Jewish World Review July 15, 2004 / 26 Tamuz, 5764
Glenn H. Reynolds
Neglecting public health
This month's Harper's Magazine includes a cover story on the decline of the public health system, by Dr. Ronald J. Glasser. Glasser lays out a number of ways in which the global public health system isn't up to the threats posed by diseases like SARS. Dr. Glasser's diagnosis seems on target, but his article leaves a lot to be desired in terms of treatment -- he concludes (in a fashion that seems somehow emblematic for Harper's) that we are probably too foolish to survive these new epidemics, and that we probably deserve to die.
I don't agree, and I think that we should be doing something about the problem. The public health infrastructure built up in the last century was an enormous achievement. It was also, as Robert Fogel notes in his new book, Escape from Hunger and Premature Death, a gigantic undertaking. Fogel writes about:
"the huge social investments made between 1870 and the end of World War I, whose payoffs were not counted as part of national income during the 1920s and 1930s even though they produced a large stream of benefits during those decades and continue to do so down to the present. I refer, of course, to the social investments in public health and in biomedical technology. . . . Also included in this category are such public health investments as the construction of facilities to improve the supply of water, the purification of the milk supply, the development of effective systems of quarantines, and the cleaning of the slums.
"The point is not merely that these benefits are often excluded entirely from national income accounts, and from the measures of real wages, but that they are greatly undervalued even when some aspects are included, because they are measured by inputs rather than by benefits (which are outputs). Moreover, these benefits accrued disproportionately to those with modest incomes."
I would argue that these investments -- which were among the most dramatic public investments of their times -- were probably not undervalued by those who made them, or by those who benefited by them. But they are undervalued by those of us who take them for granted today. We assume that health is the norm, and sickness the departure, that deadly epidemics are a thing of the past, that water from the tap is safe to drink. But like so many things in life, things are that way because people worked hard to make them that way, not because it's the natural order. And if we want them to stay that way, we'll have to work hard to keep them that way.
Which leaves the question of what to do next. I'm not a physician, or a public health expert, but it seems to me that we face two major areas of challenge. The first is to develop a reliable worldwide system of detecting, and responding quickly to, new outbreaks of disease. The SARS outbreak provided some useful lessons (like "don't cover up the outbreak of a new contagious disease"), but the real problem is that there's not enough of an infrastructure there. We need one.
This will be expensive, but cheap compared to area number two, which is traditional infectious-disease control. Keeping water clean, making sure that sewage goes where it belongs and not where it doesn't, keeping the food supply clean, making sure people are vaccinated and learn to wash their hands, etc. This is expensive. In the United States and the West generally, it calls for a renovation and updating of infrastructure laid down a lifetime ago, and for the re-focusing of a public health establishment that in recent decades has been focusing on side issues (like accidents and gun control) at the expense of its core mission. In the rest of the world, it calls for doing this core mission for the first time.
The capital costs for such a venture are enormous. Modern technologies will help in some areas, but the effort is so huge that it's bound to be enormously expensive. On the other hand, as Fogel also notes, the benefits are likely to be much greater than is generally appreciated. Fogel points out that Britain's economic explosion in the latter part of the 19th century was largely the result of better health. Before that, a sizable chunk of the population was simply too sick to work much, and served as a drag on the economy. That's the state of the world now, really -- and it will only get worse as new diseases like AIDS, SARS, and whatever comes next make their way across the globe.
Let's prove Glasser wrong, by showing that we're not doomed by our own stupidity.
JWR contributor Glenn Harlan Reynolds is a law professor at the University of Tennessee whose work has appeared in the New York Times, Washington Post, Washington Times, Los Angeles Times, and Wall Street Journal, among others. He created and writes for the influential Instapundit website. Comment by clicking here.
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© 2003, Glenn Harlan Reynolds