The Consequences of a DMV Approach to Infectious Disease

One of the recurrent themes I reiterate when it comes to whatever infectious disease emergency the world is faced with is that much of the expertise of responding to these ever evolving threats resides in public health agencies. These agencies range in depth and expertise from the CDC at one end of the spectrum to a local health department at the other. While infectious disease management is really the raison d'etre of public health and are their core and original function, recent decades have seen public health agency's exhibit mission creep. Now public health agencies often balance the demands for developing a plan for tackling obesity with one for preventing the spread of tuberculosis. Such, in my view, distractions from their fundamental role deprioritize infectious disease in a risky manner. Last night, I gained another piece of data I added to support my position.

As someone who also trained in emergency medicine -- in addition to infectious disease and critical care medicine -- I try to keep my hand in the field with a few casual shift in my hometown hospital's emergency department. Being an infectious disease physician, however, I am always on the lookout for interesting infectious disease cases that I can pluck from amongst the myriad complaints that bring people to the ED.

Yesterday, I had that opportunity when I saw a patient recently returned from a Zika-laden area of the world who had symptoms entirely consistent with Zika. The case was uncomplicated and likely will be self-limited, as most Zika cases are. But, ever conscious of the epidemiological importance of diagnosing certain infectious diseases, I believed the patient merited confirmatory testing. Such testing is largely the province of the state department of health (though commercial tests are available) and, because of that, requires consultation to arrange for testing to occur.

Because it was after hours (infectious diseases are regularly not just 9-5 pathogens) , I was predictably frustrated with the state department's health response as it took some time to reach a person who could "authorize" the test, which was being performed almost exclusively for public health purposes as my treatment of the patient would not be impacted by the result of the test. Needless to say, an after hours inquiry in which one must navigate and bounce between telephone numbers with recorded messages and an answering service unable to effectively understand or triage the needs of a caller are the opposite of the nimble response needed to adeptly manage infectious disease emergencies. It is what one expects of the DMV.

To its credit, I did receive the information needed from professional and knowledgeable health department personnel but I would say that the trouble I incurred trying to obtain this information is likely something many physicians would not endure-- a dangerous situation that limits the ability to have full situational awareness of infectious diseases circulating. I am an unequivocal supporter of reporting infectious diseases with requisite import and can only imagine how many healthcare providers understandly do not wish to wade through the bureaucratic processes needed to ensure that appropriate testing and notification occurs. So, suffice it to say, the Zika case reports in the US are likely an underestimate. 

I'd like to think that this phenomenon would not occur so readily if the original focus of the department remained intact and their resources were not scattered so far afield from their original infectious disease mission.