BETRAYAL OF TRUST
Laurie Garrett. New York, New York: Hyperion; 2000. 754 pp.
This is not bedtime reading: it cannot be read in one sitting nor can the many minutiae of its descriptions of complex situations and the logic of its arguments be captured on the first reading. It is a journalistic tour de force that, rather than adopting a subtle rapierlike approach, bludgeons the reader with an impressive amount of detail into accepting that there is such an entity as global public health and that it is in crisis. It is in crisis in the sense that there is no longer a system that can promote the public's health, protect it, or see that it is restored after it is lost. There is betrayal because the people of the world have tacitly accepted that the nation-states, either individually or collectively, should give up those responsibilities.
Author Laurie Garrett focuses predominantly on infectious diseases and the apparent failure of the world as a whole to recapture the will or the capacity to deal with the infections that were the bread and butter of public health practice at the beginning of the twentieth century. Although the chronic diseases do get mentioned, particularly in relation to aging, the arguments turn predominantly around the infectious diseases.
She begins with the age-old scourge of plague, which affected India in the middle of the last decade, after being absent from the country for 30 years. Garrett describes the basic reason why Yersinia pestis can cause the epidemic and the extent to which the Indian city of Surat is the epicenter of the epidemic. Considerable attention is given not only to the clinical manifestations but also the underlying social dislocation that was caused. Perhaps the most impressive part of the story is the unbelievable level of unpreparedness of the public health system, which had forgotten lessons painfully learned in ages past. One agonizes over the apparently ineffective efforts on the part of other countries to prevent entry of the disease. The spectacle of attempts at an international airport to identify possible disease carriers through a superficial oral questioning of passengers is nothing less than tragicomic. Less comical is the economic loss suffered by India and the apparent inability of the World Health Organization (WHO) to reassure India's trading partners that their fears were unfounded. It is chastening to read Garrett's comment that "WHO had by then allowed India to be treated as a global pariah for more than two months." The theme that is repeated throughout the book is that the State had betrayed the trust that the people had placed in it.
The second major episode that Garrett recounts in her book is the highly publicized outbreak of the epidemic caused by the Ebola virus in the small town of Kikwit in Zaire. Although I count myself as having been reasonably well informed about this epidemic, my eyes were opened by many of the details she describes. There is a dual impression here of a massive tragedy, of poor people affected by a dreadful disease for which there is no immediate diagnosis or cure, and of the heroic efforts by a large number of selfless and dedicated health workers. The reader easily understands the sensation of terror that must have gripped this community, as well as Garrett's sadness as she traces the abominable local conditions to the central government's gross incompetence and corruption. It is hard not to feel that the victims were virtually sacrificed. There are many scientific questions that she leaves unanswered, such as the real origin of the epidemic, why it reappeared after an absence of 19 years, and why some few persons actually recovered from what in most cases was the kiss of death.
While not excusable, it is easy to accept that there is a real possibility of such abject absence of basic public health infrastructure in distant Kikwit. Nevertheless, it beggars the imagination to entertain the state of disarray in Russia and the other independent states that emerged after the dissolution of the Soviet empire. Were it not for the intellectual integrity of the author, I would have found it nearly impossible to believe the state of affairs in what I would have taken to be a developed part of the world. It is almost unbelievable that the basic elements of infection control that have been in common currency since Semmelweiss would not have been accepted. That a miasma theory of infection transmission would even be entertained is remarkable, to say the least.
It is relatively easy to accept the explanation that it was the social and economic collapse that led to what has to be one of the greatest demographic tragedies of modern times. It is almost inconceivable that in any country the number of deaths could exceed the number of births in a year, but those are the data that Garrett presents. The situation is made worse by the fact that the great majority of this change was due to increased adult mortality. Every imaginable defect in the health system is bared through an impressive compilation of data. Almost every infectious disease shows increased incidence, although a great deal of attention is given to the problem of tuberculosis. It is not only the deterioration of health status that shocks, but also practices such as widespread sex slavery that contribute to the picture of a society in crisis if not absolute depravity.
The largest section of the book is devoted to the health problems of the United States of America. So many problems are exposed that it is difficult to fix on any one that stands out. The historical approach to public health in the United States is refreshing, and the recounting of the exploits of such public health giants as Dr. Hermann Biggs and the retelling of the story of Typhoid Mary make good reading. The possibility of incarcerating that lady at the beginning of the twentieth century because she was a carrier of typhoid speaks volumes about the authority of public health leaders and the extent to which the public trusted their judgment. There is much similarity between that kind of authority and the actions of the health police of nineteenth century Germany. Quite properly, considerable attention is paid to the specter and reality of antimicrobial resistance, which is one of the underappreciated public health time bombs of our era. HIV/AIDS and the reality that the new treatments serve but to hold back the flood are described with great lucidity and conviction. The author brings out evidence of growing insouciance on the part of some sections of the population who are most at risk for contracting the infection and perhaps unfairly attributes this in part to a failure of public health.
This section of the book focusing on the United States might have formed a separate book in its own right. In many parts I was reminded of the reasoning in Paul Starr's Social Transformation of American Medicine. One criticism of Garrett's book is that it moves so rapidly from one problem to another that it is difficult to see a particular logic to the organization of the different themes. We transit from Los Angeles to Minnesota to New York, dealing with different themes but without the benefit of good bridges. However, there is no doubt about the central message, that the public health infrastructure is a shadow of what it was in its glory days at the beginning of the twentieth century. The public health system suffers chronically from the politics that pay more attention to personal care medicine, and there is insufficient awareness of the fundamental role of poverty and inequality in affecting the determinants of health.
The main part of the book ends with a picture of the potential horrors of bioterrorism and the apparent state of unpreparedness of the United States. Perhaps the most frightening of the scenarios is one in which smallpox could be a terrorist weapon, since there is a real possibility that the virus is in the hands of rogue nations and groups. She does not dwell extensively on the irony or tragedy of the situation in which one of public health's greatest triumphs¾the eradication of a disease¾has made our planet susceptible to its introduction as a weapon of terror. The threat of bioterrorism is perhaps greater than the threat of nuclear devastation. With nuclear weapons, the various parties knew the nuclear capabilities of the other nations, and that in itself acted as a deterrent.
There is no doubt about the intention of the author. She intends to convince us that attention to the public's health is a public good and must be a concern of the community of nations, and she achieves that goal. I think she worries unduly about arriving at any consensus on a precise definition of public health. Although in the introduction she avers that her job is not to proffer solutions, she might have dedicated more space to the successes in addressing some of the public health problems of our time. She might have mentioned the efforts of the countries of the Americas to eliminate poliomyelitis and measles, for example. She might have speculated on the concepts of health promotion and social marketing that hold out some promise for the behavioral changes that she rightly points out must become part of the armamentarium of public health practitioners, who have perhaps been concerned too much with disciplinary purity.
Her insightful analysis makes us in the Pan American Health Organization even more enthusiastic about pursuing our efforts at investigating the extent to which the countries of the Americas appreciate the essential public health functions and the role of the State in discharging them. It is not false optimism to believe that at least in this Hemisphere there can be collectivity of approach to ensuring that these functions are discharged and the nations can keep some measure of faith with the people who have put their trust in them. Self-interest should also enter. The historian Will Durant said, "The health of nations is more important than the wealth of nations." I am sure that Garrett would add that the health of nations is also vital to the security of nations.
This book should be recommended reading for all who are interested in the prospects of our having a healthy world, but in particular it should be read by all those who teach public health disciplines and those who are the actual or potential leaders in this field.
George A. O. Alleyne
Pan American Health Organization