2006-01-25
Epidemics or Pandemics
There is supposedly a pandemic coming, and people are starting
to become concerned. I have been reading this book and it makes
me wonder? If the right people connected the Three Rules of Epidemics to this pandemic, maybe they could put a stop to it before it Tips. But then, maybe it is already Tipped.
The Three Rules of Epidemics - from the book, The Tipping Point by
Malcom Gladwell
'In the mid-1990s, the city of Baltimore was attacked by an epidemic of syphilis.
In the space of a year, from 1995 to 1996, the number of children born with the disease increased by 500 percent. If you look at Baltimore's syphilis rates on a graph, the line runs straight for years and then, when it hits 1995, rises almost at a right angle.
What caused Baltimore's syphilis problem to tip? According to the Centers for Disease Control, the problem was crack cocaine. Crack is known to cause a dramatic increase in the kind of risky sexual behavior that leads to the spread of things like HIV and syphilis. It brings far more people into poor areas to buy drugs, which then increases the likelihood that they will take an infection home
with them to their own neighborhood. It changes the patterns of social connections between neighborhoods. Crack, the CDC said, was the little push that the syphilis problem needed to turn into a raging epidemic.
John Zenilman of Johns Hopkins University in Baltimore, an expert on sexually transmitted diseases, has another explanation: the breakdown of medical services in the city's poorest neighborhoods. "In 1990-91, we had thirty-six thousand patient
visits at the city's sexually transmitted disease clinics, " Zenilman says. "Then the city decided to gradually cut back because of budgetary problems. The number of clinicians (medical personnel) went from seventeen to ten. The number of physicians went from
three to essentially nobody. Patient visits dropped to twenty-one thousand. There also was a similar drop in the amount of field outreach staff. There was a lot of politics -----
things that used to happen , like computer upgrades, didn't happen. It was a worst-case scenario of city bureaucracy not functioning. They would run out of drugs."
When there were 36,000 patient visits a year in the STD (Sexually Transmitted Diseases) clinics of Baltimore's inner city, in other words, the disease was kept in equilibrium. At some
point between 36,000 and 21,000 patient visits a year, according to Zenilman, the disease erupted.
It began spilling out of the inner city, up the streets and highways that connect those neighborhoods to the rest of the city. Suddenly, people who might have been infectious for a week before getting treated were now going around infecting others for two or three or four
weeks before they got cured. The breakdown in treatment made syphilis a much bigger issue than it had been before.
There is a third theory, which belongs to John Potterat, one of the country's leading epidemiologists. His culprits are the physical changes in those years affecting East and West Baltimore, the heavily depressed neighborhoods on either side of Baltimore's downtown, where the syphilis problem was centered. In the mid-1990s, he points out , the city of Baltimore embarked on a highly publicized policy of dynamiting the old 1960s-style public
housing high-rises in East and West Baltimore. Two of the most publicized demolitions --
Lexington Terrace in West Baltimore and Lafayette Courts in East Baltimore -- were huge projects, housing hundreds of families, that served as centers for crime and infectious disease. At the same time, people began to move out of the old row houses in East and
West Baltimore, as those began to deteriorate as well.
"It was absolutely striking," Potterat says, of the first time he toured East and West Baltimore. "Fifty percent of the row houses were boarded up, and there was also a process where they destroyed the projects. What happened was a kind of hollowing out. This fueled
the diaspora. For years syphilis had been confined to a specific region of Baltimore, within highly confined sociosexual networks. The housing dislocation process served to move these
people to other parts of Baltimore, and they took their syphilis and other behaviors with them."
What is interesting about these three explanations is that none of them is at all dramatic.
The CDC thought that crack was the problem. But it wasn't as if crack came to Baltimore for the first time in 1995. It had been there for years. What they were saying is that there was a subtle increase in the severity of the crack problem in the mid-1990s, and that change
was enough to set off the syphilis epidemic. Zenilman, likewise, wasn't saying that the STD clinics in Baltimore were shut down. They were simply scaled back, the number of clinicians cut from seventeen to ten. Nor was Potterat saying that all Baltimore was hollowed out . All it took, he said, was the demolition of a handful of housing projects and the abandonment of homes in key downtown neighborhoods to send syphilis over the top. It takes only the
smallest of changes to shatter an epidemic's equilibrium.
The second, and perhaps more interesting, fact about these explanations is that all of them are describing a very different way of tipping an epidemic. The CDC is talking about the
overall context for the disease -- how the introduction and growth of an addictive drug can so change the environment of a city that it can cause a disease to tip. Zenilman is talking about the disease itself. When the clinics were cut back, syphilis was given a second life.
It had become a lingering problem that stayed around for weeks. Potterat, for his part, was focused on the people who were carrying syphilis. Syphilis, he was saying, was a disease
carried by a certain kind of person in Baltimore-- a very poor, probably drug-using, sexually active individual. If that kind of person was suddenly transported from his or her old neighborhood to a new one --- to a new part of town, where syphilis had never been a problem
before -- the disease would have an opportunity to tip.
There is more than one way to tip an epidemic, in other words. Epidemics are a function of the people who transmit infectious agents, the infectious agent itself, and the environment
in which the infectious agent is operating. And when an epidemic tips, when it is jolted out of equilibrium, it tips because something has happened, some change has occurred in one (or two
or three) of those areas. These three agents of change I call the Law of the Few, the Stickiness Factor, and the Power of Context. '
This is a very interesting book. "The Tipping Point' by Malcolm Gladwell -- How little things can Make a Big Difference.
Patricia Downing
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