From "Marvelous Momentum" to Health Care for All: Success Is Possible With the Right Programs

Intelligent Design

Paul Farmer

The last quarter of the twentieth century saw little investment in international health or in the health problems of the world's poor. Over the past few years, as Laurie Garrett notes ("The Challenge of Global Health," January/February 2007), "driven by the HIV/AIDS pandemic, a marvelous momentum for health assistance has been built and shows no signs of abating." But after this upbeat introduction, Garrett proceeds to lay out the perils associated with this new momentum, chief among them that an influx of AIDS money has drawn attention away from other health problems of the poor, weakened public health systems, contributed to a brain drain, and failed to reach those most in need.

I respond as a physician who has lived through the dry spell, seen the rains coming, and witnessed the burgeoning of the first sprouts of hope in a long time. Because many others who work in places such as rural Africa and Haiti -- the examples used by Garrett in her essay -- also see the threat of bad seeds ruining the harvest, I will not dispute her argument about the disproportionate use of scarce health-care resources. In fact, I agree with most of her claims. I would rather focus on how the new enthusiasm about global health can be translated into efforts to close the widening "outcome gap" between rich and poor.

The stakes are enormous. It is well known in development circles that huge amounts of aid have often brought few improvements to the lives of the world's poorest. A first principle for the emerging global health movement, in fact, might well be "Do not emulate the mainstream aid industry." That said, aid is not bad in itself, and if managed appropriately it can achieve impressive results. The end of the funding drought has been a tremendous boon, especially for the destitute and sick (and those who provide care to them).

It is worth comparing the situation in 2002, the year the Global Fund to Fight AIDS, Tuberculosis, and Malaria made its first pledges, with that of today. Garrett is correct to remind us that HIV/AIDS is far from the only problem faced by the destitute sick in rural Africa, but it is the leading infectious cause of adult death there. At the beginning of the millennium, there was no real political will, and no money, to treat the poorest Africans with HIV/AIDS, in spite of declarations to the contrary. In 2007, on the other hand, there is some money for HIV/AIDS prevention and care, although it rarely makes it to rural Africa. In 2002, there were almost no antiretroviral (ARV) medications in rural Africa, nor were there personnel to deliver them. In 2007, most African nations are working to make HIV/AIDS diagnosis and care a public good for public health -- that is, a service paid for by the state or rich donors, rather than by individual AIDS sufferers and their families. Although ARVs are as yet reaching very few rural Africans, the past five years have seen significant investments, at the district, if not the village, level, to make HIV/AIDS therapy available for those who are able to walk or find other transportation to district hospitals.

The brain drain of health-care personnel from the developing world described by Garrett has not been reversed over the past five years, but the experience of Partners In Health (PIH) in Haiti and Africa offers hope. As hospitals are refurbished and become something more than charnel houses and as medications are made available, some doctors and nurses are returning to the rural public-sector institutions in which we work. There is a growing awareness that not only doctors and nurses are needed to deliver medical care: many are learning that proper "accompaniment" -- closely supervised home-based therapy, social and psychological support, and help with everyday tasks, including feeding families -- is what poor patients with HIV/AIDS need most of all, once the demand for coffins is replaced by the demand for a continuous supply of ARVs.

Garrett notes that "Guinea-Bissau has plenty of donated ARV supplies for its people, but the drugs are cooking in a hot dockside warehouse because the country lacks doctors to distribute them." I would argue that in no country in the world are doctors effective as distributors of medication. PIH has instead trained community health workers called accompagnateurs, who have achieved better HIV/AIDS treatment outcomes in rural areas of poor countries than have those registered in what is today termed "inner-city" America. Accompagnateurs, not doctors or nurses, are the appropriate distributors of medications -- which is why we have now imported the Haitian model to Boston.

In 2002, HIV/AIDS prevention and care were considered different and opposed activities, as experts and activists fought over scarce resources. In 2007, although this struggle continues, prevention and care have been integrated in some settings with excellent results. In 2002, experts advocated what could only be described as substandard care for poor Africans with AIDS, even if these recommendations were sometimes dressed in fancy-sounding names such as "home-based" or "palliative" care. In 2007, progress has been made, since some argue that while the home-based part of the formula is correct, the care component must include ARVs, and that "palliative care" -- code for helping people die with less pain -- should not be used for a disease that strikes mostly young adults and children unless that disease is untreatable. It is true that substandard guidelines persist in 2007, but they are being challenged by many who seek to improve the quality of care available to the rural poor.