Public health depends on the people’s trust

Stephen R. Leeder, University of Sydney

Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health Oxford, Oxford University Press, 2002 (490 pp). ISBN 0-19850-995-2 (hardback) RRP $69.95.

From time to time I am asked whether public health has had its day, whether it, like social philosopher Francis Fukuyama’s notion of political history, has come to an end.

In this assessment of the state of public health worldwide, United States journalist Laurie Garrett draws on first hand experience gained in India during an epidemic of pneumonic plague, from the Ebola outbreak in Zaire and the ‘collapse of all semblances of public health in the former Soviet Socialist Republics.’ She then explores the risks that are associated with globalisation in a world where there has been a loss of public health capacity. We are here talking about public health as protection of the population, not publicly funded health care.

Garrett begins with New York City, analysing how critical public health was to its genesis as seething masses of humanity poured into it by the millions from all over the world. The empirical principles of public health, developed in London, Paris and Berlin, involving sanitation, surveillance and quarantine, were expressed in bold and sometime draconian public health laws and practice in New York. Now two hundred years later, she says, five-sixths of the world resembles New York City back then, and stands in need of the same public health measures. Yet everywhere public health services and systems appear to be in decline, beaten by politics that attend only to the immediate and medical technology preoccupied with its brilliant and profitable care of sick individuals. The public trust, she argues, has been betrayed by these failures, in the affluent and impoverished nations alike.

Garrett goes on to explore what has happened to the public health infrastructure inside the United States during an era of anti-governmentalism, and how by cutting investment in it the United States has lost traction. Not only has there been a steady rise of such problems as obesity, but also more and more pockets of people are experiencing disadvantages. One of the oldest lessons in the public health book—that if you want to maintain the health of the majority you must attend to the health of minorities as well—has been forgotten.

One of the reasons governments cut back this investment is that good public health produces a negative outcome. Things don’t happen: epidemics don’t occur, accident rates are kept low, the community is healthy. The natural response to these non-events is to regard them skeptically if the budget is tight. Why are we spending so much on these services when all they are doing is preventing things happening?

Prevailing political trends make it hard for public health to be imaginative or visionary.

But this is a false state of mind. Life is not like that. It is illusory to believe we can get it so well under control.

I participated in an international symposium in Washington DC last October on health service management in several nations. The prior agenda was displaced by events following September 11 and the subsequent anthrax attacks. Tommy Thompson, the United States Secretary for Health and Human Services, made clear his profound concern that public health surveillance and control in the United States would not hold in its current form in the face of bioterrorism. Subsequently there has been a measure of reinvestment in public health surveillance in the United States, so much so that the Centers for Disease Control, for decades the faithful remnant of public health, had to ask that their standard functions be allowed to continue and they not become simply an anti-bioterrorism unit.

The crash of the Soviet Union took virtually all of its elaborate epidemiological surveillance capacity with it. More critically, long established behaviours that were consistent with the preservation of public health were overturned. Depending often on advice from the United States, a patchwork of health services, mixed government and private medical care and multiple other sources came to substitute for what was there before. Not that what existed previously was spectacular, with its strong attachment to the anti-evolutionary doctrines of Lysenko. But with the loss of social integrity and the decay of public health, the former Soviet Union experienced a massive downturn in health.

All of this is no argument against the adequate funding of medical care and biomedical research. We owe much toboth. But the record is clear. Public health—with its interactions with politics, education, and the environment—cannot be expected to sustain itself without support. Its achievements are measured in cases avoided, not cases cured, and a different approach must be used in considering its benefits and the value of investment in it.

For public health to flourish, lost public trust will need to be recovered.

In Australia, public health remains active in relation to infectious disease control and surveillance and partially so about non-communicable disease. Matters of public health concern are maintained on national agendas through agencies such as the National Public Health Partnership, a bureaucratic alliance of all states, territories, and the Commonwealth, and the Public Health Association of Australia, an aggregation of 1,500 public health professionals, especially through its policy development process. Success with immunisation, attributable in no small part to Dr Michael Wooldridge, recently federal minister for health, and tobacco control, through the work of Simon Chapman and many colleagues, are signal public health achievements. Indigenous health has improved in small ways, especially infant mortality, often as a result of the implementation of public health strategies complemented by clinical care, but remains a big challenge. Training of public health professionals has grown in the past decade, as has research funding.

Prevailing political trends, however, depart from the primacy of social justice, equity, community, and society in favour of self-reliance. This makes it hard for public health to be imaginative or visionary. With some notable exceptions, Australian public health takes little account of what is happening beyond our favoured shores. Thus public health faces a tough future: public health professionals will need more to use muscle than previously to prosecute their cause.

Garrett’s book is exhausting in its length and detail. She is entitled to write like a Russian novelist, but one wonders if her message is the more compelling for it. But this is a minor quibble.

It is easy to forget our place in the scheme of things, to forget that most of the life on this planet is single celled and that at least half of it lives beneath our feet. That’s just on the biological side! Then we have our complex interdependence with the world of work, commerce, education, politics and prosperity. In relation to both the bioworld and the ecoworld, modern technology has rendered all nations so confluent that there is no ultimate border protection. What is needed is clear recognition that our health depends on others wherever they live. We cope well with a globalised economy. We must learn rapidly to do the same with public health. History has not ended and the need for public health has not either. But for public health to flourish, lost public trust will need to be recovered, and this requires altruism and continuity, as well as first rate science.

Stephen Leeder is Dean of the Faculty of Medicine, University of Sydney.