Customer Reviews

Betrayal of Trust: The Collapse of Global Public Health

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1 star:		(3)

 

 

Yes, Laurie Garrett's books are lengthy, but what's does that have to do with the enormously valuable information she imparts to her readers. READ her books over time if you would rather. READ her books while you read another novel but READ them. I did enjoy The Coming Plague more but that was strictly due to my personal interest in that narrow topic. Betrayal of Trust covers Public Health and Medicine and its failings, setbacks, and the immediate future of our health. Betrayal of Trust is the result of her investigation of Public Health worldwide.

Ms. Garrett utilizes fascinating examples and historical data to demonstrate among other things that we have a limited community of researchers, doctors, and other health related professionals around the world that try to contain and remedy extremely serious threats and potential threats to our health and well-being.

Ms. Garrett sounds a major wake up call that the risk of a major epidemic or health crisis could strike at anytime and that we are absolutely not prepared to tackle the problem (for the many reasons she details throughout the book). We, Americans, go through our days feeling secure that the system is working when that is not reality. To merely say that the unavailability of financial support and treatment resources here and all over the world for containment and prevention of disease is an understatement of vast proportion. The spread of disease is a major problem that accompanies growing mobility of people and the unique illnesses they carry with them to other parts of the world.

I wholeheartedly recommend Ms. Garrett's books now and anxiously await her next publication - regardless of the topic.

Garrett has spent most of her career following the medical and public health beat, and her work has been awarded for it. Unfortunately, this magnum opus continues her treat of taking reportage, and packaging it like a scholarly work. The inclusion of 100 of footnotes implies a scholarly focus that is not there.

As reporting, this is perfect. The collapse of health in the former Soviet Union, the HIV/AIDS devastation of Africa, and the challenges to the minimal public health systems of China and India are all correct.

The book tries too hard, however, to make the case that you can find the seeds of similar decay in the state of the various US public health systems reviewed - NYC, LA, and Minnesota - and that there is a betrayal of trust going on in the US, also.

The fact is, there has never been more cash available for public health PREVENTION as there is today. The problem in the US is not a failure of the public health system, but of the health CARE system, that foists the provision of health services off on the prevention programs. In LA, the governmental system has to provide both public health protection AND services. In that case, the need for immediate services almost always trumps the long term view of public health protection.

A further indication of the distance between reportage and scholarly work is when you get the facts wrong. For example, the author states that one of the 'heroes' of the piece, Hermann Biggs, left the NY City Dept of Health in 1923, dispirited from the Tammany regime. In fact, Biggs left the NYCDOH in 1913, and was Commissioner of Health of the NY State DOH from 1914-1923, where many of his key public health innovations occurred.

Omissions are also common. While the NYC DOH is highlighted as an exemplar of 1990's public health, no mention is made of the fact that, during this period, mosquito and rodent control were markedly cut back. The connection to NYC's difficulty in controlling rats, and its playing catch up on mosquito control, should be obvious to as skilled a reporter as Garrett.

Summary, read the book, not as history, but rather as a clarification of just how fragile civilization's hold on health is, and will remain.

Laurie Garrett does not write short books. But it's worth the effort ploughing through Betrayal of Trust if you care about Public Health and what its decline could mean for our children and grandchildren if due care and attention is not given to this important part of contemporary life. The frightening problems caused by the collapse of the Public Health system in Russia are a potential lesson to us all who live in the USA; Garrett chillingly portrays the grim situation now faced by the Russian people. If such problems can happen in a relatively sophisticated country, then we need to think of the problems of less well developed countries. And again Garrett brings the message home with her writing. Nowadays, infectious diseases know no borders, and their spread can occur with frightening rapidity. Garrett documents this with her own observations of Plague in India and Ebola in Zaire. Add in a chapter on bioterrorism and it becomes clear that this is a book that can have a real impact on one's thinking. Sure, there are probably some factual errors here and there, which is probably not surprising in a book of this length. But look at the big picture - which is what this book is very much about.

In this masterful work of reportage, Newsday Science correspondent Laurie Garrett accounts for the present disarray of public health and makes a convincing case for the interdependancy among the disease prevention and control infrastructures of both rich and poor nations. Using examples from the commomplace (HIV/AIDS, water borne bacterial infections) to the extreme (biological terrorism) Garrett copiously documents the centuary-long decline of public health systems, in the U.S. and among other countries (with special attention to Russia and the CIS). A worthy sequal to her previous work on emerging disease ecology ("The Comming Plague").

Here are a few cautions about the book:

The book is 550 pages with 230 pages of footnotes. I note this because sometimes, including this time, I order a book without looking at how many pages it is. This one was a surprise for me when I opened the box from Amazon.

The print is very small. I had to go out and buy magnifying glasses. It was either that or use arm extensions. I am very old though. The footnotes are even smaller, and the numbers of the footnotes are impossibly small. You don't have to read all of the footnotes. Some of them are just ibid's and idem's. But there is more interesting detail in some of them.

By quoting similar statistics about the same issue in the same paragraph, she seems to contradict herself until you figure it out and can move on, slowing down your pace. Note the "old" reference above...it may simply be me.

