Centuries of Inequality in the U.S. Laid Groundwork for Pandemic Devastation

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Source: Democracy Now!

As the United States sets records for COVID-19 deaths and hospitalizations, we speak with one of the world’s leading experts on infectious diseases, Dr. Paul Farmer, who says the devastating death toll in the U.S. reflects decades of underinvestment in public health and centuries of social inequality. “All the social pathologies of our nation come to the fore during epidemics,” says Dr. Farmer, a professor of medicine at Harvard University, chair of global health and social medicine at Harvard Medical School and co-founder and chief strategist of Partners in Health.

AMY GOODMAN: This is Democracy Now!, democracynow.org, The Quarantine Report. I’m Amy Goodman.

As we continue our coverage of the COVID-19 crisis, we turn now to the world-renowned infectious disease doctor and medical anthropologist, Dr. Paul Farmer. He’s chair of global health and social medicine at Harvard Medical School and co-founder of Partners in Health, an international nonprofit that provides direct healthcare services to those who are sick and living in poverty around the world. Dr. Farmer co-founded the group in 1987 to deliver healthcare to people in Haiti. In 2014, Partners in Health was one of the first organizations to respond to the Ebola crisis in West Africa. Dr. Farmer’s new book is titled Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. I spoke to him in early December and asked him how it’s possible for the United States to have nearly 20% of the world’s infections and deaths while having less than 5% of the world’s population.

DR. PAUL FARMER: Well, I mean, we are facing the consequences of decades and decades of underinvestment in public health and of centuries of misallocation of funds away from those who need that help most. And, you know, all the social pathologies of our nation come to the fore during epidemics. And during a pandemic like this one, we’re going to be showing the rest of the world, warts and all, how — we have shown the rest of the world how badly we can do. And now we have to rally, use new tools that are coming online, but address some of the older pathologies of our care delivery system and of our country. I think that’s where we are right now.

AMY GOODMAN: What needs to happen right now in the United States?

DR. PAUL FARMER: Well, first of all, you know, I think that it’s a great tragedy that such matters as masking or social distancing or even shutting down parts of the economy, that contribute to risk but are — it’s just a shame that that’s been politicized. These are not political or partisan actions. They are public health strategies. Right now they’re all we’ve got.

But even when the vaccine is online or begins to come online, we have no history of seeing a vaccine taken up so rapidly that it would alter the fundamental dynamics of a respiratory illness like this. So, we’re facing, as President-elect Biden said, a long, dark winter. And if we can make a difference that could spare tens of thousands and perhaps more than 150,000 lives, then we should do that.

And whether or not these are called mask mandates or pleading from the president, we need state and local authorities to come together and underline the nonpartisan and life-saving nature of some of these basic protective measures. We need to invest very heavily in making sure the vaccine goes to those who need it most and those who have been shut out of previous developments like this or shut out for too long.

So we have a lot of work ahead of us this winter, but no small amount of it is going to rely on individual families and communities to take up some of these measures rapidly to make sure that the dark winter does not lead to a blighted spring.

AMY GOODMAN: Dr. Farmer, can you comment quickly on these vaccines, for people to understand, the first what’s called mRNA, messenger RNA, vaccines, what they actually do in the human body? Do they make you immune, or you can get sick and be a carrier, but you, yourself — I mean, you can be infected and be a carrier, but you, yourself, will not get very sick? Explain the choice of who gets the vaccine, also the fact that this has not been studied in children, people under 14, and so what this means for kids.

DR. PAUL FARMER: Well, in general terms, let me just say that in the 30-plus years I’ve been involved in this work, I’ve never seen such a rapid development of a novel preventive for a novel vaccine. So there’s a lot to celebrate in terms of the global effort to come together to develop new vaccines.

Again in general terms, the idea is that instead of having a natural infection — in this case, breathing in the novel coronavirus and getting sick, which leads to the outcomes that we know: death or recovery with sequelae — it also leads probably to immunity. That’s what it’s like with other viral infections in humans, or almost all of them. So, what the vaccine does is introduce something that will trick the body into believing that it’s being invaded by the virus — in this case, it’s focused on a particular protein on the outer surface of the virus — and generate that immune response, which is often robust and enduring, at least with other viruses. Now, in the case of any novel pathogen, we don’t know for sure how long that immunity lasts, right? I mean, how could you? It hasn’t been studied for long. But we know about other viruses and can take some lessons from those.

And in the case of this new vaccine or this new type of vaccines, the mRNA vaccine, we’re also dealing with that unknown. This is a new kind of vaccination. This is a new approach. It’s very exciting, in part because it seems to confer that immunity without significant adverse effects. So, I think, again, on the side of development of a novel technology, these vaccines, whether mRNA vaccines or others, are great news, right? And maybe they will influence a new generation of vaccines for other pathogens, particularly viral pathogens, which tend to be the worst ones among humans. So, that’s where we are with the development of new technology.

