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Coming: Calamity and Chaos

Paul Epstein

Betrayal of Trust: The Collapse of Global Public Health. Laurie Garrett. xiv + 754 pp. Hyperion, 2000. $30.

Over the past two centuries, public health policy has oscillated between addressing the broad social and environmental issues that underlie disease prevalence and taking direct aim at the microbiological targets that appear more manageable. The need to embrace both perspectives is an inexorable refrain that echoes throughout Laurie Garrett's new book, Betrayal of Trust.

In the 1830s, following rapid urban development and declining mortality from infectious disease in Europe and North America, population growth suddenly overwhelmed infrastructures, spawning upsurges of tuberculosis, cholera and smallpox. The deteriorating social conditions drove citizens into the streets in protest and turned physicians into social activists.

Today's resurgence of infectious disease also follows a long period of increasing life spans, as well as an epidemiological transition to chronic diseases. But in contrast to the populace of the 19th century, we are unaware of the turnaround and are unprepared to take action to address its causes.

In her Pulitzer Prize–winning book The Coming Plague, Garrett tackled lack of recognition of the problem. In Betrayal of Trust she documents our failure to take action, showing that public health has been dealt a body blow: The societal scaffolding for it is breaking down, and public health systems have been eviscerated. Her dominant theme is that the health of the public must regain its historical role as the goal of economic development and as a primary driver of public policy.

In the mid 19th century, scientists were divided into two camps: the contagionists and the anticontagionists (or sanitarians). Edwin Chadwick in the United Kingdom, Rudolf Virchow in Germany and John Griscom in the United States drew attention to the environmental causes of disease and became social activists. Sanitary- and environmental-reform movements generated the British Public Health Act of 1848, creating sewer and water systems, paving roads, and improving housing, food safety and occupational safety. Soon after, mortality from infectious disease leveled off and fell, decades before the discovery of microbes. The revelations by Louis Pasteur and Robert Koch in the 1880s and 1890s sparked a revolution in science and public health that directed attention toward microbes and away from environmental reform. During the 1920s, an interest in the ecology of disease resurfaced. With the birth of the World Health Organization in 1948, environmental engineering and infection control joined forces. But in 1976, with the discovery of hybridoma cell lines and monoclonal antibodies, the pendulum again swung away from environmental issues and toward a focus on microorganisms and molecular biology. Ironically, these discoveries coincided with a resurgence of infectious disease. It was then that the Ebola virus emerged, soon followed by Legionella pneumophila and later by HIV, Escherichia coli O157:H7 and a host of antibiotic-resistant organisms. All told, more than 30 diseases new to medicine have emerged in the past 25 years—a most unusual period punctuating long historical cycles in the ebb and flow of infectious disease.

As Garrett explores—and thoroughly documents—the state of public health in the former Soviet Union, Central Africa, India and the United States, she seamlessly weaves together perspectives—combining, for example, a discussion of the genetic signals affecting Yersinia pestis virulence with analysis of the social impact of the plague that broke out in India in 1994. Her reach is broad as she delves into the historical backdrop to the emergence of the Ebola virus, guiding the reader through the Belgian devastation of the Congo, the U.S.-orchestrated assassination of Patrice Lumumba and the subsequent corrupt dictatorship of Joseph Mobutu—all having paved the way for the poverty, disease burden, deforestation and collapse of public health infrastructures that underlay the dreadful 1995 outbreak of Ebola in Kikwit.

Because infectious diseases can travel rapidly, an international perspective is mandatory. The appearance of the mosquito-borne West Nile virus in northeastern U.S. cities highlights our interdependency with other parts of the world and the need for healthy ecosystems and clean and equitable development worldwide.

Garrett does not flinch from confronting the conflicts between private-sector motivations (and "patent grabs") and the public-sector priority of maintaining healthy social infrastructures. She argues that we must improve surveillance, disease detection, response capability, methods of reducing pest breeding, and support for the development and distribution of vaccines. But her work also highlights the need to recognize the resurgence of infectious disease at the close of the 20th century as a symptom of deterioration in the economic and ecological systems that underpin our health. "Public health in the twenty-first century," she concludes, "will rise or fall, then, with the ultimate course of globalization."

One omission: Although Garrett does mention weather in relation to plague outbreaks, she does not address the changing weather patterns associated with climate change. These are imposing new stresses on ecosystems and affecting disease containment (as when flooding, for example, leads to outbreaks of cholera, malaria and leptospirosis by contaminating drinking water and increasing the rodent and mosquito populations). Although in her epilogue she cites a U.S. intelligence community document that predicts deterioration in global health, she fails to note that the document also addresses the need for improved climate forecasting in order to develop early warning systems that can allow timely and environmentally friendly public health interventions.

Garrett delivers blunt punches in a swiftly moving style that carries the reader along despite the book's daunting size. The book comes at a time when international financial forces are widening social inequities and providing perverse incentives to harm the environmental systems that support our health and the health of plants and animals. Private industry handsomely supports reductionist science that can generate marketable and sometimes useful products. But it remains to be seen whether a strengthened public sector can fund and support the integrative, ecosystem-based science and the broad development policies needed to sustain the global commons on which our health and well-being depend.—Paul R. Epstein, Center for Health and the Global Environment, Harvard Medical School

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