Dr. Paul Farmer talking:
the most important thing to understand is that this is a reflection of long-standing and growing inequalities of access to basic systems of healthcare delivery, and that includes the staff, the stuff and, again, these systems. And that’s what—that’s how we link public health and clinical medicine, is to understand that we’re delivering care in the context of protecting the health of the population. And so, if you go down to each of these epidemics—that are, of course, one epidemic—and you ask the question, “Well, do they have the staff, stuff and systems that they need to respond?” the answer is no. And then, what will stop the epidemic, which it will be stopped, is an emergency-type response. But then again, how are we building local capacity to do that so these epidemics don’t spread—as they would never spread in the United States, by the way?
it would be great to talk to our colleagues at Emory, the infectious disease colleagues who treated patients. It’s not that they had an experimental medication; it’s that they had supportive care. And supportive care, in medical terms, doesn’t mean having someone hold your hand. It means, if you’re bleeding, you get blood products. If you’re hypotensive, or your blood pressure is low, you get IV solutions, right? That’s not what’s happening in these Ebola centers. You know, it’s really quarantine without a lot of the care, right, because supportive care requires sometimes an ICU.
And even in Haiti or in Rwanda, you know, we’ve prepared, along with the authorities, isolation rooms that are not to shut people away, but to take care of them while protecting the rest of the staff, if they have an infectious illness, an airborne illness, say.
So, you know, back to Juan’s question, why would there be such massive variation in case fatality rate? And to me, that always says, because there has not been an overlap between the epidemic, Ebola epidemic, and modern medicine. We’re talking about Medieval-level health systems and a modern plague that’s going to spread. And when we can overlap modern medical systems and modern public health systems, then we can see what the case fatality really would be. I mean, just to be provocative, what if it’s 10 percent instead of 90 percent? What if it’s 5 percent, with proper medical care? And I’m saying even without a specific therapy for that disease, which we’re all waiting for and hopeful about some of the new agents.
it seems to me the patients, the American patients who went to Emory, they were being quarantined, right? But they were also receiving care. And that requires, again, staff, stuff and systems. You can’t be compassionate without expertise, and you can’t have expertise without the supplies that you need to do a good job. So I do not see those two positions as really in contest. A human rights position should also include the right to healthcare, the right to compassion, the right to psychosocial support, just as a public health response has to be aware of how an illness is transmitted and how to protect the public. And this tension, which is very profound, as you note, is worsened by the fact that there is no good medical system in Liberia or Sierra Leone or Guinea. And we have to build one.
Ebola virus disease is a hemorrhagic fever caused by a kind of virus called a filovirus. And Marburg is another one of those. And it’s spread through close contact, in the sense of blood, mucous membranes. So, you know, when I heard someone say—unfortunately, an official say—that Ebola had gone airborne, I knew that wasn’t right. But what happens is, the symptoms include vomiting, diarrhea. It looks a lot—it can look like malaria. And this is one of the problems, is that you have to diagnose it, because we have readily available—or, we should have readily available therapies for malaria. And now with all this fear around Ebola, people aren’t going to receive care for that potentially fatal illness. So there’s all kinds of complexities.
an outbreak begins when—and again, you know, say that the reservoir might be bats, OK, or in a bushmeat, all right? The animal population and the human population are competing for resources, right, and as these cities and towns grow and as—and so, it jumps—these illnesses jump to humans, and then they have to jump to other humans, again, through close contact and like preparing someone for burial or nursing someone, right? Because if you think about, again, someone who’s vomiting or has diarrhea, and if you’ve helped nurse that person, in the sense of doctors nurse people, but your mother, your sister nurses you, you’re going to be exposed to infected secretions, right? So, the way to prevent that is sometimes called “barrier nursing,” right? That means you’re wearing personal protective equipment, and, you know, probably an apron, mask, gloves would do. But again, if someone’s vomiting, you know, you can get it in your eye, or you get tired of following strict precautions because you’re working long hours. So, again, staff, systems, stuff—you need the stuff to protect the healthcare workers and to take care of the patients, and the staff to relieve one another so they can follow this strict infection-control process.
it’s not that all places in Africa don’t have good healthcare systems. Rwanda has built back from an even more gruesome situation than the wars in Sierra Leone and Liberia, and they’ve been trying to focus on the systems issues, right? How do we link community health workers to clinics, to hospitals, for people who are sick? And we’ve been very proud to be part of that work as Partners in Health.
