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Prologue: Public Health in the News -Four major public health stories of the modern era: the AIDS epidemic, the outbreak of waterborne disease in Milwaukee, the health crisis in Russia, and the relation of the 9/11 terrorist attacks to public health. -AIDS Epidemic: ● 1980s: The New York Times began reporting on cases of skin cancer and pneumocystis among gay men, particularly gay men who had multiple and frequent sexual encounters with different partners. ● Centers for Disease Control and Prevention (CDC) formed a task force to find out what was going on. ● May 1982: NYT publishes an article recognizing the condition as “gay-related immune deficiency syndrome” (GRID), which we now know as AIDS. ● In its research, the CDC discovered that a sexually transmitted infectious agent was responsible for the syndrome, but it soon became clear that some intravenous drug users (including women and heterosexual men) had also contracted the immune deficiency, as well as some patients who had received blood transfusions. Babies could also become infected at birth if their mothers had AIDS. ● The Reagan administration mainly ignored the epidemic and the CDC received little funding for research. ● By 1983, people were starting to get really freaked out by AIDS. Some schools refused to allow children with AIDS into the classroom; blood banks had dangerously low supplies because people believed they could contract AIDS through donating blood; some fundamentalist preachers claimed that AIDS was “God’s punishment for abominable behavior” ● April 23, 1984: Dr. Robert Gallo of the National Cancer Institute had discovered the virus (human immunodeficiency virus, or HIV) and that a vaccine would be available in the next five years. However, even today, there is still no vaccine that can prevent HIV. ● By the end of 2012, almost 1.2 million people in the U.S. had been diagnosed with AIDS and 658,504 people had died. ● There is still no cure for AIDS and the only prevention is the avoidance of risky behaviors (unprotected sex, intravenous drug use, etc.) ● Ethical dilemmas/controversy caused by scientific discoveries about AIDS: the protection of the privacy and freedom of the individual suspected of being ill vs. the protection of the health of potential victims at risk of being exposed. ● Many conservative politicians believed that the only appropriate AIDS education message was abstinence from sex and drugs, and some also believed that materials targeted toward gay men promoting safe sex were immoral and “promoting sodomy.”

● Mid-1990s: drugs were developed to control the damage that the virus causes to the immune system. However, these drugs have side effects that may be fatal in some patients, and the drugs are very expensive, averaging $15,475 for a year’s supply. ● This situation demonstrates that public health involves both science and politics. Epidemiology, immunology, biostatistics, and behavioral science were all involved in the research on AIDS and AIDS prevention. -Cryptosporidium in Milwaukee Water: ● April 1993, Milwaukee, Wisconsin: an outbreak of “intestinal flu” strikes, with symptoms including watery diarrhea that lasted for several days, nausea, vomiting, and fever. ● Wisconsin State Health Department began an investigation and investigators found cryptosporidium in stool samples (it was found in 739 stool samples tested between March 1 and May 30). ● Cryptosporidium is an intestinal parasite that is most commonly spread through contaminated water. The infection can be fatal in people with a compromised immune system, like people with AIDS or people taking immunosuppressive drugs for cancer treatment or organ transplants. ● Inspectors found that one of the water treatment plants that supplied the city with water from Lake Michigan was especially turbid (cloudy). On April 9, they closed the plant. ● The investigators found that an estimated 403,000 people had been made ill by the cryptosporidium contamination of the Milwaukee water supply. The number of deaths is estimated at 54, and about 85 percent of those people were AIDS patients. ● Investigators believe that unusually large amounts of the organism may have come from cattle farms, slaughterhouses, or human sewage swept into Lake Michigan by heavy rains. To prevent this from happening again, the water treatment plant was thoroughly cleaned and they installed a turbidity monitor that would sound an alarm and shut down the system if the turbidity surpassed a certain level. ● Even though the U.S. has one of the safest public water supplies in the world, an estimated 4 million to 33 million cases of gastrointestinal illness associated with public drinking water systems occur each year. ● One of the main problems is that many communities are using outdated water treatment technology that is threatened by climate change, population growth, and other factors. Updating this infrastructure is expensive, but waterborne disease outbreaks are also expensive. -Worst-Case Scenario: Public Health in Russia: ● Following the Russian revolution, Russian citizens were suffering from famine, plague, and a general lack of sanitation as effects of the war

