Social Medicine For A Better Future

Paul Farmer is a medical anthropologist and physician. He won the 2020 Berggruen Prize.

The three overlapping crises of the past year in America — the COVID-19 pandemic, the ongoing violence against Black Americans and the January 6 Capitol attack — were all brought about by the same causes: economic and social inequality, an unwillingness to face facts and a predilection to impose the will of the minority on the majority through violence. This is the heritage that hobbled a coordinated response to the greatest global pandemic in a century, a most devastating contagion with more than half a million Americans dead, which itself is linked to another overlapping and global crisis: humanity’s ever-increasing encroachment on the natural world.

Reflecting on our current peril and how to emerge from it, three unlikely concepts come to mind: accompaniment, structural violence and a preferential option for the poor. These three concepts derive from varied sources, but they’re all regularly deployed by thinkers who identify with liberation theology, a doctrine with its deepest roots in Latin America but found wherever poverty and social inequalities lead to reflection on human suffering.

Which is to say, everywhere.

In spite of their relevance, the concepts themselves are rarely encountered in public discourse in the United States, and even less commonly heard in public-health debates. But they should become part of our thinking about healthcare and about a good life generally.

Accompaniment, first off, is not just for harpsichordists. It’s a simple and powerful idea: That the best thing to do for people going through a difficult moment — a severe bout of COVID, say, or the challenge of isolation after exposure to the virus — is not to blame them or bill them or distract them, but to keep company with them from beginning to end. The idea derives from a time before many problems were alleged to have immediate fixes. Even when a problem can be fixed or a vaccine injected, the ethics of accompaniment require that we maintain contact and dialogue with the sufferer, resisting the pressures to objectify and instrumentalize them.

“That the best thing to do for people going through a difficult moment is not to blame them or bill them or distract them, but to keep company with them from beginning to end.”

Structural violence similarly may not be a household term; it describes the many ways that inequality seeps into the lived environment. Violence is not necessarily an explosion of rage detonated by an individual with a stick, a gun or an army. The most pervasive forms of violence are often no single person’s fault, which is why racism and gender inequality can so often be dismissed as just part of the cultural backdrop. Architecture, the layout of a city, finance, access to food and water, contamination, immobility or forced mobility, limits to educational attainment and other pathologies of power too often appear as the way things are. 

But such circumstances are rarely inevitable. Johan Galtung, the scholar who put the term “structural violence” into circulation, defined it this way: “Violence is present when human beings are being influenced so that their actual somatic and mental realizations are below their potential realizations. … [I]f a person died from tuberculosis in the 18th century, it would be hard to conceive of this as violence since it might have been quite unavoidable, but if he dies from it today, despite all the medical resources in the world, then violence is present.” Those whose lives are rarely touched by structural violence are uniquely prone to recommend resignation as a response to it.

Finally, and perhaps most controversially, the stern concept of a preferential option for the poor offers a way to concentrate our efforts to halt both disease transmission and death. Such a preferential option is not based on sentimentality or charity. Since the poor bear most of the suffering in the human world, and since we have a moral duty to reduce suffering where possible, it makes straightforward sense. 

Certainly, such preferences have been marked among the pathogens and pathogenic forces. The poor, lacking protection against all sorts of artificial and natural pathogens, are often their victims and then alleged to be the source of pestilence, the reservoirs from which disease migrates to affect the non-poor. The rich suffer too, of course — but their sufferings are less likely to trickle down and spread around, and they can be counted on to fend for themselves. Long experience has shown that the most rapid and effective gains in global health are earned by treating those formerly excluded from care, without restrictions or barriers.

“Those whose lives are rarely touched by structural violence are uniquely prone to recommend resignation as a response to it.”

These are the guiding concepts of social medicine as understood by practitioners with a smattering of liberation theology and social theory in their backgrounds. Let’s apply these concepts to the challenges of the current pandemic. The fight against structural violence and for accompaniment and the preferential option for the poor can’t go away when vaccines arrive, just as they did not when effective treatments for AIDS were developed in the 1990s. These concepts, which can inform our shared quest for health equity, must guide the fabrication and rollout of new human countermeasures.

Thus far, the worldwide vaccine rollout has been both amazing and disappointing. Amazing because we’ve never witnessed such a rapid process, from identification of a novel pathogen to limning and sharing its genetic code to the design, testing and production of highly effective vaccines, some of them belonging to an entirely new and potentially revolutionary class of preventives. Disappointing because the lines to get a jab are long, and because many of us are unsure we’ll even find a line to join. 

