Paul Farmer on building up Haiti – a long-term investment

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Paul Farmer, MD, PhD, gives a plenary lecture at the ASTMH annual meeting in Philadelphia Tuesday.

“We need equity strategies to deliver the vaccines, diagnostics [and] therapeutics to those that need them most,” said Paul Farmer, MD, PhD, of Harvard Medical School and Partners in Health (PIH) speaking at the 60th Annual Meeting of the American Society of Tropical Medicine and Hygiene Tuesday afternoon in Philadelphia.

He showed a picture of a man named Joseph in 1998 who was all but skin and bones in one photograph – co-infected with HIV and tuberculosis and sure to die without intervention. Then, to the right, the picture of a healthy, smiling, barely recognizable Joseph several months later after having received care and treatment.

At that time, policymakers said it was not cost effective to offer antiretroviral treatment to people with these three afflictions – AIDS, tuberculosis and poverty in Joseph’s case. We now know well that is not the case, Farmer said. “We should be pushing forward the economists and policymakers when we know that something will make a difference,” he said.

Farmer reviewed his work in Haiti through PIH, utilizing their model of care: community-based, health-center enriched, hospital-linked. “This model links villages and community healthcare workers,” Farmer said, starting with a team of people taking an abandoned facility and rebuilding it to serve as a clinic. “We’re talking about hundreds of thousands of dollars to rebuild a clinic and roll out therapy not just for AIDS, tuberculosis and malaria, but for women’s health issues, primary health services,” he said.

On the eve of the earthquake, the PIH team in Haiti had taken this same formula and moved it across the country. There were 11 different public sector facilities that they had either built or rebuilt. But then the earthquake struck – Farmer showed a picture of a pile of rubble, once the General Hospital nursing school. Few of the nursing school students survived, nor did their teachers, Farmer said. This was decades-worth of work that crumbled.

Recent estimates note there are between 220,000 and 316,000 fatalities attributable to the earthquake, and 1.3 million homeless. Farmer quantified the devastation in relative terms by showing a slide comparing the fatalities and fiscal damages calculated in millions of several major international disasters (see slide to the right).

The international humanitarian response was immense, he said.  The Naval ship Comfort brought in 16 operating rooms at a time when most facilities on Haiti had been destroyed, and half of all American households contributed to the earthquake relief. “But that’s not the same as reconstruction,” Farmer said. “Haiti’s problems are not acute, they are chronic.”

There were more than 3 million people affected by the earthquake, he said, and as of November 550,000 still live in resettlement camps, where delivering services such as clean water and education is a huge problem. That’s before you even address cholera.

Haiti is the most water insecure country in the hemisphere if not the world, Farmer said, and before the earthquake a writer even predicted major outbreaks of water borne disease in Haiti if investments were not urgently made into municipal water systems and in-home water filtration. As of November 8, there had been almost 500,000 cases and nearly 7,000 deaths attributed to the cholera outbreak in Haiti, and it is likely larger than that due to the inability to accurately report in Haiti, Farmer said.

Farmer noted five complementary interventions to slow cholera in Haiti that Ivers et. al. put forth in an article published in Lancet Infectious Diseases in December 2010:

  • Identify and treat all those with symptomatic cholera
  • Make oral cholera vaccines available in Haiti and elsewhere
  • Shore up Haiti’s water system and improve sanitation
  • Integrate cholera-specific projects into existing efforts to strengthen Haiti’s health system
  • Harmonize global health policy and raise the bar on goals.

“We need to ask as doctors and scientists what is our equity agenda for cholera in Haiti?,” he said. For three decades there has been an effective vaccine – developed by Shanchol by Shantha Biotech that has 67 percent efficacy and available at $1.85 per dose. But vaccine roll-out in Haiti has been difficult. “We’ve been lectured that it’s not cost effective – even though we know that the price of the vaccine is not set by some greater power,” Farmer said, alluding to the need to work with drug companies to negotiate lower prices for the vaccine.

Even though reports of cholera have gone down in the past few months, Farmer warned, “The idea that this is over will again be challenged as soon as the rainy season starts.” Farmer urged long-term investment and for humanitarian organizations to work with the government, though weak, to create a sustainable system.

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