It has been well understood for some time now that COVID-19 and its ensuing global pandemic are unprecedented events in our contemporary world. Not since the Influenza Pandemic of 1918 has global life been so drastically altered so quickly due to a viral outbreak.
In the century since 1918, countless individuals, organizations, and nations have striven to eradicate the unnumbered diseases, parasites, and structural barriers that cause unnecessary death, needless suffering, and the squandering of human potential.
Paul Farmer is one of those individuals. Chair of the Department of Global Health and Social Medicine at Harvard Medical School, Farmer is co-founder of Partners in Health, serves as a Special Advisor to the United Nations, and has authored several books on the topics of global health, human rights, and international cooperation.
Given our aforementioned collective moment in history, UC Press would like to bring renewed attention to these topics and Farmer’s role as a leading public figure.
The following is an excerpt from Reimagining Global Health: An Introduction, chapter 11, “Global Health Priorities for the Early Twenty-First Century.” Written by Paul Farmer, Matthew Basilico, Vanessa Kerry, Madeleine Ballard, Anne Becker, Gene Bukhman, Ophelia Dahl, Andy Ellner, Louise Ivers, David Jones, John Meara, Joia Mukherjee, Amy Sievers, and Alyssa Yamamoto.
The term “global health” is often used to refer to the health of populations in developing countries. But the United States is on the globe, too. For the past several years, as health care costs have mounted, thorny debates over health care reform have highlighted key problems facing the U.S. health system: millions of uninsured Americans, stark socioeconomic and geographic disparities in health outcomes, provider incentives that promote overuse of unnecessary treatments and procedures, fragmentation of services across venues of care, high rates of preventable medical errors, and an inability to address the complex needs of increasing numbers of patients suffering from multiple chronic diseases. As one bellwether of these systemic problems, the United States, whose infant mortality rate ranked twelfth in the world some fifty years ago, saw its ranking drop to thirty-first in 2008. And yet health care costs are rising unsustainably: currently, the United States spends more than $8,000 per person per year on health care— far more than any other high-income country, many of which have superior health indices— and this figure is increasing. Given that many of the global health challenges considered in this volume stem, in part, from dire poverty and insufficient funding for health care delivery in developing countries, what parallels can be drawn to the crisis of the U.S. health system, which faces problems of a different order?
In fact, some recent efforts to improve health care in the United States suggest that we may be witnessing a convergence in how high quality care is delivered in countries rich and poor. In the United States, against a century-long backdrop of soaring innovations in medical science, a sobering realization is emerging: new technology alone—novel pharmaceuticals, powerful imaging devices, miraculous surgical procedures— cannot solve the country’s health care crisis. Rather, much like initiatives described in chapters 6 and 7, the most promising efforts to transform U.S. health care share several features, most of them linked tightly to delivery. First, they recognize that, by virtue of its broad mandate, primary care offers the most fertile ground for improving access, quality, and efficiency in the overall health system. Second, such efforts seek to reshape care so that it addresses the many social factors that pattern individual and population health and that determine the outcomes of many interventions. Finally, they acknowledge that, in addition to physicians and other professional health workers, community members can contribute significantly to the provision of health care and prevention efforts. Some of these new models of health care delivery in the United States increasingly resemble those pioneered in places like Haiti and Rwanda. Despite radically disparate epidemiologic, political, and financial environments, there are similar paths to be tread in the quest for high-quality, affordable care for all.
The Prevention and Access to Care and Treatment (PACT) program in Boston has utilized a delivery model similar to that used in Haiti and Peru. Its director, Dr. Heidi Behforouz, traveled to Haiti to examine the accompagnateur model with the goal of adapting it to an American city with many hospitals but too little in the way of community- and home-based care for chronic disease. In 1997, PACT adopted the accompaniment approach to provide care for AIDS and other chronic diseases for some of the poorest people in Boston. Community health workers were trained (and paid) to provide directly observed therapy in patients’ homes, as well as wraparound services such as health education, housing assistance, food support, and psychosocial support. As in Haiti and Peru, PACT has realized positive outcomes—70 percent of its AIDS patients have shown substantial clinical improvement; 35 percent have had shorter hospital stays— with correspondingly decreasing costs. An examination of Medicaid claims from patients enrolled in the PACT program revealed a 16 percent net savings. The PACT model is now being emulated in Miami, New York City, and within the Navajo Nation. But realigning incentives in the U.S. care system has been difficult, and these efforts struggle to find funding for training and compensation of community health workers.
