Rating: 
Summary: A "Must Read" book if you are interested in Public Health
Review: Laurie Garrett does not write short books. But it's worth the effort ploughing through Betrayal of Trust if you care about Public Health and what its decline could mean for our children and grandchildren if due care and attention is not given to this important part of contemporary life. The frightening problems caused by the collapse of the Public Health system in Russia are a potential lesson to us all who live in the USA; Garrett chillingly portrays the grim situation now faced by the Russian people. If such problems can happen in a relatively sophisticated country, then we need to think of the problems of less well developed countries. And again Garrett brings the message home with her writing. Nowadays, infectious diseases know no borders, and their spread can occur with frightening rapidity. Garrett documents this with her own observations of Plague in India and Ebola in Zaire. Add in a chapter on bioterrorism and it becomes clear that this is a book that can have a real impact on one's thinking. Sure, there are probably some factual errors here and there, which is probably not surprising in a book of this length. But look at the big picture - which is what this book is very much about.
Rating:
Summary: A historical perspective of Public Health
Review: Laurie Garrett has done a wonderful job of portraying public health at present and for the future as the most important solution for our ever predominant world of microbes and disease. She has with an expert ability demonstrated how heads of state all over the world have betrayed their people as they continously undermine the most basic principles of public health. Her exposition is an alert to consciousness for global experts to reconsider their priorities and put under perspectives global health issues. It is a call for humanity to become aware that our health and survival will depend on global cooperation of all people and the commitment of public statesmen to value health as the most valued asset of their countrymen. Betrayal of trust has given a historical view of the development of major global public health issues. It is a book that can enlighten many readers concerned about public health. My congratulations to Laurie Garrett.
Rating: 
Summary: Misplaced Values and the Decline of Public Health
Review: Laurie Garrett's book, Betrayal of Trust, is not only highly recommended reading for those interested in public health issues, but should be read by anyone interested in discussing contemporary problems. The book is lengthy, but well written. For the most part it accurately portrays a public health system which is in shambles in most parts of world. The book, perhaps, overdramatizes some concerns, but not in a manner that undermines the central premise of the book.Laurie is most successful in pointing out: (1) why public health is important to everyone; (2)the disarray that exists in public health system; (3)The particular threat that is imposed upon the world by the combination of infectious disease and globalization; (4)The fact that unlike other areas of medicine, advances in public health depend acutely on politics and public support for its operations. I found the sections of the book that dealt with antibiotic resistant microbes in strep and staph bacteria diseases to be absolutely chilling. Right now, even in the USA, there are patients who have died of bacteria that have become resistant to every antibiotic that we have. And the problem continues to get worse. The problem is exponentially worse in many other countries in the world where antibiotics were used haphazardly and bizarrely by untrained persons attempting to treat diseases. Its a sad state of affairs that should have been dealt with sooner. It may lead to serious disease epidemics that will kill thousands. The greatest tragedy that Garrett relates in her book is the way that short-sighted politicians and members of the public have slowly and methodically cut the budget for public health endeavors while the threats from infectious diseases have been rising. All this has occurred against the background of huge increases in spending for medical *treatment* as opposed to prevention, embodied in public health. At times Garrett fails to give the system credit, where credit is due. Effective strategies do exist to contain many diseases and there have been notable public health achievements, such as the eradication of the diseases, small pox and polio, which may not have received enough praise. Even tuberculosis which she speaks of us as being "multi drug resistant" in many patients in many countries, can be cured with aggressive treatment following established protocols. I would prefer to leave this book with the idea that these problems are fixable with alot of effort and dedication, rather than that "the sky is falling". Ultimately, though, the book deserves high praise for the provocative and authoritative way that she intelligently discusses problems of immense public interest. It is without a doubt, one of the best books of the year. Markg91359
Rating:
Summary: Valuable information we all need to know
Review: Laurie Garrett's follow-up to The Coming Plague is packed with valuable information and analysis, and she offers some insights for solving some of the nearly insurmountable and pressing problems we should all be worrying about. Garrett examines how our misconception of public health as medicine for poor people, even a handout for the poor, has potentially devastated our national well-being. Public health is everyone's concern, particularly in the global age we're in today. Her coverage of the biowarfare threat is thorough and she makes a large and unwieldy topic clear and understandable. Public health should be our number one concern, and Garrett spells out why we can't wait.
