Betrayal of Trust
Authors: A. Zumla
Journal: Journal of the Royal Society of Medicine (2002)

In the typical European or North American medical school, students are given scant information on the devastating impact of infectious diseases in the developing world. The schools seem to be in a time-warp, failing to recognize the general threat presented by certain diseases in an age of easy travel and the global village. When Laurie Garrett's best-seller The Coming Plague was published in 1994, I immediately recommended it to medical students and junior doctors for the simple fact that it was exciting, understandable and gripping, and portrayed graphically the threat of emerging infectious diseases. It covered many subject areas influencing human health which are not taught adequately in medical school—for example, the improper use of antibiotics, local and regional warfare, refugee migration, changing social and environmental conditions and poverty. Garrett's anecdotal and scary text illustrated in lay language a range of diseases such as HIV/AIDS, toxic shock syndrome, Ebola virus and Lassa fever. She had mastered an extraordinary amount of medical knowledge and presented it in lay language for all to understand.

Laurie Garrett now uses her skills as a health/science reporter and personal experiences from her extensive tours across the globe to produce a copiously footnoted book of her vision of the public health structures which are required to contain the threats that she described earlier. Betrayal of Trust1 is a sprawling 585 pages of text with 23 of notes. The first chapter investigates the pneumonic plague outbreak in India in 1994; the second dissects the 1995 Ebola epidemic in Zaire; the third scrutinizes the collapse of the public health system in the former Soviet Union and the emergence of drug-resistant tuberculosis; the fourth is a controversial discourse on the decline of public health efforts in the USA under its ‘managed care’ and ‘medicine for profit’ health system; the fifth, titled ‘Biowar’ is on the emerging threats of bioterrorism; and the final chapter is an epilogue. Betrayal of Trust is about the globalization of microbes and disease. It is scrupulously researched and referenced—though some medical readers may be troubled by its anecdotal and dramatic style.

The basic tenet of the book is that an erosion of public health infrastructure (attributable to factors including lack of political will in the USA, economic decline in the former USSR and poverty in Africa) has led to emergence of new diseases (Ebola, AIDS) and new strains of old diseases (multiple-drug-resistant tuberculosis, whooping cough, diphtheria, methicillin-resistant Staphylococcus aureus). Garrett exposes the dark side of ‘globalization’: wherever travellers go, the microbes will follow. Globalized food production means global risks of microbial infections. Misuse of antibiotics is leading to drug-resistant tuberculosis, malaria, pneumonia, staphylococcal infection. She suggests that we have experienced ‘a betrayal of trust’ at the hands of our national leaders and the various local, state and national public health agencies, which have deteriorated to an alarming degree. Dissecting the rise and fall of the public health system in the USA, Garrett argues that unethical experiments such as the Tuskegee syphilis studies have weakened trust in public health officials; that the poor receive little or no medical care; that assertions of individual rights have restricted the capacity of public health officials to respond to disease with the thoroughness that infectious threats demand; and that globalization serves to exacerbate economic inequality. Wherever you look—Los Angeles, India, Russia, Zaire—you find communities totally unprepared to deal with major epidemics or the threat of bioterrorism. In the USA every year 100 000 Americans die from infections caught in hospitals. In India an outbreak of bubonic plague reflects the failure of public health systems to control a disease easily treated by antibiotics. Ebola virus broke out in a dirty and unequipped hospital in Zaire. Garrett documents how the Russians have misunderstood public health and how the new leaders have neither the interest nor the funds to pursue it. Fifteen states of the former Soviet Union have witnessed a rapid collapse in public health; during a cholera epidemic, officials in one state refused to use the simple oral rehydration therapy. In Garrett's opinion, many of the former Soviet Union states were afflicted, like Zaire and other African nations, by deep-seeded corruption that drained the life blood from their social sectors, just as parasites suck the essence of life from the guts of infected children. A recurrent theme of the book is the low investment by most countries in preventive measures.

How can the public health systems be returned to strength and efficiency? Garrett's proposals are hardly new—political will and a modicum of funding; adequate nutrition, clean water, good sanitary systems; proper hygiene and provision of basic medical management; rich nations should help poor ones and in the process place their own houses in order. A very expensive, coordinated and seemingly effective response to ‘terrorism’ has been launched recently by the USA and Europe. After reading Garrett's book one wonders why such investment has not been forthcoming for microbial threats—a terror of enormous magnitude.

Garrett points out that ‘public health’ is a negative specialty; if it is working well, nothing bad happens. Politicians then lose interest and funding suffers until something bad does happen—for example, a fatal disease getting out of control. Public health is the most important discipline in medicine, but one would not think so from the way it is taught in medical schools. Our future doctors must be made aware of global health issues and the associated preventive measures. My own school, University College London, is I think the first and only one in the UK to have introduced special study modules and an intercalated BSc in ‘international health’.

Betrayal of Trust can be recommended to all readers of the JRSM, and especially to politicians, physicians and health workers who have not yet woken up to the fact that infectious diseases have made a major comeback and will be with us for a long time. In my annual introductory lecture on ‘infectious diseases’ to new clinical students I point out that the human race serves as a culture medium for microorganisms, but that the survival of both microbe and human depends on achievement of equilibrium. This notion offers some comfort, in that an advantage for microbes is unlikely to eliminate the human race. Garrett's book, on the coffee table, will keep us asking, ‘Can we do anything more to prop up public health?’.