The Nation, Dec. 23, 2020
Paul Farmer on How We Tell the Story of a Pandemic
A conversation with Dr. Farmer about his new book on the 2014 Ebola
crisis, clinical nihilism, and public health’s failure of imagination.
By Connor Goodwin
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.
—Connor Goodwin
CONNOR GOODWIN: You argue that the international response to the 2014
Ebola crisis focused more on getting the virus under control and less
about caring for its victims. Can you explain the colonial roots behind
the control-over-care paradigm and illustrate how it played out in West
Africa?
PAUL FARMER: That kind of clinical nihilism was not new to me. I was
long accustomed to seeing how we lower our aspirations for people living
in poverty, but seeing that play out in real time is always jarring.
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?
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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?
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