Public health vs. private medicine

Laurie Garrett, author of "Betrayal of Trust," talks about the policy battle in America that allows disease to spread and people to die.

By Dante Ramos
July 31, 2000 11:00PM (UTC)
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The world looks like a scary place through Laurie Garrett's eyes. In her 1994 book "The Coming Plague," she described the threat that a host of deadly microbes poses to human lives. And for the past five years, she has been working on another book about how governments allow diseases to spread.

In the new book, "Betrayal of Trust: The Collapse of Global Public Health," Garrett suggests that better public health measures -- as opposed to better individual medical care (though the two aren't mutually exclusive) -- can keep infectious diseases in check and prevent legitimate concern from turning into panic. She draws on a few extreme examples of poor public health systems: India, Russia and the former Zaire. But Garrett thinks America's priorities are also out of whack. Changes in the political climate have led to drastic cuts in the health budgets of New York and Los Angeles and to the near dismantling of a model public health system in Minnesota. So far, that hasn't led to disease outbreaks on the garish scale seen in the developing world, but Garrett suggests that our lack of interest in community health hurts us in subtler ways. While Americans are spending more money on individual healthcare than anyone else, life expectancy is growing more slowly here than in any other industrialized nation.


Garrett has been tracking threats of disease for years. A native of Los Angeles, she did graduate work at UC-Berkeley in bacteriology and immunology before leaving academia for journalism. She worked as a freelance reporter and as a National Public Radio science correspondent before joining Newsday as a science writer in 1988. She won the 1996 Pulitzer Prize for explanatory journalism for her reporting on the Ebola virus. Over the years, Garrett has gained a reputation as a dogged reporter who backs up her arguments with an avalanche of data. That's certainly true of her new book. "Betrayal of Trust" is thorough, detailed and meticulously documented, and its author clearly knows her subject backward and forward.

Salon caught up with Garrett by phone at her home in Brooklyn, N.Y.

What was your motivation for writing this book at this particular moment in history?


After I finished "The Coming Plague," people were asking me, What's the solution? How can we avoid having these massive epidemics overwhelm us? And the obvious answer is, you need a tough public health infrastructure that can spot the incursion of infectious diseases in the early stages and take appropriate steps to stop it before it becomes the next AIDS pandemic.

Here in the United States, I realized that for the last, say, 10 years of my career, without consciously focusing on it, I had been chronicling the collapse of our public health system. And that one thing after another that had been occurring in our country was a direct result of the fact that we had severely eroded ... the very concept and the political power of public health.

What kind of events are we talking about?


In many states in the last decade, public health officials have tried to create such things as birth defect registries to track whether in some neighborhoods there's a higher rate of birth defects. And if so, might there be something responsible for it? This has been refused by one legislature after another as if it were some Big Brother intrusion.

Another example is attempts to create a notification system for immunization ... Many states were seeing that they were beginning to have resurgences of measles, resurgences of pertussis and other epidemics in children and thought, well, let's just make it easy on families. Let's create an immunization registration system. And then we can notify parents -- your kid's now 2, and it's time for these shots. Virtually every time it's been brought up in any state, the legislature has said no way. They see it as some kind of government intrusion in private life.


That's one of the age-old questions of public health: How do you balance the individual's rights with the health of the community?

We didn't have any problem making those choices back when we had huge public health catastrophes all around us. In 1900, when waves of catastrophic epidemics would sweep through every city in this country, people didn't have a whole lot of problems with the idea that the government had a job, and that the job, among others, was to prevent epidemics and to stop these catastrophes from occurring.

When I travel around the world I rarely encounter this notion of individual rights vs. public health as a serious impediment to the ability of public health to do its job. It's a very American problem ... It's easy to be smug about it and to ignore the needs. The danger in a wealthy society is not as obvious as it was in your grandparents' day or as when as you get in an airplane and travel overseas.


What about some of the places where the danger is more obvious?