I mentioned the example of Rwanda, which remains a poor country, which is only 20 years out from, you know, the genocide. If you have more resources, you can build the systems more quickly. But again, it needs to focus on building local capacity. So, in Liberia, that would be Liberians. In Sierra Leone, that would be Sierra Leoneans; in Rwanda, Rwandans; in Haiti, Haitians. And a lot of this emergency response approach doesn’t do that, right? It’s not the function of an emergency response to build local capacity, but it needs to be done. It might not be the job of the emergency responders, but it’s got to be someone’s job. So how do you do that in the midst of strife? You invest in—you invest resources—you know, money. And there is money that could be invested more wisely in healthcare. Some of it’s foreign aid money, and some of it is local tax money. And then you invest in human capital, right? You train doctors, nurses, community health workers—in probably the other order, by the way, community health workers, nurses, doctors, because you don’t need an infectious disease doctor to treat Ebola. You don’t need an infectious disease doctor to treat AIDS. We’d like to contribute, of course, and have our contribution to make, but it’s really the system that has to be rebuilt. And that’s possible in even the most strife-torn region once the strife lets up.
I’m thrilled that those two Americans received proper care. Right? And proper care requires, if you’re critically ill and you are having hemorrhage—it’s called hemorrhagic fever for a reason—you need supportive care that’s real, not fake supportive care. And so, the more people who can get it, the happier I am. And I’m very happy that they got back and received care. So I just want to get that out of the way, because people have asked me, not so much in Rwanda, but since I’ve been back here a couple days, you know, “What do you think about people getting airlifted to Emory?” I’m saying, great, you know, no problem there.
The ethical positions that can’t take this broad view of economic disparities, but only, you know, come in to comment on specific instances, I know it has its place. But it would be far better, I think, to say, OK, here are the impact of health disparities in general, right, pre-Ebola epidemic, right. That is, you’ve got some people living in Medieval conditions still in the 21st century and some people living in the 21st century. And how do we move more people from here to here? Like, you don’t have to have—you know, treble your GDP to start building a health system. Health systems help grow your economy, investing in health and education. So, to me, that’s the big picture—rich world, poor world—rather than a narrow view of an incident, although I think we should be commenting on them.
Now, about the companies that are making various—because you mentioned vaccine. These are not vaccines. You know, we’re talking about a serum and some new—a new class of drugs, you know, that interfere with RNA, RNA interference drugs. And from what I understand, it’s actually a number of companies, right? But the thing that’s important for us to know is a lot of that is supported by the National Institutes of Health—public tax dollars. That’s how a lot of therapy for AIDS—that’s how therapy for AIDS was developed. And so, we all have a say, I think, and the world has a say—because I regard the NIH as the jewel in our crown as a nation, right? We have a say in how we build out an equity platform to make sure that those discoveries reach those in greatest need in the global sense. And I believe, actually, that the survival of our two American missionary workers could spur this forward, right? Because it’s not that they shouldn’t have received care; it’s that others should also receive it.
