For more than three decades, Dr. Paul Farmer has been on the front lines delivering medical care to some of the most poverty-stricken regions in the world, amid dire outbreaks of cholera, Zika, Ebola, and now Covid-19. He first visited rural Haiti in 1983 to learn Creole and figure out what kind of doctor he wanted to be, shortly before enrolling in Harvard’s medical school, and throughout his education, traveled between central Haiti and Cambridge, Mass. The sharp contrast between the resource-poor regions in Haiti and the abundant resources available to him on campus, where he now chairs the department of global health and social medicine, has informed his entire career.
A champion of public health, Farmer cofounded Partners in Health in 1987, a global nonprofit that uses community-based solutions to deliver high-quality care to those living in medical deserts and to challenge notions of clinical nihilism, a shrugging acceptance that some problems—social, structural, or otherwise—are simply insurmountable in combating a disease and caring for those it affects. Dismissed as unsustainable and unrealistic, Partners in Health is living proof that clinical nihilism is a failure of perseverance and of the imagination. The organization operates in 11 countries, including Liberia and Sierra Leone, which is the setting for his new book, Fevers, Feuds, and Diamonds: Ebola and the Ravages of History.
Farmer has written several books on Haiti, AIDS, and medical inequalities, and in Fevers, Feuds, and Diamonds he draws on his training in medical anthropology and his experiences to explain the historical forces that made West Africa a medical desert and the social factors that obstructed equitable delivery of effective care to those sickened by Ebola. This problem is not unique to West Africa, and part of Farmer’s project is to reframe pandemic narratives away from patient zero and questions of behavior, which put the burden of public health on individuals and fail to see the structural problems at play. The United States, for example, is incredibly rich in resources, and yet it has responded poorly to Covid-19 because it has failed to effectively deliver care and distribute these resources equitably.
He spoke to The Nation about social pathologies underpinning medical pathologies, the trappings of clinical nihilism, and the reasons a resource-rich nation like the United States has responded so poorly to Covid-19. This conversation has been edited for length and clarity.
I lived in Rwanda for a decade, mostly working as a doctor or on health care infrastructure, so I thought I knew something about the history of colonial medicine, but I didn’t. When I started reading more about it, the idea was always to control epidemic disease among the natives, and there was very little attention given to their clinical care. How do we know that? Well, when the British left Sierra Leone at the end of their formal colonial rule, they had established zero medical schools and zero nursing schools. They also banned Black doctors from the colonial medical service. The problem was structural. They couldn’t have been very concerned about caring for those already afflicted, because the infrastructure wasn’t there. It was very similar to the modern-day experience of clinical nihilism I’d seen elsewhere—“We can’t treat patients with AIDS in Africa. It’s not cost-effective, it’s not sustainable, it’s not realistic.”
CG: Partners in Health focuses on delivering care to what you call medical deserts. Can you explain this term and outline the historical forces that made West Africa a medical desert?
PF: I borrowed this term from “food desert” [an area with limited access to affordable healthy food] to describe a place where there isn’t the staff, stuff, space, and systems to provide medical care. That was clearly the case in Upper West Africa at the outset of the Ebola epidemic, and it was the case even before war leveled what was left of staff, stuff, space, and systems. The question was then, “How do you irrigate a medical desert?” It’s not rocket science. You need nurses. You need safe clinical spaces where people aren’t going to get Ebola. You need PPE [personal protective equipment], electrolytes, fluids, and then systems. To me, “systems” is infection control, actually paying nurses. We would go to these hospitals, and half the nurses weren’t even salaried. So that’s what a clinical desert feels like—you don’t have the hospital, you don’t have the staff, you don’t have the supplies.
CG: Do you think some of the groundwork you helped lay out during Ebola has been instrumental in responding to Covid-19 in West Africa?
PF: No question. In fact, my colleagues in Sierra Leone and Liberia are working with the Ministry of Health, community groups, women’s groups—even our Ebola survivors’ group has been deeply involved in responding to Covid. In Liberia and Sierra Leone we still have over a thousand employees, almost all of whom are Sierra Leonean or Liberian, all working on health care delivery and on prevention.
People say an ounce of prevention is worth a pound of a cure. But what if you’re already sick? You need trauma care. I don’t doubt that these investments have made a difference, but what’s been really frustrating, as I tried to outline in the book, is there was so much money pledged to respond to Ebola—again, for fear that it might spread—but very little of it went into building national health systems. I contrasted that to Rwanda, where everything we did and continue to do is strengthen the national health system.
CG: Could you illustrate the difference in care an Ebola victim would have received in Sierra Leone compared with the United States?
