Public health
as a public good
By ADAM TANOUS
Express Arts Editor
To spend time with Dr. Paul Farmer is to
be curiously conflicted. It is at once to begin to comprehend the enormity of
the infectious disease burden the world faces. At the same time, it is to be
inspired by this Harvard-trained doctor and his colleagues who spend most of
their clinical time in one of the poorest places on earth treating the deadliest
of diseases: tuberculosis, HIV and malaria.
A primary theme of Farmer’s latest book,
"Infections and Inequality," is that " social inequalities shape not only the
distribution of emerging diseases but also the health outcomes of those
afflicted …"
One statistic Farmer casually mentioned in
a conversation I had with him during the Sun Valley Writers’ Conference last
week was this: In 2003 the number of people who will die from the three big
killers—malaria, TB and HIV—will be 6 million. To put that in perspective,
that’s a Holocaust worth of death every single year.
While statistics can sometimes be numbing,
the barest of facts having to do with these diseases are staggering and
necessary to put the scope of the problem in perspective. SARS, for all of the
international attention and action it has received, has killed 1,000 people
worldwide to date. AIDS, by comparison, kills 8,000 people every day.
A sobering point Farmer makes in his book
is that 50 years after the "introduction of almost 100 percent effective
combination therapy (antibiotics) TB remains the world’s leading infectious
cause of preventable deaths." Farmer goes on to wonder, "If we’ve done such a
poor job delivering effective and inexpensive cures to people in the prime of
their lives, what are our chances with medications (for AIDS) that are less
effective and hundreds of times as costly?"
For most of his professional life Farmer
has been treating patients and building a hospital in rural Haiti. The hospital
is called Zanmi Lasante, which in Creole means Partners in Health, the name of
Farmer’s charitable organization based in Boston. All of the patients at Zanmi
Lasante receive care and medicines free of charge. In a country where the annual
per capita gross national income in 2002 was $440, it’s hard to imagine an
alternative policy.
Why Haiti? I asked him.
"Haiti’s poverty and story are the most
gripping and epic that I’ve come across. These are people who have been run
through the mill over the last couple of centuries. I believe it even more after
having been to lots of other dramatically poor places."
And it is this response that seems to be
at the core of Farmer’s efforts. He goes to where the death and destruction is
the greatest and tries to stop it. This is quite at odds with the overall
approach of international public health professionals who espouse cost effective
analysis. Where Farmer sees the world patient by patient, the public health
bureaucracies see it in terms of populations.
Of course, the elephant in the middle of
the room is economics. If Farmer had his way, economics would be removed from
the equation altogether. And he has a point, I think, because fundamentally
health and access to health care cannot reasonably be considered an economic
good for trade.
It is a given that health care resources,
especially on the international level, fall far short of the demand for them.
Traditionally the way we have distributed limited resources of any kind is to
let the free market decide for us. However, applying that approach to health and
health care implicitly requires assigning differing values to human life. As far
as I can see, this effort is morally and practically untenable. It hardly seems
necessary to pose the question: Could we ever decide that this person or that
person or one population or another deserves health care resources more than
another on any other basis besides medical need?
It seems clear that at a certain level,
economics fail us in the health care field. Even on the national level, it seems
the wedge economics is driving between large sectors of society is manifestly
wrong.
Infectious diseases are a bit like
pollution: They don’t recognize state, national and international borders. If
there is a TB outbreak in Idaho, the disease will travel in directions that are
determined by a complex combination of factors. How can we possibly say that any
given resident is personally responsible for being afflicted by the disease? And
we don’t. If you contract TB in Idaho you will be treated free of charge. The
reason is that, though the disease affects individuals, it is, like pollution, a
public problem. Helping the individual helps the public at large; it is a public
good.
In principle our response to HIV and AIDS
should be the same as it is to TB. It isn’t, of course. HIV is still considered
a private problem not a public health concern. If I had to hazard a guess as to
why, it would be that the mode of transmission biases us against it. Because HIV
spreads via blood and body fluids—for the most part, sexually—we tend to think
of it as a disease that somehow is someone’s fault. We assume that if we stick
to certain behaviors, then we’re okay, and it’s therefore a personal
responsibility. But to those people who contracted HIV through blood
transfusions or mother’s milk, or to healthcare workers splattered by
HIV-infected blood, that argument must seem pretty flimsy. When the phrase
"sexually transmitted" is removed from the equation the bias for laying blame
falls away.
At some point soon we need to transform
our way of thinking about infectious disease. To say that TB, HIV or malaria
are, say, an African problem, or a Russian prison problem or a problem for
promiscuous people, not only betrays a supposed belief in human equality, but it
is also naive. Somehow we have this absurd sense that pathogens are knowing
creatures, that they somehow recognize the arbitrary borders we draw around
ourselves.
Infectious diseases, though they manifest
themselves in individuals, really are a public issue. We are no healthier than
the health of our community, which itself has an ever-increasing scope. That
drug-resistant malaria might be flourishing across the world in, say Malawi,
does matter to us here in Idaho. We may have our own individual reasons to
care—whether they are based in altruism, self-preservation or economics may not
matter—but, ultimately, we do need to respond with a global perspective.