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It can't happen here
Public Health THE JOURNAL OF THE SOCIETY OF COMMUNITY MEDICINE (FORMERLY THE SOCIETY OF MEDICAL OFFICERS OF HEALTH)
Volume 88, Number 1, November 1973
It Can't Happen Here CHOLERA,a s some medical students and quite a number of D.P.H. candidates have been taught, is something that occurred in epidemic form in this country in the middle of the nineteenth century and proved to be a blessing in disguise in that it panicked the Government of the time into doing something about the health of the people and inventing the M.O.H. Smallpox, a few years ago, was accidentally imported into Yorkshire and South Wales, but during the past five years the countries in which it was endemic--and which might, therefore, export it to the U.K.--have been reduced from 30 to 7 and W.H.O. is beginning to think in terms of its world-wide eradication. Typhoid fever is also coming to belong to history; it is nearly forty years since the names of Croydon and Bournemouth were a matter for whispering in medical circles. Diphtheria, as everyone knows, was "eradicated" in Britain in the 1940s or thereabouts. It is certainly reasonable to say that any British citizen who wishes to experience any of these unpleasant diseases will nowadays probably have to go in search of them somewhere else but there is no certainty that he will have to travel to very remote places and, in any event, mass air travel and the popularity of package tours are beginning to alter the meaning of the word "remote". Cholera, for example, was until very recently considered an oriental speciality. The prudent traveller to the Indian sub-continent was expected to get himself vaccinated against the disease before he left Britain; he did not expect to encounter it in the North African holiday countries, let alone in Italy. It may well be that the foreign holiday vogue has played a considerable part in the recent outbreaks. Reasonable control of water supplies and sanitation offers a good prospect of prevention of epidemics, but there is no doubt that "control" which was adequate in the 1950s has become less so as sewage systems which could just cater for local resident populations have been overloaded by mass holiday immigration. There was a time when British assumptions that all foreigners were filthy and all "natives" nasty offered some built-in protection in that the travelling Briton never drank the local water or ate the local fruits atJd vegetables uncooked. He is now prepared to take basic hygiene on trust in places to which the travel agencies beckon him for a fortnight in the sun. We are all in favour of diminishing xenophobia, but these new incidents are a salutary warning against complacency.
2
PUBLIC HEALTH VOL. 88 NO. 1
Fortunately, the shortness of the incubation period of cholera reduces the risk of a cholera patient's starting an outbreak after his return to his own country and one can have confidence in British public water supplies, but it is possible that a patient who has a one-week incubation period might, in one of our seaside resorts with one of the more primitive systems of sewage disposal, give rise to an unpleasant episode of cholera carried by local shell-fish. W.H.O. has certainly made considerable and commendable progress in smallpox eradication and we would go so far as to guess that world-wide eradication, not long ago regarded as a pipe-dream, is something which can be considered as a realistic possibility. We would not however--nor would the W.H.O. experts--yet suggest a firm target for its completion. We note, in a recent W.H.O. report, the use of the term "interrupted"--in Ethiopia, for instance, it was stated that programme officials believed that "transmission in 9 of the 14 provinces can be interrupted by the end of the year" (1972). The Sudan had succeeded in interrupting transmission in the early 1960s, yet in both 1970 and 1971 the incidence of the disease was the highest in that country for 15 years. What that means, in effect, is that after apparent eradication in a country there must subsist for some considerable time the risk of reintroduction. It is not too difficult for an international organization to mount a campaign which mobilizes not only its own experts but the enthusiasm of a country's own workers for a "blitz" on a disease but the effectiveness of the campaign demands that there should be a long-term follow-up which maintains government and public interest over a period of years after the immediate threat, with its emphasis on urgency and its incentive to enthusiasm, has subsided. There is no need to go very far afield to contract typhoid or paratyphoid. In 1971, in Europe alone, a total of 17 outbreaks of typhoid fever were notified. France produced three, Romania (an up-and-coming holiday country) had 12 outbreaks and even Finland--for those who place special reliance on the hygiene-consciousness of the Scandinavian countries--contrived to have two. The evidence suggests less that the travelling Briton goes out to seek his own infection than that the infection obligingly comes to meet him half-way. The infections appear to come into northern Europe from Southern Europe or North Africa and it is not unreasonable to assume that some part of it at least may be brought in by the rapidly increasing number of immigrant workers. It is too early to assess the