PF: The reason no Americans and very few Europeans died is the amount of attention heaped on patients. It’s because they were airlifted out of a medical desert and into medical oases.
The clinical care we saw in West Africa—sometimes it resembled no care at all. How can you have a no-touch policy when you’re in complete PPE? How are you going to get in an IV? The answer was, you’re not going to get in an IV. You’re just going to tell them to chug some Pedialyte. That’s not going to save lives.
In West Africa the case fatality rate at the end of the epidemic was just as bad at the beginning. Why is that? I argue it’s the quality of the care or lack thereof.
CG: You make a very convincing case for why intimate knowledge of the history and social context of a region can be instrumental in effectively delivering care during an outbreak. But when a crisis like an epidemic is unfolding, it is easy to see how a historical view would be eclipsed by the dire and immediate needs of caring for an epidemic’s victims. When you were in Sierra Leone, how did you juggle learning and caregiving?
PF: The immediacy of the patient is always first. In those first weeks—which were very frightening, I might add—we all focused on one thing: slowing transmission and taking care of patients who are already sick.
The tough question is, “When do you pivot to these longer-term interventions that do require more knowledge of the context and history?” While attending to the immediacy of patient needs, we need to include addressing root factors of the problem. If there’s still no reliable public health care delivery system, the same problems are going to happen. The experience I mentioned in Rwanda, which is sort of a backstory in the book, taught us that the more that is invested in national care delivery systems, the better we’ll be at preventing the next pandemic or taking care of those who were sickened by it.
Not long after the 2010 earthquake in Haiti, we were already planning to build a major medical academic center that would train Haitian health professionals and take care of a thousand patients a day. That hospital was built in 18 months, and it’s the largest training center for Haitian health professionals.
CG: Many epidemic narratives frame the virus as the protagonist, which, in your view, legitimates therapeutic nihilism. Instead, you frame the 2014 Ebola epidemic in a wider social and historical context to illustrate how, to paraphrase Louis Pasteur, the terrain itself is virulent. How does this reframing change epidemic narratives, and why is it more useful?
PF: To go back to Covid, when people were saying early on, “Well, nobody is immune—Covid is going to be the great leveler,” we knew that was bullshit. Whether it’s a respiratory pathogen like Covid or a contact-transmitted pathogen like Ebola, there’s been no epidemic we know of that’s been a great leveler. Every patient is subject to different contexts. We have the president of the United States sick, and you have tens of thousands of essential workers sick, and they’re mostly people of color. Of course it’s going to reach all levels of society, and it reaches with special virulence into people who’ve been marginalized by a series of historical forces. So does knowing any of this make you a better clinician? Probably not. Does it make you more passionate about addressing social pathologies that underpin many of the medical pathologies? I think it does.
I finished writing this book when Covid hit, and what really struck me was the pessimism around containment. We didn’t hear people saying, “Forget about the ventilators, the PPE” so much as “It’s already out of control—there’s nothing we can do for contact tracing, social distancing.” This containment nihilism was a new experience for me. I like to think working with state authorities in Massachusetts to initiate a contact-tracing program is one of the reasons there’s less community-based transmission going on there now. That’s the problem I think we’re facing here: giving up on containment too early and now giving up on initiating more aggressive containment regimes that don’t shortchange the clinical care.
CG: Have you seen instances of the control-over-care paradigm in response to Covid-19?
PF: Anytime you write off a population or a group of people as beyond salvation, that’s often a marker of clinical nihilism. We see that here largely in the direction of poor people, people of color, and sometimes the elderly. We have a long history of not doing enough for people who can’t pay for care, and this is one of the scourges of fee-for-service medicine. How could it be otherwise? When you add a very weak insurance system, you’re going to get the kind of results we’ve seen.
CG: If you were to do a similar anthropological and historical analysis of the United States’ response to Covid-19, how would you account for the virulence of our terrain?
PF: If pandemic disease and epidemics in general reveal a lot about society, I think many of the things Ebola revealed about West Africa—and the United States, for that matter—would be a very similar set of social pathologies: inequality and weak insurance systems, including unemployment insurance. What we wouldn’t see in the United States is a terrible lack of staff, stuff, space, and systems. We’d see the maldistribution of staff, stuff, space, and systems.
One of the things I would do is to ask questions about the health care delivery system. Why is it so patchwork? Why in the state of Massachusetts do you have 350 local health departments? Why does every school department have to make its own decision? Why does every university have to come up with its own plan? What about this nation, so blessed with resources, could account for such a poor outcome?