Historians of medicine can look back to one global scourge that was reined in by safe and effective vaccines: smallpox. Smallpox was not conquered overnight; victory was ragged and a long time coming. Between 1796 and 1977, smallpox vaccines developed by the English physician Edward Jenner and others afterward were deployed in campaigns of varied effectiveness. During the Cold War, with no non-human reservoir, and after the development of heat-stable vaccines, smallpox continued to erupt largely in settings of war or disruption — settings of structural violence. Clinical deserts, which are apt to grow in war-torn areas, also gave smallpox chances at a comeback. Though the goal of herd immunity was often said to have been reached, outbreaks continued to erupt long after some countries had announced the eradication of the disfiguring disease. What was needed was a commitment to the long-term accompaniment of still-afflicted communities, and a preferential focus on their inhabitants.

The mass vaccination campaigns of yesteryear, now stalled or no longer necessary, were eventually complemented or replaced altogether with a strategy known as ring vaccination, which might be thought of as a preferential option for those most at risk. Every confirmed case or cluster was investigated through contact tracing, with vaccination offered to all contacts and sometimes to contacts of contacts. In other words, vaccines were used strategically and topically to quell outbreaks — a very different scenario from using them to prevent outbreaks in the first place.

“The most rapid and effective gains in global health are earned by treating those formerly excluded from care, without restrictions or barriers.”

Since the beginning of this pandemic, we’ve been mired in a sort of magical thinking about how it will end. Just because smallpox and bubonic plague no longer terrify us, this new pandemic too is sure to blow over and disappear without us exerting ourselves in new ways beyond the development of new vaccines. Another form of magical thinking hinders us too: pushing the danger out of sight and out of mind. Clinical nihilism — the attitude that nothing can be done — is common during epidemics afflicting mostly the poor. But in settings in which all of us are at risk, as is sometimes true of contagion shared through the air we breathe, we must also contemplate containment nihilism — the attitude that preventing contagion simply isn’t worth it. 

There are a myriad of ways in which structural violence is entrenched, and these forms of resignation had devastating effects on the United States, a country that doesn’t lack for staff and stuff and clinical space, but which does lack a national health care system, universal coverage and evidence of the sort of investments in public health and public education that are apparent in most industrialized democracies. When COVID-19 reached into the White House and the Rose Garden, Donald Trump’s chief of staff put it in clear enough terms: “We are not going to control the pandemic. We are going to control the fact that we get vaccines, therapeutics and other mitigation areas.” Words spoken on the White House lawn have a way of becoming self-confirming prophecies. 

To contemplate the means by which we might lessen our losses in the coming months and years, we could all use a big dose of sustained accompaniment during our messy vaccine roll-out. To put it bluntly, vaccines deemed 80% effective in real-world circumstances — an impressive level of coverage — still leave plenty of risk, even supposing vaccination coverage far exceeds optimistic predictions of what is possible in the vaccine-grabbing rich world. No vaccine is 100% effective, and we will fall far short of universal vaccination, even on the scale of a single country. Future outbreaks are bound to occur. That’s another reason to deploy ring vaccination, too — to go where the virus is. That requires brisk testing and clinical surveillance capacity, but most of all a focus on caring for those too often left out of material modernity. 

There’s a real chance that this global health crisis will have made everyone more aware of the need for safety nets to catch us when we fall, and these safety nets are not only our best reflection of a preferential option for the poor, but also one of our most potent means of reducing structural violence. Building these safety nets should not be done grudgingly: It’s in our interest, after all. Our aspirations regarding future public health policies, whether they involve new iterations of Obamacare, Medicare For All or comprehensive universal healthcare, are not limited to vaccine discovery. The process of rolling out vaccines, but also therapeutic tools new and old (from antivirals to oxygen) requires a commitment to accompaniment, and this will be most necessary as we contemplate those too rarely included in progress and too often exposed to structural violence. 

Such investments will bring other benefits to a weary, cash-poor, disunited nation. Hiring and training hundreds of thousands of contact tracers and community health workers might stimulate the economy as much or more than other service jobs, especially if wages are pegged to a more respectable federal minimum. This too creates conditions in which such essential workers are truly recognized as essential, something more than sacrificial lambs. 

No, I am not dreaming — just awake enough to know that achieving these aims won’t be automatic.

The Berggruen Institute and BBC World Service will celebrate the work and ideas of Dr. Paul Farmer as the 2020 Berggruen Prize laureate in the form of a virtual talk and questions program with Dr. Farmer on June 26.