“Break on through to the other side.”
JUST AS A MAP is not the territory, so is price not synonymous with value. In the field of sexually transmitted diseases (STD), a cost-effectiveness-of-interventions cottage industry emerged during 1980s. Such focus is partly encouraged by its measurability: It is easier to determine price (quantitative, hence solid) than value (qualitative, hence elusive).1 In such company belongs the accompanying article by Peterman and colleagues.2
Peterman's group endeavored to compare the price and case-finding effectiveness of three partner notification approaches for patients diagnosed with early syphilis in three metropolitan areas in the United States. Each approach shared the traditional elements of formal interviewing for sexual partner information and of verification that locatable partners were notified. The two approaches that differed from the traditional one either (1) encouraged rapid referral of sexual partners by index patients themselves or (2) augmented the traditional approach with collection of blood specimens from partners in the field. The authors found no substantial differences in the price or yield of the three approaches. That price was similar is not surprising because nearly two thirds of the operational approach in each study arm was the same. That partner notification outcomes were equally poor in each arm is disappointing and needs more interpretation than that offered by the authors.
The report by Peterman and colleagues does not contain sufficient contextual information for the reader to evaluate their partner notification outcomes. How much of their discouragingly modest returns (four fifths of sexual partners were not located) is attributable to inexperienced or under-motivated contact tracers and how much to the nature of sexual pairings in the affected populations? Experience leads me to suspect staff, rather than client, deficiencies. It is true that the data reported by Peterman et al. suggest an exceptional epidemiological context. From the data in Peterman's Table 5, I surmise a context of hypersexuality, probably fueled by crack cocaine and attendant prostitution. Use of this drug has previously been associated with high rates of partner change and high proportions of anonymous partners.3 However, in such settings, some investigators report weak partner notification yields,4 whereas others report productive ones.5–6 I suspect that observed differences have more to do with staff training and motivation than with epidemiological conditions.
It may also be useful to recall that their study was conducted at a time when the appropriateness and utility of partner notification was being broadly debated, especially in the acquired immune deficiency program (AIDS) arena. Whether these polemics affected the morale of contact tracers is an open question. Enthusiasm improves performance. Enthusiasm for partner notification is influenced by its political and conceptual contexts. A public health philosophy that portrays it as unduly invasive or ineffective and that fails to grasp its multiple advantages will not generate enthusiasm for it. To maximize performance, contact tracers need to know that their (difficult) work is valuable and valued.
Although their contribution adds to the slender literature evaluating partner notification's cost-effectiveness,7–15 it, like its cognate studies, runs the danger of being narrowly interpreted. What readers (and contact tracers) really need to know is why contact tracing is valuable and, thus, the need is to “break on through to the other side” of conventional thinking about partner notification.
Let us start by distinguishing between efficacy and effectiveness. Partner notification is more about (epidemiological) efficacy than about (cost-) effectiveness-more about the capacity to produce desired effects than about haggling over price. The proper question is not “How much bang for the buck?” but “What do we lose if we don't do it (right)?” In my opinion, epidemiologists cannot afford not to afford it-not only because properly conducted partner notification automatically points to where disease transmission is occurring,16 but also because it is the most accurate lens through which to view the epidemiological picture.17 An explanation is due. Most people, in or out of the STD field, probably view partner notification as a means of notifying exposed individuals. Period. Not only is this narrow view a consequence of public health officials not doing a good job of articulating the multiple benefits of partner notification, but it is also a consequence (alas!) of the terminology itself. Wasserheit tells us: “Names are potentially powerful tools in awakening our … senses to the importance … of a pivotal epidemiologic concept. Their refinement often reflects growing … understanding of a complex issue and may … facilitate the pursuit of new dimensions of a problem.”18 “Partner notification” is a unidimensional term for a multidimensional activity. It does not awaken our senses to its real importance. I believe that the body language conveyed by “contact tracing” does a better job than “partner notification” of mirroring the activity's three faces: It is a combined ethical, control, and epidemiological tool.
Properly conducted, contact tracing assists community efforts to reduce the disease burden19 and fulfills ethical obligations to warn the unsuspecting.20 Yet its least appreciated and probably most powerful attribute is epidemiological: It can delineate the risk networks hosting transmission17 and provide empiric estimates for mathematical model parameters.21 Ecologically, the emerging view is that STD transmission is a current and that its wiring is the sociosexual network.22 Such a network can be conceived as a three-dimensional circuit, with regions configured to impede flow and others to facilitate it. Contact tracing can be used as a multimeter to characterize both circuitry and current levels, thus indicating where focal application of our limited control and intervention energies should go. Not only can contact tracing take epidemiologists where the problem is; it can also tell them if they're in the wrong place. (We may need reminding that epidemiological cues come not only from where transmission is observed but also from where it seemingly ought to be occurring but is not.) Importantly, which other epidemiological tool is available to guide epidemiologists as quickly and surely into transmission currents? Neither targeted screening nor surveillance data come with connections (yet they should23). Network ascertainment is about connections, and contact tracing is currently our best tool to characterize risk networks and thus paint accurate epidemiological pictures. Hence, contact tracing's price may not be as important as completing the necessary epidemiological job. Therein lies the true value of properly applied contact tracing.
Much to their credit, Peterman and colleagues not only recognize the limitations of cost-effectiveness paradigms,24–25 but implicitly suggest that such an approach may be tantamount to evaluating the wrong thing. Having measured cost-effectiveness of syphilis contact tracing, they (properly) refuse to become prisoners of what they measured-"partner notification is more than a case-finding strategy"-a tacit admission that case-finding price is not synonymous with value.
With the practice of seeking sexual partners of STD patients, as with the practice of STD epidemiology,22 context is critical. “Partner notification” is the shell of the activity's context, whereas “contact tracing” is its soul. Its proper yardstick is value, not price. That is why-to paraphrase von Clausewitz-I view contact tracing as too valuable to be left in the hands of accountants.
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Ninth International Symposium on Human Chlamydial Infection June 21–26, 1998 Napa Valley, California
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