This year’s Blood and Beyond session will be hosted by Nancy Berliner, MD, Editor-in-Chief of Blood, and will showcase the work of Paul Farmer, MD, PhD. Partners In Health is an international nonprofit organization that, since 1987, has provided direct health-care services and undertaken research and advocacy activities on behalf of those who are sick and living in poverty. In his presentation, Dr. Farmer will speak about “Irrigating the Clinical Desert: Clinical and Laboratory Services and Medical Emergencies,” offering his perspective as an infectious disease doctor who helped introduce and strengthen basic clinical and laboratory services during the Ebola epidemic in West Africa and following devastating earthquakes in Haiti.
Here, ASH Clinical News spoke with Dr. Farmer for a preview of his presentation. Dr. Farmer is the Kolokotrones University Professor, the chair of the Department of Global Health and Social Medicine at Harvard Medical School, and professor of medicine and chief of the Division of Global Health Equity at Brigham and Women’s Hospital.
How, and why, did you start Partners In Health?
I helped to found Partners In Health decades ago and the organization works on three continents. Our work was born, in a way, between Harvard and Haiti, and many of our volunteers and staff are affiliated with Harvard or its teaching hospitals. Brigham and Women’s Hospital has long supported these efforts by supporting trainees and faculty.
In my presentation, I will discuss some ranking problems in global health by skipping a bit around the globe and sharing some of the lessons learned in Haiti and Rwanda, often in response to epidemics, but always with comprehensive health systems in mind. First, the most effective programs are those embedded in health systems that are able to confront any disease, from lupus to leukemia, from acute abdominal pain to mental illness. For example, if you set up an AIDS treatment program, you still need labs and you still need to address the other problems people face once their disease is well managed. Then, you have to think about their families and your staff. Rwanda brought these lessons home in part because of visionary Rwandan leaders who wished to build out a comprehensive national health program – and did. So, by the time we went with Partners In Health to West Africa to help out during the Ebola crisis, we had a good deal of experience irrigating clinical deserts and seeing them bloom.
What is a “clinical desert?” What makes delivering clinical and laboratory services difficult in these areas?
The idea of “clinical desert” is adapted from the more commonly heard notion of a food desert. It’s not related to a lack of rainfall – most clinical deserts are found in the tropics, in places like Sierra Leone – but to a lack of the staff, materials, space, and systems required for public health and clinical medicine. It’s important to irrigate these deserts and to learn how they came to be. In many of these settings, colonial rule was a major factor in the rise of enormous disparities in life expectancy.
Colonial rule was relentlessly extractive, but did little to protect health, much less promote it. Sierra Leone is an example of a clinical desert – as well as a public health one. Sierra Leone was a British protectorate or “Crown colony” for about two centuries. By the time the country became independent in 1961, the British had established no medical schools or nursing schools there. They had even taken the trouble to ban Black doctors from the colonial medical services – and this was in the 20th century. So, the workforce is limited, even without considering the previous history of extracting young people from the region, of course. The area also lacks the tools of the trade that we rely on to practice medicine, such as diagnostics and therapeutics, and the clinics and hospitals to practice it in.
Systems for safe blood transfusion and infection control were also absent. That is why the Ebola virus spread in Sierra Leone and why it killed so many of the afflicted. Still, it’s always possible to irrigate a clinical desert.
What approach does Partners in Health take to overcoming those difficulties?
Our work is rooted in community health as much as anything. Most of our 20,000 employees are community health workers laboring in or not far from the places they grew up. That doesn’t mean we shy away from tertiary care, as that is often what’s needed. We also work with national health authorities to strengthen public systems; when we build a hospital or a clinical lab, it’s the property of the local health ministry. We seek to accompany our patients, walking shoulder-to-shoulder with them, as well as the public health institutions within the countries in which we work.
Persistence is a big part of that concept of accompaniment. In Haiti, there is currently a fuel shortage that threatens the operations of our major teaching hospital and the work of its BSL-3 lab and blood bank. For some, this would be a sign that such an effort is too ambitious for a place marred by political violence, a long chain of natural disasters, and more. In fact, it’s a marker of too little ambition. So, sticking with these efforts through thick and thin, and sometimes ignoring the naysayers, leads to measurable success and improved clinical outcomes.
What do you hope attendees will take away from your talk, especially in the context of the COVID-19 pandemic?
I think the COVID-19 pandemic has awakened a lot of people, in this country and elsewhere, to the need for stronger safety nets for everyone. Of course, people living in a clinical desert have already realized this. However, I wouldn’t call New York a clinical desert and yet one in 400 people in that city died from COVID-19, reminding us that we need to invest in public health and in social safety nets – not just in better lab surveillance, but in safety nets to catch people when they fall.
We’ve learned some hard lessons about how poorly prepared some of the wealthiest countries were during this pandemic. Rwanda has done a better job than the United States on this score, and that’s because of its investments in a national health system focused on the most vulnerable, believing that would lift up all Rwandans. We need more of that thinking here, too.