The Onion, the satirical newspaper, recently published an article headlined “Experts [Say]: Ebola Vaccine At Least 50 White People Away.” That’s how—the reach of The Onion. And it’s satirical and correct, right? And so, I think that’s perhaps one of the things that was—that Dr. Brantly was intending in his comments, whether it was yesterday or today. You know, “I hope that this draws attention to the problem in Liberia.” I think that’s a very humane and correct thing to say, because 50 white people away, you know, is actually satirical but quite accurate in some senses. The demand for product, and whether that be a vaccine or a diagnostic or a therapeutic, a drug, is driven by market concerns, right? But we funded a lot of that with tax dollars, and so we should have a say. And I’m thrilled to tell you, there are a lot of people in academic medicine and at the National Institutes of Health who regard this in exactly the same way I do, which is why we have PEPFAR and why we had huge programs to help patients with AIDS in Africa, 11 million people now on therapy. It’s not that they’re a market. There is a market, and the prices haven’t changed that much since 1996 in the United States. But for these patients, they’re connected to the modern world by this equity platform. They need lots of other things, but they’re at least getting that.
Ebola has been around now for several decades, and there’s been—we’re only now talking about an experimental drug. the role of government, I’m suggesting, especially ours, since we’re here, should be very large, right? And because these—you know, one of the ironies that you’re getting at, Juan, is, you know, development of new tuberculosis drugs, those were called “orphan drugs.” But the term “orphan drug” was actually designed to describe drugs that would only have a small group of people benefiting from them. And, of course, tuberculosis, when it was described as needing orphan drugs, was the leading infectious killer of young adults in the world. So, again, these ironies are going to be addressed only through a lot of government intervention. And, you know, to its credit, the NIH, in the part of it that focuses on infectious disease, actually did fund, as I said, a lot of the research going into RNA interference agents. And in my experience in the past with people like Dr. Fauci, who heads that branch, they’re very interested in global health equity, right? They’re sometimes behind-the-scenes champions, but we need to call in those chips and say, “Hey, you know, there’s a massive epidemic here because there’s no staff, stuff or systems, and the stuff includes real treatments and vaccines.”
public health financing in the United States and the cutback in places like the NIH, because you’re not going to have corporations putting huge resources into developing these drugs, and so it’s up to the governments to do it.
I think we should look for allies in the corporations that make things we need. You know, there’s all kinds of ways to work with them. But the fact is, since it’s market-driven, there will be market failures. And, you know, here’s where vigorous intervention by governments can help.
the drugs that we’re using now for millions of people in Africa are largely generic medications now. So that switch from 1996—and I happened to be an infectious disease fellow at the time at Brigham and Women’s Hospital, going between Harvard and Haiti, and we knew that they worked, because our hospitals were full of young people dying of AIDS, leading infectious killer of young adults at that time, and they got up and went home. And so, with the help of AIDS activists, we said, “Well, we want people dying of AIDS in Africa to get up and go home.” They were already home, dying at home unattended, but we wanted them to stop dying. And that really happened in the last decade, which a lot of people said would never happen. And it has, and it’s going to go forward. And it should move forward the Ebola response, as well.
Ebola is not spread through casual contact, right? I mean, those kinds of responses can play a role, right? It’s just like the debate about what’s smart quarantine. You know, what does that look like? It’s got to be smart, compassionate quarantine. Now, when I came into Rwanda, I, just like every other passenger on a plane, had to fill out a form, that I had never seen before, because it’s an Ebola form, and then every passenger was—our temperatures were checked. And if you have a fever, you go into a quarantine, right? That’s a smart procedure. Now, the quarantine is not, again, place that’s dirty and there’s nobody to give you medical care. Even in Rwanda, they’re getting that right. They’re not trying to shut their borders. And, you know, stopping non-essential travel, I get that. But it can slow down, when you stop supplies going in—and staff, stuff, supplies—then it slows down the effective response. And so, you know, it’s that same tension. You want ready movement, not just of the pathogens, across the border, but the stuff and staff who can help. And that—we need more of that. And, you know, unfortunately, there’s a tendency for some rigid, as he said—Larry Gostin said, cordon sanitaire, not to promote the kind of smart quarantine that we need.
