Feature

The collapse of global public health

With a new century seeing the resurgence of old diseases alongside the emergence of new threats to health, effective public health infrastructures are more vital than ever – yet have been allowed to fall into disrepair, says Laurie Garrett

The year 2000 found health in the old superpowers endangered. And in the world’s poor nations, where most of the planet’s population resided, every improvement in health seemed to be smashed on the shores of underdevelopment. In 1996 Canadian scientist Joseph Decosas decried underdevelopment at a gathering of AIDS researchers in Vancouver. Holding an imaginary glass of water in the air Decosas grimly said that ‘if the solution for AIDS would be to bring a glass of clean water to everybody in the world, we would not be able to bring that. We have not been able to stop children from dying from simple diarrhoea by providing clean drinking water.’

We have not, at the millennium, been able to bring clean water, food, or life’s succour to the world’s poor.

Every night in 1997 more than 200 million Indians went to bed hungry, officially malnourished—including half of the country’s children. In China a smaller percentage of the nation’s children—one out of every five—was malnourished, but 164 million Chinese went to sleep with hunger gnawing at their stomachs. As did some 25 million Pakistanis, 15 million Brazilians, and more than a third of all Africans. In the Democratic Republic of the Congo (formerly Zaire) and central Africa half the population was malnourished, and globally in the1990s nearly 800 million people on any given day were starving, or a population roughly two and a half times the size of that of the United States of America.

No wonder that AIDS researchers moaned about the seemingly impossible requirements for a viable HIV vaccine: 100 per cent efficacy, 100 per cent safety, stability in tropical heat, and a price of less than one dollar a dose. Even at that price such a vaccine might be as elusive for the world’s poor as Decosas’s clean glass of water. While science searched for technological solutions, what really stymied most of the world was frighteningly basic.

In Eastern Europe the 1990s saw a rocky road to economic recovery, but progress did, indeed, emerge in such countries as Poland, the old East Germany, and the Czech Republic, with average per capita incomes nearly doubling during the decade. Not so farther east in the Slavic, Baltic, and Central Asian nations of the former Soviet Union. There wealth concentrated in the hands of former Communist bosses, criminals, and bankers, leaving the populaces in despair. In 2000 Russia ranked as the number one riskiest economy for foreign investment.

Progress for public health at the millennium seemed chained to economics. Nations could not advance so long as their populaces were debilitated by illness. And they lacked the financial abilities to build health infrastructures. Still, optimists drew satisfaction from the World Bank’s strong commitment to public health and its increasing global recognition that healthy nations developed more rapidly than those impeded by an ailing populace. That message was the World Health Organization Director-General Gro Harlem Brundtland’s battle cry in 1999.

But the new century finds experts at odds over the mission of public health. No two deans of the West’s major schools of public health agree on a definition of its goals and missions. While one school—the University of California, Berkeley—selected a biotechnology executive in 1998 as its dean, another—Harvard—opted that year for a leader whose battle was against the most ancient—even traditional—scourge, tuberculosis. A schism appeared and widened in academia, pitting technologists and health managers against the more traditional advocates of disease prevention and epidemiology.

Regardless of the mission statements of academic centres, it was clear by the 1990s that public health, as a discipline, was changing radically. Whether its practitioners were running family planning clinics in Cairo, antibiotic import and distribution for Sri Lanka, drinking water surveillance in Moscow, or multibillion-dollar Medicaid programmes for the United States, their political clout was diminishing and cost-effectiveness was the watchword of the day. It was no longer sufficient to prove that a given intervention prevented disease and saved lives: now it had to do so affordably.

If an arsonist torches an office building the roles of the fire department and police are obvious. When they do their jobs—stop the fire and apprehend the arsonist—the community recognizes their achievements and applauds their actions. Because of this it is politically difficult-to-impossible to slash a police or fire department budget except in times of municipal bankruptcy.

