Betrayal of Trust: The Collapse of Global Public Health
Hyperion, New York, 2000, 754 pp, $30.00 hardcover
Exorbitant prescription costs, inadequate insurance coverage, and revolutionary pharmaceutical discoveries are the focus of current health care dialogue in all public forums, from the media to political campaign speeches. In Betrayal of Trust: The Collapse of Global Public Health, author Laurie Garrett challenges world leaders and policy makers to make public healththe health of populationsat least as high a priority as medicinethe health of individuals.
Public health is a concept that has been pushed to the bottom of the international agenda in favor of technological and industrial globalization. Garrett believes that every population deserves a tough public health infrastructure that upholds standard tenets, such as clean drinking water, ecological and environmental stability, immunization access, safe food, and government leadership that provides honest information on disease and illness. Garrett argues that a healthier population will result from making public health a policy and funding priority and that the international medical community will be better equipped to treat and protect a healthier public.
Garrett begins Betrayal of Trust by examining public health catastrophes around the world. For example, hysteria and mass exodus followed when a pneumonic plague descended on Surat, India, in 1994. Not only did the Indian government fail to step in and lend any support to the population during the panic, it made it clear that public health was the responsibility of local authorities, and then proceeded to slash funding to a meager 0.04% of the federal budget.
When the Ebola virus came to Zaire in 1995, corrupt government leaders had drained the public health coffers and pocketed the nations medical budget. Hospitals could not afford the most basic supplies, including sanitary gloves and bedsheets, much less sterile equipment, anesthesia, or antibiotics. Given these conditions, it is no wonder that health care workers were the first identifiable population to fall victim to the virus. As Garrett explains, At the peak of the Ebola outbreak, nothing more exotic than latex gloves and basic protective gear was needed, along with clear-headed planning, to bring the epidemic under control.
Betrayal of Trust continues with an examination of Russias public health system following the fall of the Soviet Union, which she describes as the most astounding collapse in public health ever witnessed in peacetime in the industrialized world. Less than a year after the dissolution in 1991, Russia fell victim to a series of epidemics: diphtheria, hepatitis, influenza, typhoid, cholera, and dysentery. In addition, reported rates of AIDS and other sexually transmitted diseases skyrocketed, while alcoholism and drug abuse followed the same trend.
But Garrett also puts the U.S. public health system under the microscope. She describes what she sees as the virtual abandonment of public health as a result of the tension between democracys belief in an individuals right to privacy and the need for compulsory public health measurescreating a system where health is available only to those who can pay for it.
Garretts extensive research and powerful statistics make her case convincing and captivating. Weaving technical evidence with personal testimonies, Betrayal of Trust presents a somber look at the state of public health today and the dangers that lie ahead.
Oxford University Press, New York, 1999, 295 pp, $24.95 paperback
MARTIN S. PERNICK
One of the most contentious questions in contemporary biomedical ethics is whether or not physicians should allow certain patients to die rather than treat them and therefore prolong their lives. The debate usually centers on a definition of quality of life and whether a patient feels that he or she can have a satisfying, productive life after a severe trauma has occurred. Even more controversial are arguments regarding the treatment of children in cases when quality of life is determined not by the patient but by parents or guardians, often with the input of the physician and the state.
Yet such dilemmas are not unprecedented in modern medicine. In the early part of the 20th century, there were robust public debates about the physicians role in decisions regarding the treatment of certain patients. These debates were charged with contemporary concerns about euthanasia and eugenics. As stated in The Black Stork, eugenics favored active intervention to assist natural selection, which meant not only that a physician could refuse to treat certain impaired patients (such as mentally retarded youngsters), but that medical personnel could participate actively in killing the unfit.
Pernick tells the story of these medical and ethical debates by focusing on the tale of the Bollinger baby, an infant with multiple physical anomalies who died in the care of Harry J. Haiselden, a Chicago surgeon who became notorious for his support of withholding treatment for infants deemed defective. Soon after the Bollinger baby died in late 1915, Haiselden revealed that he had refused to treat other defective infants on the grounds that the children in question would be forced to live miserable lives as monstrosities mocked by their peers and condemned to waste public funds as they were forced into institutional care. Even more dangerous, according to the theories of eugenicists, was the possibility that such children might contaminate the gene pool, thereby threatening modern civilization.
Although there were laws against euthanasia, charges were never filed against Haiselden. More important, according to Pernick, was Haiseldens role in publicizing his actions and his eugenic creed, marshaling the forces of mass culture to ignite a public debate on eugenics and euthanasia. A film about the Bollinger case, entitled The Black Stork, which starred Haiselden as himself, focused attention on the controversy and garnered increased support for the eugenic cause.
According to polls in the 1910s, there was extensive support for eugenics, not only among political progressives but within the general populace as well, thanks to the powerful influence of mass culture. According to Pernick, Haiselden appealed to societys belief that science constituted an objective method for resolving social and ethical questions. For Haiselden and other supporters of euthanasia, science would be substituted for traditional religion as the true basis for benevolent feelings and moral obligations. Allowing defective children to die was considered a victory of objective love over sentimental love. The Black Stork is a thought-provoking book that deserves attention from anyone who is interested in the history of medicine, medical ethics, and the relationship between science and mass culture.