Treatment IS Prevention: How PIH Reconstructs What Is Good

A recurrent theme in this course has been that programs in international health need to address the root causes of disease, as well as the biosocial contexts in which these diseases arise, in order to achieve some success (Lecture 1). Paul Farmer and his model of Partners in Health support this idea, creating programs that take into account the poverty, structural barriers, and social norms that often determine who benefits from health care systems and who doesn’t (Farmer et al. 4). What I find interesting, however, is that Farmer argues that development efforts seeking to address these issues should not necessarily be prioritized over the treatment of patients in immediate need (Farmer 217). I would like to look at whether this argument is made on a fundamentally moral basis (as in we have “the moral responsibility” to treat suffering patients) or effectiveness basis (treatment is good in the long run and reinforces development goals).

I think that PIH programs directed at tuberculosis are a good place to start, as TB is a disease that is not only intertwined in the issues of poverty, but also in debates about non-compliance and cost-effectiveness. Furthermore, although cures exist, TB continues to exact an enormous toll on populations and is projected to be the cause of 30 million more deaths by 2020 (Farmer 212). Because there are so many people suffering now and so many people expected to be suffering in the future, I think there is already a contradiction in where the money should go: Should funds go towards antibiotics to cure the people suffering right now? Or would the funds be better served in long-term infrastructure improvements, such as clean water systems, that will improve overall health and prevent future TB cases?

I believe that Paul Farmer’s answer, by the way he structures PIH, is both-that there shouldn’t be an “either-or” scenario (Farmer 217). For one, the effectiveness of financial assistance, nutritional supplements, and follow-up visits (Farmer 219) may refute the idea of cost-effectiveness. The accompaniment method of PIH is far less expensive than paying for the hospitalization of the patients if they are unable to comply (Farmer 224), which is often the case if antibiotics are distributed without accompanying social programs.

In terms of whether money should be going to development or treatment interventions, I think that Farmer is correct in saying that treatment is often prevention. An effective biosocial approach will cure patients, halt the progress of MDR TB, and prevent transmission; furthermore, “individuals with active pulmonary disease are most likely to transmit the disease to others” (Farmer 225). In other words, the treatment of those who suffer most is also the most effective way to prevent transmission. In this way, I think the effectiveness rationale reinforces the moral responsibility. Farmers argument conveniently aligns the interest in patients suffering now with concerns in the future.

One of the things that has interested me throughout this course is how interventions are based on social constructions of good, more specifically the often opposing ideals of the common good versus the good of the individual. We have seen in many instances how treatments that save individuals do little to nothing to the population, and that interventions designed to significantly ameliorate health in the population may neglect the well-being of minorities (Lecture 2). I think that, while Farmer’s model of PIH does not solve this problem, the aligning of development in population with care for individuals does shed some important light on how we should create programs in trying to impact the most “good:” utilitarian notions of cost-effectiveness in affecting good are automatically limited by perceived limitations of what is possible. When we reconsider constructions of what is possible, and aspire to care of any kind for individuals in poor places, we are more than often surprised by what programs can do.

Discussion Questions:

  1. In Sierra Leone, there is an attempt by PIH to use the resources for the treatment of Ebola patients to build a sustainable health system (Fink). Yet this leads to unintended consequences, when the government of Sierra Leone, which is supposed to maintain the health clinics, fails to provide safe equipment and two PIH volunteers contract Ebola. Are there any other ways in which the alignment of vertical and horizontal, treatment and development, can have negative consequences?
  2. Although Farmer makes a convincing argument that both treatment and development are important, there is still a question as to how much resources should be devoted to one and how much to the other. Should building infrastructure and treating patients be valued equally, or is one ultimately more important than the other?
  3. How would you define and measure making “good”? Do the numbers matter?

Sources:

  • Mason, Katherine. “Lecture 1.” Providence. 09 Sept. 2015. Lecture.
  • Mason, Katherine. “Lecture 2.” Providence. 11 Sept. 2015. Lecture.
  • Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: U of California, 1999. Print.
  • Farmer, Paul, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Reimagining Global Health: An Introduction. N.p.: n.p., n.d. Print.
  • Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” New York Times 12 Apr. 2015: n. pag. Print.