Unfortunately, as I said and as you’ve underlined many times, Amy, the old pathologies of our society make it unlikely that the rollout will be smooth and evenly taken up across various communities, some of them with well-founded fears and mistrust of any kind of public health campaign. So, we’re in a bit of a pickle. I’m optimistic about what will happen in this country, but as you pointed out in opening up the hour, a lot of us are concerned with what’s going to happen in the Global South and among those who might as well be considered living in the Global South in wealthy and egalitarian countries like the United States and parts of Europe.

So, it’s going to be a rocky winter, with some highs and lows. And I hope there are more highs than lows. I hope there’s more reason for celebration than for grief. But I think it’s going to be a very, very difficult winter.

AMY GOODMAN: Just before we go to this remarkable book about dealing with Ebola and what it meant, I wanted to ask you about property rights, about patents and about countries like South Africa and India pushing for a temporary suspension of intellectual property rights and patents so that COVID-19 vaccines and medications become more accessible, particularly in the Global South.

DR. PAUL FARMER: Well, I’d just like to say something we’ve had a chance to discuss before in previous years. You know, when you look at what happened around HIV, which by 1995, ’96, those of us in the infectious disease world understood that this would be a life-saving suppressive therapy — like as with diabetes requiring insulin, you’d have to keep taking it, but this would save millions of lives, and maybe even more, and prevent transmission of mother to child — the same debates about intellectual property of course came up then.

The average wholesale price for a three-drug regimen in the years immediately after the discovery of these new agents was $15,000, sometimes $20,000, per person per year. So, if you split your time between Harvard and Haiti, as I had and do, you would imagine, if you couldn’t have an imagination beyond conventional property rights discussion, that the majority of the world would be shut out of access to this therapy. And, of course, that made the most difference, on a continent level, in Africa, where the majority of people living with HIV and dying with HIV were at the time.

And what happened later was the production of generic versions of these drugs, often in India or China or even South Africa — right? — so that a much lower cost could be tied to the same agents. And when I say “much lower,” I mean a reduction, really even within those early years, from $15,000 to $20,000, to about $300 per person per year. And with groups like the Clinton Foundation getting involved, those prices dropped even further. And right now you can get a really good three-drug regimen, even with some pediatric formulations for children, for about $60 per patient per year.

So, you could say that took a long time, but it didn’t take a long time in terms of the impact that it could have. Millions and millions of lives, maybe even 16 to 20 million lives, are being saved by these drugs. But in some places, like Rwanda, where I’ve spent 10 years, you saw the virtual eradication of AIDS among children, because if mom is on therapy, the transmission to babies in utero, or through breastfeeding probably, really does not occur. And this is not a hypothetical development. This has already happened in Rwanda, which is a very poor country with a very robust public health and care delivery system.

AMY GOODMAN: This is Democracy Now!, democracynow.org, The Quarantine Report. I’m Amy Goodman, as we continue our conversation with Dr. Paul Farmer, infectious disease doctor, renowned medical anthropologist, co-founder and chief strategist of Partners in Health, author of the new book Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. Between 2014 and ’16, Ebola killed more than 11,000 people, most in Sierra Leone, Guinea and Liberia. I asked Dr. Farmer to talk about his new book and his work in West Africa during the Ebola crisis.

DR. PAUL FARMER: Well, you know, I wrote the book, a lot of it, in Sierra Leone. And as chance would have it — and I think we talked about this in 2014 — I was in Sierra Leone in June of 2014, but for an unrelated matter. I was there for a surgical conference, which I was involved, in part, in organizing. And I remember folks coming to the conference saying, “You know, there’s already Ebola in the neighboring countries. Should we really have it? Is it a safe venue?” And my response was that you don’t get Ebola through medical conferences, but through caregiving — that is, nursing the sick and burying the dead — and that we would be OK.

Shortly after that, I left, went back home to Rwanda. And as you will recall, my colleague, Humarr Khan, Sierra Leone’s leading infectious disease doctor, died of the disease on July 29th. And I began lobbying my own friends and co-workers to join in on the fight. And so, I will add, Amy, that we were very tardy to get there, in my view, and arrived in October. And what I saw then, in both Liberia and Sierra Leone, was just terrifying. It’s not like there’s a terror with a respiratory virus that’s invisible. That terror comes when someone is sickened and fell ill. But there, in the midst of this clinical desert, there were times when we saw people collapse in the street, and knew that it was likely or possibly from Ebola and, with some shame, you know, waited for those fully masked and gowned to come and help people. Now, that was not during the time which would follow in a couple of weeks in the Ebola treatment units and community care centers and abandoned public hospitals. We’re still doing a lot of that work today.

