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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.

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The future of primary health care ensuring equity

The Future of Primary Health Care:Ensuring Equity

Paul Farmer, MD, PhD

Harvard Medical School

Partners In Health

Priority setting
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]:

    Tuberculosis196,630 (1980)232,262 (1995)

    Malaria535,273 (1980)1,056,072 (1997)

    HIV/AIDS66,315 (until 1991)31,699 (in 1995)

  • Need to continue research and investment on poverty-related 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
Leading infectious killersmillions of deaths, worldwide, 1999

4.0 million

Deaths (in millions)

2.7 million

2.2 million

1.7 million

1.1 million

Acute respiratory infections

Diarrheal diseases




Source: WHO, 2000

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

Source: WHO, 1999

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







Source: CDC, 1999

The Outcome Gap Grows States, 1999

Improved Outcomes




Introduction of effective technology

Number of people per physician source paho 2000
Number of People per Physician States, 1999Source: PAHO 2000

Number of surgeons per 100 000 population
Number of surgeons per 100,000 population States, 1999

Cuba 56

United States 51

Japan 31

Sweden 29

Germany 13

China 10

Columbia 7

United Kingdom 6

South Africa 6

Philippines 1.5

Kenya 0.6

Tanzania 0.3

Bulletin of the American College of Surgeons, 1987

J. Perez, personal communication, 2000

Leading causes of maternal mortality developing countries
Leading causes of maternal mortality, developing countries States, 1999

Cause of death % of deaths

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%

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

Malaria: The Costs of Inequality States, 1999

  • 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 States, 1999

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
Current State of States, 1999“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
Why Prevention Alone Is Insufficient States, 1999

  • 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: States, 1999

Trends in Age-Adjusted Death Rate

due to HIV Infection,1982-1998

*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








Average life expectancy at birth, in years
















Source: United Nations Population Division, 1996

Fortune 500 drug industry ranks 1 in all measures of profitability 1999
Fortune 500 Drug Industry Ranks #1 countries with high HIV prevalence, 1995–2000in All Measures of Profitability, 1999

Source: Public Citizen’s Congress Watch (, from Fortune Magazine,

April 2000, Fortune 500 (

The hiv equity initiative
The HIV Equity Initiative countries with high HIV prevalence, 1995–2000

  • 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