Visiting the epicenter of Ebola in West Africa reminded both of us of Haiti after the 2010 earthquake: how so much of what has been built can crumble, and how quickly. There is no longer a functioning health care system in either Liberia or Sierra Leone; Guinea, too, has been hard hit. Health care workers have died or fled; facilities are barely equipped or functional; proper protective equipment, without which there can be no care at all, is desperately lacking. Travel for resupply is nightmarish. The only “formula” that will turn this around is staff, stuff, space, and systems, and the right people to organize all of it. And in truth, there wasn’t much of any of this prior to this, the 25th known Ebola epidemic, and the first to invade these countries’ towns, cities, and health care facilities.
It’s more than a theoretical concern for Partners In Health, which has joined forces with local health authorities to improve care for Ebola patients in northwestern Sierra Leone. It’s hard enough to provide medical care in an emergency, but strengthening an entire health system will take time, and that is why we commit ourselves to staying. We have to get it right, linking Ebola treatment facilities to what must become a nationwide network of centers able to afford better care and smarter prevention, not just of Ebola, but of other afflictions, most of them far more common than hemorrhagic fevers — but, in the absence of such systems, no less deadly.
Partners In Health is lucky to be part of such efforts, which need new blood, in the metaphoric sense. Even before Ebola, we were recruiting our next leader. We didn’t want it to be someone who reminded us of, well, us, as we were in 1987: brash, young, inexperienced, feeling our way along, sometimes having to go back and retrofit the thing which we built. It took us years and years to build what we have in Haiti: over 5,000 local staff, clinics and hospitals in 12 sites including a brand-new teaching hospital in Mirebalais. In the old days, we treated, then trained and conducted research — but as Ebola reminds us, the three need to be started together, at a much accelerated rate.
Helping us think this through has been one of the most sophisticated thinkers and managers in these areas, board member Gary Gottlieb, CEO of Partners HealthCare in Boston, whom we announced in October as the next leader of Partners In Health.
As the marketers would say, we see all sorts of synergies. A clinician, a designer and organizer of care, a teacher and mentor of students and trainees, a funder of some of the world’s leading medical research — that’s been Gottlieb’s job description since he became CEO of Partners HealthCare in 2010.
At some level, running a complex system of sites and providers in eastern Massachusetts isn’t so different from doing it in remote, impoverished places like Liberia or much of Haiti. How do you balance the right investment in a series of smaller centers connected to larger ones, distribute the care, sustain the infrastructure, maintain the supply chain, and deepen the finding pot? How can a system become, in Gottlieb’s words, “an economic driver for a region, creating vendors of every nature, a place where you can grow food?” The work of public health leaders everywhere is to try to move from our “illness system” to a genuine “health care system,” which is hard to keep sight of during an emergency like Ebola. But a key lesson from Ebola is the need for well-designed, well-resourced medical and nursing schools, plus labs able to conduct surveillance and to guide early and effective responses.
While Boston-level infrastructure in West Africa might seem a crazy ambition, this actually will be Gottlieb’s mission. But we can learn lessons from Africa, too. As we’ve discovered in Rwanda, we must deliver care closer to where people live. We also need to recruit, train, equip, and retain an army of community health workers.
Accepting the job, Gottlieb imposed a condition: that we would make mental health more of a priority in our projects. As a psychiatrist and frequent visitor to these countries where the trauma of raw poverty and witnessing violence manifests itself directly in worsening the course of panic and anxiety disorder, schizophrenia, substance abuse, and depression, he sees that integrating appropriate interventions, which can range from the neurobiological to the counseling or psychotherapeutic, is not just part of our social-justice mission but a greater step toward fulfilling the side of global health delivery that is purely human rights. It is systems work, too: a reminder that there’s no health without mental health.
Dr. Paul Farmer is co-founder and chief strategist of Partners In Health. Ophelia Dahl is co-founder and executive director of Partners In Health.