13 thoughts on “Treatment IS Prevention: How PIH Reconstructs What Is Good”

  1. Hey Ben,

    I agree with your view that there shouldn’t necessarily be a focus on just decreasing structural barriers or just treating patients – it shouldn’t be an “either-or” situation, as Farmer noted. One major problem of the vertical approach is that it focused only on one particular diseases. But why pour all the funding into combating one disease when that money could alternatively be used to strengthen the health system and combat a multitude of morbidities and thereby decrease mortality overall?

    I think there should be more emphasis on the use of the diagonal approach, the model used by PIH and Zanmi Lausanne for their TB and HIV efforts in Haiti (Farmer et al., Ch. 6). This integrated program mainly focused on TB and HIV, but the two organizations worked together to provide health care and education for the poor, trained and involved community members throughout the program, and worked together with the government to improve the public sector, among other factors they incorporated into their health care delivery model. This diagonal approach improves and develops a sustainable health care system as a whole rather than treating individual patients for certain diseases.

    If there is to be emphasis on either improving infrastructure or treating patients, I think it should be on improving the health care system as a whole. This would include working with the government to provide health care access to all, including the poor; providing education and support for the poor, especially women and children, who have particular needs and may be overlooked; providing nutritional and financial assistance for the poor; harnessing technology in medicine, especially electronic medical records; and providing opportunities for education and training of health care workers.

    Thinking about your third question gets a little tricky. I think the numbers of how many people benefited from a certain health intervention program matters mainly for publication purposes and grant-writing/funding purposes, since donors want to see significant improvements as a result of these programs. Although it is satisfying to quantify how many lives were saved or how much morbidity was reduced because of a program, it is often difficult to attain these numbers when implementing a program that uses a diagonal approach, especially within the short timeframe that NGOs are set by donors. Therefore, I feel conflicted in saying that the number of lives saved matters the most in this situation. While it is satisfying to note the number of lives saved, the number does not tell the whole story. If an NGO is working only to obtain high numbers of lives saved, then there is probably less focus on decreasing structural barriers to health care for that particular program.

    1. Hi Yuki,

      Thank you for your response. I think you hit the nail on the head with your thoughts regarding the diagonal approach.

      The reason I brought up the “numbers” question is that, if you have limited resources for a health care project, at a certain point I think you have to at some point sacrifice quality for quantity, or visa-versa. If you’re going to have nutritional supplements, educational programs, and door-to-door follow-up’s with patients, you might not be able to reach as many people, as this is quite expensive. However, if you only provide drugs to people, this is rather ineffective and, as you say, does little to nothing to address structural barriers.

      I agree wholeheartedly that the numbers do not tell the whole story, but I also think that, with the incredible health care of PIH, you risk getting great results for very few poor people at the expense of the population-I was surprised, for example, that there are only four PIH clinics and Rwanda, and I wonder how many people these clinics are actually able to reach. At a certain point, numbers do matter. A question I still have is: where do you draw the line?

      1. Hey Ben,

        Oh okay, thank you for clarifying your third question! Yes, I completely agree with you that programs do start to add up in terms of expenses if an NGO like PIH is trying to a account for all of these structural barriers.

        That brings up the same controversy that was raised by Professor Mason in class today (11/23) – With all these services of providing shelters, food, transportation, financial assistance, etc., along with a focus on certain diseases (e.g., HIV and TB), such a program will only be able to reach a small number of people, even when a larger population in the nation as a whole needs the same assistance. I unfortunately don’t have an answer to this, since this is a problem that an NGO as well-rounded as PIH has run into. Like you said, it is a problem of quality vs. quantity, and NGOs in the global health field must try to find the right balance between addressing biosocial issues of access to treatment for a select group of people and providing access to basic treatment to a larger population. But it’s hard to really define that “right balance,” and I wish it were more clear-cut.

