Reimagine: Health Reset

Joia Mukherjee: ÒThere is no contrast, to me, between fighting against Covid and fighting for Black lives because they are so intertwined, because of the structural violent disparities that we see, you know, in the US and around the world, and who has access and who doesn't.Ó  

Peter Drobac: Hi, and welcome to Reimagine a podcast about people who are inventing the future. I'm Peter Drobac, coming to you as always from Oxford. I'm back in the closet literally as we endure a second lockdown here in the UK. I have to say the view in here is outstanding. In this series of Reimagine: Systems Reset edition, we're exploring the big systemic crises of 2020. The health crisis, the economic crisis, the climate crisis, and the crisis of inequality and injustice. Of course, they're all connected. It's a phenomenon Bill Gates called Ômutually exacerbating catastrophesÕ, but we're not here to wallow in self-pity. We're here to think like social entrepreneurs, to explore how we can build the kind of future we want.

In today's episode, we're going to look at health systems. Nearly a year into this pandemic, some countries are still struggling to implement the basics, like testing, contact tracing, and isolation, and as health systems have strained under the burden of Covid patients, other dominoes have started to fall. People with chest pain aren't turning up to hospital, treatment for cancer and any number of chronic diseases is being delayed, and mental health needs are skyrocketing as we endure the social and economic toll of the pandemic. Our system was fragile and Covid broke it. 

One of our mistakes was thinking too narrowly about what a Ôhealth systemÕ is. We focus too much on hospitals even though community-based care can be a much more cost-effective way of keeping people out of hospitals. We had the illusion that our amazing hospitals could make up for decades of under-investment in front line public health infrastructure, and we struggled to wrap our heads around the idea that so much of what determines who gets sick has nothing to do with actual health care. Nutrition, food security, poverty, pollution, racism. Unless we understand how these forces impact health, we miss the real picture. Think about this: the United States spends over ten thousand dollars per person per year on health care. That's astronomically higher than any other country. And what did all that money buy when Covid hit?  Maybe the problem is that the US health system isn't really a system at all. 

Later, we'll be checking in with friend of the pod, Dr Paul Farmer, who has a new book out this week, but first, joining me to talk about reimagining global health is one of my favourite public health activists, Dr Joia Mukherjee. 

Peter Drobac: So nice to see you, you look great! 

Joia Mukherjee: Nice to see you, you too!

PD: Joia is the Chief Medical Officer at Partners in Health, a global health and social justice non-profit. She's also an Associate Professor of Global Health and Social Medicine at Harvard, where she leads a Master's programme in Global Health Delivery. Joia has also written a terrific introductory textbook on global health delivery. What does that term mean?

Global health delivery is about bridging the gap between what we know about how to tackle disease, and what we actually do. We're all obsessed right now with the discovery of new Covid vaccines, but we pay little attention to all the things that will be needed to make sure those vaccines will actually reach the people who need them most. The supply chain, the financing, the cold chain, the last mile health workers. That's global health delivery.

Joia describes herself as Ôan ass-kicking optimist, healer, singer and lover of humanityÕ. I've known Joia for a long time and we've sung together in several countries, and before you ask there's not a chance in hell that I'll sing for you on this or any other. Joia has such a rare perspective because she works in so many different contexts. She's been on the front lines of big American teaching hospitals; in rural communities in Haiti and Malawi; and with the World Health Organization. As the daughter of an Indian father and an American mother, Joia was exposed to issues of global poverty and social injustice at a young age, and that's made it her life's work to make health care more equitable. 

I've mentioned Bending the Arc, a beautiful documentary about Partners in Health's efforts to fight scourges from HIV to Ebola, and to make health a human right, and in a pretty timely move, Bending the Arc was just released on Netflix. You should go and check it out. Joia features prominently in the film and eagle eyes may spot me in there too. So let's get to our conversation with Dr Joia Mukherjee. I asked Joia what had surprised her most about her experience providing care and support in Massachusetts, one of the richest states in the richest country in the world. 

