The Future of Primary Health Care:
Ensuring Equity
Paul Farmer, MD, PhD
Harvard 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
Malaria
HIV/AIDS
196,630 (1980)
535,273 (1980)
66,315 (until 1991)
232,262 (1995)
1,056,072 (1997)
31,699 (in 1995)
• Need to continue research and investment on povertyrelated diseases.
[1] OPS 2000.
The Poor Bear the Burden of Infectious
Disease:
Percentage of Deaths from Infectious Disease that Occur in the Poorest
20% of the Global Population
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
Leading infectious killers
millions of deaths, worldwide, 1999
4.5
4.0 million
4
3.5
2.7 million
3
2.2 million
2.5
1.7 million
2
1.1 million
1.5
1
0.5
0
Acute
respiratory
infections
AIDS
Diarrheal
diseases
TB
Malaria
Source: WHO, 2000
Infectious diseases as a cause of mortality:
Worldwide vs. low-income countries, 1998
50%
45%
45%
percent of total deaths
40%
35%
30%
25%
25%
20%
15%
10%
5%
0%
worldwide
Source: WHO, 1999
low-income countries
Reported TB cases, U.S.-born and foreign-born persons
United States, 1999
Foreign-born
U.S.-born
43%
56%
Unknown
1%
Source: CDC, 1999
The Outcome Gap Grows
Improved
Outcomes
Non-Poor
Poor
Time
Introduction of
effective technology
Number of People per Physician
Source: PAHO 2000
C ub a
U rug uay
A rg ent ina
V enez uela
R ep . D o minicana
M éxico
Ecuad o r
C o st a R ica
B o livia
B rasil
Panamá
C o lo mb ia
Perú
C hile
El Salvad o r
Guat emala
Ho nd uras
N icarag ua
Parag uay
Hait í
0
2000
4000
6000
8000
10000
12000
14000
Number of surgeons per 100,000 population
Cuba
United States
Japan
Sweden
Germany
China
Columbia
United Kingdom
South Africa
Philippines
Kenya
Tanzania
Bulletin of the American College of Surgeons, 1987
J. Perez, personal communication, 2000
56
51
31
29
13
10
7
6
6
1.5
0.6
0.3
Leading causes of maternal
mortality, developing countries
Cause of death
% of deaths
Hemorrhage
25-33%
PIH/eclampsia
7.4-30%
Sepsis, infection
(including malaria, TB)
8.3-65%
Uterine rupture
27.6%
Anemia
30-65%
Abortion
up to 50%
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
500
300
200
100
ra
g
ua
a
Ni
ca
G
uy
an
al
a
m
te
G
ua
du
ra
s
y
Ho
n
ua
ra
g
Pa
B
ol
iv
ia
Pe
ru
0
Ha
iti
Rate
400
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
Tropical Disease Research
Between 1975 and 1996,
1,233 new chemical entities were registered.
Of that number, only 11 were for tropical
diseases such as malaria.
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
“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 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
are already infected.
Meanwhile in the US:
Deaths per 100,000 Population
Trends in Age-Adjusted Death Rate
due to HIV Infection,1982-1998
18
16
14
12
10
8
6
4
2
0
82
84
86
88
90
92
94
96
98**
Year
*Using the age distribution of the projected
year 2000 US population as the standard.
**Preliminary 1998 data
Projected changes in life expectancy in selected African
countries with high HIV prevalence, 1995–2000
65 Average life expectancy at birth, in years
60
55
Botswana
Zimbabwe
50
45
Zambia
Uganda
Malawi
40
35
1955
1960
1965
1970
1975
1980
1985
1990
Source: United Nations Population Division, 1996
1995
2000
Fortune 500 Drug Industry Ranks #1
in All Measures of Profitability, 1999
35%
35.0%
30%
25%
20%
15%
18.3%
16.0%
15.4%
10%
5%
5.1%
Fortune 500
Drug Industry
All Fortune 500
Industries
4.5%
0%
Median
Median
Median
Profits as % Profits as % Profits as %
of Equity of Revenue of Assets
Source: Public Citizen’s Congress Watch (www.citizen.org), from Fortune Magazine,
April 2000, Fortune 500 (www.fortune.com).
The 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