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The Case for Optimism - Paul Farmer's Keynote Address to the Time Global Health Summit
Paul Farmer. Keynote Address to the Time Global Health Summit 2005. November 2005.
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I am seldom invited to be the upbeat speaker at conferences of this sort. Or of any sort, now that I think of it. But when I was asked to address the case for optimism in our struggle to improve the health of the world?’s poorest, I couldn?’t in good conscience refuse. There are reasons for hope.
I will offer two examples. Let?’s look back to the year 2001, not too long ago. In 2001, if we were meeting in New York to discuss these same topics, we would be arguing. And the argument would have been about whether or not it?’s even worth bothering to try to treat AIDS, for example, among poor people in places like Haiti or most of Africa. The drugs alone then cost thousands of dollars per patient per year. At the time there was no such thing as the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and PEPFAR, the U.S. AIDS initiative, wasn?’t even a twinkle in the president?’s eye. And yet, the world?’s largest charitable foundation had just declared that it would focus its vast resources on the health problems of the world?’s poor. (You can imagine the consternation of the world?’s art museums and elite universities.) Even this remarkable development didn?’t put an end to defeatism, although people like me were sick and tired, already, of defeatist arguments, which had gone on way too long already.
To ask doctors, nurses, and other providers to give up on treating the sick because they?’re too poor to pay was never, ever acceptable to my co-workers in the field.
Now it?’s November 2005. The Gates Foundation performed CPR on international health and the patient lived. The Global Fund and PEPFAR have kept the patient stable enough to move out of the ICU. We?’re still arguing, it?’s true, but we?’re not arguing about the same things. Instead of arguing whether or not to treat the poor who suffer from AIDS, or drug-resistant tuberculosis, or even drugresistant malaria (the most common kind in Africa and much of Asia), we?’re arguing about what drugs should be used to treat these diseases. AIDS drug prices have fallen rapidly, from an average wholesale price in 2001 of over $10,000 per patient per year to as low as $130 per patient per year today. I?’d much prefer to argue about generics versus branded drugs than to ask if some lives are worth more than others. I?’d rather argue about the best way to diagnose and treat, and not spend time arguing whether or not we should bother introducing modern medicine and public health to regions that have never known them. Anyone who thinks these are not better, more interesting, more valuable discussions than the old ones does not have to face, on a regular basis, the destitute sick.
We?’ve come a long way in four years. But not far enough. When we finally receive orders from on high to roll-out proper treatment plans for difficult-to-treat diseases, this is a good thing. But policy makers need to understand that changing the mantra from ?“No, you can?’t fix this?” to ?“OK, now do the right thing?” does not lead immediately to quality health care for the world?’s bottom billion. Would that it were so easy. It?’s impossible to reverse decades of neglect in the space of a few years by saying a magic word. And the results of these past few decades of neglect are not equivalent to those that preceded them; they?’re worse. For one thing?—and here?’s more optimism?—many of the tools we need to prevent or treat the diseases of poverty are in existence, if not readily at hand, and when we are told not to use them on the grounds of their ?“unsustainability?” or their lack of ?“demonstrated cost-effectiveness?” in precisely those places where such tools are needed most, we have before us a far higher-stakes argument than arguing over equal access to leeches.
Here?’s another example. In Haiti, where we?’ve worked for over two decades, we wrote, again in 2001, a proposal to the Global Fund to integrate AIDS prevention and treatment into an aggressive effort to promote primary health care across central Haiti?’s harsh and forbidding terrain. Two long years later, we received the money to do so, and that work is going well. Our Haitian team has worked with public-health authorities to use ?“new AIDS funding?” to re-open and revitalize seven facilities serving most of central Haiti. But we will not meet our goals. Usually when implementers like me report that they will not meet goals, this is not a good thing. But I?’m delighted to tell you why we won?’t meet our enrollment objectives in central Haiti: because the AIDS epidemic is shrinking there. The reasons for this will be much debated by those who love debating, but I?’ll tell you why I think the Haitian epidemic is shrinking: a decade of prevention plus treatment plus addressing social needs equals success, whether we measure success by AIDS mortality, number of new infections prevented, or number of patients who receive, through some of these so-called AIDS programs, their first real dose of primary health care.
Some things are harder to measure. One of the organizers of this conference, a science editor for Time, suggested that I share with you a couple of images. Meet Joseph, dying of both AIDS and tuberculosis at the age of 26. He was lucky enough to end up in one of our Global Fund expansion sites in Haiti. After only a few months of treatment for both these diseases, he looked like a changed man. But, in truth, he was simply Joseph again. A year or so later, he was a changed man, because he had himself become involved in AIDS prevention efforts.
That said, there exist, right now, only two large programs for the Josephs of Haiti; we need many more. And these are not large programs by the criteria we use in meetings like this one. What those gathered here in New York want are ?“scale-able?” projects that can provide services for tens of millions now in dire need.
This full speech can be downloaded on the righthand side of this page |
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