Around the world, billions of people live without access to critical lifesaving surgery. Many also have no access to cancer care, and in many places those who become ill often face the intense pain of disease without the benefit of medications to ease it.
When Ebola hit West Africa in 2014, many global experts said it would be impossible to provide even basic supportive care, such as oral rehydration, and some suggested that it would be best to avoid all contact with patients.
What is at the root of these health inequities and, more importantly, what can be done about them?
These were the central questions panelists discussed on May 19 at the fifth symposium in a yearlong series celebrating 150 years of social medicine at Harvard Medical School.
The panelists analyzed the epidemics and pandemics of the 21st century, combing the recent past and present for insights into how to best address the challenges of coming years.
“We have to start to think about epidemics a little bit differently,” said Salmaan Keshavjee, professor of global health and social medicine in the field of medical anthropology in the Blavatnik Institute at HMS. Keshavjee’s work has focused on fighting outbreaks of infectious disease, such as tuberculosis, in countries from Russia to Peru, while also trying to build a global infrastructure for researchers interested in the science of care delivery aimed at treating a wide range of maladies, including chronic, noncommunicable diseases.
A new way of thinking
The mainstream model of epidemiology often focuses on investigating microbial pathogens, missing the crucial role social, political, economic, and historical forces play in the spread and severity of disease, Keshavjee said.
To address the effects of these forces, it’s crucial to start with deep, sophisticated analysis of intersections and interactions between complex biomedical and social forces, and to look for connections that point the way toward a solution, said Allan Brandt, the Amalie Moses Kass Professor of the History of Medicine in the Department of Social Medicine (In the Faculty of Medicine) and interim head of the HMS Department of Global Health and Social Medicine.
Brandt drew on examples from the work of the department’s former chair, Paul Farmer, who died suddenly in February and had been originally scheduled to participate in the discussion.
Research insights must be translated into action, Brandt said, noting that delivering the promise of modern medicine to all people, thereby averting the many potentially catastrophic disease outbreaks and suffering that the 21st century might yet bring, will require aggressive activism and advocacy.
Keshavjee and Brandt were joined by three panelists who discussed how this approach can lead to more effective responses to some of the world’s greatest health challenges, noting that failure to take social forces into account when trying to protect global health may lead to failed responses and tragic loss of life.
Pollution and other health threats
The panelists outlined some of the more apparent, and looming, population health threats that are facing health care leaders and providers.
Pollution killed 9 million people in 2019, accounting for one in six of all deaths worldwide, according to a May 17 report from the IMHE published in Lancet Planetary Health.
Many of the deaths were caused by air pollution related to coal-fueled industrialization in countries such as China and India, noted David Jones, the A. Bernard Ackerman Professor of the Culture of Medicine at HMS and Professor in the Department of Epidemiology at the Harvard T.H. Chan School of Public Health.
Jones added that he feared that the recent rapid increase in deaths from air pollution is just one of many deadly pandemics to come that will be related to the global climate crisis.
If air is unbreathable, or temperatures become too hot to sustain human life in many areas, or if catastrophic hurricanes, floods, and fires ravage the world, traditional models of disease control, containment, and treatment will not be enough to save lives without massive social, political, and economic shifts, panelists said.
Regan Marsh, HMS assistant professor of emergency medicine at Brigham and Women’s Hospital, shared her insights on the challenges of providing effective treatment for people confronting health threats such as Ebola virus disease in nations where a history of often violent political upheaval and exploitative economic systems have left millions of people without functioning health care systems.
In his work fighting the global epidemic of untreated pain, Eric Krakauer, HMS associate professor of global health and social medicine and associate professor of medicine at Massachusetts General Hospital, said his work in Asia and the Pacific requires sensitivity to the many legal and cultural proscriptions against the use of pain medicine that have deep roots in the historic British drug trade in Asia, when opium generated significant revenue for the empire.
The Paul Farmer effect
Throughout the discussion, panelists paid tribute to Farmer’s leadership and his work to understand how diseases spread in a holistic way, as well as his efforts to find concrete solutions for the toughest challenges to global health equity, and his commitment to educate future generations of leaders, researchers, and care providers.
They noted Farmer’s progress in increasing global access to medications for treating HIV/AIDS and discussed how he used the 2014 Ebola outbreak in West Africa as an opportunity to jump-start the creation of functioning health systems in some of Liberia’s and Sierra Leone’s “clinical deserts,”—places without doctors, nurses, or hope for equitable access to medical care.
In Rwanda, panelists said, Farmer helped lead efforts that produced the steepest decline in premature mortality ever measured, which included not just improving care on the ground but deepening research capacity and building an infrastructure and institutions for education. His work helped lead to the establishment of a teaching hospital and the world’s first university dedicated to global health equity, complete with a medical school.
Farmer’s holistic vision and inclusive way of working—bringing researchers together with patient advocates, caregivers, and policymakers to work together for concrete on the ground changes to promote better health—was a source of great inspiration, and might be instructive for years to come, Brandt said.
He added that Farmer successfully tied his understanding of how health and illness operate at a systemic level to his work on the ground, and he was able to focus the public’s attention with his moral vision. The key to mobilizing action for Farmer “was identifying something that was palpably outrageous and intolerable,” Brandt said.
Once Farmer was able to clearly articulate problems in historical, structural, and human terms, making systemic structural suffering visible, “then people could go back and start to look for potential for change,” Brandt said.