potential threat to Britain from the immigrant workers whose entry to this country may be facilitated by Common Market entry, but it is important to realize that such a threat might develop and that the possibility cannot be ignored. The fourth of the diseases which we have instanced is, perhaps, not one that is likely to be imported. Diphtheria has, so to speak, been pronounced officially dead in Britain and, therefore, dead it must officially be so. It can be effectively treated; penicillin and antitoxin, given early enough, will ensure recovery with no appreciable lasting damage. However, in spite of its official demise it refuses to lie down permanently. Every few years there comes an outbreak and the unhappy story is much the same every time. Out of a clear sky there come two or three deaths. The disease is so well controlled that few doctors now in practice have met it. They do not expect it, nor are they equipped to recognize it. The first case or two are diagnosed too late for treatment to be effective; only after there have been these initial sacrifices is the profession in the locality alerted and diagnosis made on the first or second day of illness; the old maxim from the heydey of diphtheria "if you're sufficiently suspicious to take a swab for K.L.B. you're SUSlSicious enough to give "antitoxin" has fallen into desuetude. We are far from wishing to prophesy doom and preach despondency. We believe that the health services of this country, clinical and social, personal and environmental, are
IT CAN'T HAPPEN HERE
3
efficient enough to contain any outbreaks of any of the diseases which we have instanced. When they do occur they will bring with them possibly two or three deaths, probably some cases of more or less severe illness followed by virtually complete recovery, and a substantial amount of more or less localized public alarm, usually encouraged by the mass media. It might be contended that a little public panic is a salutary thing, in that it gives public complacency a necessary jolt from time to time, but perhaps the same benefits might be obtained at a somewhat lower price. We would suggest, for example, that the case for acceleration of the bringing up to standard of some British holiday resort services for sewage disposal is strong. True, there have been very few proven cases of typhoid infection from swimming in this country's coastal waters, but that may be due as much to difficulties of proving the case as to lack of cases. Certainly any risks of infection via shellfish-borne infections are as great as they used to be unless steps have been taken recently either to improve sewage disposal or to cleanse the shellfish. (And, if, as W.H.O. figures seem to suggest, various strains of Salmonella seem to be becoming commoner on the other side of the North Sea, one can hardly claim special virtue for the water on the British side !) Is it conceivable that the Department of Health has been a little starry-eyed in advising against childhood vaccination against smallpox ? The probability of smallpox being brought to the child's home town is undoubtedly lessening, but the probability of the child's later going out, so to speak, in search of smallpox is increasing. Is it so much less risky to postpone primary vaccination till he is adult than to let him have it during the second year of life ? We are, however, most concerned about the risks of medical complacency. There is the attitude, common and possibly growing, that since most infections yield to antibiotics the antibiotic umbrella is an adequate safeguard, even if the umbrella is not put up until the rain has started. Typhoid fever is notoriously protean in its initial manifestations and the sporadic case is still often diagnosed only after all the other possibilities have been excluded, instead of its having been borne in mind from an early stage. It cannot be assumed that all children have nowadays had the full routine set of immunizations and while the present odds are that a patient diagnosed as suffering from diphtheria will prove in the event to have glandular fever it is far from impossible that a patient diagnosed as having glandular fever may be the first case of a diphtheria outbreak. All the Department's panel of smallpox consultants will say that virtually all the consultations for which they are called out turn out to be cases of anything but smallpox, but the fact remains that when a smallpox epidemic does occur in Britain it is due to the "pilot case" having been misdiagnosed. The really dangerous part of the potential epidemic situation is that the number of physicians with experience of the more dangerous infectious diseases is steadily diminishing, and that pari passu these diseases are, with the increase of the number of potential patients whose one-time immunity is "wearing thin", becoming more difficult to diagnose. We would not suggest that specialists in infectious diseases can make spot diagnoses infallibly in this kind of situation but there is. certainly a need for a cadre of consultants who can say "certainly not" or "I think it possibly might be". It is not necessary that the treatment of all patients with any kind of infectious disease should be in the hands of consultants in infectious diseases, but it is still necessary--and may be becoming more necessary--that the country should have adequate cover in this branch of work.
