Plagued: The new challenge to public health

Betrayal of Trust: The Collapse of Global Public Health by Laurie Garrett

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 flea 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 resources 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, clean 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.

The epidemic was checked by the arrival of Barbara Kiersteins, a physician with Médecins Sans Frontières (MSF—Doctors Without Borders). She and epidemiologists from the World Health Organization with whom she worked grasped that what the hospital needed was simple public health protections—clean water, disposable syringes, soap, protective gear and the isolation of Ebola patients, as well as rest and food for frightened health workers.

Most gripping and sad is the story of the collapse of public health in the former Soviet Union, a collapse that probably began decades before the fall of the Berlin Wall. Though the Soviet Union drastically improved the health of its people in the first five decades after the revolution, that progress was reversed. Vast numbers now crowd Russian prisons, where poor sanitation, inferior antibiotics and widespread drug resistance have virtually created a factory for the production of diseases like tuberculosis and HIV. Many of the prisoners have illnesses that are resistant to all but the most sophisticated and costly of antibiotics. Much of this drug resistance is caused by the casual availability of antibiotics in every major Russian city. Russia’s out-of-control HIV and AIDS epidemic is spread mainly by widespread drug abuse among young people, most of whom share used needles.

The U.S.’s own failures to safeguard public health stem from a populist embrace of the market. Big government is seen as the enemy of the common people, and the market as the workingman’s best friend. Political movements that tout economic growth as the true friend of the poor and resist government regulation result in underfunded and weakened public health systems.

William Stringfellow and Walter Wink use the New Testament terms “powers and principalities” to describe the institutions and ideologies that undergird society and demand our ultimate loyalty and tribute. The powers have both visible structures and invisible or spiritual dimensions that are the source of their power and sway over people’s ultimate loyalty. Such a worldview often seems to lie behind Garrett’s analysis, though her background as a science reporter keeps her from using frankly spiritual categories.

Garrett’s principal thesis is that the health of every nation depends on the health of every other nation. Places and communities where public health protections are weak become targets of and reservoirs for infections that threaten far-flung communities, now only a plane trip away.

Garrett presents a laundry list of needed responses: reforming a pharmaceutical industry more concerned with profits than people; restraining a profit- and technology-oriented medical system that overshadows the more effective public health infrastructure; slowing the development and settlement of vast areas of rain forest; and persuading rich countries to fund global health campaigns in poor countries.

Behind Garrett’s list stands a deeply spiritual challenge: we need to give our loyalty to the welfare of humankind and all of creation, not to the powers of domination and profit. If suffering people most need disposable syringes and affordable vaccines, then shiny hospitals and huge profits for the pharmaceutical industry cannot be our primary goals.

It was once thought that democracy, with its traditions of individual freedom, property rights and the like, would limit the scope of public health, which typically advances through collective action. Yet over the long run democracies have a far better record of protecting public health than do governments like that of the former Soviet Union. Freedom of speech and discussion are more effective than a powerful state apparatus in reforming health practices, especially such practices as alcohol and other drug use or smoking. We have “talked” smoking rates down and, through democratic discussion and massive publicity, made an impressive start in checking alcohol consumption and decreasing HIV infection in the gay community. Our public and religious moralism, however, has hampered our efforts to fight the HIV/AIDS epidemic.

In state socialism, where everything is controlled, private behavior can become an act of defiance or even resistance to the powers of the state. This may partially account for the high rates of drunkenness, drug use and smoking in the former Soviet Union. Such risky behaviors can also be the recourse of those who feel defeated. A friend who visited Poland in the early 1980s noted that most of the country’s public health workers smoked and drank heavily. When he asked why, people told him, “It is our only consolation.”

We have tended to see humankind as immune from the laws of creation, as a power apart. While we have sought safety in steel and glass buildings and homes in gated communities, we share our dwelling places with viruses and other pathogens. In the biotic creation we are subjects, not rulers. We must resist intelligently and wisely the invasions of the unseen, for things invisible will always be with us.

There is a danger that the return of the age of plagues may drive us further into the arms of nationalism or of the global market. If we are to learn from the dangers ahead, we must see that we struggle not only for the health of ourselves and our communities, but for our souls. By soul I mean our capacity to transcend ourselves and connect to others—in biblical terms, to live in resistance to the powers of death.