Pathologies of our Pandemic: An Interview with Paul Farmer
By Dan Clendenin
For January and February JWJ will feature a two-part interview with Paul Farmer by Amy Goodman from the online version of Democracy Now! (December 4, 2020). I have edited the interview slightly.
As the United States sets new records for COVID-19 deaths and hospitalizations, we speak with one of the world’s leading experts on infectious diseases, Dr. Paul Farmer, who says the devastating death toll in the U.S. reflects decades of underinvestment in public health and centuries of social inequality. “All the social pathologies of our nation come to the fore during epidemics,” says Dr. Farmer, a professor of medicine at Harvard University, chair of global health and social medicine at Harvard Medical School, and co-founder and chief strategist of Partners in Health.
AMY GOODMAN: This is Democracy Now!, democracynow.org, The Quarantine Report. I’m Amy Goodman.
We turn right now to a remarkable book. It’s called Fevers, Feuds, and Diamonds. The United States has set yet another world record for daily coronavirus cases and hospitalizations with over 216,000 infections confirmed Thursday and more than 2,800 deaths. Nearly 101,000 people are hospitalized with COVID-19 across the United States. In California, Governor Gavin Newsom has issued sweeping remain-at-home orders. The Navajo Nation has requested a major disaster declaration from the federal government, facing medical supply shortages and surging case numbers. Here in New York City, the positive test rate is the highest it’s been since May, with officials warning of a second wave.
Well, for more on the COVID-19 crisis, we go to Miami, Florida, where we’re joined by the world-renowned infectious diseases doctor and medical anthropologist, Paul Farmer. He’s chair of global health and social medicine at Harvard Medical School and co-founder of Partners in Health, an international nonprofit organization that provides direct healthcare services to those who are sick and living in poverty. Dr. Farmer co-founded the group in 1987 to deliver healthcare to people in Haiti. In 2014, he traveled to West Africa to treat Ebola patients. Between 2014 and ’16, Ebola killed more than 11,000 people, mostly in Sierra Leone, Guinea and Liberia. In his new book, just published, about the Ebola epidemic, Farmer looks not only at the modern-day crisis, but at the decades of colonialism and extraction that fueled it. The book is titled Fevers, Feuds, and Diamonds: Ebola and the Ravages of History.
Dr. Paul Farmer, welcome back to Democracy Now! It’s great to have you with us.
PAULFARMER: Thank you, Amy. It’s great to be back.
AMY GOODMAN: Well, this is a true magnum opus. It is an epic work. And before we go deeply into what we can learn from based on how Ebola was dealt with, I wanted actually to go to the epilogue of your book, which is what we are living in today, in this country and around the world, this unprecedented pandemic. And as we speak today, Paul, all records have been shattered — not in the poorest countries in the world, but right here in the wealthiest country in the world. Over 2,800 people have died. We have less than 5% of the world’s population but nearly 20% of the world’s infections and deaths. How is this possible?
PAULFARMER: Well, I mean, we are facing the consequences of decades and decades of underinvestment in public health and of centuries of misallocation of funds away from those who need that help most. And, you know, all the social pathologies of our nation come to the fore during epidemics. And during a pandemic like this one, we’re going to be showing the rest of the world, warts and all, how — we have shown the rest of the world how badly we can do. And now we have to rally, use new tools that are coming online, but address some of the older pathologies of our care delivery system and of our country. I think that’s where we are right now.
AMY GOODMAN: In your epilogue, you begin by saying, “‘The only means of fighting a plague,’ observes Dr. Rieux, the protagonist of Albert Camus’s novel, set in a fictional Algerian city, is ‘common decency.’” And I thought about that in relation to national policy. You have President-elect Joe Biden and Vice President-elect Kamala Harris yesterday talking about what they will do. Now, he has long known Dr. Fauci, who will play a key role. Vivek Murthy was just being named the surgeon general. He’s saying that for the first 100 days, they will ask the entire U.S. population to wear masks. And yet this flies directly counter to what President Trump is doing right now, who will hold scores of holiday parties inside the White House. The secretary of state, Mike Pompeo, has invited nearly a thousand people to the State Department for holiday parties. Of course, this is inside. It’s winter. We are not just talking about what the future will look like. President Trump is in office for another almost two months. When you have nearly 3,000 people dying a day, we’re talking about tens of thousands of more needless deaths. What needs to happen right now in the United States?
PAULFARMER: Well, first of all, you know, I think that it’s a great tragedy that such matters as masking or social distancing or even shutting down parts of the economy, that contribute to risk but are — it’s just a shame that that’s been politicized. These are not political or partisan actions. They are public health strategies. Right now they’re all we’ve got.