if the pathogens don’t have borders, you know, or don’t respect borders—Partners in Health was founded with the idea that every human life has equal value and, in fact, that we should pay more attention to poor people. So, I would say, if we have resources, that we should bring them in. So, I mean, I’m already not even allowed to be part of that conversation. First of all, that’s also epidemiologically absurd, right? Because we don’t have any reports of Ebola or other hemorrhagic viruses in the border he’s referring to, which is our big one to the south.
interestingly, some of the work is being funded—in West Africa, is being funded with Defense Department dollars. To me, that’s a better use of them, right? To use them to fight an Ebola—you know, the bioterrorism money—I mean, it’s kind of silly, in a way, right? But it’s a better use of it, in my view. And, you know, I should mention, that we do have partners in both Liberia and Sierra Leone, you know, partners of Partners in Health. And, of course, we’re sending people the other way, and they’re sending people the other way, to help with the epidemic, including, you know, again, largely Sierra Leoneans and Liberians, but including Americans. And one of them is called Wellbody Alliance, the one in Sierra Leone. The other one has the name that we’re really talking about, which is Last Mile Health, right? Because they’re talking about going the last mile to serve the rural poor. And, you know, I think that the congressmen who were quoted, it would be great if they could pay attention to that part of it, that we should work harder to serve poorer people, I mean, especially kids. They’re talking—they used the word “kids.”
The New York Times today, the headline of the article, “In Redesigned Room, Hospital Patients May Feel Better Already.” And the caption says, “Butaro District Hospital in Rwanda opened in 2011, designed for beauty and fighting disease.” And it’s talking about it being a model, though it talks about a place in New Jersey, actually, it starts.
Partners in Health built it for the public health authorities. And it was designed for beauty and fighting disease. if you’re sick and you’re feeling horrible, you know, do you want to be in an ugly place? And if it’s ugly, it’s probably dirty, right? And it’s probably got tuberculosis flying around in the air. That’s one of the leading killers of patients in hospitals in the southern part of Africa. So its design, it was designed with the help of a group called Mass Design, which is focused on, again, a preferential option for the poor—in architecture.
that cost $4.3 million, which is under probably $50 a square foot. So, you know, when we hear about these huge amounts of money going into foreign aid with, you know, enormous overhead, that beautiful hospital—it made the front page of The New York Times; I had no idea that it would be on there today—is beautiful. The beds are facing courtyards. You know, this is the place I was saying I wanted you to come visit. I was there last week seeing patients. And I think it’s beautiful.
Now, how is it safer? Well, let’s just take infection control, because we’ve been talking about it. The air is circulated. Some of the louvers can’t even close. There is a giant fan circulating the air for a reason, so that people don’t get infected with tuberculosis while they’re patients in that hospital. And there’s also the capacity for isolation, meaning someone’s sick with an infectious pathogen that could be spread to staff or to other patients, we have the capacity there. And that is in a place that only 10 years ago had not one doctor, no hospital, no electricity. You know, it’s on the border with Uganda. And, you know, if you can do it there and make the front page of The New York Times, then you can do it in Liberia, Sierra Leone and Guinea, and for rural people, for poor people. And if that had happened, right—that’s where these epidemics came from. They came from rural areas. And the people living there don’t have access, as I said, to modern medical care, and they should. And you can, and it’s not expensive.
the Clinton Health Access Initiative is still working there, right, especially in Liberia, and just as these groups I mentioned, Wellbody Alliance and Last Mile Health, they’re all still there. And as far as the international emergency response, that’s what Doctors Without Borders does, right? It goes into troubled areas and tries to respond in emergency fashion. And, you know, the CDC—I think it’s great that we sent 50 people there. It’s a terrific investment of U.S. taxpayer dollars, in my view. But that’s not going to build the systems, right, and rebuild local capacity that would make this less likely to happen in the long term. Yet we can channel more of those dollars to local capacity—I mean, I hate that jargon, but whatever you call it, it means training people from Liberia, Sierra Leone, etc.—Haiti, Rwanda, in our case—to respond to their public health crises. That doesn’t mean we can’t be of use. The whole world can be of use. But it needs to be linked to this long-term approach.
