Ebola, Covid-19 And The Elusive Quest For Global Health Equity

Paul Farmer has written several books. But his new book, “Fevers, Feuds, And Diamonds,” published during a pandemic, is particularly important, as it presents a critical dissection of the Ebola outbreak in West Africa, and the lessons we can learn from Ebola today, even as we struggle to contain the Covid-19 pandemic.

Farmer is Chair of the Department of Global Health and Social Medicine at Harvard Medical School, and co-founder of Partners In Health (PIH), an international non-profit, featured in the film Bending The Arc (on Netflix). In this interview, Farmer reflects on the key messages of his new book, and its relevance to the bigger inequities that plague global health.

Madhukar Pai: Your book does an incredible job of demonstrating how diseases like Ebola spread and why they kill. As you put it, “most of West Africa is a public health desert, which is why Ebola spreads there, and it is a clinical desert, which is it kills there.” While an overwhelming majority of the mostly White American and European healthcare workers who contracted Ebola survived, the infection killed two-thirds of their West African peers. As you point out, many died because even simple intravenous rehydration treatment was not made available to them in the clinically barren settings they were in. In contrast, a great majority of the stricken expatriates were flown back to the US or Europe, where they received modern care in modern hospitals.

It seems like you have spent your entire career trying to ‘irrigate’ these clinical deserts. You have inspired many others (and co-founded PIH) to do the same. Should this be a key mission for folks working in global health — to help irrigate the public health and clinical deserts and make sure 21st century medical care is delivered for 21st century problems?

Paul Farmer: I don’t see why else we’d consider ourselves invited into the desert. Of course, we should be concerned enough to listen to what people living in the desert are saying. In my experience over almost 40 years, they invariably talk about irrigating it, in diverse ways. They talk about staff (for example, nurses and doctors), stuff (including medicines and diagnostics and personal protective equipment), safe space (like well-designed hospitals), and systems (for, say, infection control or payment of workers). I don’t believe that marshalling these resources is the responsibility of clinicians alone; it’s the price of admission for all who engage in the noble struggle for global health equity.

Madhukar Pai: You spend a lot of time explaining the “control-over-care approach” and its historical, colonial origins in your book. This public health approach emphasized isolation and outbreak containment, but failed to ensure adequate clinical care to sick individuals. Since global health is the newest iteration of colonial and tropical medicine, it seems global health experts still push the hygiene/control model, even today.

We see that with Covid-19, where emphasis was placed on measures such as self-isolation, hand-washing, social distancing and quarantine, with little serious investment in rapid testing and treatment of sick individuals. In many low and middle-income countries (LMICs), even oxygen is not available to treat people with Covid-19, let alone ventilators. What is our way out of this dominant “control-over-care approach,” which permeates all aspects of global health?

Paul Farmer: This is a rich vein of questioning, and I’d like to make two points in response. The first is about continuities and discontinuities in what’s termed “global health.” If we recognize that global health has colonial origins—and that colonial practices have been sustained well into the postcolonial era—we must also appreciate our own agency in rolling out new paradigms that are rooted in care, solidarity, and social justice. Do we want global health, as is practiced from universities across the globe, to be radically different from colonial health or tropical medicine? If so, then let’s stop referring to it as “global public health” or “global health security” and start calling it “global health equity.” This could mark a radical departure from the colonial-era policies that deemed caregiving too expensive or trivial for the “natives.”

The second point is about Covid-19. In North America, I’m not so sure that we’re seeing clinical nihilism at work. In fact, what I worry about is a species of containment nihilism, in which we give up way too early on such important initiatives as contact tracing and isolation with proper accompaniment. This may be in part because the control-over-care paradigm was always designed for the colonial subject, who was usually Black or Brown, and most often poor. It’s difficult to impose a containment-only agenda on the descendants of White settlers in North America. In these settings, to give up on care—as has been done so often on the continent of Africa, and was done far too readily in response to the West African Ebola epidemic—is not something that would sell politically.

Madhukar Pai: Your new book, like your previous books, emphasizes the importance of understanding historical and colonial context. As you put it, “the study of Ebola can’t be only about recent events.” There are growing calls to “decolonize global health” and “decolonize the aid sector, to address the persistent impact of colonialism. What are the challenges for folks working on decolonizing global health or aid?

Paul Farmer: One thing we might do more often is to dig deeper into the historical record. We’re standing on the shoulders of outsized figures, some of whom were reactionaries but some of whom lost their lives in the struggle to decolonize global health. There were, of course, unrecognized campaigners for access to medical care. There were even some colonial health officers who refused to implement what they regarded as racist and exclusionary practices. By reflecting on past battles and even small or pyrrhic victories, we may be inspired to work harder to bend the arc of history toward justice.