But the reason I wrote the book was I got to know a number of patients quite well. And as they recovered, we became, very often, friends, that initial group that I met in October and some that I met in Ebola treatment units in the course of the worst weeks of the epidemic. And one of them, a young man named Ibrahim, on the night that I met him, told me that he had lost more than 20 members of his family to Ebola, and asked me to interview him. And even though, as you point out, I’m an anthropologist as well as a physician, that was a very unusual kind of experience to have someone who just experienced such loss and was still recovering to make such a request. And that kind of convinced me that these stories from West Africa and the history of the place would be an important thing for me to learn about. And that was the genesis of the book.

AMY GOODMAN: And so, talk about Ebola, the outbreak and then how it was contained. You talk about it as the “caregivers’ disease.”

DR. PAUL FARMER: Well, Ebola, like the coronavirus, is an RNA virus. And also, likely, both are zoonoses. That is, they come from other species, animal species, and then leap into humans. And if you look, stand back and look, a lot of the diseases that cause the highest number of deaths among humans have these zoonotic roots. And Ebola is one of those. Its natural host is still disputed. It may be a bat. You know, that seems plausible. But in the midst of all that, its origins, in what species it came from, was not really the task at hand. The task at hand there was stopping transmission from person to person, because once introduced into the human family, Ebola spreads easily through contact.

And the two main sources of exposure are caregiving — first, you know, nursing the sick, cleaning up after them, and, second, the last act of caregiving, in most parts of the world and in most religious traditions, is burying the dead. And those were causing the transmission. Now, the problem there, unlike the United States, is that there were not professional caregivers, and there were not professional undertakers or morticians, so, of course, family members and traditional healers had to fill in that gap. And that’s why so many people got sick and so many traditional healers got sick.

And then, of course, the professional caregivers also experienced enormous risk. It wasn’t just Dr. Khan. It was thousands and thousands of nurses, laboratory technicians, ambulance drivers and doctors. And of the thousand or so that got sick during that time, probably more than half of them died. So, that’s, again, another huge loss for any country, but if you’re living in a medical desert and don’t have a lot of physicians and nurses and lab techs and ambulance drivers, it’s really something. Going back to the U.N. secretary-general’s comments about COVID, the effects of that will be felt for years and decades, if we don’t step in and work to build those health systems again.

AMY GOODMAN: Certainly —

DR. PAUL FARMER: I don’t know if that’s a — sorry.

AMY GOODMAN: Certainly, as we’ve learned, dealing with health, with epidemics, with pandemics, if people have any questions about whether altruism is a motivation, we just understand we are all connected. You, Dr. Farmer, talk in your book about colonization, the slave trade, the catastrophic consequences on African nations. Talk about — though this is not usually talked about in health terms, you put the two together.

DR. PAUL FARMER: Yeah. Well, let me just start, Amy, by saying that during the epidemic, the great majority of our attention, and certainly mine, was on the clinical response — that is, trying to make sure that Ebola treatment units, at least the ones with which we were affiliated, were not only places for isolation, but places for care.

And care for Ebola is not rocket science, even without what are called specific therapies, like an antiviral, like remdesivir, for example, for COVID. Even without specific therapies, the interventions that are required to save the lives of the majority of Ebola patients are to replace the fluids that they’ve lost through nausea, vomiting, diarrhea, sweating — right? — the torrid heat of the area. All those losses of fluids and electrolytes are what really imperil the lives of those sickened with Ebola in the short term. And we have therapies for that. They’ve been around for a hundred years. They’ve been improved over time. You know, these oral rehydration salts, what you probably call Pedialyte, are important. And for those who cannot take oral medications, because they’re nauseated or vomiting or in a coma, there are IV solutions that can save lives in that manner.

And even that was not happening across the region. And there were reasons for that, right? People were frightened. And anything that involved a sharp — that is, a needle, to put in an IV, for example, or a blood draw — poses some risk to healthcare workers, right? But it would have been better just to say, “Hey, we’re frightened,” because anyone in their right mind would be frightened. But instead, we started having arguments about what kind of care was the appropriate care. And the arguments, I mean, especially within what are called the international actors — which doesn’t mean Academy Award-winning actors, but the NGOs and humanitarian groups that had flooded this region after the civil wars that afflicted it for some time, and then returned, obviously sometimes a different cast of characters, including ones that we know well, like the CDC — came back, just a decade after this conflict ended, to be involved in the Ebola response.

And I made the argument in the book that the response was hampered by the fact that the attention was largely to containment, not to care. And, of course, this generated very painful echoes from colonial rule, which in that part of the world was largely a 20th century phenomenon. This is not remote history, as you know. So, in order to improve the quality of containment efforts, we should have focused more on the quality of care. And, you know, we’re going to face that when the next epidemic of Ebola comes along.