● The communist government ran campaigns to teach people to practice basic hygiene and prevent disease. The government also promised free medical care and built new hospitals. These efforts dramatically reduced the incidence of typhus, typhoid fever, and dysentery. ● Stalin oppressed science and one of the government’s top priorities was keeping bad news a secret from the public...this hindered the success of the public health campaign. ● Late 1980s: Gorbachev administration reveals that infant mortality rates had been rising since the 1970s, but were not published because they were embarrassing to the government. Rates of cancer, respiratory disease, and birth defects were also rising. ● The Soviet medical system had many problems: shortages of drugs, vaccines, and medical supplies; unhygienic practices, poor training of doctors, shortages of nurses. ● After the disintegration of the Soviet Union in 1991, public health in Russia and other former Soviet nations grew much worse. By the mid-1990s in Russia, deaths were almost twice as common as births. ● As of 2014, the life expectancy at birth for Russian men is 64.4 years and 76.3 years for women. That same year, the life expectancy for American men was 77.0 years and 81.9 years for American women. ● In 2014, the infant mortality rate in Russia was 7.1 per 1,000 live births compared to 6.2 in the U.S. ● All of these factors led to a decline in the Russian population of about 6 million after 1992. ● Middle-aged men were especially affected by the crisis, and are still disproportionately affected today: these men are dying in large numbers from motor vehicle accidents, suicide, homicide, alcohol poisoning, and cardiovascular disease. ● Infectious diseases reappeared in Russia in the 1990s, including tuberculosis. ● Although Russia has less than half of the population of the United States, it has almost as many citizens carrying the HIV virus (about 1 million people). ● The Russian medical system is extremely underfunded. The World Bank recommends that Russia take the following steps to improve public health: ○ Control excessive alcohol consumption by targeting supply (regulation of production, prices, etc.) and demand (educational campaigns) ○ Control tobacco consumption (taxation, legislation for banning tobacco advertising and promotion) ○ Promote changes in diet and physical activity (school programs on the importance of health, nutrition, and physical activity) ○ Improve road safety by promoting the use of seatbelts and helmets, enforcing laws to prevent accidents due to drunk driving, and implementing current road infrastructure with low-cost safety design features

● Another factor contributing to Russia’s public health crisis is environmental pollution. The Soviet emphasis on industrialization led to a neglect of environmental protection and civilian public works. ● A 2007 report found that 10 of the 30 most polluted places in the world were in the former Soviet Union. ● 2008: a report estimates that 10% of all deaths in Russian cities could be attributed to air pollution. ● A 1999 report found that water pollution is the most serious environmental concern in Russia. Less than half of Russia’s population has access to safe drinking water. ● The accident at the Chernobyl nuclear power station in 1986 poured radioactive material into the atmosphere that contaminated water and soil over 50,000 square miles of Ukraine, Belarus, and western Russia. ● Even today, the Russian government focuses more on economic development than environmental concerns. -Public Health and Terrorism: ● In response to the September 11, 2001 terrorist attack, emergency response plans were activated in the regions where the crashes occurred. ● Public health agencies in New York wanted to ensure the safety of cleanup workers and area residents following the attack (dealing with spoiled food, polluted water, etc.) ● On October 2, 2001, a man named Robert Stevens was admitted to a Florida hospital, suffering from a high fever and disorientation. Doctors confirmed that Stevens had inhaled anthrax, and he died on October 5. ● That month, more workers in the media and in Congress were also exposed to anthrax. Of the 22 cases diagnosed of a 2-month period, 11 of those patients had inhaled the anthrax, and 5 of those 11 people died. ● In 2008, the FBI identified the perpetrator of the anthrax mailings as Bruce Ivins, a scientist working on drugs and vaccines against anthrax at the U.S. Army Medical Research Institute of Infectious Diseases. There remains some doubt about Ivins’ culpability. ● The anthrax attacks were a reminder that the public health system is America’s best protection from bioterrorism. ● The U.S. government has increased funding for disease surveillance, public health laboratories, and emergency response systems to respond to bioterrorist attacks....