A Plague Of Indifference


The Collapse of Global Public Health

By Laurie Garrett

Hyperion -- 754pp -- $30

Eugene Le Bar, a tourist from Mexico City, wasn't feeling well when he reached Manhattan in the winter of 1947. After checking into his hotel, he went sightseeing anyway and walked all over the city. Later that week, he sought help at two different hospitals. In less than a week, he was dead of smallpox. It was the first outbreak of the highly contagious disease in New York since 1902, when 310 people died. The city's health commissioner quickly mobilized, using his authority to order round-the-clock vaccine production and aid from the military, Red Cross, schools, and hospitals. By the end of April, all of the city's 6 million residents had been vaccinated. The rapid immunization effort limited a potentially devastating epidemic to just 11 cases with two deaths--a public-health triumph.

Sadly, it was one of the last unqualified public-health successes of the 20th century. Ask yourself: How likely is it that a similar mobilization of resources could take place if a tourist arrived in the U.S. today with some horrible infectious disease? The question is more than theoretical. New York got a glimpse of how vulnerable it is to offshore epidemics in 1994, when an outbreak of pneumonic plague infected 6,500 people in a remote corner of India.

In the era of jet travel, the plague was not destined to remain remote. Every day, some 2,000 to 3,000 passengers from India arrive at John F. Kennedy International Airport in New York--where there is no health safety net in place to identify any that might be seriously ill. New York City instituted emergency surveillance measures in 1994 and was able to identify one passenger with plague--along with three suffering from malaria, one from typhoid fever, and four from various other viral infections. But 13 plague-infected patients still slipped into the community. Luckily, plague is completely curable when treated properly, so the U.S. government's ability to mobilize against contagious disease was not put to the test. But if those 13 travelers had been infected with the incurable Ebola virus, the results could have been deadly. "The recent plague experience in India provides a clear example of the high price of ignoring global microbial threats," federal health officials warned at the time.

It is a price that is likely to get higher, and we will be paying it many times over, according to Betrayal of Trust: The Collapse of Global Public Health by Laurie Garrett. A Pulitzer Prize-winning health reporter for Newsday, Garrett sounded the alarm over the rise of new strains of deadly infectious diseases in her 1994 book The Coming Plague. In this spectacularly well-researched and well-argued follow-up, she details how poorly prepared the world's public health-care systems are to deal with these outbreaks of disease. She doesn't skimp on the details--at 754 pages, including almost 200 pages of footnotes, the book's biggest flaw is that it contains too much material to absorb. But there is no question that Garrett has built a compelling case that global public health at the dawn of the 21st century is in many ways far less able to deal with disease and pestilence than it was 100 years ago.

Public health is not a matter of medical care. Rather it consists of a nation's obligation to ensure that all of its citizens are provided with the basic tools of physical well-being: public sanitation, clean water, uncontaminated food and drugs, general vaccinations, epidemic-control programs, and preventive health measures. Garrett points out that less than 4% of the total improvement in life expectancy in the U.S. since the 1700s--from 30 years to 75 years--can be attributed to 20th century advances in medicine. Instead, the bulk of the progress can be traced to public-health practices instituted prior to 1936, such as tenement removal, clean water, sewage systems, the control of infectious diseases, and better nutrition for the nation's poor. At the start of the last century, public health was predicated on the belief that preventing disease in the poorest members of society ensured protection of all.

In today's global economy, that principle, Garrett makes clear, holds little sway anywhere, and the consequences are dire. In most of the developing world, there is virtually no public-health infrastructure. Drinking water is contaminated, children are unvaccinated and malnourished, hospital hygiene is ignored, and antibiotics are improperly used, giving rise to drug-resistant disease. All of this means that infectious diseases such as plague, tuberculosis, and malaria, once thought to be largely vanquished, are raging unchecked in these nations--and thus threatening developed nations at a time when their own public health systems are crumbling.

The U.S. is Garrett's case-in-point. Decades of budget cuts, neglect, and public disinterest have left the U.S. public-health infrastructure ill-equipped to handle an infectious-disease outbreak. Garrett documents that the emphasis on private medicine over public health has left the U.S.--where per capita gross domestic product is $28,000--with an infant mortality rate and life expectancy equal to that of Costa Rica, where per capita GDP is just $2,640.

Garrett takes us on an around-the- world tour of public-health failures, starting with that 1994 epidemic of plague in Surat, India. Her next chapter is a heartbreaking account of an outbreak of the horrific and untreatable Ebola virus in Zaire in 1995. Between February and June of that year, the disease killed 296 people--79% of all those infected. Most frightening, though, is that the disease was actually spread in Zaire's dilapidated hospitals. These houses of healing had become death traps. Fully one-third of the epidemic's victims, in fact, were health-care workers. In some hospitals more than half the staff was wiped out by Ebola.

The India and Zaire chapters are the book's most compelling, primarily because Garrett was actually there to chronicle the two epidemics. She follows these two snapshots of the ravages of disease in the developing world with a chapter on the complete breakdown of public health in the former Soviet Union. Less than a year after the collapse of the Communist regime in 1991, what had been one of the world's best public health-care systems was almost completely dismantled, and the nation was battered by massive epidemics of diphtheria, polio, flu, typhoid, cholera, and multidrug-resistant tuberculosis. Life expectancy nosedived, from 65 to 56 by the end of 1998. By January, 2000, Russia's death rate was 2 1/2 times its birth rate, and UNICEF declared "a societal crisis of unexpected proportions and unknown implications."

From the collapse of Russia's health care, Garrett moves to the book's lengthy centerpiece on public health in America. Although her data are compelling, this is where the book bogs down. To make her case that U.S. public health has been woefully neglected, Garrett piles on statistic after statistic, and runs through virtually every public-health threat of the 20th century, from polio to AIDS to obesity.

Her bias is easy to divine from the chapter's title: "Preferring Anarchy and Class Disparity." Garrett argues that the pervasive power of hospitals, the American Medical Assn., and private insurers, combined with an antigovernment mind-set and lack of interest in the poor, has left the public-health system in a shambles. She does a great job of making her case, but the chapter, which runs 214 pages, drowns the reader in a grim parade of disease outbreaks and woefully lacking public responses. Here, there are none of the case histories or patient voices that make the sections on India, Zaire, and Russia so effective.

Garrett has done a masterful job of laying out the near-crisis state of public health. After finishing Betrayal of Trust, the reader isn't likely to escape the feeling that something must be done urgently. But a book this long will simply not win enough of those readers to create the public outcry that this issue needs. Garrett has convinced me that public health needs a Silent Spring, Rachel Carson's much shorter book that awoke the public to the dangers of insecticides. One hopes that Garrett or someone equally talented will write it before another epidemic hits.

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