Setbacks: Global Health Inequity is Solvable

extreme poverty since nineteen ninety eight. With every ounce of our energy, we need to direct ourselves to making this a temporary setback. Today we're bringing you the first episode in our Setback series, a collection of conversations about the pandemics impact on education, hunger, and of course global health. And it's fitting that we're starting today with one of my personal heroes, doctor Paul Farmer. As much as anyone I can think of, Farmer has changed the way the

world looks at the unequal distribution of healthcare. He has spent the last forty years committed to improving health equity across the world, most notably establishing long running medical support services for communities in Haiti and Rwanda. He's the author of a fascinating new book that I'd call a medical and moral thriller. It's titled Fevers, Feuds, and Diamonds, about the twenty fourteen Ebola outbreak in West Africa. It's intensely

relevant to understanding the global impact of COVID nineteen. Everyone knows that COVID vaccines are being distributed unequally. What's less appreciated is that disruptions from the pandemic are increasing inequality in the distribution of other health resources. This could ultimately lead to hundreds of thousands of additional deaths for children under five, and caused tens of thousands of additional maternal deaths.

And I retain plenty of optimism. We have tools at our disposal that would have been unimaginable just a couple of decades ago, but the will to deploy them and deploy them justly still has to be summoned. In April twenty twenty, the World Health Organization, along with the European Commission and the Bill and Melinda Gates Foundation, launched a plan to get COVID vaccines to low income countries. It's

referred to as covacs. There are many reasons to do this and The best ones, in my view are that science and the fruits of science ought to be evenly distributed like human capacity is. For all the devastation he seemed, Farmer remains hopeful that the setbacks from the pandemic don't have to mean a more unequal distribution of healthcare going forward. I'm Paul Farmer. The inadequate health resources of pork in a poor underserved people in affluent ones are a problem

we can solve. Paul Farmer is a professor at Harvard Medical School, chief of Global health Equity at Brigham and Women's Hospital in Boston, and the co founder of the organization Partners in Health. I began by asking him to describe the global healthcare situation in his own words. Well, I mean, right now, we could focus almost entirely on the setbacks. You know, one of the biggest problems we've faced all over the world is that with a shutdown,

obviously people aren't able to readily access their care. What if they have cancer, what if they have diabetes, what if they have severe hypertension. So you know, those are ranking problems I think to anybody who's involved in global health. But that's just the tip of the Iceberg. A lot of the efforts that we have engaged in to address social determinants of ill health are also being setback. Economic educational programs, cultural endeavors, employment opportunities. There's been a major

contraction and anti poverty efforts overall. So it's going to be a troubling reflection on what's happened this past year and a last I'm worried it's going to be projected forward into a future as well. Paul. There are two different ways to think about the future in this setback. One is that it's just a temporary setback where we lose a year and quickly get back to where we were. The other is that it's a twenty year setback. How do you see it, well, I mean I see it

as a struggle between those two options. With every ounce of our energy, we need to direct ourselves to making this a temporary setback. That's going to require rapid engagement in responding to some of these social problems and medical problems and health problems. But every week, month, season that goes by where we can't point to a resumption of some of these economic and social activities is going to mean more likelihood that the setback will endure, and so

I mean, I retain plenty of optimism. We have tools at our disposal that would have been unimaginable just a couple of decades ago, but the will to deploy them and deploy them justly still has to be summoned. There's certainly more consciousness about healthcare disparities in this country on

the basis of race and socioeconomic status. Then I remember in the conversation for a long time, do you see the pandemic as any kind of awakening, either in the United States or globally about the disparities between the global North and the global solve wealthier countries and poorer countries.

For sure. I mean in my lifetime too, and I'm sixty one, I have never seen this level of engagement in attention to the social pathologies that face us, and also the pathogens that face us beyond the social pathologies.