Other than that I found the book very interesting. As I talked about it with others, many asked to "borrow" it after I completed it. I find this a little bothersome sometimes, don't you? You get the book back about half the time.

The chapters on Russia and America were the most interesting. The ones on Kitwik and India were the least. By far, the Russian chapter was the scariest. Had I read this book before going there last year I might not have gone. DON'T DRINK THE WATER, including ice cubes (giardia). I never drink water when I'm in another country. I find it safest to stick with beer, and bottled water to brush my teeth. Anyway, this was her best chapter by far (it's very long) giving a more human element than any other chapter and far more interesting detail about everyday life for some. It was the chapter that made me want to send money to someone, especially that woman and her ill son. Sometimes I just have to put myself between children and odds bigger than they. It's the father instinct in me.

The book was written before 9/11 and I kept wondering, when reading the American chapter, what difference that would have made in her narrative. Oh, and I'll never doubt soldiers who complain of things like Gulf War Syndome again.

Remember when local health departments tested you for TB and other things before you could get a food handler's permit to be a waiter or a meat cutter or whatever, and they'd also trace one's sexual partners when one got treated for a sexually transmitted disease (note "old" reference once again)? They don't do that anymore. Our health department doesn't even care. I called them yesterday and asked them if I had an STD (not much chance of that anymore) should I tell all my sexual partners or would they. The answers? "Naw" and "NO." That's interesting, isn't it? One, it suggests that the author is correct in that the government is betraying us in matters of public health. Two, it suggests that I have way too much time on my hands.

I love Laurie Garrett's work and have read both this book and _The Coming Plague_. And I am ready for her next treatise whenever she may print it.

What reviewers say about the lengthiness and sometimes meandering style is true. When I read her first book, I was reminded of a joke I heard when attending an exhaustive, three day long training about HIV/AIDS counseling and testing. One of the presenters quipped that you might feel like you were dying of AIDS even though you never had it.

Reading this book, you can feel wearied and overcome by the problems. But, if you go with her style, where she interweaves facts with stories of real pepole impacted by the very trends she cites, you get a greater sense of the dimensions of the problems and the reality of the issues.

As we watch our president dismantle so many care systems, I think the chapters on what happened to Russia when they did the same have extreme relevance.

The publish date of this fine book means that some of its data is aging but the representation of the problems and trend remain timely.

Read it.

Laurie Garrett's follow-up to The Coming Plague is packed with valuable information and analysis, and she offers some insights for solving some of the nearly insurmountable and pressing problems we should all be worrying about. Garrett examines how our misconception of public health as medicine for poor people, even a handout for the poor, has potentially devastated our national well-being. Public health is everyone's concern, particularly in the global age we're in today.

Her coverage of the biowarfare threat is thorough and she makes a large and unwieldy topic clear and understandable.

Public health should be our number one concern, and Garrett spells out why we can't wait.

This is a truly prophetic warning from the acclaimed author of "The Coming Plague", which itself was an eloquent best-seller warning of the approaching debacle of increasing microbial threat based on human arrogance, rapid increases in virulence, multiple drug resistance (MDR), and the appearance of entirely new viral entities, comes this articulate, literate, and extremely well researched investigation into the woeful state of the world's public health organizations. Earlier she had warned of the disrepair and dangerous lack of preparedness of public health agencies, and here she writes with cutting clarity as to just how irretrievably damaged they now are. Many international authorities are now openly worried because these national and international public health organizations constitute the only potentially effective line of defense for quick public health countermeasures to intervene and combat both the initial appearance of microbial threats (through inoculation, maintenance of public sanitation systems, and rapid response to perceived threats) as well as continuing support for stemming the effects of such outbreaks once they occur. Without such agencies the public is left literally to the mercies of fate.

This new work is an informative and fascinating decent into a terrifying world in crisis, and Ms. Garret quickly exposes the dark side of the highly vaunted globalization process. For even while Asian economies prosper under the new prosperity, dangerous new breakout of old microbial enemies such as pneumonic plague threaten the population with devastating new pandemics. Meanwhile, multiple drug resistant (MDR) forms of Tuberculosis have appeared in epidemic proportions in Russia, combining with the ravaging effects of drug addiction, alcoholism, and malnutrition (as well as the regional exposure to radiation poisoning connected to Chernobyl in the Ukraine) to exact a treble toll on life expectancy and quality of life in the struggling provinces. And this is just the most obvious tip of the iceberg.

Domestically we face new emerging threats from MDR Tuberculosis, West Nile virus, and other new "superstrains" of microbial entities we were arrogant enough to believe we had permanently vanquished. This phenomenon, when combined with the rapid and increasingly popular modes of international travel now threaten us with a Pandora's box of so-called "Third world diseases" for which we have little of no natural immunity. As Garret reveals the results of her detailed investigation into the nature of the threat, the reader must take pause. We have, she suggests quite eloquently, suffered from a betrayal of trust from both our national leaders and the various local, state, and national public health agencies, which have deteriorated to such an alarming degree that they are now virtually unable to stem the tide now confronting us.