This struggle has not been for lack of proven effectiveness of community-and home-based care for chronic disease, nor even demonstrable cost-effectiveness of pilot efforts. Another example is the Camden Coalition of Healthcare Providers, started in 2002 by Dr. Jeffrey Brenner. Seeking to cut costs while providing better care, the Camden Coalition began by identifying patients for whom the health system was incurring the highest costs. The result was not surprising: poor patients with multiple chronic diseases received most of their care—much of it uncoordinated and costly to the health system— in the emergency room. Health care expenditures for these patients averaged an astonishing $1.2 million per patient per year. The Camden Coalition sought to change the status quo by providing home-based comprehensive care to a small group of high-cost patients, while also attending to social determinants of ill health: lack of access to healthful foods and regular exercise, drug and alcohol abuse, housing contaminated with mold. The results have been dramatic: hospital and emergency room visits decreased by 40 percent, and costs decreased by more than 50 percent. The Camden Coalition’s model of home-based care for the sickest patients improved the quality and equity of care, while bringing down overall health expenditures.
Health Leads, another organization started in Boston, has pioneered a different approach for offering wraparound services to poor patients in several American cities. By setting up volunteer-based service centers in hospital waiting rooms, Health Leads enables doctors and nurses to “prescribe” social services like food support and housing improvements, along with medications. Health volunteers, many of them college students, then help patients attend to these social prescriptions. For example, Harlem Hospital Center refers all patients with elevated body mass index to Health Leads, which helps them access healthy foods, gym memberships, and other weight-loss resources. This approach shifts the burden of addressing patients’ social needs—something doctors and nurses are not trained to do—to volunteers and community members who are better suited to help with these problems. One study found that Health Leads more than tripled the demand for social work at a partner clinic, helping overstretched primary care doctors counter the social barriers to good health among their patients.
Yet another example of community-based health care delivery in the United States is Atlantic City’s Special Care Center, run by Dr. Rushika Fernandopulle since 2007. By recruiting “health coaches” from patients’ neighborhoods, the Special Care Center provides home-based care for poor patients, many of whom have chronic diseases. After one year, an evaluation documented impressive outcomes: 63 percent of smokers with lung disease had quit smoking; hypertension in the patient population was largely under control; and many patients’ cholesterol levels had decreased. Moreover, hospital admissions and emergency room visits had dropped by 40 percent, surgical procedures by 25 percent, and costs rose by only 4 percent, compared to a 25 percent increase the previous year. Unpublished data from subsequent years reveal further savings, as the model has been expanded.
These and other examples— all of which seek to foster “patient-centered medical homes”— point to a way forward in the United States. Community-based programs that provide home-based care, including psychosocial and wraparound services, to the most marginalized (and often sickest) people in the country can increase access to care, improve quality of care, and simultaneously cut aggregate costs. And we need to mean it when we say “home-based care,” since many of these medical homes are not homes at all. Yet the home is the locus of most caregiving. In other words, health care delivery strategies similar to those pioneered in Haiti, Rwanda, and elsewhere in the developing world might offer a means of easing the U.S. health care crisis.
Policymakers have begun taking steps toward reform along these lines. The 2010 Affordable Care Act created the Center for Medicaid and Medicare Innovation, which has $1 billion to invest in novel initiatives capable of improving quality of care while reducing costs, money that could support, expand, and strengthen programs modeled on the sorts of examples offered here. The Affordable Care Act also offers new incentives for primary care providers, which could help rebalance the health system away from specialty care and, in turn, save thousands of lives and millions of dollars. But further policy change is needed to scale up models of effective and affordable health care delivery capable of transforming primary health care in the United States.
Making sure that the field of global health includes the health challenges of the United States and other high- and middle-income countries—and, conversely, making sure that discussions of health care reform in these wealthier settings include lessons from global health—is crucial for advancing equity around the world. Health inequity is a problem everywhere, not just inside the borders of developing countries. In addition, if global health is perceived as a problem of the “other,” of interest only to the few who feel motivated to help poor countries, then it is unlikely to gain the depth and breadth of engagement that will be
required to address many of the problems we face.
Fully integrating global health into the feedback loop between medical research, service, and training would bolster the primary care transformation in the United States. It has become increasingly clear that the social determinants of health have a decisive impact on the specific burden of disease experienced by communities anywhere in the world. Yet the great majority of the world’s medical students and practitioners are not trained to consider these powerful processes beyond superficial “social histories” of individual patients. Resocializing medical education is among the most important priorities for modern medicine in the early twenty-first century, and global health has a critical role to play in this effort. Case studies drawn from resource-poor settings around the world often provide the starkest demonstrations of how social forces become embodied as adverse health outcomes; students and doctors can apply such lessons about the pathophysiology of social determinants of health wherever they happen to practice. Furthermore, keeping global health as “other” forfeits the chance for reverse innovation—using tools designed for the developing world to address problems faced in places of greater abundance. Efforts to improve health anywhere will need to mine best practices developed in all settings and apply them as befits the local setting. Global health research and practice can enhance knowledge of disease and treatment in countless ways, and it should be integrated fully into the training of health care providers everywhere in the world.