Rating: 
Summary: we got the tumor, but killed the patient
Review: 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
Rating: 
Summary: Good ideas, flawed execution
Review: The message of this book is clear, vitally important, and well driven home: public health is in bad trouble worldwide, due to failure of public and governmental will. One might call that "civic culture," or just plain old-fashioned morality. In any case, the world's governments are not spending nearly enough on public health. Garrett deals first with what may be the world's worst cases--Zaire/Congo and the former Soviet Union--and then shows that the same problems, in much less virulent form so far, exist in the United States. All this is true. However, I must agree with several other reviewers that the book is full of errors. The scientific name of the common rat, _Rattus rattus_, is misspelled "_Ratus ratus_" throughout. In the Zaire chapter, footnote 113 was obviously intended to correct and replace the inaccurate #114, but both were left in. And so on. More serious is the extremely cursory and misleading treatment of food, nutrition, and the results of failure in that area. Garrett loves the romance of new diseases, and tends to ignore problems that are not new or infectious. She treats nutrition as if nothing of much value were known and as if there were few (if any) problems beyond just getting enough food. Diabetes is mentioned a few times, but is not in the index. Yet diabetes is a vastly more important public health problem than Ebola virus, and may soon rival TB and AIDS worldwide, as genetically susceptible individuals consume more and more sugar, alcohol, and the like. (By contrast, her section on drugs and the failed "War on Drugs" is outstanding.) But most serious of all is the lack of a coherent plan for solving the world's problems. Garrett's major recommendation is more spending; necessary, surely, but not a plan in itself. What should we do first? What next? How can we be maximally cost-effective? How do we balance needs when funding is short--for instance, how should a Third World country balance providing clean water against building new hospitals? Above all, how do we get back the unique morality that brought us public health (as well as public education, conservation, and other public goods) in the early 20th century? The idea of aggressively acting for the comprehensive benefit of the entire citizenry is really quite rare in history. As Garrett points out, it is in desperate shape in the US today. Garrett could have made a much stronger case if she had focused on clear proposals.
Rating:
Summary: Good ideas, flawed execution
Review: The message of this book is clear, vitally important, and well driven home: public health is in bad trouble worldwide, due to failure of public and governmental will. One might call that "civic culture," or just plain old-fashioned morality. In any case, the world's governments are not spending nearly enough on public health. Garrett deals first with what may be the world's worst cases--Zaire/Congo and the former Soviet Union--and then shows that the same problems, in much less virulent form so far, exist in the United States. All this is true. However, I must agree with several other reviewers that the book is full of errors. The scientific name of the common rat, _Rattus rattus_, is misspelled "_Ratus ratus_" throughout. In the Zaire chapter, footnote 113 was obviously intended to correct and replace the inaccurate #114, but both were left in. And so on. More serious is the extremely cursory and misleading treatment of food, nutrition, and the results of failure in that area. Garrett loves the romance of new diseases, and tends to ignore problems that are not new or infectious. She treats nutrition as if nothing of much value were known and as if there were few (if any) problems beyond just getting enough food. Diabetes is mentioned a few times, but is not in the index. Yet diabetes is a vastly more important public health problem than Ebola virus, and may soon rival TB and AIDS worldwide, as genetically susceptible individuals consume more and more sugar, alcohol, and the like. (By contrast, her section on drugs and the failed "War on Drugs" is outstanding.) But most serious of all is the lack of a coherent plan for solving the world's problems. Garrett's major recommendation is more spending; necessary, surely, but not a plan in itself. What should we do first? What next? How can we be maximally cost-effective? How do we balance needs when funding is short--for instance, how should a Third World country balance providing clean water against building new hospitals? Above all, how do we get back the unique morality that brought us public health (as well as public education, conservation, and other public goods) in the early 20th century? The idea of aggressively acting for the comprehensive benefit of the entire citizenry is really quite rare in history. As Garrett points out, it is in desperate shape in the US today. Garrett could have made a much stronger case if she had focused on clear proposals.
Rating:
Summary: Not really so hot
Review: This book has been over-rated...it is strewn with errors despite appearing to be academic. Which I think is a very big negative. Balancing that, Ms. Garrett has an engaging writing style - but in a psudo-academic book, that is also a problem.
Rating:
Summary: Prophetic Warning About Current State Of Public Health!
Review: This is a truly prophetic warning from the acclaimed author of "The Coming Plague", which itself was an eloquent best-seller warning of the approaching debacle of increasing microbial threat based on human arrogance, rapid increases in virulence, multiple drug resistance (MDR), and the appearance of entirely new viral entities, comes this articulate, literate, and extremely well researched investigation into the woeful state of the world's public health organizations. Earlier she had warned of the disrepair and dangerous lack of preparedness of public health agencies, and here she writes with cutting clarity as to just how irretrievably damaged they now are. Many international authorities are now openly worried because these national and international public health organizations constitute the only potentially effective line of defense for quick public health countermeasures to intervene and combat both the initial appearance of microbial threats (through inoculation, maintenance of public sanitation systems, and rapid response to perceived threats) as well as continuing support for stemming the effects of such outbreaks once they occur. Without such agencies the public is left literally to the mercies of fate. This new work is an informative and fascinating decent into a terrifying world in crisis, and Ms. Garret quickly exposes the dark side of the highly vaunted globalization process. For even while Asian economies prosper under the new prosperity, dangerous new breakout of old microbial enemies such as pneumonic plague threaten the population with devastating