India is this enormous sprawling nation of a billion people of virtually every religion on the planet and highly contested and occasionally volatile political forces ... Several years ago, when the Congress Party was running India, the decision was made to relinquish virtually all responsibility for the public health of the people of India to the state level, but there was no increase in revenue streams to the states to cover that. As a result, public health virtually died overnight. When plague first broke out, it broke out in the state of Maharashtra. It went virtually unnoticed until some villages had bubonic plague rates exceeding 10 percent of the population.

When you arrive in Surat, you're the only one getting off the train, because everyone else is leaving.


They all thought I was out of my mind ... India has one of the highest illiteracy rates in the world ... It's very easy in such circumstances to have rumors take on a kind of life that exceeds anything we saw with the Monica Lewinsky episode in Washington.

The overreaction was stupendous. When [the disease] actually did appear in pneumonic airborne form, it was cause for a slight ratcheting up of concern, but certainly not to the degree that panic ensued. Instead of having government officials issuing proclamations that very clearly spelled out what was going on -- this is what bacteria are, this is the antibiotic one should use, etc. -- the state and federal governments freaked out and left everything to the wits of a handful of very dedicated civil servants in the town of Surat.

The global community totally overreacted. The World Health Organization totally failed to respond. And the result was that the Indian economy lost what was conservatively estimated to be about $2 billion in revenues and [experienced] a stock market collapse. [Indians] were placed under international boycotts for the most absurd possible reasons. Do you understand that the Gulf states banned Indian postage stamps? They banned food. They banned everything. Every country reacted absurdly.

Turning to the Ebola outbreak in the former Zaire: You were in Kikwit soon after the first cases were reported. At what point did you arrive on the scene, and what was going on?


Once I arrived I immediately discovered that there was such a sour taste in the mouth of these scientists from the previous gang of journalists. Some scientists, even the ones who knew me well and whom I had worked with in the past, were very hostile. The scientists themselves were sleep-deprived and strung out. They had witnessed a massive amount of death and real fear.

The community was gripped with a kind of terror that I've seen in civil wars, but it's different ... This is a terror that strikes when you really don't understand; you don't know how you can protect yourself; you don't know whether the person you just hugged is a carrier.

One of the themes of the chapter on Kikwit is the connection between the spread of disease and poverty and corruption in government. How do those conditions amplify an outbreak?

People always talk about corrupt societies and bemoan the money that's lost and the inability to get a school built or to get your business on track because of corruption. They forget that corruption actually kills people, that corruption is actually murder when it strikes your public health system.


In the case of Zaire, there's no doubt whatsoever that that country experienced wave after wave of infectious diseases because of rampant corruption. Hospital systems and public health systems had been looted of everything. Doctors were performing surgery with instruments that were non-sterile -- not because they were stupid but because they had no more fuel to run the generators and therefore to run the autoclave and therefore to sterilize the instruments. This epidemic never would have happened if an index case hadn't shown up in one of these completely looted-to-the-bones hospitals, and the individual hadn't gone in for surgery.

Once it got into the hospital, the explosion really claimed healthcare workers. The bulk of all that first wave of deaths was doctors and nurses and lab technicians and orderlies. They didn't know what was killing them. It hadn't been identified as Ebola. They didn't know therefore how to protect themselves.

They had been coming to work every day. The vast majority never left their posts, even though most of them had gone unpaid for years. I'm not sure most American doctors would do that under similar circumstances.

When you're talking about the American health system, you make more of a distinction between public health and individual medical care than you do when you talk about other countries.


Because it's a clearer distinction in the U.S. We don't have a national healthcare system. In Sweden, medical care and public health are all government functions and usually through the same agencies, so the lines get more blurred. But in the United States, public health is really a government function, usually at a fairly local level, and medicine is ... an almost entirely private function, with some parts of it heavily government subsidized but in largely private facilities.

How is that bad for the health system?

