Exactly a year ago, America was gripped by a panic it had never known: "Fearbola." As the deadly Ebola virus snaked through West Africa, reaching epidemic proportions for the first time and killing thousands, Americans were infected with a violent worry about an outbreak on our shores — even though an Ebola flare-up was highly unlikely in the developed health systems of the US.
The greatest problem with Fearbola was that it diverted the discussion away from something that would actually control the spread of deadly diseases in West Africa and beyond: strengthening health systems.
Paul Farmer, one of the world's most influential thinkers on global health (who was immortalized in the fantastic book Mountains Beyond Mountains), has been preaching that message for decades. At the height of the outbreak, and long before it, the physician and Partners in Health co-founder argued that the best way to control viruses like Ebola would be to train local health workers in Africa, ensure hospitals are well-equipped with resources, and check that systems for disease surveillance are functioning.
Last month, Farmer helped put his ideas into action with the launch of the University of Global Health Equity in Rwanda. The new health sciences institution, owned and operated by Partners in Health, was established to train the next generation of African medical professionals and global health-care leaders. From Rwanda, Farmer spoke to us about this Ebola epidemic and how to prevent the next one. This conversation has been edited for length and clarity.
What did you learn from this Ebola epidemic?
I learned this is another setting in which we’ll fail to make the link between an emergency intervention and building the health systems that are required to prevent and take care of people once primary prevention fails. We still haven't learned how to deal with urgent crises and long-smoldering crises.
There's not a caring deficit, though. We had a thousand people sign up to volunteer [with Partners in Health] within a month of the outbreak, and many more with Doctors Without Borders. Ebola is a disease of people who care. It’s a caregivers' disease. So one thing I take out of this [epidemic] is that plenty of people care.
What did you think of the US's government and military response to the outbreak?
We deployed a lot of resources, talent, and passion. I'm proud of what was done. I'm proud of the official response. The caliber of people who were engaged from the government side was very high.
But it’s what we haven't done yet that is the problem. I don't think we can point and say that some of these resources are going to be used for building up the health-care system.
So what should the US government do to strengthen the health infrastructure in Africa?
One of the things we will be doing here in Rwanda is a human resources for health project to address the staff part of the formula. Patients come in, they have a lot of cancer, but there's no cancer doctor able to procure the chemotherapy agents or pathology. You don't have the staff, and you need to work on training people, making a long-term investment in medical education — doctors, nurses, managers, all the community health workers — and that takes many years.
It’s not attractive to many development funders to spend money on long-term postsecondary education. That’s why we’re launching the university here.
How will your university address some of these health systems problems?
The idea is that this is a regional resource, very focused on global health equity. The way it’ll be different is that we start focusing on health-care delivery from the beginning. The students spend two years in this particular degree program that launched in September — the master of science in global health delivery — and they spend part of their time at work. They may work at UNICEF or the Ministry of Health or at an NGO. But they are making a firm commitment to this coursework.
When we open up the medical school and nursing school at the university, students will also take a global health delivery degree. So if you train as a doctor, you study medicine but also health delivery — the pragmatics of delivery.
So you'll help build the health workforce in Africa, as well as the number of people who understand health systems and delivery. But once more local health professionals are trained, isn't the trickier part of the problem paying and retaining them?
If you asked me that question 30 years ago, I would have thought 100 percent of the answer lay with salary compensation. I don't think that’s true right now.
I think there are lots of forms of compensation, and a decent wage is a key one. But also the fact that when nurses don't have the fellow staff or safe systems to work with, no matter how much they're paid, it’s an unpleasant experience.
Then there’s the issue of continuing education. It’s incredible to me that it’s so controversial to argue, even at this low point in the medical history of West Africa, that we need to invest in advanced training.
Why should that be controversial? We all went to advanced training, graduate and postgrad. In the US, if you're a teacher of nursing or medicine, rest assured you have gone through your MD, PhD, internship, residency, and fellowship. So to think African doctors and nurses don't have the same aspirations is just not prudent.
The brain drain is a lot more complex. It's very highly tied to compensation — but it's also the quality of the work environment, the presence of educational opportunities. Finally, if you are well paid, with good educational opportunities, in a gleaming hospital with plenty of staff and systems in place, but people can't access that system, a lot of health professionals are unhappy about that, too.
Rwanda is an interesting contrast for its health miracle — it's an outlier in Africa with some of the biggest gains premature mortality and vaccine-preventable illnesses anywhere. What went right?
I came here to work here 11 years ago with Partners in Health. The difference between 2004 and now is pretty stunning. And that’s certainty true of the whole country, not just where we work.
When we came here, of the 30 districts, there were four without functioning district hospitals. We helped put in place district hospitals to train community health workers. We got to work on policy issues with [the Ministry of Health]. I don't think it's an exaggeration to say that these interventions across the country are why there’s been the steepest declines in mortality ever documented anywhere in the world at any time.
Rwanda had to play catch-up — it started behind everybody else because of the genocide and more. If you look at what scant data was available back then, they were starting from a much worse baseline, and then they plowed ahead. If Rwanda has done this, it's important for other nations to know how — if they want — to emulate that and to improve health-care delivery.
So Rwanda makes me optimistic. If you can do it in Rwanda — come back from where they were at end of genocide — you can do it in [the three countries most affected by Ebola] Liberia, Sierra Leone, and Guinea. But you have to invest — not just donor investment, but public investment. A large fraction of the public budget goes into health care and education in Rwanda, and it's very high compared with other countries.