If, in contrast, the workers in that office building are strong, healthy, and long-lived, it is next to impossible to prove that the efforts of local public health officials are responsible. Public health is a negative. When it is at its best, nothing happens: there are no epidemics, food and water are safe to consume, the citizens are well-informed regarding personal habits that affect their health, children are immunized, the air is breathable, factories obey worker safety standards, there is little class-based disparity in disease or life expectancy, and few citizens go untreated when they develop addictions to alcoholic or narcotic substances. In the absence of failures in these areas, politicians faced with budgetary crises, or dictators eager to expand their local and regional power, may feel justified in hacking away at government health budgets. Even if epidemics emerge, such as those of HIV, Ebola, pneumonic plague, or drug-resistant tuberculosis, national leadership is often insulated from the danger, as they typically are far more wealthy than the imperilled citizens and have access to elite health coverage.

And public health advocates, fearing for their jobs or programmes, may be tempted to bend to political whims of the day, veering away from the voice of Science to back ideological or religious trends. Such was the case in the Soviet Union, where rational genetics and the medical social practices flowing from Darwinian evolutionary under-standings were abandoned in favour of the absurd anti-genetics belief system of Lysenkoism. Only those Soviet scientists bent on perverting public health’s mission, concocting ghastly biological weapons of mass destruction, were spared the shackles of Lysenkoism in favour of genocidal weapons based on the central dogma of DNA. The scope of activities that fell under the rubric of public health by the end of the twentieth century was quite broad. In 1988 the US Institute of Medicine (IOM) struggled for a definition of public health, arriving at the following: ‘The committee defines the mission of public health as fulfilling society’s interest in assuring conditions in which people can be healthy.’

Elsewhere in their report, the Institute of Medicine committee tried to justify their overbroad definition:

Knowledge and values today remain decisive elements in the shaping of public health practice. But they blend less harmoniously than they once-did. On the surface there appears to be widespread agreement on the overall mission of public health, as reflected in such comments to the committee as ‘public health does things that benefit everybody,’ or ‘public health prevents illness and educates the population.’ But when it comes to translating broad statements into effective action, little consensus can be found. Neither among the providers nor the beneficiaries of public health programs is there a shared sense of what the citizenry should expect in the way of services, and both the mix and the intensity of services vary widely from place to place.

In other words, there was no agreement about what constituted ‘public health’ other than assuring that people were healthy. In the absence of a coherent definition of the discipline it was no wonder its advocates were struggling to defend their budgets and policies. During the 1980s, the IOM found that every state lost funding and personnel in all areas except provision of clinical health care. Such vital services as drinking water and food quality control, environmental and occupational health, laboratories and disease control all lost money and personnel.

Even the prestigious Institute of Medicine found it difficult to distinguish medicine from public health. Though the two pursuits classically shared few interests and often were in direct conflict, political pressures over the course of the last half of the twentieth century had blurred the borders between the two. In the United States ‘public health’ had become—incorrectly—synonymous with medicine for poor people. Few Americans at the millennium thought of ‘public health’ as a system that functioned in their interests. Rather, it was viewed as a government handout for impoverished people. When Congress and the White House set out in 1990 to reduce the national debt public health suffered and the loss of federal funds was felt all the way down to the level of neighbourhood clinics. In its first term the Clinton administration tried to map out a new national health-care system, tightly linked with public health and able to absorb the then thirty-seven million uninsured Americans. Unable to find common ground with the Congress and the health insurance industry, the White House was soundly defeated.

By the end of the decade, more than forty-four million Americans were uninsured, the nation had no coherent health-care system, and the numbers of uninsured was swelling by 100 000 people each month.

In lieu of a national medical infrastructure, public health and curative medicine were provided by a hotchpotch of for-profit insurers, physician organizations (PPOs), county, state, and federal insurers, health maintenance organizations (HMOs), and managed care companies. With every passing day it became more difficult to decipher who, if anyone, was protecting the public’s health. And government public health budgets continued to plummet, dropping 25 per cent between 1981 and 1993. While the federal and some overall state health budgets increased between 1994 and 1998, the bulk of those funds were directed to provision of medical care. Most key public health programmes took substantial hits.

