Paul Farmer on Why Health Equity Is as Important as Drugs and Vaccines in Fighting Ebola, Cholera and other Infectious Disease

Posted 5 November 2017

Outbreaks of infectious diseases often invite such a sharp focus on the biology of the pathogen and the need to develop new drugs and vaccines that even many experts lose sight of the fact that it’s a lack of health equity that routinely inflicts most of the suffering.

That was a key message from physician and medical anthropologist Paul Farmer PhD, MD, in his keynote address at the opening plenary of #TropMed17, where he was invited to revisit the Ebola epidemic from his perspective as a relentless advocate for health equity. The co-founder and chief strategist for the NGO Partners in Health made it clear that if the ultimate goal is to reduce the burden of disease, it is time to give health equity equal stature in the world of tropical medicine research.

“It keeps recurring again and again that when we have scientific progress, we have new vaccines, we have new diagnostics, we have new therapies, and yet we fail every time to put together an equity plan,” Farmer said.

He noted that in the outbreak of Ebola virus disease in West Africa in 2014 and 2015, the biggest threat ultimately was not the disease itself but the lack of infrastructure that could help prevent its spread and provide adequate care for those who were sick. Farmer said that disparity explains why Ebola exploded in Liberia, Sierra Leone and Guinea, yet was quickly contained when cases appeared in Nigeria and the United States.

Farmer said he noticed something similar in Haiti during the cholera outbreak that occurred in the aftermath of the 2010 earthquake. Farmer said the conventional narrative focused on the widespread damage caused by the earthquake as making Haiti more vulnerable to the spread of cholera. Yet Farmer said “that was not the case.”

“The earthquake-affected zones were among those less affected by cholera because people in camps were drinking purified water,” he said. “The most vulnerable populations were in the rural areas not affected by the earthquake.”

He said the cholera epidemic in Haiti was “in a way a humiliation” for people like him because, while as a physician he could be successful in treating individual cholera patients, “there was no way to make up for an absence of sustained investments in water and sanitation.”

For Farmer, even the term “tropical disease” can be misleading because it obscures the role of health equity as a key factor in determining who is at risk. “Latitude,” he said, “is not the primary determinate of tropical disease. Malaria used to be in Boston. It is really about poverty as much as anything else.”

Farmer believes there are many missed opportunities in failing to move aggressively, in the immediate aftermath of major disasters in poor countries, to deal with long-standing deficiencies in health systems. He said in the wake of the earthquake in Haiti, some development professionals “scoffed at the proposal” from Partners in Health and Haiti’s Ministry of Health to build a major new academic health center. Farmer said the view from the perspective of many development economists is that such investments are not “cost-effective or sustainable.”

Thanks to an outpouring of support, including a large amount of donations from US households, the project moved forward and the result was the pital Universitaire de Mirebalais—HUM for short—a 205,000-square foot, 300-bed facility.

Farmer said that while development economists have their logic, his logic is simply: “If not now, when?”

“We are at a similar juncture in West Africa,” he said, where he fears an opportunity to address the fundamental problems that led to such a devastating Ebola outbreak appears to be slipping away.