JM: The thing that surprised me the most is, because I've worked in the Global South for the last 21 years, and had less and less experience in the United States, I think I am surprised and taken aback at the catastrophic failure of, not only the leadership in the US, which is profound and can be the topic of many many discussions, but also the system. And what I've seen is that we don't really have a system. We have hospitals that are outstanding, that can take excellent care of sick people, but we don't have a system that reaches into the community. We don't have linkage between primary health care and hospital care, and so as we are trying to support, at Partners in Health, the public sector, the departments of public health, and states and cities and towns, they are woefully under-resourced and really not particularly connected with any kind of system. Contrast that with a place we both have worked, Peter, Rwanda, where the public health system is connected with the health system, it is part and parcel of the health system. So epidemic control, preparedness, treatment, is all under the same umbrella, and I think on some level I knew that, but to see the consequences of the lack of systems thinking in the United States is just stunning, disappointing, and was surprising. 

PD: Yeah, you know, there's this disconnect right, we think that the US has the most sophisticated health system in the world, but as you said it's really just about the medical care, treating the sick, it's not about what it takes to keep folks well. It's not actually about public health infrastructure and what we've learned is that it's testing and tracing, and that kind of infrastructure, that's so critical. We've seen here in the UK where it also didn't exist until the pandemic, is that it's being built as a parallel system by unnamed private companies with no-bid contracts, and in fact so after decades of disinvesting in the public sector, we're kind of still repeating those mistakes. 

So Joia, you've been involved in this really fascinating project in Massachusetts and then, as you mentioned, other places around the world where, you know, Massachusetts like a lot of places where it's caught off guard because they didn't have that community-based infrastructure, so how did you and Partners in Health, this NGO, this non-profit that works around the world globally, end up building a contact tracer army right at home in Massachusetts?

JM: Because Governor Baker knew of our work around the world, he invited us to step in and support scaling contact tracing. And so our system was essentially to create a pop-off valve for the local boards of health, for the Department of Public Health. So we were able to scale up to, at full-force, 1700 contact tracers scaling across the state, we were able to get close to 90% percent pickup rate on every call, shepherd people through 14 days of quarantine successfully, and we were able to bring the case rate down. It's going up again because of the cooler weather and reopening but then we were able to rescale. The other special sauce is that we always have understood that protection of the most vulnerable is the way to deal with any disease, but particularly epidemic diseases. That without food support, without housing, without transportation support, that you cannot have an equitable response. So we put together an army of what we call Covid care resource coordinators who are local to communities, often are social workers, some are nurses, but they're connecting people to the material resources that they need to stay safe. Because we know that quarantine and isolation are extremely economically regressive and the very people who are most at risk for Covid are the least able to quarantine. So the CRC folks have helped to deliver groceries and diapers, infant formula, have tried to get people shelter, we've worked with the Boston Healthcare for the Homeless to find places for people, and that material support is, I think, what we will be able to look back and analyse, has allowed Massachusetts not only to respond, but respond with some degree of equity. 

PD: Let's stay on the issue of governance and kind of look through the global health lens. You know through the pandemic, World Health Organization has come under some criticism for its role in managing the pandemic. I feel a lot of that's unfounded, some of it's politicised, some may be rooted in a misunderstanding of what WHO is meant to do or can do. What's your perspective on global health governance and the role of WHO? 

JM: Yeah I mean I think WHO has been an important standard setting body. The WHO has been important in supporting countries to pre-qualify medicines, have the essential drug list, provide support for responding to pandemics like Ebola, where they actually had lots of boots on the ground. I mean the WHO was very involved in both the West African pandemic as it was in Congo, but the problem again is kind of money. Because the WHO doesn't have a lot of money, and the contributions to the WHO are largely voluntary. And so when you are talking about an organisation that has the scale and reach of the WHO but relies on the kind of just generalised good will of governments, it's going to be hard to govern. We absolutely need the WHO, we need more global governance, but we also need more global accountability for harm. And right now with a voluntary system, you know, it's like the notion of corporate social responsibility, if these systems are voluntary, they're not going to be equitable. I think a lot about the framing of human rights that we have in the world right now, which is very much related to World War 2. It's really about the role of the nation-state in protecting its own people. But I kind of feel that in the era of globalisation, it's really not about the nation state alone, right, whether it's labour, whether it's capital, whether it's new drugs, I mean there are so many ways that we are all yoked together as a global community, and most of it now is what is driving profit, and I think we ought to have a new framing of human rights that has a global responsibility, a cosmopolitanism of who has the right to health. And the WHO has an important role to play in that, but we have to really rethink what that architecture is because right now if the nation state is the only entity, or the main, it's not the only, but the main entity in respecting, protecting and fulfilling rights, and you happen to live in Chad, well then that's the rights you get. The WHO as a standard setting body, it has exceptional leadership by Dr Tedros, who knows what it's like to transform a health system, who understands these sort of multi-part tight agreements, still there's only a limited influence that the WHO can have. And now with their biggest donor pulling out it's going to be very very difficult. 

