Several years ago, Laurie Garrett wrote a surprise best-seller, The Coming Plague, about how the overuse of anti-biotics had helped to create resistant strains of disease, how the encroachment of mankind onto previously uninhabited wild territory was exposing us to new diseases, how the ease and frequency of world travel was enabling these diseases to spread across the entire globe at a rapid pace, and how the public health sector throughout the world was ill-equipped to deal with these emerging threats to global health.  It was good, scary stuff, combining the in-depth reporting of a Woodward and Bernstein book with the blood-curdling disaster scenarios of a Michael Crichton thriller.  The only thing missing, other than a sense of perspective, was some kind of prescription for how to avoid this "coming plague."  Well, now Ms. Garrett has written a follow up volume in which she examines the current state of the Public Health sector and offers some policy proposals for how to repair it, and her ideas make this book much more terrifying than its predecessor.

Once again, she recites the gory details behind some of the particular disease outbreaks that have struck across the globe in the past few years, but that's really just to make sure we're plenty worried and prepared to take her seriously.  The core of the book is a dissection of the rise and fall of Public Health in the United States and some rather drastic ideas about how to return it to its former glory.  Garrett makes the case that : assertions of individual rights have limited the capacity of public health officials to respond to diseases with the thoroughness that the situations demand; that things like the Tuskegee syphilis experiments have weakened our trust in public health officials; that the failure to create a universal health insurance program has created such imbalance that the wealthy receive the best care in the world, while the poor receive little or none; that general economic disparities have resulted in an underclass which is simply exposed to more disease; that overuse of antibiotics has enabled microbial diseases to adapt and become resistant to our best treatment strategies; and that globalization is serving both to exacerbate economic inequality and to expose every corner of the planet to diseases from every other corner.  Taken together, these trends have caused a complete breakdown in the Public Health system that was devised in the United States around the turn of the 20th Century.

It is Garrett's opinion that such a system is absolutely vital to any society and that it should be revived.  Here is a quote from Dr. Herman Biggs, a New York City health official, speaking in 1900, which she cites with some approval :

    The public press will approve, the people are prepared to support, and the courts sustain, any
    intelligent procedures which are evidently directed at the preservation of the public health.  The
    most autocratic powers, capable of the broadest construction, are given to them under the law.
    Everything which is detrimental to health or dangerous to life, under the freest interpretation, is
    regarded as coming within the province of the Health Department,  So broad is the construction of
    the law that everything which improperly or unnecessarily interferes with the comfort or enjoyment
    of life, as well as those things which are, strictly speaking, detrimental to health or dangerous to
    life, may become the subject of action on the part of the Board of Health.

The idea of granting this kind of open-ended autocratic power to government is shocking to anyone who believes in the kind of civil liberties that the U. S. Constitution guarantees.  However, Garrett  quite frankly proceeds from a belief that public health concerns must trump such petty worries over personal freedom.  She believes that the paramount purpose of government is to guarantee the physical health of all of its citizens.  Toward this end she suggests that America must adopt a Universal Health Care system, must redistribute income to alleviate poverty, and must provide government with power to take whatever steps Public Health officials feel are appropriate in order to contain the spread of disease.

Obviously the idea that we should make such fundamental changes to the American system raises a number of objections.  First, the threshold question is whether she even understands the magnitude of what she's suggesting.  In her Introduction she says that :

    Public health is not an ideology, religion, or political perspective--indeed, history demonstrates that
    whenever such forces interfere with or influence public health activities a general worsening of the
    populace's well-being usually followed.  as envisioned by its American pioneers public health was a
    practical system, or infrastructure, rooted in two fundamental scientific tenets: the germ theory of
    disease and the understanding that preventing disease in the weakest elements of society ensured
    protection for the strongest (and richest) in the larger community.

This is so completely inaccurate that it is hard to determine whether it represents complete naiveté or utter disingenuousnous on the author's part.

There is nothing more political than the determination of the purposes for which governments are instituted.  It would be entirely appropriate for a society to determine for itself that it wished to elevate public health above all other considerations, to structure a government with such extensive powers that it could take any action at all in order to better public health, but ours has not done so.  In fact, though our Declaration of Independence explicitly mentions Life as one of the inalienable rights with which we have been endowed by our Creator, it is a right which is balanced against Liberty (and the Pursuit of Happiness, Jefferson's unfortunate substitute for the more appropriate Property).  Nowhere, in any of our founding documents, nor in the Amendments thereto, nor in the speeches of any of the Founders, will you find a reference to a generalized "right to health".  At the very least, if Ms Garrett wants to replace the rights that the Constitution does secure with a right which it manifestly does not, she ought, out of intellectual honesty, to be advocating the type of political changes this would entail, not denying that her goal has any political aspect whatsoever.