A second worry that I have in hearing discussions of decolonizing global health is a minor one at the moment but one that surges again and again. Just as colonization was ever about extraction, so too should decolonization be about reparation. What that means, as I try to show in the book, is attention to the material needs of people facing outrageous risk of illness and injury. What they seek (and have long called for) is the staff, stuff, space, and systems needed to lessen their risk and provide care when prevention fails. We are ever reminded by those on the short end of the stick of the need for material investments to alleviate the suffering that is the lot of so many in the clinical desert. We neglect their eloquence at our peril.

Madhukar Pai: You have always emphasized the importance of social medicine. Lack of social safety nets (e.g. paid sick leave and unemployment benefits) and universal health coverage (UHC) played a big role in America’s disastrous response to Covid-19. Why do many folks in the United States see ‘social medicine’ as a bad thing? Why is there so much push back to UHC? Do you see things changing as a result of Covid-19?

Paul Farmer: Spoken like a true Canadian! Social medicine is a regrettably obscure branch of the profession, but it’s the only one that can reliably turn our attention to broader social context and to the history of what came before us. In other words, it urges those of us involved in clinical and public health endeavors to look around (at what’s going on outside the hospital, for example) and to look back in time. Practitioners of the fields in which I trained, infectious disease and medical anthropology, may or may not be interested in the history of the conditions that shape the local worlds of those they treat or study. Epidemiologists are famous for “cleaning” their data and “scrubbing” it of the social detail that many of us hold to be important. So what is the overarching framework that would allow us to integrate varied forms of knowledge—from political economy to the molecular-level advances that underpin so much medical progress—to better understand complex social phenomena like epidemics and pandemics? Social medicine fits the bill. That’s why I’m such an evangelist for social medicine as an analytic and teaching tool.

The more important part is how we use our analysis to radically reshape social safety nets and deliver needed services. Our failure to make this link is in part why Covid-19 has so spectacularly devastated the United States. It’s not for lack of scientific capacity—American vaccinology showed that in short order—nor for lack of visionary leaders like Tony Fauci. It’s because we have a patchwork system of underfunded public health institutions that are not well attuned to lessons of social medicine. And because we have terrible fragmentation. Why do we have 351 separate local departments of health in Massachusetts? Why should we have to elaborate a new reopening plan for every school district? Until last week, we did not have an all-of-government response to Covid-19, and this is a reflection of social and political pathologies rather than of a national shortage of the resources needed to respond effectively to the disease. Does social medicine show us that humans flourish better with effective, well-woven safety nets? Yes, it does.

Madhukar Pai: Global health, as practiced today, is mostly centered on inequities in LMICs. But many high-income countries (HICs) handled Covid-19 quite poorly, and the inequities within HICs were clearly exposed. Should global health also address health and social inequities within HICs? Is this why PIH is now engaged with Covid-19 work in the United States?

Paul Farmer: My answer to both questions is an emphatic “yes.” Part of the beauty of global health equity is that it’s truly global. In the past, we talked about colonial medicine, imperial medicine, tropical medicine, and a successor regime called international health. These were overtly colonialist in nature and focused on control over care. The idea behind “global health equity” is to break that bond. To do that, we must address health disparities wherever they occur, as you’ve noted many times. When these disparities are brought into sharp relief, as is the case in North America right now, they can serve as a rallying point for bringing experience derived from global health back to what some might call “home”—in my case, the United States.

For example, the notion of relying on community health workers for contact tracing or accompanying patients with chronic disease has been worked out (and practiced) much better in places like Rwanda than in the United States. Much of PIH’s recent Covid-19 work in the latter, from Massachusetts to Immokalee, Florida, has been based on lessons learned in Rwanda, Haiti, Liberia, Sierra Leone, and elsewhere; indeed, some of it is being led by colleagues from those countries.

With Covid-19, Rwanda has done so many of the things the United States has failed to do: flattening the curve, preventing widespread dissemination of the virus, promptly testing and tracing and treating patients, and marshalling the forms of social support needed to permit isolation and quarantine. We have to learn from settings in which the response to Covid-19 has been more effective.

Madhukar Pai: 2020 was a year of racial reckoning, and everyone now sees how racism pervades all aspects of medicine and society. Racism and white supremacy are major issues in global health. As you put it, much of “African history reads as a case study in unvarnished racism of the white-supremacy hue.” And you also make the connection between racism and socialization for scarcity. Global health is dominated by individuals (like us) and institutions (like ours) in high-income countries. So, how do we address this deep power asymmetry within global health?

Paul Farmer: I hope you’re correct in saying that everyone is now aware of the pathogenic nature of racism, but I’m withholding judgment because until we all understand how social pathologies like racism and gender inequity get in the body and how we get them out, we’ll always struggle with health disparities. Some of them will be transnational, others transregional, and others within a locally defined community as small as a village, town, or city.

