Public Health’s Precarious Nature

Laurie Garrett has some advice for everyone working in public health and global health: “Never let your guard down.”

Hard-won victories over diseases like measles are increasingly tenuous as rising nationalism and populism undermines trust in government and thus, public health, says Garrett, a journalist and author who has reported on global health issues for decades. “Public health can never assume and take for granted that something they know to be a great success and has saved millions of lives is accepted as such by the community at large or the powers that be,” she says.

In this Q&A, Garrett, a Foreign Policy columnist and a former senior fellow for global health at the Council on Foreign Relations, surfaces the origins of vaccine mistrust and explains the precarious nature of public health.

Garrett has won Peabody, Polk and Pulitzer awards—the 3 “Big Ps” of journalism. The author of The Coming Plague: Newly Emerging Diseases in a World Out of Balance and other books will address graduating students of the Johns Hopkins Bloomberg School of Public Health on May 21.

You've written about the link between the rise of populism and anti-vaccination sentiments. I'm curious how you see these threads intertwined, and what are the impacts on global health?

Whether you're talking about vaccines or a whole range of classic public health interventions, we're really in a tight spot right now. Not just in the United States, but all over the world because of the collapse of globalization as a driving force in the world and the rise of nationalism and populism.

With nationalism and populism comes anti-governmentalism and a kind of general suspicion of people in power … and of any institution that issues mandates or demands of any kind. Public health is number 1, inextricably bound to government, and number 2, uses amongst its many weapons to protect the health of the masses as it were … mandates and legal instruments.

It's no coincidence that as Trump was rising yet not voted as president yet, he latches on to Robert F. Kennedy Jr. and the whole idea that vaccines are somehow dangerous. It again ties in with all these dark, sinister conspiracy theories.

Here's the question then. How do we get back from that?

There's many aspects to that question. Public health people didn't create the anti-globalization movement, and public health people can't unilaterally unseat some of the political leaders around the world that have been using a suspicion of vaccines as part of their mobilization of mass support.

What they can do is recognize [that] with a little bit of hubris we all got pretty darn comfortable with the success story of global health.

What do you see in the future? How are things going to work out?

For the institutions of public health, put aside global, just think local: Complacency has to end. They're all now seeing what it's like to deal with anti-vaccine movement. They're starting to wake up. They're starting to flex some muscles, seek legislative authority, and realize that you can never let your guard down. Public health is not a steady staircase upwards. It's a few steps up and then somebody knocks you down the stairs, and you start all over again, climbing.

The credibility of public health is at risk every day, and I think that schools of public health need to much more aggressively teach and demand knowledge on the part of graduating students. They must teach governance. They must teach people the political system that they will have to address. It's unconscionable that somebody can get a degree associated with global health and not know how the United Nations works. And it's unconscionable that somebody can imagine that they're going to go into public health and likely end up working in city, county, or state government, and not have any idea how to write a bill and get it through their state legislature, or write a regulation and get it through the city council.

Many people seem have taken vaccines for granted. Do you think that seeing the measles outbreaks and sick children will be enough to persuade people to return to vaccines, to give up the vaccine skepticism?

My point is larger than that. My point is this: Public health can never assume and take for granted that something they know to be a great success and has saved millions of lives is accepted as such by the community at large or the powers that be. And that means you can never stop talking about clean water. You can never stop talking about washing your hands. You can never stop talking about food safety and the need for food inspectors. It's a classic problem that when public health is working, it's a negative, meaning there's no great cataclysmic events occurring.

Vaccine skepticism and the groups that promote this are very big in the US, the UK and Europe. What about elsewhere?

One of the highest rates of vaccine refusal in the world right now is the Philippines. [And] there's a huge problem in Muslim countries, Indonesia in particular at the moment, because of false words from Imams claiming that pigs are used to make vaccines in one way or another. It's also [happening] in Jewish populations. It's one of the many things that has been rumored and spread falsely in Brooklyn where we now have nearly 500 cases of measles, and they're all in the Hasidic community.

So, what do you do if the evidence is clear, but presenting that evidence by itself doesn't work?

How do we counter false messaging and put forward a really strong message? I think we're in a very similar boat to the climate change advocates that are trying to fight not only deniers but more importantly a kind of fatalism that has set in over humanity? "Well, okay, we've screwed it up. I guess the whole planet's going to go, but at least I'll be dead before that happens."

This has been a grim conversation. I hadn't by any means intended to be this dark.

You're going to leave the new graduates weeping the aisles?

Let me just give you the positive side of all this because there is a positive side. There's a lot to be very, very excited about. I think that we're seeing a generation coming, and a lot of the kids graduating will be of that generation—probably most of them—that is just fed up with the BS. They've had it. They know that the existential threat to the planet is real. For them, coming out of college right now, climate change and all of its associated issues, the whole anthropogenic devastation of the planet is as great and immediate and urgent concern as it was for my generation to prevent thermonuclear war.

And they are energized about it, and I'm seeing leadership and ideas coming forward from them that are fresh, smart, well thought-out. [They] utterly reject the old things of the past.

I feel like there's an energy coming through that's going to really turn this all upside down, and I'm very excited about that.

Ed. Note: This interview has been edited for clarity and length.

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