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How we can save millions of lives

By Paul Farmer,

Ten million people — many of them young and most of them poor — will die around the world this year from diseases for which safe, effective and affordable treatments exist. In Haiti, these are known as “stupid deaths.” What’s more, inadequate health services predominate precisely where the burden of disease is heaviest, keeping a billion souls from leading full lives in good health.

In recent years, initiatives such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria have helped rein in some of the biggest scourges. We’d be hard-pressed to point to a more inspiring achievement in global public health since the eradication of smallpox in 1977. Massive efforts have been made to address the “delivery challenge”: getting the medicines to those who need them. Citing evidence that, in addition to saving lives, treatment for AIDS also reduces the transmission rate by 96 percent, Secretary of State Hillary Rodham Clinton this month proposed more investment in PEPFAR, even calling for “an AIDS-free generation.”

Scaling up PEPFAR, alongside other health initiatives, would bring a high return. And as we deepen the response to specific diseases such as AIDS or TB, we can broaden access to primary health services. The many sources of affliction in poor settings — malnutrition, cholera and other waterborne diseases, and fatal complications of childbirth — can be meaningfully addressed only by strengthening health systems to deliver care efficiently and equitably.

Partners in Health, a nonprofit I’ve worked with for almost three decades, started by moving resources and primary care into a part of central Haiti where almost none existed. As TB, AIDS, cancer and other diseases emerged as leading killers, we did our best to combat them: Treating patients no matter the cause of the illness nor the cost of the remedy is what health-care workers are trained to do. Some of our AIDS and TB treatment efforts in rural Haiti and elsewhere achieved success rates rivaling those in hospitals in Boston. We witnessed another benefit: Delivering care for cancer, AIDS or multidrug-resistant TB improved a community’s general health. Fewer women died in childbirth, and infant mortality declined.

Because providing services for complex conditions requires a full-time salaried staff, comprehensive facilities, trained community health workers, a robust referral network and a reliable means of delivering care in rural areas, it lays the groundwork for addressing health problems of all kinds. Our colleagues — most of them working not far from where they were born and raised — learned to diagnose and treat many of the health burdens of poverty: HIV patients infected with TB, children with diarrheal diseases or pneumonia, families without clean water and adequate food. A comprehensive health system allows thousands of people to live productive lives.

Redoubling treatment efforts for leading causes of morbidity and mortality is not only the right thing to do, but it also must be a cornerstone of any effort to redress the inequitable burden of disease on the poor. It must be done in a way that helps build lasting, comprehensive, aid-independent health systems — as PEPFAR is doing,on an unprecedented scale. The Obama administration and Congress will need conviction and grit to transform Clinton’s vision into bold treatment targets and funding levels. Resources may be limited but, despite the global recession, they are less limited now than ever before. Economic problems pass, but their health effects — cruelly visible in hospitals and morgues — linger. Every “stupid death” is a rebuke to the systems that allow so many to go without care.

The writer, a physician and anthropologist, is a co-founder of Partners in Health and chair of the Department of Global Health and Social Medicine at Harvard Medical School.

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