So you know they're they're from the very beginning, even before the murder of George Floyd, there was reason to think that, you know, such a catastrophic series of events could awaken a lot of people about the need for a better safety net, for example, health insurance, unemployment, insurance protection for vulnerable workers, prisoners, people who've been you know,

shoved around onto reservations and meat packing plants. I think that sense of possibility is still very much alive, this heightened awareness of our vulnerability, of our collective vulnerability, but also our heightened awareness of the inequalities of vulnerability. So you know, I would proceed up domistically even if I weren't convinced, because that may be just psychologically necessary. But I think this is very real, and we have to act promptly while people are still alive to some of

these challenges before they fade away. Your new book, Fevers, Feuds, and Diamonds is about the Ebola epidemic that broke out in West Africa in two fourteen, and one of my takeaways reading it was that a lot of the harms we think of as coming from the disease are really the harms coming from the underlying healthcare system, in place

or not in place. What I mean is that, right that we are attributing things to the novelty of a virus that in many case just project reflections of what was there in terms of our capacity to deal with a healthcare crisis of any kind. You know every time there is a health crisis, and a pandemic is the classic example. Once you're sick, who lives and who dies?

And on both scores, I think we're seeing, not just in the United States but across the world, a reflection not just of the novelty of the pathogen, but what's the opposite of novelty, the longstanding nature of our social pathologies. Social disparities are our social pathologies make things worse. The good news is that means we can alter that risk, because although we don't alter the shape of viruses, yet,

we can't alter the shape of our social conditions. I think often about an article you wrote some years ago that I think might have had that title, who Lives

and Who Dies? And you talked about, if I remember it right, what you called stupid death, and you told the story of a traffic accident you had I think maybe when you were still a medical student or many years ago, when you were hit by a car and it was theorious but because you've got high quality medical care, we lived, and probably it didn't it didn't do you the kind of permanent harm it would have somewhere else in the world. And then you talked about another accident

to someone you knew, I think in Haiti. You know the term that I got, that expression stupid deaths from from Haiti. I heard it in my first years there, and I went there in nineteen eighty three for the first time, and I'm still working in the same parts of Haiti. And you know, in those early years, not only did I hear about stupid deaths, I saw some

of them. And those happened to be the years in which I was hit by a car in Cambridge, Massachusetts, and knew right there lying in the street that you know, I would be okay, you know, And I was comparing that to the kind of circumstance that is faced by

all too many to this day. You know. It's it's as if, you know, someone would say to you after you've been hit by a car, well, you should have looked both ways before you crossed the street, right, And it's not very helpful to look back and explain away these disparities of risk and outcome without making an intervention

to lessen that risk. Here we're facing a respiratory pathogen and it's a different set of needs, but I think the needs are nonetheless material as well as social meaning, you know, do we have the staff, the stuff, the space, and the systems to respond to our health crisis. So right now we're talking about COVID, but we could be talking about surgical trauma, or AIDS, or ebola or any one of a series of maternal mortality and Sierra leone.

Each of those problems requires and always has a set of material responses, which you know, I've just summarized as staff, stuff, space, systems, and support. And I got all that, you know, as a medical student transferred from one hospital to another and then to rehab and then to having surgical care that I needed, except I knew I would those disparities staff stuff, systems. It's a bit of a tongue twister. I think I got it right. Are not exactly reflected with COVID nineteen

the way you might expect. There's an article in The New Yorker that Sanartha Mukherjee wrote that looks into that a little bit. Nigeria, for example, one of the countries you talk about in your book in relation to ebola,

doesn't seem to be getting hit at hard. United States, obviously wealthiest country, you know, most expensive systems, has gotten hit very hard, but focusing particularly on the question that why some poorer countries, some countries in the developing world, are not having the experience of the pandemic that's a severe Why do you think that is? Well, you know, I'm going to try and resist the conventional explanations. I will mention them. They include the age structure of the population.