PD: Hopefully that won't last. I mean we're very much in an age of entanglement, the 21st century is characterised by problems that are all supranational, right, the pandemic's a great example. We're in an age of pandemics right: globalisation, urbanisation, climate change, you know, there's lots of other emerging pathogens out there, the next pandemic threat may be around the corner. Climate change, you know, we could go onÉ so what you're talking about is more than tinkering with existing institutions, itÕs really rethinking our systems of governance and maybe we need a new Bretton Woods?

JM: Yeah. But not with the monetary thing. But yeah we do, I mean we need to, and I think to be honest that is what the right wing is so afraid of. You know, when you look at the rhetoric of the extreme right in any country right now, this notion of globalists is such a bad thing, because I think that's what they're afraid of, you know, we have to collaborate to get ourselves out of this mess. Whether it's the mess of Covid, the mess of climate change, the mess of racism, these are transnational problems and they need transnational solutions. And while New Zealand is an island, the rest of us are not, so we really have to rethink for the 21st century, I think, a new way of envisioning how we're going to solve problems. 

PD: Yeah, I want to focus now back in on health systems, Joia, and you talk to us a little bit about what's broken or what's been broken in the US and some other health systems, and this notion of the disconnect between medicine and public health, and in sort of disconnect with community. If you had a magic wand, and I was going to ask this about an unnamed country but maybe country's not the right unit of analysis in light of our conversation, but if you had a magic wand and could design a health system that were fit for purpose for a population, what would some of the key features, or key principles, or key values, would be of any effective health system?

JM: Yeah I mean first I would just say that we have to have general social protection for everyone, regardless of the health system, because without proper housing, without food security, even in Massachusetts, you know fully 10% of the people that we're providing support to, it's for food security, so in the richest state in the richest country we still have that. So there's no addressing health without the social determinants, so that's just thing one. And then I would say, you know, what I've seen work are really looking at the system and the system from the household right up to an advanced facility, so community health workers have a huge role to play in coordinating, shepherding, knowing the families that are around them, and looking for signs, symptoms, problems before they get very very serious. And shepherding people to, you know, decent first level primary care, if you will, make sure that things like blood pressure are managed before someone has a stroke. But we also need hospitals that are  responsive, because we know that the pain and suffering that is caused by an unset fracture, you know, are profound, and we can't just say some people just get this primary health care and nothing else, because the real burden of disease also extends to hospitals, and that these  should be coordinated from community, to primary care, to hospital, they have to be made  fully accessible, and that means minimising user fees, making sure everybody has the ability to get there, transportation etc, and then quality. And a lot of the quality is related to the providers having the material resources they need, you know, quality when you have a drug stock out is immaterial, quality if you don't have a blood pressure cuff is immaterial, so we have to resource each level adequately and not use one as a crutch for the other one. And that's of course what we see around the world in impoverished countries is, well we can't do hospital care but let's just do more vaccines, but like you can vaccinate a kid all you want but if they have a broken leg they need a fracture set. 

But the flip side of that is what we have in the US which is you know excellent quality care at the hospital level but just nothing else, and we're just missing the opportunities and it's very uneven access to that, excellent quality care is very inaccessible to many people. So I think we've got to think about health as a social good not as a profit making, not as a either/or, but what is the general medical care that people need to live a long life. And they've managed it in some places, Cuba, Thailand, Costa Rica, not necessarily rich countries, where you have community level engagement, decent good primary care access to high quality hospital care. I mean I think it's possible, but it has to be done with the mindset of this is a basic right, minimise barriers, and really make this accessible for people at a high quality. 

PD: This is such an important lesson we've all been talking like broken records, about testing and tracing, and isolation, but what we don't talk about enough is the support element. It's hard to expect someone to stay home for weeks if their job is on the line, if there's no food on the table, if that person is responsible for caring for others, but if they don't isolate, chains of transmission continue. Without support, the whole system breaks down. 

