Public Health and Local Customs

In This Painted Veil, Edward Norton plays an infectious disease specialist who has relocated to inland China because of a cholera epidemic. He immediately is forced to face the problems related to public health and local customs when he discovers that the families of the dead have been burying their family members near the river because their spirits, it is believed, need the water to find rest. I'm not sure what exactly the belief was, but it doesn't matter on one level because by burying the dead so close to the water supply, cholera was seeping into the river, and had infected the water supply. Norton's character had previously learned that the town's well was also infected with cholera, so this was now officially a bad discovery.

Public health decisions are usually top-down, or at least, historically. Partly this is because the public health decisions are necessary because of market failure problems, and market failure problems have arisen because it's in no decentralized agent's best interest to change their behavior. So, we tax polluters, rather than rely on the market to internalize these externalities. In the same way, we public health agencies provide public goods by trying to isolate the public good aspects of an infectious disease epidemic, and thereby attempt to control the epidemic by discriminating on those public good nodes - like the water supply, or maybe locating patient zero. In one of my favorite, neglected, papers on risky sex, Ayres and Baker recommended penalizing unprotected sex during first-time sexual encounters as a misdemeanor, since first-time sexual encounters were both the main instances when date rape happened (and thus requiring a condom increased information flow between both parties, thus helping deal with these problems of communication that are often related to date rape), as well as targeted the groups who were at the center of the storm of an STD epidemic.

But when these attempts at helping the community necessarily violate the individual liberty of local citizens, it's extremely delicate, and the movie really only glossed over this. There's a scene where it's very clear it's about to hit the hand, but thankfully Norton's character had an epiphany that would let him divert water upstream into town, and therefore circumvent the bodies. But what if he hadn't come up with such an idea? He was only able to do that, because the giant water wheel that was being used to draw water out of the river to irrigate the crops, existed. But not every problem has a water wheel waiting there, so what is to be done? As the young economist, fresh out of grad school, I come down on the side of efficiency pretty much every time. Screw the locals and their customs. They either accept this, and thus thousands of lives are spared, or they get locked in jail. (Note this is only one reason among numerous reasons why no one asks me to do anything of any consequence, methinks).

In the post-AIDS article, Pisani says similar kinds of confrontations between public health and community morals are at work today. It's not the same, obviously, as bereaved families refusing to move the bodies of their dead relatives, whose corpses are rotted with cholera, but its effects are nonetheless the same. It may mean discouraging anal sex, since it's such a significant driver of STD within the network given the much higher per-act probabilities of infection associated with the practice. It may mean tracking down all the current and previous partners of a newly infected HIV-positive patient, which necessarily violates many standards of privacy we associate with both sexual partnerships, which is even more complex within a highly disenfranchised group like the men who have sex with men (MSM) network. Nevertheless, it seems like nowhere do you see the tension between medical necessity and community ethics come to an impasse as you do in regards to public health. Some of this seems to me to be due to the problems of the two equilibria both being the consequence of decentralized behavior. Both the development of the ethical standards in the community and the behaviors that drive an epidemic are the consequence of people's chosen behaviors - utility maximizing behaviors, you might say.