June 10, 2003
Laurie Garrett
It took me over a month to do justice to this book, and I have taken into account the thoughts of other reviewers. A book of this importance would indeed have benefited from an international advisory board of public health, medical, insurance, and policy experts; it would certainly have benefited from greater structure, firmer editing, and a foreword by someone like a former Surgeon General of the United States. As it is, it appears to have overcome these deficiencies with hyped-up marketing and sweetheart reviews, and this in some ways counterproductive because this book could have, should have, become a mainstream topic in the Presidential campaign. It failed to do so for several reasons, not least of which is the propensity of both candidates and their advisors to avoid serious thinking, but also because the book is not helpful to a popular understanding of the very real global and domestic threats to the health of our children today and in future generations. Having said all this, I commend the book for its content and do not recommend it as avocational reading. There are some very important points that the book brings out, and I will itemize these in order of importance: 1) Public health is about detection and prevention, medicine is about remediation. In the long run, investments in public health are vastly cheaper and more effective than after-the-fact medical intervention; 2) The insurance industry in the developing world has failed to support public health investments, and in a remarkable collusion with the pharmaceutical, hospital and managed health care industries, has created a very expensive and increasingly ineffective system focused on drugs (to which diseases are increasingly resistant) and hospitals; 3) Hospitals are no longer reliable in terms of protecting patients from both error and secondary infection from other patients. People are coming out of hospitals, in many cases, with more diseases than when they went in; 4) The health of our nation depends on the health of all other nations-not only does a collapse of public health in Africa lead to failed states and forced migrations, but it also is but an airline flight away from infecting Kansas; 5) Clean drinking water, uninfected food, and good environmental and occupational health conditions are at risk in many parts of the United States and Europe, not only in Russia and the rest of the world; 6) The United Nations, and the World Health Organization in particular, are in disarray and ineffective-in large part because of a lack of support from member nations-at dealing with the public health commons. There is no question but that the author has hit a “home run” in terms of describing the harsh reality of epidemics in India and Africa, the collapse of public health in Russia, the rapid migration of many diseases from Russia through Germany to the rest of Europe and the U.S., and the severe costs in the U.S. of a retreat from the collective good with respect to public health. Unfortunately, it is a home run hit in isolation, not a game-winning home run, because it fails to drive home, to the only audience that matters-the U.S. voter-exactly what political and economic initiatives are required to achieve three simple objectives: 1) re-establish the public health infrastructure in the U.S.; 2) redirect the entire health care industry toward preventive measures-including water and food quality controls-instead of remedial prescriptions; and 3) provide compelling incentives to the rest of the world for cleaning their own house (this presumes that we are able to clean our own first, a very questionable assumption at this point in time). This is a valuable book, a five in terms of intent, a three in terms of execution, and I am glad that I took the time to read it. It provides a wonderful foundation for enjoying, at an intellectual and policy level, the medical and public health novels by Robin Cook.
