oship-dev team mailing list archive

[Luciana Tricai Cavalini <lutricav@xxxxxxxxx>]

Hi OSHIP community,

Tim Cook escreveu:
> http://www.ted.com/talks/larry_brilliant_wants_to_stop_pandemics.html 
>
> ...some time later because you really did watch the video.  :-)
>   
Thank you, Tim, for sending the video. I respect Larry Brilliant a lot 
for the work he chose to do as a doctor.
Nevertheless, we have people in the OSHIP community that might think 
that Dr. Brilliant's point of view is uncontroversial. It is not. From 
my perspective, as an epidemiologist and dealing for some time with the 
material reality of what he discusses in his excellent presentation, and 
then trying to teach that to healthcare students, I think it is 
important to express my criticism on 3 of his arguments:
1. Dr. Brilliant minimizes the impact of universal and continuous 
vaccination strategies to prevent and control the diseases he worked 
with. Neither smallpox nor polio would be eradicated if there were no 
effective vaccines available. His argument is that vaccines don't 
control those diseases because every year new susceptible children are 
born. This is a "campaignist" understanding of vaccination programs. If 
one goes there to an epidemic/endemic area and just does one 
cross-sectional vaccination campaign, it is evident that the disease 
won't disappear, because new susceptibles will come along not only due 
to births, but also due to migration. The only way to perform effective 
vaccination programs is establishing it as a universal and continuous 
healthcare strategy. Babies need to come to live having their first 
vaccinations as soon as possible, and having all others immediately 
scheduled. Of course that can only happen if the vaccination is 
available continuously. And that was done for the smallpox and polio 
eradication campaigns: the global population was universally vaccinated 
for 2-3 decades (in the smallpox case) and, since the disease provides 
permanent full immunity after one single dose of vaccination, the last 
smallpox spots remained in places where vaccination was culturally 
unacceptable and certain cultures had to be devastated and "modernized" 
in order to have its subjects vaccinated and thus achieving complete 
eradication, something that is not presented by Dr. Brilliant because it 
is probably such a delicate matter for his audience.
2. Dr. Brilliant relies the development of his system on what is 
considered the worst evidence for epidemiological surveillance: the 
press. They have detected diseases by searching 2,000 news sites. One of 
the first things that we learn as public health medical residents is 
that your epidemiological surveillance system is totally flawed if the 
local press knows about a certain epidemic before you do. You should 
resign from your job if you let that happen. For a epidemics to be 
appealing enough for the press to care about it, either the number of 
cases is huge and rampant or the epidemics is very lethal, and in both 
cases you've already lost control of it 5 weeks before. What we need is 
to make the suspicion *soon after the citizen feels the first signals or 
symptoms*, even if he/she still didn't come to the doctor (e.g. if the 
person types his/her symptoms on his/her Personal Health Record of if 
the Family Health Program knocks at the door), but usually we will only 
be able to raise this suspicion soon after the patient knocks at the 
doctor's door. The fact is that, nowadays, we have the citizen knocking 
at the doctor/hospital's door 3-4 times before he/she is admitted, and 
for epidemics control that's too late, irregardless of the the disease 
type. Our system, EpiS3, will have the capabilities of performing this 
early suspicion, and then send the alert messages needed, to the 
citizen, to the doctor, to the minister of health, whoever. So, yes, 
Google detects epidemics 3 weeks earlier than the World Health 
Organization, but it is still too late; we need to get closer to the 
moment the disease is detectable, and EpiS3 can do that.
3. Dr. Brilliant, being a classic type of NGO activist, something that I 
usually respect, undermines the role of the National States as a key 
party of the disease control strategies. The fact is that no NGO in the 
world, no matter how wealthy it is (think about Bill and Melinda Gates 
Foundation) can afford the implementation of a universal and everlasting 
healthcare strategy. Only National States can afford that. Dr. Brilliant 
doesn't clarify in his presentation, for example, that almost all 
National governments strongly supported the continuous work required to 
sustain the follow-up and vaccination strategies for both the smallpox 
and polio eradication. No universal and everlasting healthcare strategy 
has been ever implemented in the world without the concourse of massive 
resources (e.g., financial, workforce, infrastructure, logistics, 
supplies) coming from the National governments where it was implemented 
(and that includes the  of the US pseudo-liberal healthcare system, that 
is known by being at least 30% directly funded by the US government - 
I'm here only thinking about Medicare and Mediaid and not including the 
tax waiver). So, Dr. Brilliant may detect the epidemics he wants with 
Google tools: without the support from the local governments he is 
unable to control a single case of any epidemic. And that's the power of 
real open source projects just like EpiS3: ideally, you provide the 
solution and the local communities define if they want to implement it 
or not, and then they lobby their local government to force it to be 
implemented, because there's no community-targeted healthcare policy 
that can possibly be implemented top-bottom. That's why the Family 
Health Program and the SAMU, being such great ideas, take 10-15 years to 
produce their first impacts on healthcare indicators such as mortality 
or hospitalization rates: because they started as an uniform policy for 
the whole country, ant that was so inadequate for so many places, that 
flexible local government strategies had to be allowed, and that took 
all that time. It's sad, but that's how things work in the capitalist 
society; and if you don't like it, then try to change it (or at least 
die trying)... ;-)
Well, I got a little bit carried away! I would be surprised if I still 
have one person in the audience that still didn't go to sleep. But my 
idea was to show that most of the ideas in that video are very good, but 
some are controversial, and maybe that's something important for some of 
you guys to know.
I wish everybody a wonderful Sunday!

Cheers, Luciana.


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