But even when the vaccine is online or begins to come online, we have no history of seeing a vaccine taken up so rapidly that it would alter the fundamental dynamics of a respiratory illness like this. So, we’re facing, as President-elect Biden said, a long, dark winter. And if we can make a difference that could spare tens of thousands and perhaps more than 150,000 lives, then we should do that.
And whether or not these are called mask mandates or pleading from the president, we need state and local authorities to come together and underline the nonpartisan and life-saving nature of some of these basic protective measures. We need to invest very heavily in making sure the vaccine goes to those who need it most and those who have been shut out of previous developments like this or shut out for too long.
So we have a lot of work ahead of us this winter, but no small amount of it is going to rely on individual families and communities to take up some of these measures rapidly to make sure that the dark winter does not lead to a blighted spring.
AMY GOODMAN: Dr. Farmer, can you comment quickly on these vaccines, for people to understand, the first what’s called mRNA, messenger RNA, vaccines, what they actually do in the human body? Do they make you immune, or you can get sick and be a carrier, but you, yourself — I mean, you can be infected and be a carrier, but you, yourself, will not get very sick? Explain the choice of who gets the vaccine, also the fact that this has not been studied in children, people under 14, and so what this means for kids.
PAULFARMER: Well, in general terms, let me just say that in the 30-plus years I’ve been involved in this work, I’ve never seen such a rapid development of a novel preventive for a novel vaccine. So there’s a lot to celebrate in terms of the global effort to come together to develop new vaccines.
Again in general terms, the idea is that instead of having a natural infection — in this case, breathing in the novel coronavirus and getting sick, which leads to the outcomes that we know: death or recovery with sequelae — it also leads probably to immunity. That’s what it’s like with other viral infections in humans, or almost all of them. So, what the vaccine does is introduce something that will trick the body into believing that it’s being invaded by the virus — in this case, it’s focused on a particular protein on the outer surface of the virus — and generate that immune response, which is often robust and enduring, at least with other viruses. Now, in the case of any novel pathogen, we don’t know for sure how long that immunity lasts, right? I mean, how could you? It hasn’t been studied for long. But we know about other viruses and can take some lessons from those.
And in the case of this new vaccine or this new type of vaccines, the mRNA vaccine, we’re also dealing with that unknown. This is a new kind of vaccination. This is a new approach. It’s very exciting, in part because it seems to confer that immunity without significant adverse effects. So, I think, again, on the side of development of a novel technology, these vaccines, whether mRNA vaccines or others, are great news, right? And maybe they will influence a new generation of vaccines for other pathogens, particularly viral pathogens, which tend to be the worst ones among humans. So, that’s where we are with the development of new technology.
Unfortunately, as I said and as you’ve underlined many times, Amy, the old pathologies of our society make it unlikely that the rollout will be smooth and evenly taken up across various communities, some of them with well-founded fears and mistrust of any kind of public health campaign. So, we’re in a bit of a pickle. I’m optimistic about what will happen in this country, but as you pointed out in opening up the hour, a lot of us are concerned with what’s going to happen in the Global South and among those who might as well be considered living in the Global South in wealthy and egalitarian countries like the United States and parts of Europe.
So, it’s going to be a rocky winter, with some highs and lows. And I hope there are more highs than lows. I hope there’s more reason for celebration than for grief. But I think it’s going to be a very, very difficult winter.
AMY GOODMAN: On Thursday, the United Nations Secretary-General António Guterres criticized countries that rejected COVID-19 facts and the World Health Organization’s recommendations.
SECRETARY-GENERAL ANTÓNIO GUTERRES: From the start, the World Health Organization provided factual information and scientific guidance that should have been the basis for a coordinated global response. Unfortunately, many of these recommendations were not followed. And in some situations, there was a rejection of facts and an ignorance of the guidance. And when countries go in their own direction, the virus goes in every direction. The social and economic impact of the pandemic is enormous and growing.
AMY GOODMAN: So, that’s the U.N. secretary-general. I mean, it’s very interesting that the United States, the most horrific record in the world now on COVID-19, and then Trump’s allies in the world — Brazil, Jair Bolsonaro; you have Narendra Modi in India; you have Boris Johnson, who was in intensive care himself and then switched his kind of herd immunity approach, one that President Trump is taking in this country, not through vaccines, but through, essentially, just leaving the population and letting COVID-19 rip through our country. You have the science-denying leaders, a number of them authoritarian, and the effects in those countries, and also, though, places like the United States buying up the vaccines in the world. If you, Dr. Farmer, can talk about Trump pulling out of the World Health Organization and also what that means when the wealthiest countries then buy up the available vaccines?
