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Talking Points

  • Public health systems are extremely fragile.
    Public health systems are among the first government functions to suffer under societal stress. Examples given supporting this assertion include contemporary India, all the former Soviet nations, and central Africa, all based on first hand observation. (For this book Garrett did on-site research on five continents, spanning five years.)
  • Wealth gap exacerbates public health stress.
    Public health systems are the first government functions to suffer under a severe wealth gap. History shows that public health prospers when class disparities are lowest; when there is a large, self-interested middle-class. Today, however, globally and in the United States specifically, we are witnessing a record wealth gap, which poses a serious threat to public health.
  • Public health versus over-used individualized medicine approaches to populations.
    Western models of individualized medicine are too costly and offer little benefit in terms of life expectancy. They fail to address the fundamental roots of bad health in poor countries (such as un-clean water, lack of vaccines, etc.).
  • Growing antibiotic-resistant diseases need desperately to be addressed and will pose a serious health problem in the future.
    There are strains of strep, for example, which will undoubtedly be resistant to available antibiotics.
  • Insurmountable illicit drug use.
    Public health has never dealt well with illicit drug and alcohol issues. This inability has encouraged strong political support for the criminalization of substance abuse, versus treatment. The population as a whole has, as a result, had its health threatened by needle-borne diseases such as hepatitis B, C, D, and HIV.
  • Anti-governmentalism compounds the problem.
    Rampant anti-governmentalist fervor in the U.S. targets, among other things, public health programs such as those for vaccination of children and registration of infant birth defects.
  • Racial discrepancies are severe in public health.
    U.S. public health has a truly sorry racial legacy that has never been successfully addressed. African Americans and, to a lesser degree, Hispanics and Native Americans, are severely alienated from the system, and are least likely to participate in population-based control efforts, such as mass immunizations, HIV education campaigns, STD efforts, and well-baby programs.
  • The public health discipline has lost its way.
    Public health, as a discipline and practice, lost its way during the Western health transition (post WWII, going from infectious diseases to cancer), largely because the models of infectious disease prevention didn't translate neatly to the chronic disease paradigm. The chronic disease paradigm (except for the case of tobacco) was approached as a matter of individual behavior. Public health thus became not the Great Protector, but the Great Chastiser, telling people that they were personally responsible for their own illnesses (diet, exercise, alcohol, etc.). This message rested on often contradictory data, and the public eventually stopped listening, or only heeded selectively. Thus, in the U.S., for example, Americans reduced their cholesterol intake but increased their overall caloric intake, becoming a majority-obese nation.
  • Managed care as serious challenge to adequate public health.
    Economics has only addressed public health and medical issues aggressively in the last decade, presenting strong financial arguments in favor of preventive and population-based approaches to health. But health care companies and governments largely make decisions about health-spending based on different priorities. In Europe and North America this means spending is skewed towards massive outlays for end stage disease intervention, while basic needs for the health of the people go unmet. In poor countries, corruption, military priorities and singular epidemics such as TB and HIV, can tilt all public health spending away from basic infrastructural needs.
  • Bioterrorism.
    The threat of bioterrorism is growing at an uncontrollable pace with smallpox, for example, being cultivated as a means of warfare. Public health has spawned a virtual bioterrorism prevention industry in North America and Europe. A backlash has also emerged, claiming the threat is overblown post-Cold War paranoia. Public health must insist that its role in local bioterrorism detection and response is paramount and resist efforts to completely militarize the issue. By collaborating with law enforcement, it might risk public credibility, especially in minority communities, and it must take great pains to keep its relationship with military and law enforcement authorities cordial, but at arms’ length.
  • International pharmaceutical practices.
    Drug companies will increasingly become the focus of tension as drug resistance against affordable agents mounts, and life expectancies are impacted. HIV is a lesson in this regard. In the case of HIV, pressure in affluent circles skewed resources away from public health approaches, such as vaccine R&D, prevention campaigns and contact tracing, and pointed them instead toward a search for a cure. As a result, we are now saddled with an extraordinarily costly drug regimen of only minimal efficacy and are playing catch-up in pursuit of both a vaccine and effective prevention interventions for countries with heterosexual adult infection rates in excess of 5% of 18-50 year olds. From a global point of view, we sacrificed public health for individualized medical attention that has proven to be the most costly ever offered as a solution to an infectious disease

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