Volume 88, Number 1, November 1973
It Can't Happen Here CHOLERA,a s some medical students and quite a number of D.P.H. candidates have been taught, is something that occurred in epidemic form in this country in the middle of the nineteenth century and proved to be a blessing in disguise in that it panicked the Government of the time into doing something about the health of the people and inventing the M.O.H. Smallpox, a few years ago, was accidentally imported into Yorkshire and South Wales, but during the past five years the countries in which it was endemic--and which might, therefore, export it to the U.K.--have been reduced from 30 to 7 and W.H.O. is beginning to think in terms of its world-wide eradication. Typhoid fever is also coming to belong to history; it is nearly forty years since the names of Croydon and Bournemouth were a matter for whispering in medical circles. Diphtheria, as everyone knows, was "eradicated" in Britain in the 1940s or thereabouts. It is certainly reasonable to say that any British citizen who wishes to experience any of these unpleasant diseases will nowadays probably have to go in search of them somewhere else but there is no certainty that he will have to travel to very remote places and, in any event, mass air travel and the popularity of package tours are beginning to alter the meaning of the word "remote". Cholera, for example, was until very recently considered an oriental speciality. The prudent traveller to the Indian sub-continent was expected to get himself vaccinated against the disease before he left Britain; he did not expect to encounter it in the North African holiday countries, let alone in Italy. It may well be that the foreign holiday vogue has played a considerable part in the recent outbreaks. Reasonable control of water supplies and sanitation offers a good prospect of prevention of epidemics, but there is no doubt that "control" which was adequate in the 1950s has become less so as sewage systems which could just cater for local resident populations have been overloaded by mass holiday immigration. There was a time when British assumptions that all foreigners were filthy and all "natives" nasty offered some built-in protection in that the travelling Briton never drank the local water or ate the local fruits atJd vegetables uncooked. He is now prepared to take basic hygiene on trust in places to which the travel agencies beckon him for a fortnight in the sun. We are all in favour of diminishing xenophobia, but these new incidents are a salutary warning against complacency.
2
PUBLIC HEALTH VOL. 88 NO. 1
Fortunately, the shortness of the incubation period of cholera reduces the risk of a cholera patient's starting an outbreak after his return to his own country and one can have confidence in British public water supplies, but it is possible that a patient who has a one-week incubation period might, in one of our seaside resorts with one of the more primitive systems of sewage disposal, give rise to an unpleasant episode of cholera carried by local shell-fish. W.H.O. has certainly made considerable and commendable progress in smallpox eradication and we would go so far as to guess that world-wide eradication, not long ago regarded as a pipe-dream, is something which can be considered as a realistic possibility. We would not however--nor would the W.H.O. experts--yet suggest a firm target for its completion. We note, in a recent W.H.O. report, the use of the term "interrupted"--in Ethiopia, for instance, it was stated that programme officials believed that "transmission in 9 of the 14 provinces can be interrupted by the end of the year" (1972). The Sudan had succeeded in interrupting transmission in the early 1960s, yet in both 1970 and 1971 the incidence of the disease was the highest in that country for 15 years. What that means, in effect, is that after apparent eradication in a country there must subsist for some considerable time the risk of reintroduction. It is not too difficult for an international organization to mount a campaign which mobilizes not only its own experts but the enthusiasm of a country's own workers for a "blitz" on a disease but the effectiveness of the campaign demands that there should be a long-term follow-up which maintains government and public interest over a period of years after the immediate threat, with its emphasis on urgency and its incentive to enthusiasm, has subsided. There is no need to go very far afield to contract typhoid or paratyphoid. In 1971, in Europe alone, a total of 17 outbreaks of typhoid fever were notified. France produced three, Romania (an up-and-coming holiday country) had 12 outbreaks and even Finland--for those who place special reliance on the hygiene-consciousness of the Scandinavian countries--contrived to have two. The evidence suggests less that the travelling Briton goes out to seek his own infection than that the infection obligingly comes to meet him half-way. The infections appear to come into northern Europe from Southern Europe or North Africa and it is not unreasonable to assume that some part of it at least may be brought in by the rapidly increasing number of immigrant workers. It is too early to assess the potential threat to Britain from the immigrant workers whose entry to this country may be