AMY GOODMAN: Your description of people, the life histories of the Ebola survivors, is deeply moving. Can you talk about Ibrahim Kamara and Yabom Koroma, some of the people that you dedicate this book to?

DR. PAUL FARMER: Well, you know, it’s not always been easy to talk about them, because they endured such losses, and they were not easy to hear about. Of course, having been involved in their care, I thought I knew something about their losses, but it turns out there were many more. And I had an epiphany, which I’m embarrassed to share. But, of course, it wasn’t long before we understood that every adult patient that we cared for who survived Ebola — or didn’t — had also survived a brutal civil war.

And when I started talking with Ibrahim, who is the very man I mentioned earlier, who’s the person, really, in a way, who inspired me to write this book, I couldn’t believe the details, and spent many, many months — and in the case of Yabom, years — interviewing and learning about them. And, of course, this happens over time. But Yabom’s story was different. If I could just go back and say, Ibrahim was probably 26 when he fell ill with Ebola, and did not have children of his own. His most grievous losses were his mother, his siblings, family members, grandparents, aunts, uncles. Yabom, on the other hand, was 39, and she lost, in addition to her husband, some of her children, her mother also, and other family members.

And what I learned about these two was that they moved between villages and the capital city during the war, after the war and even during the epidemic, because, very often, they were called to perform those caregiving services for afflicted members of their family. And again, in the case of those who perish, who was going to bury them at the time that they fell ill? And this was in August of 2014. So, they faced these impossible choices — another reason it was difficult and painful to write about them — choices that I’ve never faced, like: Do we respect our mother’s dying wish to be buried in her home village? And, of course, that was also against the recommendations of public health authorities. But there wasn’t enough in the way of assistance with caregiving or with respectful burial of the dead until later in the epidemic. And so, their compassion led to their own infections and to infections among other members of their families.

Now, I will add, Amy, that, of course, I still am friends with these people, and they’ve recovered, to varying extents. Yabom almost lost her eyesight, as well, because, as I think we discussed when we were together in August of 2014 to talk about Ebola, one of the complications is a blinding inflammation, that can be readily treated with steroids and eyedrops that cost pennies or a dollar to save someone’s vision. So there were lots of complications, to say nothing of grief and psychological and emotional complications. There were lots of complications that endured in the months after the epidemic was declared brought under control.

AMY GOODMAN: Dr. Farmer, you write that every American and most Europeans who fell ill with Ebola in West Africa survived. “Different mortality outcomes emerged from the same strain of Ebola, depending on care that was or wasn’t available depending on your country of origin.” If you can explain this, and then expand that to what we are seeing today in this country, for example, also on the issue of racial differentials and disparities?

DR. PAUL FARMER: Well, you know, this is something that I encourage my students to grapple with or our trainees in clinical medicine, you know, which is case fatality rate, because case fatality rate is a report card on the quality of the medical system, right? And there are many parts to that — referral to a clinical facility able to manage complications.

And we’re going to be facing the same challenge in the coming weeks. If hospitals become saturated, if we don’t flatten the curve, then they become overwhelmed. And not only do they perform more poorly in terms of caring for those sickened by the pandemic — or, in the case of Ebola, the epidemic — they also fail to provide the services that people need for other problems, other illnesses and injuries. And we saw a lot of that during Ebola, but we’ve also seen it in the United States once our hospitals in New England and New York became overwhelmed. And that’s, of course, exactly what happened in West Africa, as well. It just happened earlier and more devastatingly.

But that’s just the first part of the equation. You know, case fatality rate is a marker, a report card, on what happens after you get infected, right? We also have racial disparities and other social disparities, as you’ve noted, in risk of infection. So, all along that noxious path, we have to make interventions that lessen the risk for infection, but also that lessen the risk for a bad outcome once infected. And I think that is the goal before us with COVID-19, just as it was a goal during Ebola.

Now, why am I bringing this up as a controversial matter? Because if the report card is only about disease control — that is, stopping the epidemic — and not about survival once infected, why is it that people would go to an Ebola treatment unit to be isolated, if they fear they will not receive care? And the answer is, they won’t. Right? And this was not new. Treatment centers and treatment units that were really isolation and quarantine facilities proliferated across the continent of Africa during — under colonial rule and remained a feature there even after the end of colonial rule. And that pathology of focusing on disease control over care, I think, really weakened the epidemic.

AMY GOODMAN: Dr. Paul Farmer, author of the new book Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. He’s chair of global health and social medicine at Harvard Medical School, co-founder and chief strategist of Partners in Health, also featured in the documentary Bending the Arc.

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