There's less obesity, there's asthma, diabetes, hybrid tension, there's perhaps

less of it in a largely younger population. But instead of focusing on the susceptibility or the nature of the virus alone, it's also a risk to focus on the nature of the individual and the physiology of an individual alone, and instead we have to also bring into other questions like it's not unthinkable, of course, that some of these places have had very robust public health responses to COVID, and that they deserve some of the credits, the credit

the humans deserves some of the credits for having been the architects of this response. Let me just take Rwanda, a country where I lived on and off for a decade. The quality of their response to COVID, both in terms of prevention and in care, has been pretty pretty damn good. So all this to say, Jacob, I think that when we go back, or when we start to explore this even now, we're going to be called to come up with lists of factors that could explain these disparities and

also sort them out and put them in order. I imagine that folks in Singapore and China and Taiwan are justifiably proud of their ability to bring this their fraction of the pandemic under control. We could be justifiably proud, for example, in the United States, of our ability to martial scientific research to come up with vaccines in such short order. But we're probably not called to be proud of our public health delivery system, which is very patchwork

and it's also underfunded massively. If you were to compare Rwanda to the United States, not just in terms of their programmatic response to the pandemic, but the fraction of their public treasury that they put into public health and healthcare, it's much much larger than the United States the public treasury. So they're also prioritizing public health very high up on their agenda. It's not some black box mystery where we have to say, well, what is it about Rwandans that

makes them so invulnerable to disease. It's not the case at all. It's rather, what is it about their response that has made them able to do a better job than we have here in the United States. The reason to ask that is not to win an argument, but rather to learn from our colleagues and the experience of Rwanda. Paul, you've talked about a kind of nihilistic thinking which can

take effect in relation to public health problems that seem insoluble. Recently, I've seen you use this term containment nihilism to talk about what we can't do in relation to the pandemic. Can you explain a little more what you mean about that. You know, one of the things that I've seen again and again in my clinical practice over the years is clinical nihilism. You know, the argument that, oh, we can't do anything for these people, they're too poor. It's not

cost effective, not feasible, not sustainable, not even prudent. Now, of course, those are also predominantly black and brown people, right, So that's clinical nihilism, and it's a very hard sell in the United States, you know, I mean, would you openly argue for a different standard of care for the bronx than Manhattan. It would be a very difficult sell politically. It's the functional equivalent of Jim Crowe. But it's just

not something that you can sell. But we do see a different kind of nihilism in the United States, and that's containment nihilism. And it was so striking, you know, every time we made a suggestion like we should do more contact tracing, we'd find takers, even governors of entire states like Massachusetts. Right, But it's not anything that ever

became a national program yet. That's containment nihilism, right. And then after the really dramatic moment of having the President of the Republic gets sick, you remember the next day after his hospitalization, his chief of staff said, we are not going to contain the pandemic. We're going to only do this through vaccination. So again, that's about as eloquent a statement of containment nihilism as you can get. It's

a great phrase for surrender. It's a great it's a surrender. Right. Unfortunately, even with great vaccines, we have to do contact tracing, we have to observe social distancing, we have to mask all of the conventional public health demands really are still out there and we'll be around for a while. But containment nihilism is not what we saw in the Ebola epidemic and West Africa. There was clinical nihilism, and I think here in the States we're seeing a lot more

containment nihilism. Paul, How does the roll out of vaccination globally look to you in terms of equity? I mean, there are many developing countries where essentially no one has been vaccinated. As you said, the vaccination seems to be part of the success story. That say, it's both in terms of the development and the rollout. I don't know. Overall, it's not going badly. The numbers that are accelerating, you know, things seem pretty good. But we just see this vast gap.

