On the heels of my recent post regarding Gaetan Dugas and the origin (myths) of HIV/AIDS in the U.S. comes this 10/29 editorial from NYT science writer Donald G. McNeil, Jr.
The editorial is strange, IMO.
After recounting the facts, McNeil states that
The debunking of the Dugas myth raises a moral question: Is it right to hunt down the first case in any outbreak, to find every Patient Zero?
Actually, I am not aware of many public health ethicists who would find this an especially compelling moral question. The primary issue here is epidemiologic, not moral, IMO. Does it make good epidemiologic sense to search for the “patient zero,” for the initial human vector as to epidemic disease? Is doing so crucial for good contact tracing and public health surveillance? If it is not, then there is no moral conflict whatsoever, since we have no business tracing such initial vectors if there is no public health payoff.
If it does make good epidemiologic sense to trace the initial human vector in this way, then it seems obvious that we have moral obligations to minimize the likelihood that such tracing and surveillance stigmatizes persons. This is especially the case when dealing with vulnerable and historically oppressed populations (GLBTQ, immigrant women in early 20th c., etc.), and I have little doubt that American actors have historically failed to meet this obligation far more often than they have succeeded. But our practical failures do not equate with moral difficulties. There is not much of a moral quandary here. Either it makes epidemiologic sense to do this kind of tracing and PH surveillance or it does not.
If it does not, there is no moral problem. If it does, we have moral obligations to behave in ways that minimize the risk of stigmatizing anyone, but especially the already-disadvantaged groups that bear disproportionate disease burdens.
Nothing here is controversial in the slightest, IMO.
McNeil goes on to give an example of these apparently difficult moral questions:
Should they all be publicly named and vilified like Mary Mallon, the Irish cook who became known as Typhoid Mary and died after 23 years quarantined on an island in the East River in New York?
Umm, no. No, they should not. But if this kind of tracing is important for population health, maybe we could try doing so without publicly naming and vilifying them? This does not seem especially problematic, nor too much to ask, even if we have typically failed persons like Ms. Mallon or Mr. Dugas. Again, the moral question here just is not a difficult one, as suggested by the fact that the question McNeil poses here seems almost rhetorical.
He continues by providing the obvious answer:
Of course not, many ethicists argue. They disapprove of stigmatizing any patient, and the best preventive is to not hunt one down.
But epidemiologists disagree. To them, it is vital to trace the source of every outbreak — because that is often the only way to stop it.
Again, this seems something of a straw man. I do less with infectious disease than most public health ethicists (I focus much more on NCD), so maybe I’m wrong here. However, I am a stigma scholar, and I’m not aware of many PHEs who think the solution to structural stigma is to abandon public health surveillance entirely if such surveillance is important to population health. Of course, the solution to structural stigma is to intervene at both micro and macro levels, by (1) deploying anti-stigma mechanisms that regulate individual, person-centered interactions; and (2) address the larger social structures that fuel and perpetuate stigmas against marginalized and disadvantaged groups.
To be charitable to the author, I suppose we can say that there may well be an ethical tension between good PH surveillance and risks of stigmatizing vulnerable populations. This is why caution and good PH practice is needed. But I know of no reason why the two are incompatible, nor am I aware of any card-carrying PHE who takes such a stark position (that we must in all cases decide between good PH surveillance and no PH surveillance).
PHE is difficult enough, and there enough wicked, intractable problems around without inventing new ones that do not so qualify.