The Future of Primary Health Care:Ensuring Equity

Paul Farmer, MD, PhDHarvard Medical School

Partners In Health

Priority Setting

• Cardiovascular disease and cancer are the first cause of mortality in Latin America.

• But the notification of cases of tuberculosis, malaria, and HIV/AIDS keeps increasing [1]:

Tuberculosis 196,630 (1980) 232,262 (1995)Malaria 535,273 (1980) 1,056,072 (1997)HIV/AIDS 66,315 (until 1991) 31,699 (in 1995)

• Need to continue research and investment on poverty-related diseases.

[1] OPS 2000.

Malaria 57.9%

Childhood Diseases 55.0%

Diarrheal Diseases 53.2%

Perinatal Conditions 45.0%

Tuberculosis 44.4%

Maternal Conditions 43.2%

Respiratory Infections 42.6%

HIV/AIDS 41.8%

Source: Davidson R. Gwatkin, May 1999

The Poor Bear the Burden of Infectious Disease:

Percentage of Deaths from Infectious Disease that Occur in the Poorest 20% of the Global Population

Leading infectious killersmillions of deaths, worldwide, 1999

Source: WHO, 2000

Acute respiratory infections

AIDS Diarrheal diseases

TB Malaria

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Dea

ths

(in

mil

lio

ns)

4.0 million

2.7 million

2.2 million

1.7 million

1.1 million

Infectious diseases as a cause of mortality: Worldwide vs. low-income countries, 1998

25%

45%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

worldwide low-income countries

pe

rce

nt

of

tota

l de

ath

s

Source: WHO, 1999

Reported TB cases, U.S.-born and foreign-born persons United States, 1999

Source: CDC, 1999

Foreign-born

43%

U.S.-born

56%

Unknown

1%

Time

Improved Outcomes

Introduction of effective technology

Poor

Non-Poor

The Outcome Gap Grows

Number of People per PhysicianSource: PAHO 2000

0 2000 4000 6000 8000 10000 12000 14000

Haití

Paraguay

Nicaragua

Honduras

Guatemala

El Salvador

Chile

Perú

Colombia

Panamá

Brasil

Bolivia

Costa Rica

Ecuador

México

Rep. Dominicana

Venezuela

Argentina

Uruguay

Cuba

Number of surgeons per 100,000 population

Cuba 56United States 51Japan 31Sweden 29Germany 13China 10Columbia 7United Kingdom 6South Africa 6Philippines 1.5Kenya 0.6Tanzania 0.3

Bulletin of the American College of Surgeons, 1987J. Perez, personal communication, 2000

Leading causes of maternal mortality, developing countries

Hemorrhage 25-33%

PIH/eclampsia 7.4-30%

Sepsis, infection 8.3-65%(including malaria, TB)

Uterine rupture 27.6%

Anemia 30-65%

Abortion up to 50%

Cause of death % of deaths

Stokoe U. Determinants of maternal mortality in the developing world. Aust NZ J Obstet Gynaecol 1991; 31:8-16.

Highest Maternal Mortality per 100.000 Live Births

Source: PAHO 2000

0

100

200

300

400

500

Rat

e

Malaria: The Costs of Inequality

• 300-500 million people are infected with malaria each year.

• Malaria causes more than 1 million deaths each year, 90% of which occur in Sub-Saharan Africa.

• If malaria had been eliminated 30 years ago, Africa’s GDP would have been as much as $100 billion greater in 2000.

Sources: WHO 2001; WHO Press Release 2000

Between 1975 and 1996,

1,233 new chemical entities were registered.

Of that number, only 11 were for tropical

diseases such as malaria.

Tropical Disease Research

Source: Sylvia Pfeifer, “Public-Private Partnership Attacks Tuberculosis—Aim is to Spur Development of New Drugs,” Knight Ridder/ChicagoTribune, October 20, 2000.

Current State of Current State of “AIDS Care” in Poor Countries“AIDS Care” in Poor Countries

• Palliative care

– Programs in “community-based care” or “home care” are inadequate, even as hospice care

– no real analgesia, no antifungals, too few antibacterials, no central or even peripheral lines for rehydration

Why Prevention Alone Is InsufficientWhy Prevention Alone Is Insufficient

• Many of those at greatest risk of HIV infection already know that HIV is a sexually transmitted pathogen and that condoms could prevent transmission.

• The risk of HIV in vulnerable populations stems less from ignorance than from the precarious situations in which millions live.

• Gender inequality adds a special burden to women living in poverty.

• Prevention programs ignore the 30 million people who Prevention programs ignore the 30 million people who are already infected.are already infected.

0

2

4

6

8

10

12

14

16

18

82 84 86 88 90 92 94 96 98**

Year

Dea

ths

per

100

,000

Po

pu

lati

on

**Preliminary 1998 data

Meanwhile in the US:Meanwhile in the US:Trends in Age-Adjusted Death RateTrends in Age-Adjusted Death Rate

due to HIV Infection,due to HIV Infection,1982-19981982-1998

*Using the age distribution of the projected year 2000 US population as the standard.

Projected changes in life expectancy in selected African countries with high HIV prevalence, 1995–2000

Source: United Nations Population Division, 1996

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Average life expectancy at birth, in years65

60

55

50

45

40

35

ZimbabweZimbabwe

ZambiaZambiaUgandaUganda

BotswanaBotswana

MalawiMalawi

Fortune 500 Drug Industry Ranks #1 in All Measures of Profitability, 1999

Source: Public Citizen’s Congress Watch (www.citizen.org), from Fortune Magazine, April 2000, Fortune 500 (www.fortune.com).

35.0%

15.4%

18.3%

5.1%

16.0%

4.5%

0%

5%

10%

15%

20%

25%

30%

35%

MedianProfits as %

of Equity

MedianProfits as %of Revenue

MedianProfits as %

of Assets

Fortune 500Drug Industry

All Fortune 500Industries

The HIV Equity InitiativeThe HIV Equity Initiative

• To expand the treatment of HIV with HAART to those sick with AIDS in Haiti’s Central Plateau

• Programmatic approach on successful DOTS-based tuberculosis-control efforts

• The program gives medical and social support