And this pandemic has put the lie to the notion of where expertise comes from. So much of global health and international development is neo-colonial, there's a perception that expertise, like money, is concentrated in rich countries and needs to be granted to poor countries. But Covid has turned the world upside down. Vietnam is leading the way, Thailand is leading the way, Rwanda is leading the way. Partners in Health is using expertise from Haiti and Rwanda to provide relief in America, and to see that come full circle and help our brothers and sisters in the US to get out of this catastrophic situation is a spark of hope. 

One of the other phenomena we've seen in this historic year is the recognition of another pandemic, that of systemic racism. In the wake of the murders of George Floyd, Breonna Taylor and others, the movement for Black lives has emerged as perhaps the largest social movement in a generation. Racism is a bit like a virus, it gets into the body and causes disease. In some American cities like New Orleans, a predominantly Black neighbourhood can have an average life expectancy 25 years less than a predominantly white neighbourhood a few miles away. I wanted to talk to Joia about work she's done for years at the intersection of systemic racism and health, and how we've seen this manifest during the pandemic.

JM: Unfortunately I think there's no more potent force sociologically than racism and its linkage with capital in the world, and you and I have seen this so much in Africa. The fact that people are talented and brilliant and just don't have the resources and that is from the social construction of race that was created in the you know 1500s and then we see it in the United States. And one of the things that's interesting, something I'm working on a lot with a couple of students, is linking the data from redlining of neighbourhoods that was done in the 50s on who could and could not get a mortgage, that was really based on the racist notion that Black  neighbourhoods weren't safe, and you can look at neighbourhoods that were redlined and not surprisingly Covid is a much bigger threat in those neighbourhoods, that black Americans are at least three times more likely to die of Covid. Issues of accessibility, of impoverishment, of oppression, have then an outcome in the body and that outcome can be seen with Covid, it can be seen with diabetes, it can be seen, you know, with HIV, any number of things. 

So I think what we're seeing is hopefully some level of reckoning around the world and in the US of what Achille Mbembe has called necropolitics, the idea that governments both internationally on a global governance scale, and nationally on our government scale in the US, just think that Black lives are not worth saving, that Black lives in fact are dispensable. And I think we need to call out that level of racism. I was just talking to my class of Master students at Harvard in global health delivery and saying that when the essential drug list was created, for example, in four countries like countries in Africa, the idea was it was just generic drugs. And that is essentially saying that anyone on the African continent should have to wait for a generation, the length of patents, to get the fruits of modern medicine. And I think every movement that you and I have been involved in, Peter, from the aids movement to treatment of drug resistant TB, fight against Ebola, it has to be rooted in this foundation and understanding that unless we believe that Black lives matter equally, that we cannot actually address these  problems, and there is no contrast to me between fighting against Covid and fighting for Black lives because they are so intertwined, because of the structural, violent disparities that we see in the US and around the world, and who has access and who doesn't, and of course we're all  worried about if and when we do get a vaccine, how do we assure that the people who are truly at the highest risk are the ones to get it first, because we know that in HIV it took almost a decade before the fruits of modern medicine got to the majority of people who were suffering, who are people of colour in Sub-Saharan Africa, Asia, and elsewhere. So I think that we should look at every disease through a lens of economic, social and racial equality, and address the inequities as part of our plan from the beginning and really call out these systemic, and you know I don't even love the word systemic because it sounds too passive, I mean these are violent forces and we have to continue to work to mitigate the harm that's been done historically and the harm that's continuing to be done by leaving people out of the fruits of modern medicine and the social protection that people need to stay safe. 

PD: Yeah and it's a I think a great lesson for those who are interested in health and health systems, that the main drivers of who gets sick and who doesn't are not your genetics, it's not pathogens, it's about who you are, where you're born, the colour of your skin, income etc, all of these non-medical forces that are really driving this, and so really to transform our healthcare systems and the health of populations, we need to look outside of, inside and outside of, medical care really. 

JM: Yeah and there's you know there's a great article by our friend Mary Bassett and Sandro Galea that was published about reparations and public health and I think we have to look at this as an indictment of our history of racism and oppression, and that undoing these massive social factors like inadequate housing, unemployment, and non-gainful employment, this has to be part of our response. And I think if we don't we're just gonna continue to lose Black lives, continue to tacitly basically live as if Black lives don't matter. And so I really think that reparations should be central in our pandemic plan, whether it's reparations in Africa or reparations in Haiti or reparations to our Black brothers and sisters in the US. 