A recent Washington Post column reads, “Over the past two years, the [World Health Organization] has seen its budget decrease by 12 percent and cut more than 300 jobs. The current budget saw cuts to WHO’s outbreak and crisis response of more than 50 percent from the previous budget, from $469 million in 2012-13 to $228 million for 2014-15.”
I think that’s a big mistake. You know, we need global—I call them—you know, I just called them earlier “global health equity platforms.” That’s not the language of the World Health Organization. But we need global institutions, because the pandemics are global, or they’re not just regional. When I say “global,” they’re not, you know, down there waiting in Mexico to jump up over our borders in the bodies of those devious kids. But they are translocal. All right, you know, I shouldn’t use silly academic jargon, but they’re not contained in national borders. So, you need robust translocal institutions like the World Health Organization. And when I hear these figures, you know, about budget cuts like this and I think about—I’ve just been reading Matt Taibbi’s book; I’m sure he’s been on this show quite a bit, or his books—I just—it drives me nuts to think that we’re arguing over this tiny, little pie, this tiny, little pot, for global health equity, or public health, whatever you want to call it, and these vast amounts are being squandered on foolishness, or they’re being literally stolen. And we can’t do public health without more resources. We can’t. We need more money to do this. And it’s cost nothing, next to these, you know, again, foolish endeavors, or worse. And cutting, shrinking these budgets and always thinking about contracting and contracting the public sector is a huge mistake.
The New York Times reports, “A teenage boy who was wounded on Wednesday during clashes at an Ebola-stricken neighborhood in Monrovia, Liberia, died of bleeding and hypothermic shock after being shot in his legs. … The teenager, Shakie Kamara, 15, was part of a large crowd of young men who tried to storm out of the neighborhood, West Point, which was placed under quarantine the night before. Soldiers fired live rounds to drive the protesters back into their neighborhood.”
a 15-year-old is not a young man, but a child. And, you know, that just is an awful way to respond, even if he had been—it doesn’t matter how old, but shooting a child, who then dies of the injury, right—so, hypothermic shock and bleeding just means he died of his gunshot wound, of course. And, you know, anything on that side of the response is not smart, it’s not humane, it’s not going to work. On the other hand, you know, you have the response—I mentioned Last Mile Health, who worked with the public sector. It’s not like we’re saying NGOs, you know. These are people working with local authorities in Kono district to build a completely different kind of response, which is, let’s have community health workers help us find the patients, let’s have proper care for the patients, and let’s find everything we can to get them better and prevent spread in that way. And that’s what we should all be focused on right now. And there’s no reason we can’t stop this with the adequate investment in, again, staff, stuff, systems right now.
I was in Kono Hospital with colleagues of mine from—a colleague of mine from England, from King’s College. And, you know, looking around the hospital—they were getting ready to set up an Ebola ward. This is Sierra Leone. I’m just thinking, “What a tragedy, what’s about to happen to them,” because they just—no wonder the health workers are frightened, right? They know they don’t have—the people know that they don’t have the personal protective equipment that they need. They know that they don’t have what it would take to treat people with dignity and compassion. And, you know, it’s a very frightening thing. I’ve lived through situations like that—you know, the earthquake in Haiti—when you know you just don’t have what you need to help people survive. And it’s frightening, you know? And it’s demoralizing.
— source democracynow.org
Dr. Paul Farmer, infectious diseases doctor and medical anthropologist. He is a founding director of Partners in Health and a professor at Harvard Medical School. From 2009 to 2012, Dr. Farmer served as the U.N. deputy special envoy for Haiti working under former President Bill Clinton. He currently serves as the special adviser to the United Nations on community-based medicine and is also on the board of the Clinton Health Access Initiative. His books include Infections and Inequalities: The Modern Plagues.