were geriatrics, an immigrant community, health care workers, et cetera, and messages that, to me, seemed clear. The focus groups were coming back and telling us, that’s not what we’re hearing from you.

So I think, you know, it’s a constant learning about, you know, just because we think that we’re saying something, you know, that is at an appropriate level of language and appropriate simplicity and focusing on trying to get our message out clearly is not necessarily how it’s being heard. And the importance of, you know, ideally doing it ahead of time, I think that’s easier said than done for some of these issues. But at least at the time of the emergency, to have that be part of the effort in the communication strategy to sort of, with everything that we’re doing, somebody should be saying, you know, is this the best way to do it? What isn’t getting through? How can we do this better? Both by bringing community leaders in as well as directly engaging.

JIM

You know, if I could just add to it, several times today the reference to public engagement or community engagement was used, and that’s used in two different ways. One is sort of a broad, generic phrase of getting them involved. And the other one is more of a rigorous, structured, truly engagement to basically identify and synthesize the public’s beliefs and values that would help shape and form public policy and action.

And using the true public engagement tool and approach in the last two or three years, I think, has made outstanding benefits to developing some of the guidance we have. We’re working with some of the vaccine safety concerns and issues. So I think clearly that it’s a tool, it’s an approach, it’s a methodology, and it’s getting a lot of traction within the public health community to better shape policy.

JEFF

If I could just add two very quick points. One is, I mean, I think this notion of doing polling and focus groups and testing our messages is incredibly important because it’s always amazing to me how the language that we consider to be so incredibly clear is heard in an entirely different way by the public. And we just have to constantly be testing what we are doing.

I think the second is, you know, there were several moments where we talked about vaccine hesitancy today. And that’s not just among traditional, you know, this is across the population, I think, where there’s a lot of questioning and a lot of resistance. And, you know, the question that came up this morning about adjuvants was, I think, a very good example of, I think, an appropriate decision being made not to try a new technology in a population that is already so suspicious of vaccines.

And I think the second question that is directly related is here we have health care workers who have incredibly low rates of influenza vaccination, and they’re the ones who are supposed to be setting the example. So we have a huge educational campaign to do around vaccines to begin with. And if we did that for all of existing vaccine-preventable diseases and we convinced people that vaccines were safe and that new technologies actually can be a good thing when it comes to vaccines for everything else, you know, we throw out our cell phones every year, but with new technology and vaccines, we’re not going to trust.

We need to get to a different place in that. And if we get to a different place, this is, again, sort of, you know, all hazards type approach, we’ll be preventing disease and we’ll make people more willing to accept new interventions, new countermeasures when they’re available.

JENNIFER

Great. I’m glad we’re closing on a positive note. Anyhow, I’d like to thank all the panelists for a thought-provoking discussion today.

You know, I think what I take from the panel discussion today and some of what we heard earlier today is that we know that government leaders and health officials should anticipate that there’s going to be political pressure in the midst of infectious emergencies to demonstrate that they’re responding swiftly and with certainty.

We heard pretty clearly from our panel today that just employing measures for the sake of looking as though you’re taking strong action is not recommended, that there are a number of measures that may have serious adverse consequences.

We also heard that communication and public engagement can go a long way in terms of maintaining credibility and faith in leadership in the midst of an event.

We also heard that the decisions of which measures get taken will largely depend on the specific epidemiology of the disease, but that, you know, many factors go into deciding which measure to use. And the measures used for one virus may not be the same as another, but we also understand that decisions are not entirely up to science, that there’s also politics behind it as well, and that decisions will often have to be made in the face of uncertainty, and so we have to maintain sort of the flexibility of response and constant reassessment as we go along.

I think we also heard pretty clearly that there would be a number of actions that may be theoretically possible, but given the current state, which we also heard throughout the day of, you know, public health staffing and even in the medical care sector that some measures may not be practically or operationally feasible.

And we did hear that some either more guidance or maybe coordination between responding agencies is important. It’s not entirely clear how to proceed, but clearly it’s something that was brought up a lot, and we should probably be using this time now between events to figure out exactly, you know, what that should look like.

So I’d like to thank our panelists for a great discussion today, and do I have a minute to give them a round of applause?

Thank you.

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