That her mission is entirely political is obvious from the solutions she propounds.  The last century saw any number of nations seek to implement her suggestions : universal health care, redistribution of wealth, and authoritarian powers for public officials.  The Earth is littered with the dead, the tens of millions of dead, of those nations.  A good number more nations tried to implement her first two suggestions while still retaining some limits on government action--the nations of Western Europe and the British Commonwealth for example--all of them failed to deliver effective health services and ended up redistributing an ever smaller wealth.  Ms Garrett would seem to have chosen either the Soviet Union, if we assume the worst of her, or France, if we give her the benefit of the doubt, as her Utopia.   God help us.

It is also instructive to look at the time period that Ms Garrett has chosen as the Golden Age of Public Health in America.  What she leaves out of the picture is as important as what she includes.  For instance, in an interview she has said :

    Q:    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?

    A:    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.

She chooses to portray this as an era when the privileged classes were more concerned with the general welfare and willing to sacrifice some private rights for the public good.  She barely mentions that what underlay much of this willingness to turn government loose on disease was a virulent anti-immigrant passion.  The rich weren't saying come up to our neighborhood and delouse our houses; they were saying take whatever measures you have to in order to protect us from the disease-ridden immigrant scum in our ghettoes.  This was hardly a model of enlightened general interest for us to reinstitute today.

In fact, her discussion of the most recent similar situation reveals that even she would not now condone the types of actions that she claims were so beneficial to society back then.  Though Ms Garrett refers to any number of truly minor outbreaks of disease as "epidemics", the only one that most of us would recognize as being even widespread (though still not an epidemic) was the AIDS outbreak in the 80s.  This was, of course, almost entirely a behavior dependent contagion.  If Draconian public health measures are too be considered, then surely this was the moment that called out for them.  Government by seizing and isolating gay men and intravenous drug users could have had a significant impact on the spread of the disease, could have limited in exactly the way that Ms Garrett suggests would justify such gross violations of civil rights and democratic standards.  However, not only does she not endorse such a course of action, she both castigates Reagan and other conservatives for targeting the behaviors involved, and lauds public health officials whose focus on condom usage in all likelihood exacerbated the problem (because condoms have notoriously high failure rates during anal sex).  Despite her protestations of being non-political, how else are we to interpret this section of the book but as unblinkingly politically correct.

Ms Garrett may--unlike her predecessors Malthus and Ehrlich and Sagan and Rifkin and Gore and company--be proven right one day and doomsday may come.  We may unleash a disease upon our society which is so virulent and so contagious that we will wish that there had been an enormous and all powerful public health apparatus in place to deal with it from the get go.  But in the first place, I doubt it.  And second, it strikes me as a rational choice on the part of our society to take the chance that it will never happen, rather than to surrender our liberties in advance of this remote possibility.  It is even a responsible choice to be willing to incur the initial deaths, no matter their number, that such an outbreak might cause.  Just as we have eventually foregone some civil liberties during wartime--suspension of habeus corpus during the Civil War and internment of Japanese-Americans during WWII to name but two examples--I have no doubt that during a serious health catastrophe we'd be willing to accept government actions that would at other times be unthinkable.   On the day that New York City's streets are filled with folks with blood dripping from their eyes, rest assured we'll all be clamoring for the Feds to round them up, and their kin, and anyone who looks or seems similar to them.  But on the morning after, if any of us are still alive to ask the question, will we think that we did the right thing, or will the cure have proven to be as bad as the disease ?   How proud should we be of fighting in WWII when it meant putting our own citizens in concentration camps for no other reason than their ancestry ?    I'm willing to face such difficult questions in the aftermath of a horrific event, I'm not willing to have to face them when they are merely prophylactic measures.

In The Coming Plague, Ms Garrett was warning us about emerging diseases; here she's warning us about ourselves.  Her fear is that we have too much freedom.  She wishes to see that freedom restrained by the power of government.  Certainly freedom has always been a risky proposition and it is definitely possible to have too much freedom; such a situation is called anarchy.  But the chief risks to human freedom have not historically come from a surplus of such, rather they have come from the desire of some men to wield power over other men, the desire of the one to limit the freedom of the other.  They cloak their desire in many guises; often seemingly benign, frequently telling us it's for our own good.  But one thing remains constant, no matter the bogeyman they scare us with, whether the doomsday they foretell comes to pass or no (and so far it's always been no) : as they gain power, we lose freedom.  I fear the Laurie Garretts of the world much more than I fear any virus.

(Reviewed:07-Aug-01)

Grade: (F) Orrin C. Judd

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