PD: Amen. I want to pivot a little bit but to stand this theme of the interconnectedness of different systems that we often look at in kind of silos. You wrote an op-ed recently that really caught my interest arguing that global health is national security and that the US government, the most militarised government in the world, had its sort of perspective on national security all wrong, because itÕs not about tanks it's about health care and other forces. Could you talk a little bit about that? 

JM: Yeah thanks Peter. I mean it's funny because I'm a little allergic to the notion of health security because I think anytime you invoke health security there is an Ôus and themÕ aspect of it and so the last thing I want to say is that security ought to be about building walls, um, about otherising people who are sick, but I think if we look at security as solidarity, as justice, then we have a totally different type of security and many of the places that we've both worked, the security that we have, even in an unstable place, is the community connections that we have, is the sense of shared humanity that we have with others. And I have worked in Burundi and Haiti during de facto government, in different places during coupe d'etats, and I never felt unsafe because I knew I was seen as a member of the community, someone who is trying, someone who is listening, and that is a different notion of security. That is the notion of security as solidarity, that's the notion of security we have when we love our family and protect them.  And we need to think more about the security of interconnectedness rather than the security of otherness. About compassion and solidarity and the same security you want to give to your children, that they feel loved, they feel like they're protected, is what I want to give to any children, right, not only my own.

PD: Yeah and it doesn't always feel this way but I hope that one of the lessons of this pandemic is that we're all in this together and none of us are safe until all of us are safe, and so we have a responsibility for the collective. 

JM: And the destruction you know, I think the destruction of lives like if you look at Syria, Iraq, Afghanistan, that just makes people there more vulnerable to infection, to harm, it makes all of us more vulnerable. So I just think we have to rethink this around just a different approach. And when you look at Jacinda Ardern in New Zealand, there is I think a room for radical rethinking of governance around feminist principles, feminist principles of care, feminist principles of equity, and feminist principles that the most vulnerable are the those worthy of protection. And so I think when you look at what women's leadership has done in this pandemic versus the really hyper sort of macho militaristic leadership we see here and elsewhere, I think we also have a philosophical choice.

PD: Yeah IÕve been thinking recently that if we could we could make a pact amongst all blokes to just not run for public office for 10 years, just 10 years right, and just give women a shot to make up for centuries of being excluded let's see where we get to. 

JM: And I think part of my view of feminist philosophy is it's not only about putting women in power, because I don't think women being part of a male-dominated establishment and a patriarchy is going to work, right, because this patriarchy is part of the problem, right. So it's about really changing what matters and where we invest our money, and you know maybe it's humanism, maybe it's not feminism, maybe it is feminism, but it's certainly not just having women lead in a way that is still militaristic, patriarchal. I don't think Margaret Thatcher put a lot of care for it in the world. 

PD: Point taken. I want to focus in on this idea of the right to health a little bit, because it's so politicised and because I've heard you, we have a lot of students out there listening, and I've heard you teach students around the world what human rights is really all about. You know you sort of say Ôdo you support human rightsÕ everybody says duh of course I do, but people don't often understand really what we mean when we talk about human rights, and you brilliantly sort of talk about the difference between civil and political rights, and social and economic rights. Would you enlighten us? 

JM: Yeah so I mean if we look at the modern framing of human rights which comes from the Nuremberg trials and led to the universal declaration of human rights, it was a very comprehensive document that looked at all of the things, all of the ways in which race were violated by, for example the Nazis. I mean that is really what came out of it. And you know when we look at pictures of the liberation of the camps, what we see are starving people, so food security is there. We know that there was medical experimentation, and the right to health and autonomy is there. We know that there was discrimination based on religion and so freedom of religion is there, etc. So it's such a comprehensive document that looks at all of the ways that rights can be violated, and ought to be supported. 