This is serious albeit absorbing reading, and is not recommended for squeamish or immature readers. It is a quite accurate and absolutely devastating look at the nature of a monumental public health threat that is emerging throughout the world even as we speak, one poised to cause catastrophic and tragic losses of life and irreparable social, political, and economic harm to the various nations in which it strikes, and one for which we have done amazingly little to prepare for. We now have the global village Marshall McLuhan warned about, and in such a community there is increasingly no place to hide from the frightening prospects of a wide range of microbial threats all too-naturally rising to confront us. This is a terrific book, a cogent, entertaining, and superbly documented foray into the horrifying realities of our looming public health disaster. I highly recommend it

I'll start with the bad - yes, there are areas of this book that I think an editor never saw. That said, I'm not sure it detracts so much from the quality - the point comes through, and to discuss the minutia of politicking and health plans would have drowned the reader in prose outside the point of the book.

Now - to the story. Like The Coming Plague, this book does a wonderful job of pointing out the science of disease, how diseases emerge and re-emerge, and why everyone needs to care, whether it's in your country or not. I think this gives detail unavailable due to the mass of diseases covered in her first book; as a result, this one can do a more thorough job in getting the reader to understand the universal repurcussions of the decisions made on all levels about health care. It will also make you start to care about those countries you usually ignore.

Again, I think everyone would benefit from reading this book. It reads like a set of thrilling short stories, with the most compelling hook of all - they're true.

This is an excellent and yet deeply flawed book. It will (and should) frighten us all into action, and given recent events of Sept 11 and its aftermath - the imminent threat of terrorism that may be biological in nature - this book is extremely well timed.

The thesis of the book is that, for a variety of reasons (lack of political will in the US, economic deterioration in the former USSR, and poverty in Africa) public health infrastructures worldwide are in serious decline at the moment that horrible new diseases (Aids, ebola) and new strains of old ones (TB, whooping cough, diphtheria etc) are emerging. If these public health infrastructures are not repaired, she asserts, we are in for horrendous trouble. She may well be right and for this reason, we would do well to heed her plea for renewed investment throughout the world in preventive medicine, epidemiology, and other measures to promote collective, as opposed to the privatized (or "medicalised") health model.

It is easy to dismiss this argument as crypto-socialist,but to do so is a disservice both to the talents of Ms. Garrett and to the idea of public health itself. To prove her case, Garrett embarks on an historical tour of the public health systems of both the US and the USSR, both of which were pioneers. The US, in New York but also in Minnesota, developed science-based systems to recognize dangerous contagious agents and to stamp them out via quarantine and later vaccinations and for bacteria, antibiotic treatments. The statistics speak for themselves and are well documented in Garrett's book. Not surprisingly, the USSR developed a more coercive and less scientific system, which was in decline before the fall of communism in 1990; since then, it has declined so alarmingly that death rates in the former Soviet republics are twice as high as births!
What is needed, she says, is larger investments to maintain the fragile infrastructures of scientists, other health care professionals, and access facilities.

The wider landscape she describes - the context of this deterioration - is bleaker and more terrifying than I had imagined possible. It involves antibiotic-resistent strains of tuberculosis and other ancient scourges, an unprecedented Aids epidemic in Africa and Asia, and in the wake of the defunct Soviet biological warfare programs with 30,000 scientists who disappeared - some apparently into the Middle East - the specter of bioterrorism. (Indeed, some of the Sept 11 pilot-terrorists were getting trained with crop dusters, which could deliver small pox or anthrax to threaten millions.) We may be approaching the end of an era in which we believed science was triumphing over human disease. I now fear for my children. Developments in India (plague) and the Congo Republic (Ebola) are also covered in grim detail.

It is here that Garret's argument begins to run into trouble. What has emerged in the US, she says, is a hybrid of conservative ideology (blaming the victim with claims that health is the individual's responsibility) and a "medicalised" model whereby we seek high tech, individualized cures to ailments rather than the less expensive preventive cures that the collective public health model offers. I believe that this is a straw-man dichotomy that oversimplifies the problem, in effect setting up conservative budget cutters to blame for a failure of collective will. While this is certainly true to a degree, the political and economic dimensions of the problem are so complex that Garrett fails to do them justice. Moreover, the medical approach is complementary to the public health one. If the reader want a more realistic appraisal of these issues, (s)he must look elsewhere.

Furthermore, there are numerous inaccuracies and errors throughout the book, which damage its credibility. For example, at one point Garrett states that Crick worked at "Oxford University in Cambridge, England"! While this is trivial and an editor should have picked it up, it is symptomatic of the rushed feel to the book, which was obviously written too quickly and perhaps sloppily. Moreover, Garrett glosses over a number of issues that deserved far deeper scrutiny: she dismisses the demise of the Clinton health plan in one page (it was simply "overly complicated"), and rejects claims by the pharmaceutical industry that the cost of drug development is $500 million (because governments fund basic science). The list of these errors and omissions is indeed long.

SO in the end the book is a mixed bag. For me, it will serve as a treasure trove of information for my latest writing project, but I worry about the accuracy of many of her claims. It is a very good call to arms for a serious issue and a warning to us all.

REcommended with reservation.