Why public health collapsed—and how to reclaim it

Laurie Garrett wrote about the system's problems (and solutions) in 2001

In Betrayal of Trust: The Collapse of Global Public Health, Pulitzer Prize-winning health journalist Laurie Garrett explores the fragility of public health infrastructures. Though published in 2001, her work identified problems that would later be exploited by social media influencers in a politically-split nation. While there’s Covid-19, the lessons echo loudly into our times.

Garrett emphasizes that public health relies on a fundamental trust between governments and their people. This trust goes both ways:

• Citizens trust that their government will:

  • Respond swiftly and effectively to health crises

  • Utilize sound scientific evidence in decision-making

  • Provide accurate and timely information

• Governments expect individuals to:

  • Contribute financially through taxes

  • Participate in public health measures (like vaccinations)

  • Adhere to public health guidelines

The entire system is jeopardized when either party breaks this trust.

Garrett is something of a Cassandra. Her 1994 book, The Coming Plague: Newly Emerging Diseases in a World Out of Balance, predicted many of the circumstances that produced Covid-19.

Of course, public health officials are perpetually preparing for plagues; it’s part of their job. The public is rarely aware of their work, however, so when a plague hits we’re often caught off-guard, wondering why agencies aren’t doing the work they’ve actually been doing all along. This is the gap that wellness influencers and contrarian doctors exploit.

This isn’t to give bureaucracies a free pass. Anti-vaxxers aren’t the only people who’ve criticized public health agencies for poor messaging. Still, imagine the impossibility of breaking through social media noise with complex, detailed press releases, as the CDC and HHS were tasked with doing. The problem is multifaceted.

Let’s look at why Garrett believes trust eroded, then consider her recommendations for how to earn it back.

How the system collapsed

Garrett highlights several key factors contributing to the erosion of trust between public health agencies and the people they’re tasked to protect.

Inadequate response and misinformation

Trust evaporates when governments fail to effectively respond to public health emergencies. Garrett considers India’s 1994 bubonic and pneumonic plague outbreak. The government's response was slow, diagnoses were delayed, and assistance to affected areas was lacking. This fueled public panic, further exacerbated by the government’s failure to provide accurate information as events unfolded.

Shifting responsibility and "personal responsibility"

This one is big in conspirituality, weaponized by wellness influencer and far-right pundits alike: emphasizing personal responsibility over governmental action. This trend, particularly prominent during the Reagan and Bush (and we can add Trump) administrations, was marked by a "blame the victim" approach that focused on individual behavior rather than addressing systemic issues. This mindset is exemplified by the growing emphasis on diet and exercise for preventing chronic diseases while simultaneously witnessing a surge in the number of uninsured Americans.