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Commentary and Analysis | BIOTERRORISM

A Health System Primed to Fail

November 04, 2001|M. GREGG BLOCHE and LAWRENCE O. GOSTIN | M. Gregg Bloche and Lawrence O. Gostin teach health law and policy at Georgetown and Johns Hopkins Universities, and they co-direct the two schools' joint program in law and public health

WASHINGTON — When the anthrax scarce began a few weeks ago, the U.S. public health system was as ill-prepared for bioterror as our armed forces were for war when the Japanese struck Pearl Harbor. Within weeks of the attacks on the World Trade Center and the Pentagon, our airmen and Special Forces delivered a blow to the leadership of Osama bin Laden's terror network and Taliban supporters. But here at home, the faltering responses and conflicting messages of health authorities have fanned fears and may cost lives.

Why? With hindsight, it's easy to spot mistakes. Why, for example, did health officials not realize that powder as fine as chalk dust might leak from an envelope? Why were postal workers not tested and treated as quickly as congressional staffers? Why were statements about the size and hazards of the spores so inconsistent and confusing?

These criticisms, though, obscure the larger story--of institutions programmed to fail. For at least a half century, our national commitment to an effective public health system has been on the wane. In differing but parallel ways, political liberals and conservatives have become skeptical, even hostile, toward government's role in the health sphere.

Liberals have come to see personal choice as paramount in medical matters--and government constraints on individuals' health-related behavior as intrusive. In the 1960s and 1970s, activists and scholars targeted doctors' paternalism toward patients and remade the law of health-care provision to protect patient autonomy. Public tracking of community-wide disease troubled civil libertarians, who feared invasions of personal privacy and stigmatization of disadvantaged groups.

Conservatives, meanwhile, have opposed most public financing and provision of medical services. They have cast health care as a matter of consumer choice and pushed public policy toward deference to the medical marketplace. Conservatives have taken a similar view of disease prevention, treating it as a personal matter, not a public responsibility.

The unsurprising result has been an absence of political support for strong public health programs and institutions. Instead, we have the public health system we've "wanted"--ill-funded, fragmented, highly respectful of personal choice and unprepared for a nationally coordinated response to crisis.

It wasn't always this way. Public-health authorities in the 18th, 19th and early-20th centuries acted decisively, on a grand scale, against population-wide health threats, including frightening epidemics. Before the Civil War, health officers helped to plan towns and cities with an eye toward controlling infectious disease by securing clean water and food. Public-health authorities drained swamps to contain mosquito-borne illnesses, and they organized the safe disposal of animal and human waste.

Americans saw these activities as vital to their security, no less so than military force or police and fire protection. Taxpayers supported the needed spending. Lawmakers empowered local health authorities to move robustly when contagion threatened. Destruction of buildings, killing of infected animals and even restraints on the movement of infected people were provided for by law and widely accepted by citizens.

Because the hazards of contagion crossed class and racial lines, public health measures that aided the worst-off won support from the well-off. Mosquito-infested swamps, sick farm animals and airborne infections threatened everyone, though the poor often lived in areas at highest risk.

The Industrial Revolution of the late-19th and early-20th centuries brought new health dangers, from the building of factories in densely populated areas and the crowding of poor people into slums. Filth and squalor spread disease, and government responded. Physicians and sanitary engineers made regulatory decisions concerning location of factories, control of poisonous substances and other city planning matters. In proportion to other public expenditures, public health budgets were much larger than they are today.

The U.S. commitment to public health--and its regulatory powers--as vital to the pursuit of the common good persisted through two world wars. Campaigning for the presidency in 1932, Gov. Franklin D. Roosevelt reaffirmed this commitment, proclaiming, "Nothing can be more important to a state than its public health; the state's paramount concern should be the health of its people."

But after World War II, American public health fell victim to its own success. Thanks to city-planning and sanitation campaigns of the early-20th century and the antibiotic revolution of the 1940s, fear of infectious disease waned. The conquest of polio through vaccination in the 1950s delivered the coupe de grace for public health's middle-class constituency.

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