After spending my entire adult life in this work and seeking to listen carefully to our host communities, I’ve come to believe that higher education, advanced clinical training, and a focus on addressing health disparities are every bit as important as basic investments in the staff, stuff, space, and systems needed to respond to epidemics. We should support new universities and related institutions that are remedying the asymmetries you’ve mentioned and often doing so in closer proximity to the kind of suffering we’re describing.

In the last 10 years, I’ve worked on two such projects: the University of Global Health Equity in Rwanda and University Hospital of Mirebalais in Haiti. It has been a major challenge to keep these institutions funded, but I believe they’re important markers of an attempt to decolonize global health and expand access to first-rate training opportunities. Isn’t this what we all should be doing, when so many young women and men ask us to support their education — so that if they were born in a refugee camp in Sierra Leone or a squatter settlement in Haiti, they too might become a nurse or a doctor or a researcher?

Madhukar Pai: Ebola disrupted all healthcare services, and many people died of other conditions that could not be managed well. We see the exact same problem unfolding now with Covid-19. Years of progress in TB, AIDS, malaria, immunization, etc. have been lost due to Covid-19 lockdowns and health service disruptions. And the world is in the deepest recession since World War II. Do you worry that clinical deserts will expand in this context? How do we advocate for countries to invest more in health in the post-Covid-19 context?

Paul Farmer: I worry about this every morning, noon, and night, as I’m sure many others do. To see recent gains against AIDS, tuberculosis, maternal mortality, and other problems so imperiled by Covid-19 lockdowns and the ensuing recession is nothing short of heartbreaking. Then again, we have more tools to mitigate these disruptions than we did even a few decades ago, to say nothing of when the last big one occurred, in 1918. We just need to get these tools into deserts. As hard as this work is, I can’t point to a single example of a decently funded and well-planned health equity effort that hasn’t succeeded with sustained attention. And the more desiccated the medical desert, the greater the possibility for rapid change.

For inspiration, I often turn to Rwanda, which had been desertified only 25 or so years ago by genocide and strife. But in the aftermath of such devastation, the country’s leaders made ample investment of the public treasury in health care, education, and social safety nets. Within two decades, the nation had engineered a reversal unrivaled in much of human history, achieving some of the steepest declines in premature mortality ever recorded.

Madhukar Pai: America has lost credibility as a leader in global health, but there is renewed hope with measures taken by the Biden administration. What are your hopes for the United States under the new leadership?

Paul Farmer: One way the United States can play a leadership role is by bringing Covid-19 to heel within our borders. This will only strengthen our ability to serve beyond our borders, which is very much needed globally. But that we’ve had a mediocre vaccine rollout in the United States does not imply that we can’t be a nation associated with brisk advocacy for ready access to the vaccine in countries with little chance, as things now stand, of meeting even the least ambitious goals for vaccine coverage this year.

Consider the rollout of antiretroviral therapy for HIV. Rwanda has long achieved clinical outcomes superior to those recorded in America. But the United States and other nations developed medicines and made them available, if belatedly, to patients across the African continent. That massive contribution from the American people will not be forgotten, and we have a chance to do better in the midst of our struggle against a new virus. I am, in other words, making a strong plea for transnational solidarity. It’s true that American prestige has dimmed in many settings across the world. It’s also true, I believe, that the Biden administration can make rapid inroads in restoring that confidence.

Madhukar Pai: Your books focus on how inequities generate epidemics. With Covid-19, we are now seeing the richest countries ‘clear out the shelves’ and buy up most of the vaccines. It might take years for LMICs to get the vaccines they need (just like it took years for HIV medicines to reach them). We never seem to have an ‘equity plan’ for ensuring the best interventions reach those who really need them. Are you surprised? Do you have any thoughts on what an equity plan could look like for Covid-19 vaccines?

Paul Farmer: We sit in the partitioned amphitheater of vaccine nationalism, and it’s not clear that we’re going to change our audience members in the first act. It’s not a surprise that elected officials tend to look out for the people they represent; that’s part of the local social contract. But there are many ways of underlining the need for global solidarity in the face of Covid-19, whether for vaccine distribution or intensive care for those with severe disease.

I can’t help but encourage those in positions of privilege to contribute generously, advocate passionately, and make equity a central goal of the process, rather than an afterthought. At the same time, there’s nothing like a respiratory ailment to remind us that until everybody is safe, nobody is safe. The history of smallpox and its eradication provides just one piece of evidence that when complacency kicks in and vaccine coverage wanes, new hotspots of transmission arise. Covid-19 is a sharp reminder that everyone should be concerned with making vaccines available, regardless of ability to pay, the country in which you happen to be born or live, or any of the other criteria that have long been abused to deny equitable access to the fruits of modern science.

Acknowledgements: I’m grateful to Paul Farmer, Ishaan Desai and Katherine Kralievits for their time and effort.