  2. Hey Ben,

    Great post! I think your question about numbers is interesting and I’m glad you brought it up, because while quantifying results isn’t always the most revealing evaluation of a GH program, at a certain point it is necessary to understand more precisely what the impact of a certain health program is. I agree it’s surprising that there are only 4 PIH clinics in Rwanda and I think you’re right to question how much of the population is able to access it’s extremely important services . I think it comes back to the population vs. individual issue that has come up so often in this course, especially with regards to NGO intervention, and also your comment about doing the most ‘good.’ While it’s not perfect, and not always quantifiable, I think that the most important success marker of PIH’s programs is how much good they do even if this means for fewer people as opposed to a larger population. As you mention, the construction of ‘good’ is very much socially constructed, and I think it relates to our discussions in lecture about social construction of reality: the suffering and subsequent alleviation of suffering for one person will be different from another person’s. Consequently, it’s very hard to quantify how much ‘good’ a program does as this is different for everyone.

    1. Exactly! Considering that good is socially constructed, that reducing suffering for one person in one way will be very different in meaning for another, how can we possibly measure how much “good” we’re doing?

      Still, I don’t think you can justify providing extraordinary treatment to very few individuals when you have the resources to help out a larger number of people in an extremely vulnerable population. I think that what Farmer is doing is proving that it is possible: that, for example, MDR TB treatment is possible in developing countries. But he also continues to treat regular TB cases. It’s a bit of a balance.

  3. Hi Ben,

    Thank you for your thoughtful post. I really appreciated you bring up the point that Farmer makes when he argues that development efforts seeking to address these issues should not necessarily be prioritized over the treatment of patients in immediate need. I believe that this only creates short term fixes and if we want to see a healthier world, long-term fixes need to be just as important, if not more important than immediate need.
    Building infrastructure should be top priority i believe because building infrastructure creates a more permanent solution for treating patients. Treating patients will be that much more feasible with infrastructure in place. This is not to say that immediate treatment isn’t important because it is, I just think that immediate treatment will be easier with the proper infrastructure in place.

    For your third question, I do think numbers matter to an extent. Of course we want to see prevalence rates decrease and mortality rates increase, however we must look at these numbers over a longer term and need to see change in other factors that cannot be measure such as happiness and quality of life ( I know quality of life technically can be measured, but I think that measure can lead to incomplete results. This measure also doesn’t account for peoples different meanings of suffering).

    1. Hi Sarah,

      Thank you for your response. I agree with you that building infrastructure makes it easier to treat patients. In this sense, development leads to treatment. It’s also interesting to think how treatment leads to development-for example, we talked a little about the better health of a population can lead to better economic productivity. This, in turn, creates an economy that develops higher-quality infrastructure, which in turn provides ever better treatment. I wonder how much these ideas play out on the ground. I’d guess it’s much more complicated than all that.

  4. Hi Ben! I really enjoyed your explanation of the relationship between treatment and development, and that they are not necessarily mutually exclusive. The overlap is where a vertical approach may come in, using a certain disease as the basis for strengthening a broader health system. Ideally these would always go hand in hand and reinforce each other, but this is not always the case, so prioritization is an important part of the decision making process which brings me to your second question. Building infrastructure will have a long-term impact, but when this is compared with an instant life or death situation, it is wrong to accept a preventable death. I think that perhaps both are equally important, but in a time of crisis the immediate saving of a life should have priority. If the situation moves to greater stability and lives are not in immediate danger, that is when infrastructure should become the focus. There is no right or wrong answer, but especially for emergency relief organizations, the immediate value of life should be placed higher than infrastructure if it comes down to an “either-or” scenario.

  5. Hello Ben,
    You brought up a really interesting discussion about moral responsibility vs effectiveness in global health. I agree with your conclusion that in Farmer’s work effectiveness aligns with moral responsibility, and I would propose that this is why PIH’s approach is seen as successful in the world of global health. To follow up and address your second question, I think that PIH’s successes is not based on the fact that infrastructure and treatment are valued equally but that they are both valued and that they are valued at different values according to the particular populations of interest. For instance, in Rwanda, the intervention takes advantage of the fact that PIH has well-resourced academia and that Rwanda has a strong and willing Ministry of Health. Rwanda is at a point where it is financially and fiscally feasible to pay attention to infrastructure rather than specific burdens of disease. In Haiti, using political investment in health as a starting point is not applicable. Thus, the best way to address the burden of health is direct treatment that gradually introduces horizontal interventions (which reflects a diagonal approach). Essentially, success in global health can’t be defined by a standard and equal level of infrastructure or treatment. Nor do I think it is necessary to dwell on finding precise measures of each. As we see in PIH’s work, there are ideals for global health work, but the components of that work are optimized for a particular population. It is more important to recognize that both must be valued in order to achieve improved health.

