BETRAYAL OF TRUST:
The Collapse of Global Public Health
By Laurie Garrett
Hyperion, 754 pages, $30
The central message of this blockbuster of a book is simple and stark: Public health, Laurie Garrett tells us, must become global if local populations in the U.S. or anywhere else are to be spared exposure to lethal epidemics old or new. But administrative arrangements to safeguard public health are grossly inadequate everywhere and are decaying dangerously even in countries like ours, where antibiotics and other early 20th Century triumphs once promised to eliminate infectious disease as a serious threat to human life.
Garrett explains that this book is a sequel to her 1994 wakeup call, “The Coming Plague: Newly Emerging Diseases in a World Out of Balance.” “It was clear to me then that the only dam that could effectively hold back the river of microbes and threatening pathogens was . . . (a global) public health infrastructure.” What had been sufficient to check old diseases was no longer enough; the health of humankind called for science, politics, economics “and even elements of religion, philosphy, and psychology” to combine in mounting an effective counterattack. Concluding, “I needed to know more,” she set forth to visit trouble spots like India, Zaire and the former Soviet Union to see how severe old and new challenges to public health had become.
This book combines her observations, cast mostly in the form of excerpts from interviews with overburdened and undersupplied local medical personnel, with a 214-page chapter on the history of, and recent setbacks to, public-health administration in the U.S., written mostly in her own voice. The book concludes with a chilling account of how up to a dozen governments have stockpiled lethal disease organisms for use as weapons, while private groups and rogue individuals are using the Internet to spread information about how to conduct biological warfare for their own private or sectarian purposes.
Garrett’s book is a veritable encyclopedia of recent epidemics, some of them precariously contained, others still in full spate. But she remains hopelessly vague about how to avoid “the coming plague” she had previously announced. So after nearly 600 pages of dire discovery of how disease outbreaks threaten us all, her concluding sentence seems implausibly optimistic: “It would be up to public health to find ways to bridge the hatreds, bringing the world toward a sense of singular community in which the health of each one member rises or falls with the health of all others.”
What should we make of her message?
First of all, a different reporter in a different age might have written her first two chapters differently, for the outbreak of bubonic plague in India and of the Ebola virus in Zaire in 1994 and 1995 were medical triumphs as well as local disasters. Both, after all, attracted a handful of public-health experts to the scene and both disappeared without killing many people. Garrett instead concludes that “public health was in a shambles. It could not meet its basic twentieth century core duties, that is, to ensure the public’s safety at the community level, much less handle the new challenges posed by twenty-first century globalization.”
But, all too obviously, her informants had a vested interest in exaggerating disease dangers; and as a reporter Garrett had a parallel interest in dramatizing her subject matter by turning the story into a struggle between good guys–that is, public–health administrators who knew what ought to be done–and all those who deprived them of the power and resources needed to protect the public properly. Garrett’s roster of bad guys features corrupt politicians, and doctors devoted to curing instead of preventing disease, along with all the short-sighted, selfish individuals in this and other wealthy countries whose personal circumstances make them indifferent to disease in distant lands and among slum-dwellers close by.
Her readers may well ask if disease dangers are as great, and preventive measures as ineffective, as she says they are. Only time will tell. So far AIDS is the only new infection that has attained global statistical significance. The spread of resistant forms of old infections–TB, staph and malaria in the forefront–may well turn out to be more important, since means for consciously limiting the spread of AIDS exist, whereas these and other older infections are now far harder to contain because antibiotics are losing their power to destroy new-model “superbugs.”
The really critical question, however, will remain unanswered unless and until a disastrous global epidemic breaks out. Lethal infectious diseases abounded locally in times past, and a sudden outbreak sometimes killed more than half of a city’s inhabitants. Today a new, comparably lethal and acutely infectious disease might spread around the globe so fast as to overwhelm local medical establishments of every sort with consequences impossible to foresee. Smallpox, suppressed in the 1960s through the most successful of all public-health campaigns, is, ironically, a likely candidate for such a role, since samples of the virus were preserved in the U.S. and the Soviet Union, and Soviet scientists used smallpox viruses, among others, for manufacturing biological weapons. Deliberate or accidental release of the smallpox virus among 6 billion now mostly unvaccinated human beings might provoke an unprecedented dieoff. And, as has been true throughout human history, some hitherto unknown infection always constitutes a similar threat.
Garrett assumes that right-thinking public-health experts know what ought to be done to reduce the risks of global epidemic while simultaneously improving everyone’s everyday health everywhere. Her model for wise and successful public-health management derives from the way a handful of medical men reduced the incidence of bacterial diseases in New York City after 1890. They had a new (and still controversial) germ theory of infection to guide their action, were supported by middle- and upper-class fears of contagion from the slums and so were able to override opposition and meet with swift success.
But in most of the world, including the U.S., no such conditions prevail today. As Garrett tells us, in 1976 bold and swift action by the U.S. government to forestall a lethal form of flu turned into a public-health fiasco when the predicted epidemic failed to appear. Instead, hastily improvised mass vaccination provoked a legal tangle of almost unimaginable complexity when a few individuals suffered nasty side effects that may or may not have been correctly attributed to their flu vaccinations. Other recent American health campaigns against AIDS, drugs, tobacco and rising medical costs are also cluttered by controversy. In short, on every front, public-health administrators find themselves obstructed by rivals. The same is true in other countries, where different medical ideas and different attitudes to health and disease prevail, allowing little scope for American or any other foreign models of public-health administration.
Noisy confusion about human health and disease therefore prevails throughout the world. Garrett’s survey of recent outbreaks of disease in India, Zaire, the former Soviet Union and the U.S. is a powerful reminder of how precarious life remains. But her belief that public-health safeguards are obvious and available is surely mistaken. The partnership between humankind and disease is age-old and will presumably last as long as we do, despite our best efforts–scientific and otherwise–to escape infections and other crippling illnesses.
