Cholera's Rebuke of "Root Cause" Absolutism in Public Policy
Vindication of addressing symptoms directly
“Treat root causes, don’t just address symptoms,” is common wisdom throughout the world of public policy. But as a default mode of thinking, it is wrong. Sometimes treating symptoms—to the exclusion of addressing the root cause!—is the exact right thing to do, and “root cause” discussion is a distraction at best.
Conceptually, we accept this in other fields outside of public policy. I encountered a great example in the field of medicine during a recent reread of Michael Crichton’s Andromeda Strain (1969). In the excerpt below, a scientist is attempting to understand how to best treat a new pathogen that causes all of a person’s blood to clot almost instantly:
The example of cholera came to mind. For centuries, men had known that cholera was a fatal disease, and that it caused severe diarrhea, sometimes producing as much as thirty quarts of fluid a day. Men knew this, but they somehow assumed that the lethal effects of the disease were unrelated to the diarrhea; they searched for something else: an antidote, a drug, a way to kill the organism. It was not until modern times that cholera was recognized as a disease that killed through dehydration primarily; if you could replace a victim’s water losses rapidly, he would survive the infection without other drugs or treatment.
Cure the symptoms, cure the disease.
But Leavitt wondered about the Scoop organism. Could they cure the disease by treating the blood clotting? Or was the clotting secondary to some more serious disorder?1
The Andromeda Strain was published in 1969, just a few years after oral rehydration therapy (ORT) became the standard treatment for cholera, even though the bacteria that caused it was well known by that time.
The history of cholera
Cholera’s timeline goes something like this:
Prior to 1800: the symptoms are understood, but that’s it. The disease ravages any place it touches.
1832: Thomas Latta (the father of IV infusion therapy, or father of the saline drip) treats cholera by pioneering IV saline lines. He was largely ignored by the scientific community. IV treatments were also difficult technologically, so this didn’t take off.
Latter 1800s, the germ theory era:
1854: John Snow (one of the “fathers of epidemiology”) famously isolates the source of an 1854 London cholera outbreak via interviews and dot/point-source maps, even though he didn’t understand the exact causal mechanism of cholera. The scientific and public policy establishment did not generally accept his findings.
1854: Italian anatomist Filippo Pacini isolates the bacteria that causes cholera, but isn’t widely recognized for it at the time.
1884: German physician Robert Koch isolates the cholera bacteria to wide acclaim. He hypothesizes that the bacteria produces some kind of poison that causes the disease.
20th century, toward full understanding and treatment:
~1940s: rehydration and supplementation of electrolytes gains steam in research and treatment for cholera.
1959: the cholera toxin, the actual causal mechanism of cholera, is proven by Sambhu Nath De.
1968: scientists firmly establish effective ORT treatment for cholera.
While antibiotics and other treatments can be used to help treat cholera, ORT is generally the best option, as well as being the least invasive. In this way, it’s not that different from norovirus.
Do we know the root cause of cholera? Yes. Do we treat cholera by directly attacking the root cause? No—treatment is almost always directed at symptoms exclusively, and it works very well.
Of course, you could tell a different story here. You could say the root cause was addressed by public health interventions of the nineteenth and twentieth centuries, namely sewer systems that effectively separated drinking and wastewater. You could also say that cholera’s root cause is addressed by having people boil water before drinking it, thereby killing the cholera bacteria.
But I’m talking about the scenario where someone is experiencing cholera itself. It doesn’t matter if they live in a place with a good sewer system if they still get cholera somehow. In that case, addressing symptoms is the way to go, and they will get better. Just telling them that they have a good sewer system, or that they should have boiled their water, or doing anything other than getting them rehydrated, will hurt or kill them!
Whether one needs to address an upstream root cause, or address downstream symptoms, is clearly context dependent.2 But if your policy problem is like someone who has cholera right now—you better address the symptoms!
Acknowledging that addressing “root causes” is not always the appropriate frame, and that vigorously addressing symptoms sometimes is, is vital for shaping correct policy responses.
Some further reading:
For more stories about cholera in New York City specifically, see The Cholera Years: The United States in 1832, 1849, and 1866 by Charles E. Rosenberg (originally 1962).
For a quick read: John Noble Wilford’s “How Epidemics Helped Shape the Modern Metropolis” in The New York Times (2008).
The Andromeda Strain, by Michael Crichton (1969). If you don’t know Crichton, he wrote a ton of books, including Jurassic Park (one of my favorites). His biography is fascinating, and his books are both entertaining and shot through with ideas across medicine, mathematics, and all the other ingredients of the best techno-thrillers.
Crichton, Michael. “Chapter 11: Decontamination,” The Andromeda Strain (1969). Vintage Books 2017 edition, p.121.
I think most policymakers would be better off if they adopted the average attitude of prevention versus treatment of most medical professionals (this isn’t to say that medical professionals nail it all the time, just that they are far better than many policymakers). Which is to say: of course you want to prevent disease in the first place. But if people get a disease, you better treat them!