All posts by Benjamin S Guggenheim

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?


  • 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.