'The Dread Of Responsibility' — Paul Farmer On The Pandemic And Poor Countries

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Dr. Paul Farmer, professor of medicine at Harvard University, has spent three decades helping poor countries fight devastating diseases – from tuberculosis to cholera to Ebola to Zika. As co-founder of Partners in Health, he works to strengthen health-care systems in Haiti (where the group started), Malawi, Rwanda and other low- and middle-income countries, where he's seen what works – and what doesn't work – when disease strikes.

In an interview with NPR, Farmer shared his perspectives on the COVID-19 pandemic – and the new challenges to be faced in parts of the world where health-care systems already face too many challenges.

This interview has been edited for length and clarity.

How are you feeling right now about the pandemic?

Stress and paranoia are well-warranted. The question is, about what.

What are you worried about?

I'm worrying about getting test kits to Haiti, Peru, Rwanda and other countries where Partners In Health works. We don't really know what's going on there [regarding case numbers] without testing. That's what I'm obsessing about.

They have such varied health systems, varied degrees of preparation for what's coming or may be happening now. They all need test kits. They also need properly staffed ICU beds.

Are health officials worried in those countries?

Oh yeah. I was in Rwanda in mid-February. I know they're concerned, trying to pull together the supplies and staffing they need. It was a pretty smooth operation well before they had a case. The leadership of Partners In Health in Haiti, who are all Haitians, they're very worried. They're worried the ministry of health will be overwhelmed. The dread of responsibility lays heavy on their shoulders.

That dread is what a lot of folks feel if they're caregivers, clinicians. It's kind of scary.

And what you're all dreading is...

How many people show up with shortness of breath and a fever and a cough or even low oxygen in the blood. How do we get this staffed up? We need to take care of people once they're sick.

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What lessons have you learned from the Ebola outbreak of a few years ago?

Some people have said there was too much focus on [creating] Ebola treatment units [ETUs]. I don't buy this. I would say, as someone there in the summer of 2014, if we had focused on the quality of care [for patients] more and sooner, then the case-fatality ratio would have been lower and community trust would have been higher. People knew that many ETUs were deathtraps and fled them. The focus on containment [by isolating and quarantining patients] quite understandably frightens people, but expert mercy calms them. They're worried: Who will take care of them or their families if they get sick? Somebody needs to reply: "We will."

How do those fears and worries about COVID-19 differ in, say, the U.S. and Haiti?

In the U.S., we have emergency rooms, we have intensive care units. We still lack beds and ventilators, which is appalling given how much warning we've had, but we can still address these deficiencies. That's not the case in Haiti. As far as I know, in a country of 10, 11 million people, there are fewer than 30 ICU beds.

And in affluent economies, doctors don't have to go to the hospital and say, is there going to be electricity today, or will the oxygen concentrators work?

What are oxygen concentrators?

They take the air around us, remove nitrogen and concentrate oxygen so that it's therapeutic for those with pneumonia, for example.

All these mechanics of a hospital, we [in affluent nations] don't have to deal with them. The oxygen is piped right into every room. But the dread of responsibility for my coworkers in Haiti is that they have to worry: Where do we get the oxygen, the IV solutions, can we space the beds for intensive or supportive care in a way that doesn't infect the caregivers? And we've exhausted a lot of supplies as health-care workers are more attentive to putting on gloves, changing gloves, gowning up. We're seeing real supply chain challenges.

Some of these concerns are on the U.S. agenda as well.

We have botched up some of the testing in the U.S., too, but we have tons of resources compared to Haiti and Rwanda.

There's also a burden on family caregivers.

In a setting where there are very few professional caregivers, care is usually given by your mom and your auntie and your traditional healer, that's just how humans are if you don't have doctors and nurses.

And in West Africa, family caregivers as well as professional caregivers got taken out by Ebola.

What lessons did we learn from Ebola that are relevant to coronavirus?

The biggest lesson for me is every time we fail to focus on improving the quality of health care we drive people away or make them mistrust the medical system. Flattening the curve through social distancing and containment is a good thing as long as people have a way to get to professional care if they need IV fluids or oxygen. We need to integrate containment and care. That's a big lesson.

And one thing we haven't discussed is money. In rich countries, there is money to address a pandemic. How do poor countries manage?

There are a lot of new funding instruments that didn't exist before the Ebola epidemic – a pandemic emergency fund through the World Bank, for example. But how do you tap into funding like that? It's a very complex process. Even when there are so-called emergency funds, I learned after the earthquake in Haiti in 2010 there are so many pledges, so little delivery.

Why is that?

There's no malignant intent. These bureaucracies are difficult to extract money from to deliver care. That surprises people. Even during the Ebola epidemic, it should have been easy to get the staff, space and systems we needed and to strengthen health systems. And I can tell you it was not easy.

Partners in Health had to rely heavily on private philanthropy just to work out kinks or get supplies that should have been readily obtained once an international public health emergency was declared.

And in this emergency, rich countries are struggling to fight the disease on their home front as well.

People in, say, Britain and the U.S. may say, 'Why should we worry about an epidemic on distant shores when it's here.' That said half of all American households donated to earthquake relief in Haiti. That says something nice about our species. We'll see what happens.

What's your long-range outlook?

We'll get through it where there are resources. We have tools that were unimagined during the 1918 flu epidemic. We have resources people would not have dreamed of 102 years ago. I know Chinese authorities have been criticized for trying to tamp things down. But they actually published the genome [for the novel coronavirus] and within days that meant people in scientific institutions were pursuing vaccine development and therapies. I'm mostly worried about the kind of places that can be termed "clinical deserts."

So are you hopeful or in despair?

Optimism is okay: Let's all hope for the best. But that's not preparing. Maybe a little cloud of pessimism would spur us to prepare better for a public-health catastrophe.