Illness As Illness

Back in the 1980s, AIDS loomed as the devil of diseases. Unfailingly fatal, it had seemingly arisen out of nowhere and it leapt immediately to pandemic proportions, threatening perhaps to wipe out the human race. No wonder some saw it as the wrath of God. Over the last decade, however, at least for the wealthy West, it has turned itself, or has been transformed by expensive medical interventions, from a Horseman of the Apocalypse into a somewhat manageable disease.

By way of parallel, books about today’s health hazards have changed too. A decade ago, what attracted authors were the new flesh-eating killer viruses--Marburg, Ebola and other hemorrhagic fevers--the ones that within days would reduce your body to pulp, blood spurting from every orifice. Remember works like Richard Preston’s sensationalist “The Hot Zone” or its movie version, “Outbreak,” with Dustin Hoffman clad in a moon suit defying deadly microbes out of Africa? Nowadays, perhaps because the shock value has been lost, what we are getting are rather more sober--but for that reason perhaps all the more chilling--accounts not of scary invasive pathogens but of daily dangers, like Lyme Disease or tuberculosis, skulking in our midst. That’s a change evident in the work of the distinguished New York medical journalist Laurie Garrett. Six years ago, in her rightly acclaimed “The Coming Plague: Newly Emerging Diseases in a World Out of Balance,” she dramatized the threat posed by grotesque new diseases. Now she has turned her attention to the failings, both medical and political, in our globalized society that have made us needlessly susceptible to diseases at large, old and new, including ones we once had licked.

Displaying masterly craftsmanship, Garrett explores this predicament with four case studies, each successively more detailed and closer to home--literally for her American readers, but also, if more metaphorically, for me, a British reviewer. More and more it is clear, as the story in this book unfolds, that diseases travel without regard to boundaries, societies or economics.

Surat, India, 1994: pneumonic plague erupted and pandemonium ensued. In a city polarized between rich and poor (a labor force employed in diamond-polishing), responsible public leadership and moral authority proved hopelessly lacking. Responses swung from panic to denial, from cover-ups to victim-blaming. The doctors fled (rather like what happened in London in 1665, as Samuel Pepys recorded in his chronicle of the plague years in his “Diary”); conspiracy theories and anti-Pakistani paranoia mushroomed; overseas governments responded opportunistically, with Islamic states slapping bans and quarantines on Indians; and the World Health Organization sat inactive.

Mercifully few people died, but even those fatalities were unnecessary because plague is a disease readily handled today with routine antibiotic treatments. The experience in Surat serves as a brief curtain-raiser for Garrett’s three other studies and her book’s key thesis: If, in this day and age, disease gets the better of us, it is entirely our own fault--the product of greed, myopia and lack of collective will. Basic measures, medical and political alike, give us all the weapons we need to hold catastrophe at bay.

Kikwit, Zaire, 1996: Ebola virus broke out in an epidemic that quickly grew more serious than it should have been. Lack of basic equipment in the hospital (goggles, gowns and masks, antiseptic soap and sterilizing gear), coupled with faulty or lax hygiene, spread the virus to nurses and medics and from them to other patients, their families and communities. But this was hardly surprising, concludes Garrett, given that decades of ghastly political corruption under Gen. Sese Seko Mobutu had run down the country’s health-care system. In Garrett’s telling, the 1997 toppling of Mobutu brought neither reform nor improvement but instead local henchman of Laurent Kabila, who converted the hospital’s only ambulance for use as his private chauffeur-driven limousine.

The story becomes more intricate when Garrett turns to the former USSR. From Lenin onward, the Soviet regime had established a comprehensive public health infrastructure that was praised in the 1930s by sympathetic Westerners (even though it was based upon totalitarian premises and practices). Yet diphtheria, polio, cholera and other once-vanquished infections now roam across many of the former Soviet republics; venereal disease is shockingly rampant (more than 300,000 reported cases of syphilis in Russia in 1996 alone); narcotics addiction is spiraling, as is AIDS; and, though ritzy clinics have sprung up to treat the new gangster plutocrats, for ordinary people the hospital system is breaking down. Most striking, life expectancy is spectacularly plummeting--for men by as much as six years during the last decade, down to a grim 56. Can this be any surprise in a country in which wages no longer are paid, food shortages worsen and solace is found in vodka, heroin and sex?

