(PW, August 21, 2000)
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It was in Zambia's copper belt in 1979 that Laurie Garrett first laid eyes on a dead infant. The young journalist had journeyed to Africa in search of experience and adventure, and one day found herself in a ramshackle clinic. A mother suddenly appeared with a baby that was "beyond crying." The doctor quickly offered his diagnosis: "This child is malnourished and has measles," he announced wearily, "and there is nothing we can do at this point." Minutes later, the infant was dead; Garrett was stunned. "This child has measles and there's nothing you can do?" she wondered incredulously. It was a transformative moment for a young woman steeped in the glories of Western medicine, and one that left her thinking: "I have to understand this."
To understand and explain the relationship between public health, disease and underdevelopment has been Garrett's quest ever since. Her first book, Betrayal of Trust is at once a nightmarish journey through the shattered landscapes of Zaire, India and the former Soviet Union, and an impassioned call for a robust, comprehensive international public health infrastructure--"a singular community in which the health of each one member rises or falls with the health of all others."
In a recent interview, Garrett, a youthful, intensely serious woman of 49, explains why she decided to write a sequel to huge story here! We have fundamentally screwed up!" Her digging took her to filthy, crumbling hospitals in the former Soviet Union; to plague-ridden sections of India; and to the anarchic chaos of Mobutu's Zaire. What she saw left her shocked and saddened. "I began to realize the scale of the problem, and also to realize that this was not going to be a small book. Therefore, it ended up being the monster that ate up five years of my life."
Betrayal of Trust begins with a harrowing description of a plague outbreak in Surat, India: "Amid the squalor of open sewers, ramshackle crowded houses, and roaming livestock," she writes, "emerged a cluster of poor Surati men shouting, 'Plague! Plague! Plague!''' In the end, after 56 people had perished, the disease was finally vanquished--but not before it laid bare the frailty of India's public health infrastructure and the incompetence of its bureaucracy. A subsequent chapter finds Garrett in the former Soviet Union, where the public health system--once among the most formidable in the world--crumbled in the years following the collapse of communism; for Garrett, that decline is "the most astounding collapse in public health ever witnessed in peacetime in the industrialized world." The result is national malaise, but also an explosive rise in diseases like AIDS, tuberculosis and alcoholism..
But the heart of the book documents the collapse of public health in the United States, and Garrett's portrait is a sobering antidote to the news media's interminable proclamations about U.S. prosperity, for she documents the extent to which America's 20th-century public health infrastructure--which enabled the nation to eradicate diseases like polio, smallpox and tuberculosis--has fallen apart. The culprit, in her view, is reduced government spending on public health, but also an individualistic strain in American culture that emphasizes liposuction over vaccination. For the poor, the results have been catastrophic. Between 1980 and 1991, 603 rural and urban hospitals, most serving low-income people, were shuttered. But Garrett insists that everyone is at risk: 76 million Americans endure food poisoning every year, she notes, but the FDA, weakened by cutbacks, has been forced to reduce its budget for food inspection. At the same time, public indifference to vaccination has, in major American cities, led to a resurgence of measles, tuberculosis, whooping cough and cholera--some of whose strains are drug resistant. A laissez-faire attitude toward vaccination, Garrett warns, leaves the U.S. open to germ warfare attacks of the sort that devastated Tokyo's subway system in 1995.
Given the scale of the book and complexity of its subject matter, PW in her spacious apartment on Pineapple Street in Brooklyn Heights, located just a short distance from the promenade and the Brooklyn Bridge overpass. The place is overflowing with Zimbabwean sculptures, Mozambican etchings and Mexican statuettes. A Nelson Mandela doll sits in a corner; a kitschy red Che Guevara baseball cap hangs on a nearby chair; and prints by Picasso, R. Crumb and Weegee line the walls. A large portrait of Albert Einstein hangs near Garrett's immaculate desk, while a poster announcing a concert by Bob Dylan and Van Morrison overlooks the large window, through which the contours of the Manhattan Bridge can be discerned.
"This book required, I think, a great deal more intellectual rigor on my part than Newsday, she suffers from repetitive stress injury and is completely unable to type. So she composed the chapters in longhand, and Fed-Exed the legal pads to two colleagues in Northern California and Seattle, who typed the manuscript while adding their own comments.