PAULFARMER: Well, first of all, wealthy countries buying up the available vaccines is nothing new. And that’s why there have been a number of efforts to make sure that doesn’t happen with these new crop of vaccines to prevent COVID-19. And that’s going to be among the tasks that I mentioned for the coming months. And again, it will happen within countries in addition to between countries.
Another thing that I would say as a sort of pushback is that vaccines do not require cognitive change to be effective, right? So, whether you attribute COVID or polio or measles to, let’s say, even sorcery, or whether — sorry that sounds like a stretch, Amy, but it’s something I’ve heard again and again — once the vaccine is in you, it seems to work the same within those who understand the nature of the disease and its origins and those who don’t. And that basic point, I think, is important, because we do have to address vaccine hesitancy, but we don’t have to convince people that, for example, this is an RNA virus that comes in through the respiratory route and that you can develop immunity. Those are parallel activities, if you ask me, to an effort to make sure that we have an equity platform, a global equity platform, for distributing the virus — sorry, distributing the vaccine.
And then, back to the point that you made, which is about science deniers who are in leadership positions, that makes not only vaccine distribution difficult. It makes research difficult. It makes common and shared understandings of how diseases work difficult. So it’s something that we should deplore and try to get rid of in our public discourse. But we still have to proceed with the vaccine distribution, and knowing that it will not engender a lot of culture and cognitive changes in the short term.
And that’s something, you know, I saw, Amy, in West Africa during the Ebola crisis, where very often — as you read in that book, very often people did attribute their illness or their family member’s illness to events and processes that had nothing to do with an infectious pathogen. I’ve seen that all over the world. But when there were rules applied around social distancing, around PPE, around how burials were to be conducted, when those rules were applied and when there was better care provided for those afflicted, that’s when we started to see some decline in the incidence of Ebola in West Africa.
And I just want to underline that we don’t have to make everybody who gets this vaccine an expert in virology or vaccinology. We need to get them protected.
AMY GOODMAN: And just before we go to this remarkable book about dealing with Ebola and what it meant, I wanted to ask you about property rights, about patents and about countries like South Africa and India pushing for a temporary suspension of intellectual property rights and patents so that COVID-19 vaccines and medications become more accessible, particularly in the Global South.
PAULFARMER: Well, I’d just like to say something we’ve had a chance to discuss before in previous years. You know, when you look at what happened around HIV, which by 1995, ’96, those of us in the infectious disease world understood that this would be a life-saving suppressive therapy — like as with diabetes requiring insulin, you’d have to keep taking it, but this would save millions of lives, and maybe even more, and prevent transmission of mother to child — the same debates about intellectual property of course came up then.
The average wholesale price for a three-drug regimen in the years immediately after the discovery of these new agents was $15,000, sometimes $20,000, per person per year. So, if you split your time between Harvard and Haiti, as I had and do, you would imagine, if you couldn’t have an imagination beyond conventional property rights discussion, that the majority of the world would be shut out of access to this therapy. And, of course, that made the most difference, on a continent level, in Africa, where the majority of people living with HIV and dying with HIV were at the time.
And what happened later was the production of generic versions of these drugs, often in India or China or even South Africa — right? — so that a much lower cost could be tied to the same agents. And when I say “much lower,” I mean a reduction, really even within those early years, from $15,000 to $20,000, to about $300 per person per year. And with groups like the Clinton Foundation getting involved, those prices dropped even further. And right now you can get a really good three-drug regimen, even with some pediatric formulations for children, for about $60 per patient per year.
So, you could say that took a long time, but it didn’t take a long time in terms of the impact that it could have. Millions and millions of lives, maybe even 16 to 20 million lives, are being saved by these drugs. But in some places, like Rwanda, where I’ve spent 10 years, you saw the virtual eradication of AIDS among children, because if mom is on therapy, the transmission to babies in utero, or through breastfeeding probably, really does not occur. And this is not a hypothetical development. This has already happened in Rwanda, which is a very poor country with a very robust public health and care delivery system.
AMY GOODMAN: We’re going to go to break, and when we come back, we’re going to talk about Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. Our guest for the hour, Dr. Paul Farmer. Stay with us.
NOTE: JWJ will post part 2 of this interview with Paul Farmer on February 7.
Dan Clendenin: email@example.com
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