You know, it seems that our whole country is going to be vaccinated before a lot of poor countries are vaccinated at all. Yeah, I mean, this is the great worry. I will say that there's a fairly massive coalition of people coming together to try and diminish vaccine inequality or vaccine apartheid, or wherever we call it. I mean, supply

is the problem. There will be other problems with distribution, but you can't have the distribution challenges if you don't have the supply the mechanisms that have been pulled together to address this, and you've probably already heard of or spoken about covacs, but the targets are still not high enough. They're not as high as the R oneans want them

to be. It's something like countries with barely more than ten percent of the world's population have already cornered the market, have already bought actually about half of all the doses. And you know there are going to be lots of complaints about that, of course, and legitimate complaints, so we're really going to have to again redouble our efforts to

address this. The timeline of implementation, if you want to call it that, the time between the development of an effective technology that could be a medicine or a vaccine

and its widespread distribution is usually measured in decades. But as people now know in the United States as well, if there's ongoing community transmission of the coronavirus, the novel coronavirus, then there's going to be ongoing mutation and the emergence of new and more troubling variants, which is already occurring, is sure to increase so that's one of the you know, one of the reasons that I'm not suggesting we use

fear to stimulate more investment in vaccine equity. I'm just saying people should know that there is a There are many reasons to do this, and the best ones, in my view, are that science and the fruits of science ought to be evenly distributed, like human capacity is. We

got the COVID nineteen vaccine really fast. The system worked in that case, but for other diseases that primarily affect the global South, we don't have vaccines, or at the very least, vaccine development can take a very long time. So how can we have a system that does a better job of eradicating diseases that primarily affect the developing

world and not the rich countries. Sometimes we talk about the discovery science, right, the basic science, discoveries, the development of the new tools, A lot of that is done by pharma and biotech, right, and then finally the delivery. So getting from the first day of discovery to the third day of delivery requires the assistance. I'm sure a lot of these companies that you know are know how to make tools, whether those be medical treatments, or vaccines,

So we just need to bring everybody on board. I don't want to sound like I'm singing kumbaya, but again, there's even a cold headed logic would say, well, if there's already COVID vaccine in rural Rwanda, that means that you could move quickly. It's possible to see vaccine in the field in the arms of people who in the past have been shut out of medical modernity. But they don't need to be. And that's one reason that my solvable problem is to argue that these are not insurmountable problems,

none of them. Yeah, that's really interesting. I mean you've changed the terms of the debate from how do you do it? Instead of whether it can be done? You've made it. Yeah, I hope that. I hope. I mean I would love to claim that I put that on my tombstone, know because you know, how are you going to put a man on the moon with that kind of logic? You know, can we do this? It had to be how do we do this? I assume, I

mean I wasn't there, but that's when you didn't take on. Yeah, in medicine and public health, it's hard to point to any example of sustained attention to a health problem that resulted in failure because you know, implementation was impossible. It's it wants you to say, how do we do this? Rather than should we do this? I mean part of

me wanted to say, you're halfway there. Bill Gates and the Gates Foundation, who played a very big role in the Kovac's program, he have thought a lot about this problem. He takes the position very explicitly all lives have equal value. I mean, he says something, you know, very similar to

the kind of thing you say. But he also takes the view around vaccines that you need the profit motive and the private sector to drive the innovation and development around vaccines, and that they need patent protections, and often you hear criticism of that that the patent protections in particular keep vaccine prices high and keep vaccines out of

the out of reach for the poorest countries. Do you think his approach is right or the best available solution or neither, Well, you know, I think, And first of all, I don't doubt that his work and the world I'm talking about the work of the foundation is premised on this notion that all lives have equal value, don't doubt it,

and have some experience discussing these matters with him. I also don't doubt that a great titan of industry knows things that I would never know about things like patents. But I also I further believe that people like me have something to add even if we don't know a lot about trade agreements. When I say people, I mean

I mean clinicians, nurses, doctors, community health workers. You know, we have responsibilities as well to communities that we're serving, and if those communities are not well served by current trade arrangements, including patent law, then we should suspend or wave them in the middle of crises like this. This is a global health emergency the likes of which we've

not seen in our lifetime. I would imagine that many people in industry, and including in the farm industry, could agree there are moments when you would wave intellectual property rights in order to increase production. And you know, right now we're in a situation, as you know, where a production is, the chain is the chief barrier. It's supply

as a chief barrier. And so if a country like Rwanda can convince those who do hold patent rights over new technologies like mrina vaccines, that they too could participate in the production of vaccines and in their distribution elsewhere in the world. I think that would be a good thing for the species. Meaning our spec Paul, I wanted to step back and ask you a more personal question.