facilitated by Common Market entry, but it is important to realize that such a threat might develop and that the possibility cannot be ignored. The fourth of the diseases which we have instanced is, perhaps, not one that is likely to be imported. Diphtheria has, so to speak, been pronounced officially dead in Britain and, therefore, dead it must officially be so. It can be effectively treated; penicillin and antitoxin, given early enough, will ensure recovery with no appreciable lasting damage. However, in spite of its official demise it refuses to lie down permanently. Every few years there comes an outbreak and the unhappy story is much the same every time. Out of a clear sky there come two or three deaths. The disease is so well controlled that few doctors now in practice have met it. They do not expect it, nor are they equipped to recognize it. The first case or two are diagnosed too late for treatment to be effective; only after there have been these initial sacrifices is the profession in the locality alerted and diagnosis made on the first or second day of illness; the old maxim from the heydey of diphtheria "if you're sufficiently suspicious to take a swab for K.L.B. you're SUSlSicious enough to give "antitoxin" has fallen into desuetude. We are far from wishing to prophesy doom and preach despondency. We believe that the health services of this country, clinical and social, personal and environmental, are
IT CAN'T HAPPEN HERE
3
efficient enough to contain any outbreaks of any of the diseases which we have instanced. When they do occur they will bring with them possibly two or three deaths, probably some cases of more or less severe illness followed by virtually complete recovery, and a substantial amount of more or less localized public alarm, usually encouraged by the mass media. It might be contended that a little public panic is a salutary thing, in that it gives public complacency a necessary jolt from time to time, but perhaps the same benefits might be obtained at a somewhat lower price. We would suggest, for example, that the case for acceleration of the bringing up to standard of some British holiday resort services for sewage disposal is strong. True, there have been very few proven cases of typhoid infection from swimming in this country's coastal waters, but that may be due as much to difficulties of proving the case as to lack of cases. Certainly any risks of infection via shellfish-borne infections are as great as they used to be unless steps have been taken recently either to improve sewage disposal or to cleanse the shellfish. (And, if, as W.H.O. figures seem to suggest, various strains of Salmonella seem to be becoming commoner on the other side of the North Sea, one can hardly claim special virtue for the water on the British side !) Is it conceivable that the Department of Health has been a little starry-eyed in advising against childhood vaccination against smallpox ? The probability of smallpox being brought to the child's home town is undoubtedly lessening, but the probability of the child's later going out, so to speak, in search of smallpox is increasing. Is it so much less risky to postpone primary vaccination till he is adult than to let him have it during the second year of life ? We are, however, most concerned about the risks of medical complacency. There is the attitude, common and possibly growing, that since most infections yield to antibiotics the antibiotic umbrella is an adequate safeguard, even if the umbrella is not put up until the rain has started. Typhoid fever is notoriously protean in its initial manifestations and the sporadic case is still often diagnosed only after all the other possibilities have been excluded, instead of its having been borne in mind from an early stage. It cannot be assumed that all children have nowadays had the full routine set of immunizations and while the present odds are that a patient diagnosed as suffering from diphtheria will prove in the event to have glandular fever it is far from impossible that a patient diagnosed as having glandular fever may be the first case of a diphtheria outbreak. All the Department's panel of smallpox consultants will say that virtually all the consultations for which they are called out turn out to be cases of anything but smallpox, but the fact remains that when a smallpox epidemic does occur in Britain it is due to the "pilot case" having been misdiagnosed. The really dangerous part of the potential epidemic situation is that the number of physicians with experience of the more dangerous infectious diseases is steadily diminishing, and that pari passu these diseases are, with the increase of the number of potential patients whose one-time immunity is "wearing thin", becoming more difficult to diagnose. We would not suggest that specialists in infectious diseases can make spot diagnoses infallibly in this kind of situation but there is. certainly a need for a cadre of consultants who can say "certainly not" or "I think it possibly might be". It is not necessary that the treatment of all patients with any kind of infectious disease should be in the hands of consultants in infectious diseases, but it is still necessary--and may be becoming more necessary--that the country should have adequate cover in this branch of work.