Public health as a public good

Adam Tanous, Idaho Mountain Express Arts Editor, September 3, 2003

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.