It's a question I'd like to ask all our guests, Unsolvable, which is essentially, how did this become your life's work? How did you end up devoting yourself to global health equity? I can answer in one word, which is uncharacteristic of me Haiti, meaning the brevity part is uncharacteristic. I went almost by accident to Haiti between college and medical school and learn things there in one year that I think it would have taken me many years to absorb in

a classroom, for example. And that's where I learned both the devastating toll of not having a safety net, but also the almost shameful facility with which one could be put in place. The other regular question we like to ask Unsolvable Paul is what can listener do? And in this case, it's to make up for the setbacks brought by the pandemic. I might divide it into two separate answers.

One is, you know, talking about those increased and highlighted disparities in the United States, but then in terms of the global gap, in the global shortfalls. You know, I would love to see people the age of my students grasp on to this as they're you know, a hankering that will endure, that they will keep pushing forward an equity agenda, and I don't mind calling a social justice agenda.

What's wrong with social justice? That's almost asking people to make a stance part of their response, just a personal stance. I am against these kinds of health disparities. I am for their decrease. And then there are a specific tasks I mean partners in health of course, which is really the implementation arm of anything I have. I'd say in a lot of places I work requires pragmatic solidarity. In order to do this work, we need support. And it's

not just in far off places. We need support in Massachusetts, in Nabel Nation, in new work and immacaly. You know, there's a long list of really pragmatic matters that we need to address. I'll just give one example. If in the state of Massachusetts, which is a very blessed state

in terms of overall wealth. In terms of a safety net, the great majority of the people who we encounter in our work doing contact tracing in Massachusetts those who need social support, eighty percent of them cite food insecurity eight zero percent. And you know, we live in a country where there's enough to feed everybody. That's another very pragmatic

example of the kind of assistance people need. And it also includes all the other things that you think about, like not being evicted, or having unemployment insurance, or help for the disabled who need to get their vaccines or in home care. On the global level, it's a very similar kind of set of concerns, at least for the patients I know best and the populations I know best.

They are concerned with the same set of problems. Getting their kids back in school, resuming their activities, and opening up the clinical services and educational services that they want. Again requires a lot of pragmatic solidarity. And I only say that because you know, what is it the partners and Health is doing beyond that, not much. It's really

pragmatic solidarity. Sometimes we're saying, Okay, we'll help you build a hospital, or we'll help you start a medical school, but it's still the pragmatic part of it's still there, and I just hope more and more people who are listening get involved in global health equity. That's kind of the term we use rather than public health. It's a role for everybody. Paul, It's an inspiration and always a pleasure to talk to you. Thank you so much for

joining us, Unsolvable. It's great to see you, Jacob. Thank you. Paul Farmer is a professor at Harvard Medical School. He's Chief of Global Health Equity at Brigham and Women's Hospital in Boston and the co founder of the organization Partners in Health. His new book is called Fevers, Feuds and Diamonds, Ebola and the Ravages of History. To learn more about international health resources, disease prevention, and poverty eradication, please check

out the links in our episode notes. Solvable Senior producer is Jocelyn Frank, Research in booking by Lisa Dunn. Catherine Girardou is our managing producer, and our executive producer is Mia Loebell. Special thanks to Heather Fame, Kadijah Holland, Maya Konig, Emily Rostak, Eric Sandler, Carly Mgliori, John Schnar's, Christina Sullivan, and Maggie Taylor. Solvable is a production of Pushkin Industries. If you like the show, please remember to share, rate,

and review it. It helps us get the word up. You can find Pushkin Podcasts wherever you listen, including on the iHeartRadio app and Apple Podcasts. I'm Jacob Weisberg.