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Thursday, June 04, 2020

Review: Betrayal of Trust

I read Laurie Garrett's The Coming Plague in the 1990s but in the intervening years the USA always managed to avoid a major epidemic, so I assumed that her warnings had done the right thing. Then COVID19 happened and I realized we were just lucky. Which meant that her other book about public health might be similarly prophetic, so I checked out Betrayal of Trust (electronically) from the local library.

The book goes to great pains to separate public health from medical provision. The former is about prevention, and the latter is about treatment. She chronicles several major disasters that could have been mitigated (or even prevented) by a solid public health system: a bubonic plague outbreak in India,  the Ebola epidemic in Zaire, the rise of antibiotic resistant diseases (notably TB) in the former Soviet Union and the shift away from public health in the USA due to the perception that the big causes of mortality (cardiac problems and cancer) are non-contagious and therefore public health did not have to play a role.

Early on, Garrett points out that the big gains in life expectancy in the West were achieved long before antibiotics and other miracles:
Vital statistics data from England, Wales, and Sweden show that in 1700 the average male in those countries lived just twenty-seven to thirty years. By 1971 male life expectancy reached seventy-five years. More than half that improvement occurred before 1900; even the bulk of the twentieth-century increases in life expectancy were due to conditions that existed prior to 1936. In all, 86 percent of the increased life expectancy was due to decreases in infectious diseases.15 And the bulk of the decline in infectious disease deaths occurred prior to the age of antibiotics. In the United Kingdom, for example, tuberculosis deaths dropped from nearly 4,000 per million people to 500 per million between 1838 and 1949, when antibiotic treatment was introduced. That’s an 87 percent decline. Between 1949 and 1969 the TB death rate fell only another forty million cases to 460 cases per million, or 9 percent. (kindle loc 281)
During the Ebola epidemic, she notes that the requests for materials are very similar to what we're seeing during the COVID19 outbreak:
“Send respirator masks, latex gloves, protective gowns, disinfectant, hospital linens and plastic mattress covers, plastic aprons, basic cleaning supplies and cleansers, water pumps and filters, galoshes, tents …” It was not the high-tech equipment popularized in science fiction movies that would halt Ebola’s spread, Kiersteins knew. What Kikwit needed were the basics: soap, gear, and safe water. (pg 67)
She charts the rise of public health in New York City, which pioneered the initial systems that reduced the incidence of epidemic disease in the city despite the opposition of many to vaccines. But because circumstances were so dire, the public health department was authorized to use force. The trust in the public health system reached a high during the Polio epidemic:
In the fall of 1953 more than eighty thousand six-to-eight-year-old New York City schoolchildren rolled up their sleeves for shots of either Salk’s vaccine or a placebo. In 1954 and ‘55 tens of thousands of children nationwide enlisted as Polio Pioneers to serve as willing guinea pigs for the vaccine.185 And though every aspect of the Salk vaccine effort was mired in politics, ethical debates, and production and distribution snafus, there were never shortages of schoolchildren lining up for polio shots. The fear of polio was far greater than any parental concerns about the experimental nature of the vaccine.(pg. 315)
We can see the decline of public health occurred decades ago, during the shift in the late 1960s and 1970s:
Instead of emphasizing collective health and disease prevention, the path now would lead to further medicalization and individualization. Sadly, the data would later show that America was thereby exiting the period of her greatest health improvement since the Biggs era. Between 1968, when LBJ’s programs were in full swing, and 1975, when budget cuts had whittled such programs to the bone, the overall U.S. annual death rate had dropped 14 percent.323 Every health indicator had shown remarkable improvement. Cardiovascular deaths: down by 23 percent. Infant mortality: dropped 38 percent. Maternal mortality: plummeted an astounding 71 percent. That was the legacy of an aggressive war on poverty and expansion of health services for the poor. It occurred in a period that was denounced by the AMA and American Hospital Association as “regulated,” a code word meaning “very bad” or even “socialistic” in the New Right circles of rising political superstar California governor Ronald Reagan. (pg. 349)
The question is whether the USA still has the capacity to rebuild a robust public health system even after the obvious need for it. Garrett points out in a final chapter that a strong public health system is quite possibly the best protection against bioterrorism or genetically engineered bioweapon attacks. Unfortunately, she doesn't provide much hope as to whether such a system is politically feasible: the book was published in 2011, and there's no sign that in the intervening years much has been done.

Nevertheless, for a great discussion of the issues and lots of stuff I didn't know before, this is a great book. Recommended.

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