new pandemics. Meanwhile, multiple drug resistant (MDR) forms of Tuberculosis have appeared in epidemic proportions in Russia, combining with the ravaging effects of drug addiction, alcoholism, and malnutrition (as well as the regional exposure to radiation poisoning connected to Chernobyl in the Ukraine) to exact a treble toll on life expectancy and quality of life in the struggling provinces. And this is just the most obvious tip of the iceberg. Domestically we face new emerging threats from MDR Tuberculosis, West Nile virus, and other new "superstrains" of microbial entities we were arrogant enough to believe we had permanently vanquished. This phenomenon, when combined with the rapid and increasingly popular modes of international travel now threaten us with a Pandora's box of so-called "Third world diseases" for which we have little of no natural immunity. As Garret reveals the results of her detailed investigation into the nature of the threat, the reader must take pause. We have, she suggests quite eloquently, suffered from a betrayal of trust from both our national leaders and the various local, state, and national public health agencies, which have deteriorated to such an alarming degree that they are now virtually unable to stem the tide now confronting us. This is serious albeit absorbing reading, and is not recommended for squeamish or immature readers. It is a quite accurate and absolutely devastating look at the nature of a monumental public health threat that is emerging throughout the world even as we speak, one poised to cause catastrophic and tragic losses of life and irreparable social, political, and economic harm to the various nations in which it strikes, and one for which we have done amazingly little to prepare for. We now have the global village Marshall McLuhan warned about, and in such a community there is increasingly no place to hide from the frightening prospects of a wide range of microbial threats all too-naturally rising to confront us. This is a terrific book, a cogent, entertaining, and superbly documented foray into the horrifying realities of our looming public health disaster. I highly recommend it
Rating:
Summary: at times brilliant, prescient, inaccurate and frustrating
Review: This is an excellent and yet deeply flawed book. It will (and should) frighten us all into action, and given recent events of Sept 11 and its aftermath - the imminent threat of terrorism that may be biological in nature - this book is extremely well timed. The thesis of the book is that, for a variety of reasons (lack of political will in the US, economic deterioration in the former USSR, and poverty in Africa) public health infrastructures worldwide are in serious decline at the moment that horrible new diseases (Aids, ebola) and new strains of old ones (TB, whooping cough, diphtheria etc) are emerging. If these public health infrastructures are not repaired, she asserts, we are in for horrendous trouble. She may well be right and for this reason, we would do well to heed her plea for renewed investment throughout the world in preventive medicine, epidemiology, and other measures to promote collective, as opposed to the privatized (or "medicalised") health model. It is easy to dismiss this argument as crypto-socialist,but to do so is a disservice both to the talents of Ms. Garrett and to the idea of public health itself. To prove her case, Garrett embarks on an historical tour of the public health systems of both the US and the USSR, both of which were pioneers. The US, in New York but also in Minnesota, developed science-based systems to recognize dangerous contagious agents and to stamp them out via quarantine and later vaccinations and for bacteria, antibiotic treatments. The statistics speak for themselves and are well documented in Garrett's book. Not surprisingly, the USSR developed a more coercive and less scientific system, which was in decline before the fall of communism in 1990; since then, it has declined so alarmingly that death rates in the former Soviet republics are twice as high as births!
What is needed, she says, is larger investments to maintain the fragile infrastructures of scientists, other health care professionals, and access facilities. The wider landscape she describes - the context of this deterioration - is bleaker and more terrifying than I had imagined possible. It involves antibiotic-resistent strains of tuberculosis and other ancient scourges, an unprecedented Aids epidemic in Africa and Asia, and in the wake of the defunct Soviet biological warfare programs with 30,000 scientists who disappeared - some apparently into the Middle East - the specter of bioterrorism. (Indeed, some of the Sept 11 pilot-terrorists were getting trained with crop dusters, which could deliver small pox or anthrax to threaten millions.) We may be approaching the end of an era in which we believed science was triumphing over human disease. I now fear for my children. Developments in India (plague) and the Congo Republic (Ebola) are also covered in grim detail. It is here that Garret's argument begins to run into trouble. What has emerged in the US, she says, is a hybrid of conservative ideology (blaming the victim with claims that health is the individual's responsibility) and a "medicalised" model whereby we seek high tech, individualized cures to ailments rather than the less expensive preventive cures that the collective public health model offers. I believe that this is a straw-man dichotomy that oversimplifies the problem, in effect setting up conservative budget cutters to blame for a failure of collective will. While this is certainly true to a degree, the political and economic dimensions of the problem are so complex that Garrett fails to do them justice. Moreover, the medical approach is complementary to the public health one. If the reader want a more realistic appraisal of these issues, (s)he must look elsewhere. Furthermore, there are numerous inaccuracies and errors throughout the book, which damage its credibility. For example, at one point Garrett states that Crick worked at "Oxford University in Cambridge, England"! While this is trivial and an editor should have picked it up, it is symptomatic of the rushed feel to the book, which was obviously written too quickly and perhaps sloppily. Moreover, Garrett glosses over a number of issues that deserved far deeper scrutiny: she dismisses the demise of the Clinton health plan in one page (it was simply "overly complicated"), and rejects claims by the pharmaceutical industry that the cost of drug development is $500 million (because governments fund basic science). The list of these errors and omissions is indeed long. SO in the end the book is a mixed bag. For me, it will serve as a treasure trove of information for my latest writing project, but I worry about the accuracy of many of her claims. It is a very good call to arms for a serious issue and a warning to us all. REcommended with reservation.
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