Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico University of California Press, 2013, PB, 520pp, £33.00, 978-0520271999
If you are looking for the definitive book to introduce you to the changes in healthcare provision in poor countries in recent decades, this is the book. It covers the medicine, the sociology, and the ethics of the subject. Its focus is the search for equity in global health provision. When the authors called the book ‘reimagining global health’ they meant re-imagining it as based on a right to health, not based on utilitarian cost-effectiveness. They had in mind the recent successful struggle to make AIDS drugs available worldwide for treatment, drugs that, on a cost-effectiveness analysis, would never have been provided. You may ask, ‘Why should GPs be interested in “Global Health”?’ The answer, which this book seeks to help us to understand, is: ‘Because it is our globe and our health.’ It is also because some of the lessons learnt in poor countries are applicable in the health services of richer countries.
There has been a dramatic fall in maternal and childhood mortality in poor countries in the last 40 years (www.gapminder.org). How has this marvellous improvement come about and how can it be maintained? Here we are in safe hands with the US Harvard professor Paul Farmer and his colleagues. They will introduce you to such new concepts as Foucault’s ‘biopower’, of which state-sponsored vaccination is an example, and Galtung’s ‘structural violence’: the conditions in which poor people live that constrains their free choices.
Paul Farmer cut his teeth setting up primary care in rural Haiti, work that had to start all over again after the devastating 2010 earthquake there. He demonstrated the importance of designing health services, not on the basis of cost-effectiveness, but as fundamentally reparative efforts in a setting where social and economic rights were abused; where food was short, transport scarce, and choices constrained. In other words, they provided food and transport subsidies to sick patients to enable them to complete treatment (for TB or AIDS).
One strand in the ‘Global Health’ debate is between those who see health as a human right and those who see the provision of health services in terms of ‘cost-effectiveness’. Both viewpoints have something to offer. The 1980s and 1990s were dominated by ‘structural adjustment programmes’ imposed on low-income countries by the IMF, leading to reduced state health spending and a focus on the most cost-effective solutions. These solutions were first the Global Ocean Biodiversity Initiative (GOBI), then the Global Alliance for Vaccines and Immunization (GAVI) programme of worldwide vaccination. Together these abolished the wards full of children dying of measles that I saw as a young doctor in East Africa. On the other hand, it was from a human rights perspective that the Alma-Ata conference (1978) had made an unfunded commitment to ‘Health for all by the year 2000’. This was soon forgotten after the effects of the 1978–1979 oil shock.
However, more recently, thanks to AIDS activism worldwide, we have seen a return to the human rights perspective with the wonderful provision of AIDS treatment in low-income countries. This required the challenging of patent law on antiretroviral medicines in developing countries as well as much generous funding, a lot of it from the US government. As of June 2019, 24.5 million of the 37.9 million infected with HIV worldwide are accessing antiretroviral therapy (www.unaids.org/en/resources/fact-sheet). More recently, there has been an awareness of the danger of isolated single-disease approaches and a renewed perception of the need to strengthen the whole healthcare infrastructure of a country, ‘health systems strengthening’ as it is called. Where a specific programme is designed to strengthen the health system in general, this is called the diagonal approach.
Finally, Farmer argues for the inclusion of the care and prevention of neglected tropical diseases, some non-communicable diseases, some cancers, and some surgeries (especially obstetric), together with social prescribing in a strengthened health system based on primary care.
- © British Journal of General Practice 2020