We have given the bulk of health power to physicians and to organized medicine and most recently to the health management corporate structure, and we have allotted very little prestige and power to the practitioners of public health. They are paid far less; they are given dingy, lousy offices; and they're treated like lesser beings. They rarely succeed in beating the AMA [American Medical Association] or any organized medicine on any issue.

Several times we have come very close in this country to voting for some form of national healthcare. Each time, public health has been completely left out of the discussion. What are the things that increase life expectancy in America? What are the things that can make sure children do not die in America? That's never what we talk about ... We always start the debate from the wrong place, which is an assumption that everything that anybody wants that's called "medicine" should be paid for by government or not paid for by government.

You talk about the difference in what people spend on healthcare from age zero to 65 and age 65 and older, and the latter number is four times more than the former.

At least.

How do you shift some of those dollars from the end stages of life to the beginning stages of life, when the immediate benefits aren't quite as clear, without looking like Dr. Kevorkian?

There are several answers to this. First of all, most of what determines how long one is going to live are events that occur in the first 12 years of life: how well you eat, how much you exercise, how well you brush your teeth. If you're going to put a heavy investment, it makes a lot more sense to put it in childhood ... I'm of the age group that when John F. Kennedy issued the president's physical fitness exams, we all had to go out and prove we could do so many pushups and so many sit-ups. I can't even imagine kids today managing to do it, with about half of the children in America physically obese.

The other part of that is, and I'll put this to you in very personal terms: While I was hitting the finish line on this book, my father went into terminal illness and he was very ill. He had a strange form of autoimmunity that surfaced when he reached his 80s, in which his immune system was attacking his bone marrow and destroying his red blood cells ... With constant transfusions of blood and injections of cortisones he could keep this vaguely in check and have some good days, some quality days, in between rounds of transfusion.

I was sent overseas on assignment to Africa for Newsday, and while I was in Africa my father made a decision. He decided that he never wanted to be in an ICU; he knew where this disease was going. And he decided that this transfusion was his last, this round of cortisones was his last and that he was going to die. I rushed back from Africa, and he died a few days later ... I think he went with great courage. The whole family, we all feel so proud of him. I realize that some families would make a different choice. They would feel that any amount of money -- any amount of hospitalization that could keep him alive another day, another two days -- was warranted. But I don't understand why. I can't see it.

To me, one of the things we've done by putting such emphasis on individualized medicine and ICU and disease treatment is that we've stripped all dignity from the individual. And I'm not sure that it's the individual who wants $4 million spent on their care in two weeks to keep them alive, hooked up to machines, gasping in between pain-alleviating shots. I think it's the family that cannot bear to see them go and a system that's structured to keep spending money.

Do you see any political will or emotional will on the part of Americans to change that system?

Yeah. When you ask the right questions, the surveys show that Americans are thinking with wisdom about this. It's simply that we've not had the debate start at the right point. If you start the debate from the point of who should pay for us to have absolutely everything we want done to us medically, you're going to lose.

We've ended up with a terrible system full of injustice that leaves no one satisfied except the very, very rich ... How can we pursue the sort of brave new world of medicine the Human Genome Project promises us and do so in a way that doesn't result in, say, 2 or 3 percent of the global population having access to this grand scheme? And 94 to 97 percent not only don't have access to this expensive medicine but actually lose access to older drugs that are no longer patentable but that used to protect them.

In a couple of places, you quote Paul de Kruif, who was a science writer in the 1930s. At one point, he says, "I don't know why it took me so long to see that the strength and life-giving results of the toil of those searchers were for sale; that life was something you could have if you bought and paid for it." How much of that reflects your own feelings, or are you more optimistic than that?

Certainly it reflects my opinion of the state of public health on a global level. I think we have made a decision for quite some time that if you're in a poor country, your health is going to be worse, and if you're in a rich country, your health is going to be better. And somehow that's OK. We have no apparent moral or ethical problem with that. Which I personally find very troubling.

Dante Ramos

Dante Ramos is deputy editorial page editor of The Times-Picayune in New Orleans.

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