Betrayal of Trust: The Collapse of Global Public Health

Christian Century, May 2, 2001 by Dan Beauchamp

Betrayal of Trust: The Collapse of Global Public Health. By Laurie Garrett. Hyperion, 754 pp., $30.00.

I THINK THE YOUNG MAN you just met has plague, the doctor told me. I was visiting one of my students at a community health clinic in Embudo, near Taos, New Mexico. The physician had called the highway patrol to take a blood sample to the state health laboratory. The next morning the diagnosis was confirmed.

I went with the doctor to the young man's house on his family's sheep ranch up in the mountains. A beautiful sheep dog lay on the porch. When the physician said that the boy probably had been infected by a flea from the dog, the father gave the animal a quick, dark look. The physician then told him that he must not shoot the dog. He gave the man a can of Ilea powder and told him to dust the animal and the bedclothes. The dog probably had killed an infected prairie dog or rat. The doctor reassured the father, "There is no shame in la plaga. Your son will be well soon and will return home." And he was.

That incident was 25 years ago. At that time I thought the age of epidemics was behind us. Plague was an anomaly in developed societies. The courses I taught on public health focused on modern hazards like highway accidents and the misuse of tobacco, alcohol and other drugs. Oddly, the coming of HIV/AIDS didn't dampen our optimism about public health. HIV/AIDS seemed the enormous exception to the rule, and the means of its spread (sex, intravenous drugs) dominated the discussion.

Then in the late '80s everything changed. Epidemiologists and virologists began sending up the alarm, noting the connection between AIDS and smaller outbreaks of other diseases. Evidence mounted that epidemics were not only back, they had never left. Books like Laurie Garrett's The Coming Plague, Richard Rhodes's Deadly Feasts and Arno Karlen's Man and Microbes: Disease and Plagues in Ancient and Modern Times helped draw public attention to the threat of more epidemics.

Garrett's new book assesses the global preparedness for the fight against a new generation of plagues. In her earlier book, she outlined the principle forces that have returned the threat of epidemics to all parts of the globe instead of keeping it confined to the poorest and remotest places on earth:

* The rapid growth of human populations, especially in urban areas, and the resultant overcrowding, malnutrition and extreme poverty--conditions that compromise the immune system and amplify epidemics.

* The increased movement of new viruses from plants and animals to humans caused by the penetration of human settlements into previously undisturbed regions like the deep forests of Africa and South America.

* An apparent worldwide warming trend that greatly disturbs ecological niches and further encourages the movement of viruses.

* The unprecedented movement of people and goods around the globe, including a soaring army of refugees.

* The lack of stability and re sources among governments stressed by overpopulation and public health calamities.

Garrett, one of the nation's premier science writers and a specialist on HIV/AIDS, explores the failure of public health systems in a selected group of nations and in global health groups such as the World Health Organization. She describes the bureaucratic bumbling that led to a tragically ineffective response to an outbreak of bubonic plague in India in the early 1990s, the collapse of the public health infrastructure before and after the fall of the Soviet Union, and the weakening of U.S. public health as a result of an overenthusiastic embrace of the market.

Garrett stresses the fascination of nations with the drama and high technology of medical systems that serve individual patients. Public health measures like vaccines, dean water, nutrition, modest, accessible clinics and a system that makes these protections available to all may seem drab in comparison. Public health focuses on the health of whole communities and populations and stresses prevention, which may mean doing such things as raising the price of tobacco, making automobiles more safe or establishing systems for the removal of waste water.

ONE OF GARRETT'S major themes is that public health and politics are joined at the hip and that a nation's public health is a fair index of its politics. Take, for example, an outbreak of the deadly Ebola virus in Zaire in 1994, only the second time this virus has surfaced. In the early '90s the Mobutu government was on its last legs and fighting another of Zaire's many civil wars. Mobutu and his cronies had spent decades plundering the nation's resources and treasury. Huge sums of Western aid never reached those it was meant to serve. Mobutu had built a few impressive hospitals and the nation did have trained doctors, but the public health system had collapsed from neglect. So when the epidemic began in the town of Kikwit, located near the rain forest, the hospital had no idea how to respond to this terrifying disease that causes blood to pour from its victims' bodies.