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| Book cover photo by John Steen |
One systemic defect in the many state and regional bioterrorism preparedness planning efforts now under way is the absence of a communitarian perspective. As evidence of the national, and even international blindness underlying the problem, and as a definitive description of its scope, there is a book that should be read by anyone who cares about public health, health policy, and public policy. It is Betrayal of Trust: The Collapse of Global Public Health, by Laurie Garrett (Hyperion, 2000).
In 754 pages, including 154 pages of endnotes, the author details the recent epidemiological threats that have challenged world public health, including pneumonic plague in India, Ebola in Zaire, the collapse of public health in the former Soviet Union, and last but certainly not least, the erosion of public health in the United States at the very time when we are threatened by bioterrorism ("Preferring Anarchy and Class Disparity: The American Public Health Infrastructure in an Age of Antigovernmentalism."). And to the maxim that all health is public health, she would have us add that all public health is global.
Amid a wealth of epidemiologic detail, Garrett manages to provide a cogent description and commentary on the American political milieu in which public health resources have risen and fallen. The nearest thing to a Golden Age of Public Health here was, in retrospect, the major advances in disease control made at the turn of the twentieth century, but all that seems to have been forgotten after World War II, except for a brief period in LBJ's Great Society in the mid-1960s.
The effects of our neglect of and even hostility toward public health over the past 20+ years are detailed at the city (New York City), county (Los Angeles County), and state (Minnesota) level. Minnesota can be seen as having briefly developed a population health system with a communitarian focus that was arguably the best ever achieved by any state.
That public health's problems are a reflection of an ancient dichotomy is best explained in the opposition of Hygeia and Panakeia in Greek mythology, where Hygeia represents public health promotion within a socialist political system, and Panakeia represents curative personal health within a free enterprise system. Our current perception of this is revealed in how we spend 1 percent of our health care dollar on hygiene, and 99 percent on panaceas.* Public health is contained within a political compact between people and their government, and when people no longer trust nor support their government, the commitment represented by public health can no longer be fulfilled.
Garrett's view here is as broad as that of the World Health Organization's World Health Report 2000 that was published at the same time as her book. Each details the failures of world health systems seen as a function of each nation's quality of governance and stage of economic development. (For a summary of the WHO report, see my "With Liberty and Justice for All?" from the 3rd Quarter 2000 issue of Health Planning Today accessible at http://www.ahpanet.org/files/With%20Liberty%20and%20Justice%20for%20All.pdf .) I would argue that the answer to public health's problem is to be sought in a renewal of civic discourse and engagement, i.e., more democracy. That Garrett would probably agree is shown by her dedication of her book to the late Dr. Jonathan Mann, a powerful advocate of a very broad vision of public health as providing leadership in the promotion of human rights.
Laurie Garrett has been a science and medical reporter at Newsday since 1988, and is the author of The Coming Plague, a best-seller in 1994. She is the only recipient to have awarded the three big "P"s of journalism - the Pulitzer, the Peabody and the Polk. She received her second George C. Polk Award, Best Book of 2000, for Betrayal of Trust. In March 2004, Laurie took the position of Senior Fellow for Global Health at the Council on Foreign Relations.
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* When viewed on a per capita basis, Americans spend an estimated $4,000 per capita each year on personal medical care, compared to an estimated $44 for population-based public health services.