Prima facie at least, it looks as if the collapse of the Soviet Union and the fraught transition to a market economy have been an unmitigated disaster for its health-care system. But it would be shallow to blame perestroika and Yeltsin’s free market for everything--after all, the current crises of morbidity and mortality are in large measure the consequences of communist environmental vandalism and heedless industrialism, of which Chernobyl is a tragic reminder. Garrett also provides ample firsthand evidence of how unchecked corruption and the breakdown of social cohesion are contributing to health-care crises on a staggering scale.

“Betrayal of Trust” is most devastating in Garrett’s indictment not of India, Africa or Russia but of the United States. Her final case study finds that in a land of prosperity and democracy, the existence of systematic ill-health and poor medicine sticks out like a sore thumb and defies explanation. It is positively indecent, she holds, that an ever-increasing proportion of the nation finds medical insurance quite beyond the range of its pocketbook (the tally of uninsured currently runs at approximately 45 million individuals) and that in many major cities (Los Angeles is closely scrutinized), public health provision, particularly mother and baby clinics, is under daily threat. It is, moreover, terrifying that, as a result of slovenly medical practices, drug-resistant tuberculosis and other smart bugs are once again on the march and reported cases of AIDS are rising: There are nearly a quarter million HIV-positive people in New York City alone.

Much of the blame in the United States lies, she contends, with the policies of conservative politicians from the ‘70s and ‘80s, notably Ronald Reagan, who instituted systematic cuts in public health provision. Particularly reckless was Reagan’s cynical refusal to address AIDS. But Garrett is no less scathing about the hopeless botch made of health reform during the early years of the Clinton administration, at a time when much of the nation was actually eager for changes in the medical system.

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Garrett’s is an unashamedly preachy book, and her missionary zeal sometimes gets the better of her judgment, as in her relentlessly negative and unbalanced, attitude toward recent health developments in the United States. America seems far more successful than most European countries in its public education campaign against smoking and in bringing down heart disease. Given that the book’s subtitle is “The Collapse of Global Public Health,” more international comparisons would have been illuminating. Does Garrett believe that there have been any success stories (Canada? Japan? Scandinavia?) that have lessons to teach? Or is, indeed, the message universal, if muffled, gloom?

There is also something simplistically black and white in Garrett’s case studies. Enemies to health lurk all around: ignorance, cupidity, corruption. Public health must ride up on a white charger to slay these dragons. But, as history shows, public health has come in many guises; it is not simply, as this book implies, an unmitigated “good thing.”

Garrett glories in a Golden Age of public health that existed about a century ago, notably in her own stamping ground, New York City. Admiringly she quotes, more than once, the great champion of public health of those times, Dr. Hermann Biggs, who insisted that “public health is purchasable. Within natural limitations a community can determine its own death rate.” That is certainly true, but the issues are really more complicated than that--after all, that was also the era in which “Typhoid Mary” was locked away for life by New York’s public health authorities, despite her having committed no crime. Do we really want to risk a return to that kind of punitive hygiene policing? In the name of “public health” some countries, like Cuba, have quarantined HIV-positive people in camps (although the Cuban government ended that policy in the mid-’90s). This is not for a moment to suggest that Garrett would advocate any such punitive measures, but the line between desirable public health measures and dubious policing actions is one which (as the politics of AIDS has shown) is hard to draw.

“Betrayal of Trust” has been assiduously researched; Garrett’s grasp of modern medicine is sure-footed, and it is only when she delves into the past that minor mistakes creep in: Louis Pasteur, perhaps significantly, wasn’t a physician, and it was in Cambridge not Oxford that Crick and Watson elucidated the double helical structure of DNA--and not DNA itself.

None of this seriously detracts, however, from the value of “Betrayal of Trust.” Garrett’s message is loud, clear and convincing. Be it India, Africa, Russia or the United States, securing basic public health standards should pose no insuperable problems; all it requires is sufficient political will and a modicum of funding. At the very least, it requires adequate nutrition, clean water, good drainage, proper hygiene and sound medical management. Rich nations should help the poor and in the process put their own houses into order. Political disintegration, get-rich-quick multinational capitalism, mass migrations of refugees and other phenomena of our globalizing times are providing magnificent new opportunities for disease. And in “Betrayal of Trust,” Garrett has delivered a sober warning for the new century.