    1. Hey Nikisha,

      Thank you for your comment. It was very insightful, and I should have thought about your point while writing my blog. I completely agree with your remark that programs will prioritize treatment and development differently based on the political context. A very convincing answer.

  6. Thank you for your post Ben. I found your analysis on effectiveness and morality very insightful. The case of TB certainly paints how vertical approaches can indirectly be somewhat horizontal – treating sick individuals helps slow the spread of the disease, reduce costs which put a burden on other aspects of the system, and healthy people can also contribute to the economy/strengthening the system in turn.

    However, I wonder how much Farmer’s answer to the question of infrastructure vs treatment – both – is a bit of a cop-out. Clearly both are valid goals, but as your second question points out, this is not very helpful when it comes to directing resources. I wonder if organizations with more specific focuses can also achieve more measurable and concrete goals. I think this is also relevant for your first question – the alignment of vertical and horizontal seemed to fail in Sierra Leone because PIH tried to do too much – they were an organize committed to improving infrastructure which was taking over an acute care center, and both assuming responsibility for the management of this center but also depending on the existing leadership structure to handle oversight. Perhaps it was a case of trying to accomplish both at once and therefore not accomplishing either satisfactorily.

  7. Hi Ben, thank you for sharing your insight. You brought up tough questions that are difficult to answer, but indeed very important for the global health field to consider. I do think that one problem that arises from the alignment of vertical and horizontal treatment is that the disease one is trying to eradicate will circumscribe how widely the horizontal net is cast. With the PIH example of TB, indeed it was encouraging to read about the horizontal efforts PIH engaged in, in addition to providing treatment for TB. However, these horizontal efforts were all in some way directly related to TB. There wasn’t any investment in developing mental health services as a result of this PIH project as it is difficult to draw out a link between mental health and TB.

    I do think that ultimately more resources need to go towards investing in infrastructure. In the long term this would be able to positively impact more individuals. I think that there is a moral drive towards treating patients as, like we saw with the Peter Singer thought experiment, we are more inclined to alleviate suffering that is directly in our line of vision.

    Given what we have learned about in regards to the RCT approach towards global health research, I would steer away from the idea that numbers matter. What matters is whether or not the intervention is sustainable, and that might not give you numbers for several years.

  8. Hey Ben! Thanks for your thoughtful and interesting post. In response to Discussion Question 1, I do believe there are other ways in which aligning these programs can have negative consequences. If one organization is trying to do too much, many things may fall through the gaps. This is why, I believe, partnerships and collaboration is so important to Farmer and the PIH Model – they are semi-cognizant of the fact that they cannot do this alone, and reach out to other resourceful agents of change. In this light, I do think a diagonal approach is often best (using a specific illness as a lens for obtaining stronger PHC), and should be utilized whenever possible.

    In addition, I really like your statement on how cost-effectiveness can create limitations that don’t otherwise exist (perceived limitations), and recall a scene in Infections and Inequalities where Farmer states that treating MDRTB in NYC prisons is no more difficult or expensive than treating it in Africa. These perceived limitations have huge effects on funding and attention, and drastically influence our program and resource decisions on the ground.

    I also think it is incredibly important to point out, as Nikisha stated, that different communities need/value different things, and are able to produce certain results at certain times. For example, Rwanda’s government being willing to participate compared to Haiti’s unwilling government raises an interesting question — how on Earth can we ever define or compare their situations? There are so many complex social factors and constructions that make it difficult to synthesize the information, and make a lump statement for all beings, even in one particular area. In addition, constructs like DALYs and Age Weights make it difficult to obtain an unbiased, un-medicalized opinion on suffering and illness.

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