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Politics and Plagues: Laurie Garrett sounds an alarm for the disastrous state of global public health

2001; Lippincott Williams & Wilkins; Volume: 10; Issue: 3 Linguagem: Inglês

10.1097/00019048-200103000-00005

1536-9943

Claire Panosian,

Health and Conflict Studies

Betrayal of Trust: The Collapse of Global Health By Laurie Garrett Hyperion New York 2000 ($30) “At the dawn of the 20th century, the Western world fused the idea of civic duty and public health. Conquering disease was viewed as a collective enterprise for the human good. . . . Where did we go wrong?” asks Newsday’s medical writer and futureshockmeister Laurie Garrett in the epilogue to her new book Betrayal of Trust: The Collapse of Global Public Health. Six years after her first best seller, The Coming Plague, fueled nightmares of microbial Armageddon, the journalist-turned-prophet is now on to politics and plagues. Her thesis? With globalization, no person or corner of the planet is safe from antibiotic-resistant superbugs, epidemics, or biowar. Why then, Garrett asks, have recent investments in disease control declined, while relative spending on curative medicine—goods and services beyond the reach of most global villagers—skyrocketed? And will this brazen self-interest by the world’s wealthy someday rain doom on us all? Needless to say, for many disease sufferers in Betrayal of Trust, it already has. It’s hard to know what to credit—Garrett’s in-your-face storytelling, her avalanche of historical and contemporary health data or simple force of will—but her proposition is convincing. By the final pages of Betrayal of Trust, we also believe. The road to faith is long, however—more than 700 pages of text and notes from 5 years of stalking disease and bureaucratic decay in India, Africa, the former Soviet Union, and our own United States. Interspersed are epidemiologic statistics that sometimes raise more questions than they answer. But, in the end, even these support the cause. The mere fact that field data on, say, multidrug resistant tuberculosis or HIV-tainted blood transfusions, can be fragmented, anecdotal, or downright flawed, argues in itself for better epidemic intelligence and global monitoring. In 1994, a flurry of plague on the west coast of India sounded an early warning. Over a single week, the quasi-outbreak produced a panicked exodus of half a million people from the economic boomtown of Surat. Headlining her chapter “Filth and Decay: Pneumonic Plague Hits India and the World Ill Responds,” Garrett rebukes the World Health Organization and Indian health authorities for a palsied response to the potential global wildfire. After all, just one spew of bacteria-laden phlegm on an international flight could have lit the blaze. (“Well maybe . . .” a seasoned plague pro, of whom there are precious few these days, might reply. Among killer respiratory pathogens, smallpox beats Yersinia pestis transmission hands down any day.) In any case, while international carriers doused pesticide, Sudan jailed all travelers from India for 6 days, China barred Indians period, and WHO waffled—how big, really, was the outbreak of plague in Surat? Several thousand cases, or fewer than a hundred? The truth is, we’ll never know. India’s government, no doubt embarrassed by its own crippled public health machinery and mishandling of the crisis, never released its cache of biologic specimens for outside review. In contrast, global teamwork helped to rein in Zaire’s 1995 epidemic of Ebola virus hemorrhagic fever. That is, once the world finally learned of desperate patients, relatives, and hospital workers perishing from the blood-borne landa landa (evil spirit) in the benighted town of Kikwit. Garrett’s original Ebola coverage, complete with sights, smells, and anguished cries in the night (“Afwaka! Somebody has died! Somebody has died! He was my husband! He was my husband!”) won her a Pulitzer prize. Her recap in Betrayal of Trust is a cautionary tale of political corruption, human misery, and the sometimes hidden dangers of sick bays. Ironically, with its utter lack of every-day gear like sterile needles and latex gloves, the single biggest boon to Ebola’s spread in Kikwit was its own general hospital. But the former Soviet Union’s disastrous state of health and the post-Cold War defections (who knows where: Iraq? Libya? Sudan?) of key military biologists are the twin thunderbolts most likely to jolt Garrett’s readers from lingering complacency. First, she surveys the carnage of an unraveled Soviet economy and medical system: a twofold excess in death versus birth rates, rampant alcoholism and heroin addiction, scores of sickly and abandoned children, widespread environmental pollution, crack-pot science (a still-pervasive legacy of Lysenko, the Stalinist era’s hero of anti-intellectualism), mistrust of vaccination, and decrepit hospital gulags where ordinary infected people go without treatment while, elsewhere, power bosses hoard life-saving drugs as they once did caviar and cognac. Three hundred pages later, we join Garrett on the first visit by any U.S. journalist to VECTOR, the former USSR’s once premier virus weapons lab outside Novosibersk, Siberia. In 1997, it is a ghostly complex with broken windows, surrounded by Russian soldiers with threadbare uniforms and pathetic little ken of the lethal contents of Building Number 1—in Garrett’s own words: “row upon row of industrial freezers (housing) Ebola, Lassa, smallpox, monkeypox, tick-borne encephalitis, killer influenza strains, Marburg, HIV, hepatitis A, B, C, and E, Japanese encephalitis, and dozens of other human killer viruses. And there were dozens of different strains of smallpox viruses–140 of them were natural, wild strains. Some were handcrafted by the bioengineers of VECTOR, giving them greater powers of infectivity, virulence, transmissibility.” Some experts take issue with Garrett’s (and others’) Jeremiah-like vision of biowar. In fact, the debate is now routine fare in major medical meetings. Nevertheless, after reading her eyewitness account and recalling recent history, it’s hard to deny her claim that biologic weaponry vies today with nuclear arms-making as the world’s most potent intellectual property. As for American public health and medical science, Garrett names heroes and villains and openly states her mistrust of the new frontier: molecular and genomic medicine. Its illusory promise of health for all, she argues, plays directly into pharmaceutical profit mongering and ignores historical fact. After all, haven’t nutrition, housing, sewage and water systems, epidemic control, immunization, education and literacy, and prenatal, maternal, and child health programs—in short, public health—saved more lives than any high-tech medical intervention yet employed or imagined? This seeming antiscience stand, along with Garrett’s impassioned, attention-getting style, could raise the hackles of many a dedicated doctor or research scientist. In response, how easy it would be to quibble with her occasional factual error, or bloodlessly intellectualize her case: yes, of course medicine needs public health, and vice versa, and so on. Don’t go there. Someday, Garrett may be thankful for medicine’s imperfect craft. But right now she deserves thanks. While hard-working professionals in public health silently battle on, she gives voice to their stifled moral outrage over lost lessons and opportunities. At its core, Betrayal of Trust is a call for international activism long overdue. May its readers include policy-makers, finance ministers, and global philanthropists. With Laurie Garrett’s glaring challenge before them, they too, like the front-line heroes she honors, hold the power to save lives.