Public Health Betrayals A fascinating reality of public health is that when it is working, nothing is happening. People are healthy, they participate in their community's welfare, and they themselves are likely to want to be more engaged in the culture's economic and pleasurable activities. But the problem with a negative reality like this suggests Laurie Garrett in Betrayal of Trust, is that there is a tendency for governments of all types -- democratic or authoritarian, and one might guess, even those in the news today that are in the midst of disarray -- to cut back on whatever services they have. With the end result being that people don't get to live or die right (2000:7).

Garrett shows why the underlying issue of organizing a community for health is not just a matter of medical, cultural or technological advancement. She goes through a variety of stories of how different countries have been challenged by particular health crises and why their situations ended as they did -- often poorly for sick citizens. And time and again the conclusion she reaches is that the saviors of these nations and ultimately of the world whenever there are illness battles on the planet will be public health warriors -- the individuals who do what is necessary to ensure basic and reasonable care, support and the use of often simple medical interventions. There is no need to do as the U.S. And other countries do in depending heavily on complex and sophisticated technologies, not even when or if the world is faced with the evil possibilities of diseases transmitted by supergerm technologies (p.12).

The stories of particular nations that failed in their times of sickness are most interesting when they bump up to issues that the world is facing right now. Nearly all countries that are going through dramatic bouts of uncontrolled change -- brought about through economic and political crises -- and it is clear that they are likely to not be prepared to use the lessons they have learned from past health scares. While it is, of course, true that the public now has some capability for compensating for poor public health actions (by using Twitter and Facebook, for example, to bring together a flash mob of response), even this might not be good enough if there is no true community-empowerment infrastructure to keep such movements successful. It is simply necessary to have some levels of public health preparedness as uncertain futures unfold.

In Betrayal of Trust, the author makes this kind of point by sharing what happened in 1994 in India with the outbreak of the Bubonic Plague. After setting the stage of the circumstances and noting how it dramatically devastated people and their economy, she reviews how it was the lack of trust toward the government that didn't allow even the professionals of medicine to keep to their convictions. Many doctors left the country, totally shutting down many citizen defenses. Had the people of that nation trusted their government -- and had other nations trusted India's officials -- this crisis could have been managed.

In recapping the experiences of Zaire, the same could be seen when face-to-face confrontations happened in the hospitals with the Ebola virus. It generated incredible panic, to know small degree because it was nosocomial in strength, meaning it was spread to otherwise uninfected patients because they were in the hospitals. This severely demoralized all of their formal and informal systems, and made it practically impossible for localities to get together to help. Only with the introduction of Doctors Without Borders, who bring their own public health empowerment models, was it possible to overcome the distrust and do what ultimately helped, forgo technological advancements and plan for using simple supplies for cleanliness.

Perhaps even more relevant for today was the deterioration of the Soviet Union and Russia's care system. Although it had a well-grounded public health component based on...

Diseases of all kinds spread rapidly, and the nation began almost instantly to feel the effects of self-imposed epidemics, such as alcoholism, drug abuse and even heart ailments associated with poor diets. Without the centralization of services, the combative elements like community collaboration fell apart. The country and its people became wholly dependent on the goodwill of other countries and outside forces, not their own warriors.
In the United States today, we face these same kinds of concerns on different levels. While we still mostly assume our public and even private hospital systems (and government emergency and security agencies) can address explosive health emergencies, we have all in all allowed the weakening of our own community health sectors -- the places where the health warriors live and collaborate. With upwards of 50 million people not qualifying for health insurance, this leaves an avalanche of those in need having to depend on local clinics that are often full and that lack some basic capabilities. Even though what the Obama administration has done with lessen this concern, the major focus for care will still be on the use of large-scale hospitals and services that stand alone and depend on technology as their first round of defense. Neighborhood health warriors will still be used as secondary lines of defense with virtually no elements of offense. (Perhaps the best resource can be found at http://www.nachc.org/.)

If there is one advantage that the U.S. has that others don't seem to have been able to benefit from, it is the emergence over the last few years of the concept of documentary entertainment media shows. Programs like the movie Philadelphia with Tom Hanks dramatically personalized what can happen when even the larger systems of care are derailed by outside prejudices. It became clear that some of our best government care programs were controlled by ignorance not medical need. These costs of bigotry as depicted in Milk and Laramie were, of course, again tied to gay people and AIDS, often at the expense of other challenges. The shows dramatically highlighted mental health shortcomings.

Both Milk and The Laramie Project also ended up being about death. This was important because more attention was being focused on this part of our care system -- and also an element that was unnaturally manipulated by political ends. But, at least in the case of The Laramie Project, the story didn't stop with the killing. Outspoken Christian extremists used the episode to pronounce their beliefs on AIDS and immorality by protesting at funerals. This connection likely brought the issue of death with dignity back to the same issues of life with dignity.

Unfortunately so far, even with the building of this bridge, we now know that U.S. attitudes and practices regarding death and dying are themselves massively and expensively governed by political pressures. We have not learned in this regard either about the community and family possibilities of dying with end of life warriors. And the result is yet again, a health care system that deals with death poorly and is costly because of its legal and social weaknesses.

The tone of this failure can best be felt in the writings of Atul Gawande and the limitations of American medicine when it comes to saving someone's life or ending it well. His use of the concept of our nation being out of touch with the "art" of dying is perhaps the best encapsulation of his viewpoints. But in reality, he showcases through many real cases what it means when we let ourselves down as people and don't let our communities play their role in the dying process. Instead, he notes, our nation uses medical hope as a plan and counts on the miracles of statistical improbability -- which makes it very hard for doctors to do right and almost impossible for ordinary people to…