Betrayal of Trust may have taken an even heavier toll on Garrett. In 1998, after returning from Zaire, she collapsed from exhaustion and began to lose weight rapidly. What she thought was a tropical virus turned out to be Grave's disease, a thyroid disorder. In her travels through the former Soviet Union, Garrett visited Chernobyl, in Ukraine, for 10 days in 1997, and spent time in the radioactive alienation zone. "The number one health effect seen among the people in that area is thyroid dysfunction, and Grave's disease is quite common there," Garrett says. "It's possible--we'll never know for sure--that I had overexposure to radioactive substances. All the food was radioactive."
Garrett is exhausted. Her father passed away last month, and she has just returned from an AIDS conference in South Africa. But she energetically ticks off the events that drew her to the writing life. Born in Los Angeles in 1951, Garrett attended UC-Santa Cruz. In 1969, she dropped out for nearly a year to pursue "full-time antiwar work" all over Northern California. Graduate school in science at UC-Berkeley followed, but a chance encounter with a producer at KPFA radio led to a position as a part-time science reporter. Success came rapidly: a series she coproduced won a George Foster Peabody award in 1977. After a brief stint at the California Department of Food and Agriculture, where she studied the health impact of pesticide use, Garrett decided to seriously pursue a career in journalism. The most "cutting-edge" thing she could do, colleagues advised, was to become a foreign correspondent, so in 1979 she moved to Lusaka, Zambia--a city that, in the twilight of the Rhodesian civil war, became the headquarters for insurgents from all over southern Africa, from SWAPO in Namibia to the ANC in South Africa. Living in Africa "fundamentally changed my world view," Garrett recalls, and by 1980 she was on the staff of National Public Radio covering science. In 1988, she joined Newsday.
Much of the research for The Coming Plague, by Garrett's own admission, "rode on [Preston's] coattails." It still enjoys brisk sales: the paperback is used as a textbook in schools of public health and medicine, and in undergraduate science courses.
Consequently, Garrett's second book was eagerly anticipated within the industry. FSG fought to keep her, but Glusman was outbid at auction by Little, Brown. But all was not well at the latter. "They had a big shakeup," Garrett recalls. "A few weeks after we signed the deal, the editor who had sought it was ousted. The book was orphaned within the house." Garrett and her agent, Charlotte Sheedy, moved Betrayal of Trust to Hyperion and entrusted the project to Leigh Haber. Was Hyperion reluctant to publish such a long book? "Oh, yeah," Garrett laughs. "It was cut by a third."
Betrayal of Trust argues that the United States should urgently reconsider its priorities concerning public health and medicine; the tension between the two is a major theme in the book. In Garrett's view, public health--which she defines as "the health of populations," whereas medicine is "the health of individuals"--has simply fallen off the agenda. In the U.S. in 1992, she notes, 99% of all private and public funds were spent on medical care; less than 1% was spent on public health.
"We've reached a level where the whole tent of public health is full of holes," Garrett says, "and no one knows what exactly should be under that tent." Americans, she insists, are certainly not indifferent to public health matters. "Most Americans, when really pushed to define what they mean by health, are not thinking about the machinery they're going to be plugged into in the intensive care unit, or liposuction, or Viagra," she says. "They're thinking about the things that provide reasonable life expectancy"--i.e., "clean drinking water, clean air to breathe, safe food to eat, reasonable levels of immunization."
Packed with history, Betrayal of Trust concern the deterioration of public health in Minnesota, a state that pioneered it at the beginning at the century. By the end of the century, Minnesota, too, had succumbed to the temper of the times and was slashing its expenditures on vaccination, food inspection and disease control.
At the moment, Garrett is not optimistic about the prospects of public health in the U.S. Last year, a poll found that 57% of respondents could not define "public health" properly, even when given clear descriptions from which to select. Is that the ultimate triumph of Reagan-era, free-market ideology--that the very idea of public health has been obliterated? "It's an enormous problem," Garrett says with a sigh. "It's a huge problem, one that I hope gets corrected with this book, to some degree. If I had one fantasy aspiration, that would be it."
Is Garrett satisfied with the way in which the major presidential candidates are confronting public health issues? "They haven't taken them on at all," she retorts. "I've never heard either of them utter the phrase 'public health.' As far as I know, it's not on the agenda."