By 1998 the states with the most people enrolled in HMOs and managed care plans had the weakest safety nets. In California, for example, which led the nation in HMO enrolment, one out of every four citizens was uninsured and the state’s largest county health system repeatedly faced bankruptcy.

The health management perspective also found adherents in Europe, Latin America, and the developing world. Managed care advocates marched across Russia, the Baltics, Eastern Europe, and the Caucasus preaching the gospel of cost controls and team care. Western European governments, long the prime health providers in their societies, hung on to the managed care miracle in hopes of slimming down their budgets, a key component at play in the new global capitalism.

And the World Health Organization, once the conscience of global health, lost its way in the 1990s. Demoralized, rife with rumours of corruption, and lacking in leadership, WHO floundered. Other international agencies—notably the World Bank and UNICEF—stepped in to the breech. By 1997 the World Bank was the biggest public health funder in the world, bankrolling $13.5 billion worth of projects, primarily in developing countries.

‘The health of the world stands at a crossroads,’ wrote an august group of international health leaders. ‘For half a century, most countries have achieved impressive progress in their health conditions. Yet the causes of ill-health do not stand still— humanity’s very progress changes them. The past decade has witnessed a profound transformation in the challenges to global health; persistent problems have been joined by new scourges in a world that is ever more complex and interdependent. The idea that the health of every nation depends on the health of all others is not an empty piety but an epidemiological fact.’

It was time to face reality: as the vital statistics of the human race appeared to be improving, the threat, even materialization, of reversal was ever present. It begs the question: what is public health?

It is not curative medicine. CT scans, open heart surgery, hormone treatments, fibre optic images—these are all great boons for medicine, but they are not public health. And, perhaps surprisingly, they have not been responsible for the vast improvements in the public’s health. Even vaccines and antibiotics—both of them vital tools of the modern public health arsenal—have contributed comparatively little to population-based improvements in such key indicators of public health as life expectancy, infant mortality, and infectious disease deaths.

Vital statistics data from England, Wales, and Sweden show that in 1700 the average male in those countries lived just twenty-seven to thirty years. By 1971 male life expectancy reached seventy-five years. More than half that improvement occurred before 1900; even the bulk of the twentieth-century increases in life expectancy were due to conditions that existed prior to 1936. In all, 86 per cent of the increased life expectancy was due to decreases in infectious diseases. And the bulk of the decline in infectious disease deaths occurred prior to the age of antibiotics. In the United Kingdom, for example, tuberculosis deaths dropped from nearly 4000 per million people to 500 per million between 1838 and 1949,when antibiotic treatment was introduced, an 87 per cent decline. Between 1949 and 1969 the TB death rate fell by only another forty million cases to 460 cases per million, or 9 per cent.

The same can be said for the United States, where less than 4 per cent of the total improvement in life expectancy since the 1700s can be credited to twentieth-century advances in medical care.

It is a matter of considerable academic debate which factors were most responsible for the spectacular improvements seen in life expectancy and infant mortality in the United States and Western Europe between 1700 and 1900. Some of the following were key: nutrition, housing, urban sewage and water systems, government epidemic control measures, swamp drainage and river control engineering, road construction and paving, public education and literacy, access to prenatal and maternity care, smaller families, and overall improvements in society’s standards of living and working. In the early twentieth century elimination of urban, overcrowded slums that lacked plumbing and toilet facilities clearly improved the health of tens of thousands of Americans and Europeans.

The critical dilemma for the twenty-first century was embedded in the disparity between the rich and poor, both within and among nations. In the wealthy world the twenty-first century was greeted by stock markets ebullient about biotechnology and protein-based public health—the alleged pharmacopoeia of future disease prevention.

But in much of the world the core advances in public health pioneered between 1890 and 1920 in New York City had, even a century later, to take hold. Drinking water remained contaminated; human waste was dumped untreated; children went unvaccinated and malnourished; hygiene was ignored in hospitals and precious antibiotics were dispensed like sweets in black markets worldwide.

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