Abuja — Paul Farmer, the legendary global health equity warrior, recently died in his sleep from heart-related complications at the University of Global Health Equity (UGHE) in Butaro, Rwanda, the university he co-founded.
So many tributes have been written to Paul Farmer, and he deserves all the accolades bestowed on him posthumously. My tribute to Farmer is to amplify his teachings on the social determinants of health. It is crucial for health workers and health planners to take these on board to create comprehensive strategies for planning and delivering healthcare.
One of Farmer's famous quotes aptly describes this, "You have to look at what's happening to the patient in front of you and think about ways to address social disparities. If there's food insecurity, then you provide food when you provide care. Or if patients drop out of treatment, you provide transportation to the clinic, or you send community health workers to the patient".
I wholeheartedly agree. In 2019, I was at UGHE as part of an executive education for my cohort of the Atlantic Fellows for Health Equity at George Washington University. After our 10-day study at the university and the surrounding Butaro communities, I became even more convinced that healthcare without social determinants of health is inefficient.
In honor of Farmer, here are four examples of social determinants of health that health care workers and governments should consider.
Access to clean water
Sub Saharan Africa has a population of 1.14 billion, yet just 24% of the population has access to safe drinking water, according to the United Nations. This means that a whopping 912 million do not have access to drinking water (more than 120% the population of Europe). Therefore, it is unsurprising that infectious diseases are rife in the region.
Here's a common possible scenario that illustrates the problem: A child is treated for diarrhea at a health facility and is about to be sent home. The parents are told to ensure the baby drinks clean water. They must use clean water to wash cooking utensils.
However, the family's only source of water is a contaminated river. Although they want to adhere to the advice of health workers, they are constrained in how limited their choices are. Two weeks later, the child has diarrhea again and is also vomiting. The family is unlucky this time. The current episode is very severe. The child dies before they get back to the health facility. The solution to this is simple - sub Saharan Africa governments must provide clean water in every community.
Availability of uninterrupted electricity
A survey of 13 health facilities in 11 sub-Saharan African countries showed that 26% had no access to electricity. Furthermore, 28% of health facilities had reliable electricity among the 8 countries reporting data. Let me make the impact of this clearer.
Imagine a woman who is in labor in one of these health facilities without access to electricity. She has labored for a long time and now is unable to push out her baby. She needs a suction machine to help pull out the baby.
The suction machine is available. However, there is no electricity to power the machine. The woman is weak, her family is in tears and the midwife is helpless. Referring her to another health facility is out of the question because of long distance, poor roads and lack of transportation. The woman dies. Her unborn baby dies. These tragedies could have been avoided with electricity. To mitigate such tragedies, governments must invest in clean renewable energy such as solar power.
Access to clean cooking stoves
Across communities in sub-Saharan Africa, families use woods and even cow dung for cooking. Sometimes, cooking using both materials is done indoors, where there is poor ventilation. In the process of cooking for their families, women inhale smoke.
Being caregivers, their children are mostly with them. Sadly, mother and child are exposed to smoke particles which are injurious to their health. Having these materials as their only fuel for cooking means that they are always at risk of respiratory conditions such as asthma and other chronic obstructive lung diseases.
Although they may have access to treatment of their chest conditions, as long as the source of smoke inhalation is not removed, they will keep needing healthcare. This is why use of clean cooking stoves is a way to end this inequity.
In Kenya, the Clean Cooking Alliance is leading an initiative to develop clean efficient-burning cook stoves to improve health, the environment, and save families money in East Africa.
Mitigating the Impacts of Climate Change
Climate Change is a defining health inequity of our time. Its impacts on health vary. For example, Climate Change leads to flooding, droughts, population displacement, forced migration and lots more. When there is drought, families walk long distances in search of water.
Women, girls and children are the most vulnerable. Some sources of water are rivers. Fetching water from these rivers expose them to different neglected tropical diseases (NTDs) including river blindness, schistosomiasis and others.
Treating these infections through mass drug administration in their communities is a short-term measure as long as there are no plans to mitigate the impacts of climate change. Therefore, ending the scourge of NTDs affecting about 1.5 billion of the world's poorest people is not achievable without addressing Climate Change.
Farmer's death at only 62 is untimely. However, his death at UGHE is symbolic, for he watches over a world-class institution that is training the next generation of health equity warriors. Africans believe that death is not an end. It is a transition to a new world.
We are consoled that Farmer has joined our ancestors, watching over us. We must not despair. We must keep putting the social determinants of health at the center of healthcare delivery and planning. That is what he would do, and it is the most equitable thing to do.
Dr. Ifeanyi McWilliams Nsofor is a graduate of the Liverpool School of Tropical Medicine. He is a Senior New Voices Fellow at the Aspen Institute and a Senior Atlantic Fellow for Health Equity at George Washington University. Ifeanyi is the Director Policy and Advocacy at Nigeria Health Watch.