But unfortunately the next big conflict, which was the Cold War, really politicised these rights. And on the one hand you had the US and Western Europe focused on civil and political rights, free speech, voting, almost as an indictment of the Soviet system, and the Soviet system saying no the rights are these social and economic rights, health care, education etc, as an indictment of the capitalist system. And then you have the really important social force of neoliberalism which was the idea of unfettered capital promoted by Milton Friedman and Friedrich Hayek and they really conflated capitalism with civil and political rights, and the idea that democracy is where capitalism can thrive. And again this was really a result of the cold war, and so what we saw from, you know, the 1940s when all of this was really starting to become part of our consciousness into the 1970s, the liberation of the African continent by Africans, it was really this politicisation of rights, And because we won the Cold War and we had the money from, in the way of the World Bank, the IMF, which was heavily influenced by neoliberalism, the notion that civil and political rights free speech, voting, judiciary system, those became real rights, and these other rights like the right to health, education etc became  what we call them in the United States entitlements. Now these are considered real rights by even the UK with the National Health Service, by certainly most western democracies. But the US is still extremist in our view that these social and economic rights are not full rights, and what we see with the more right-wing administrations that we have in the US, the more those basic rights get eroded, the trying to repeal of the Affordable Care Act, these kind of things. So we've gone to even more of an extreme place in the last four years but no administration in the US modern history probably, you know, with the exception of Roosevelt and the exception of Johnson, has really expanded our public contract. And we're just allergic to that in the United States and I think that's why we have the Covid outcomes we do. And you know I think it's a mystery to a lot of people, but I think these basic social and economic rates are what underlie our pandemic problems.

PD: My thanks to Dr Joia Mukherjee. Joia really helped us understand how looking at the whole system can change our perspective. Before we go, we're going to have a quick update from friend of the podcast and JoiaÕs colleague, Dr Paul Farmer. Our very first episode of Reimagine was a conversation with Paul back in the early days of the pandemic. Paul had been on the front lines of the Ebola epidemic in West Africa and we spoke about the lessons we should draw from that when it came to Covid. And in fact, Paul has just released a book out this very week about Ebola and its implications. It's called ÔFevers, Feuds, and Diamonds: Ebola and the Ravages of HistoryÕ. The bookÕs about how inequality and exploitation fuelled the spread of a deadly virus - I know, hard to see the relevance in 2020 right? The book is both a gripping first-hand account of the West African Ebola epidemic and a sweeping historical look at how pathogens exploit our own social fault lines. I'm biased, but it's really good. We've put a link to the book in the show notes for this episode, go grab yourself a copy. Paul was also the inspiration for the title of our last episode, Redwoods in Rwanda, he was the one who brought seedlings of these mighty giants to plant around the hospital and university we had just built as a symbol of our long-term collective vision. Apparently, the little redwoods are doing just fine. 

Paul Farmer: I've been there since you have and I can tell you that they're going to survive, I mean the first lot of them are already at 10 feet tall so how's that? 

PD: Nice, I'm sure you're texting the gardeners every other day to make sure and ask for pictures. 

PF: How did you guess? 

PD: Paul, many of your books are ostensibly about pathogens, in this case the Ebola virus, but the power of your writing lies in what it reveals about the human condition, about who we are and who we could be. What drove you to write Fevers, Feuds and Diamonds? 

PF: Well you know I've always been interested in pathogenic forces, you know, pathogenic forces like racism, gender inequality, you know, or even those translated into really harmful policies. And you start to see how easily they're left out of the discussion. Right around Thanksgiving 2014, so at the height of the epidemic, I met a young Ebola survivor, Ibrahim, and he was 26 at the time, and he turned to me and he told me that he'd lost over 20 family members to Ebola in the course of one month, and I just sat there. I was shocked and he looked at me waiting for an answer, and I just didn't have one ready. I mean I didn't know what to say, I had never seen a single pathogen take out an entire family or that many people in a family, and then he said something else that really stuck with me. He said ÔI'd like you to interview meÕ. And you know I think it was one of the first times that had ever happened to me, in all those years you and I spent together in Rwanda, how many people came up to us and said ÔI'd like you to interview me about my experienceÕ? It just doesn't happen that often and I thought well maybe I should write something about Ebola because, as ever, the pathogens are propelled forward by pathogenic forces and these ones are deeply rooted. And I'd like to learn more about them. 

PD: Paul, when we spoke last spring you helped us kick off this podcast and we asked you to sort of, in a moment of crisis, to help us take the long view, and one of the things you said that really stuck with me is, and I'll quote: ÔShame on us if we can't seize this moment to make some desperately needed changes to our human social architectureÓ. 

PF: Sounds pretty good. 

PD: It was pretty good, yeah, that's why we asked you back! 

PF: I stole that statement, shame on us, from Tony Fauci, and I remember he and I were speaking on the phone, I was I think in Monrovia, the capital of Liberia, and you know he just said to me on the phone Ôshame on us if we don't learn anything about Ebola in the course of this dreadful epidemicÕ and, you know, I took that Fauci-ism and just applied it evidently to our discussion about Covid. And I think that's a legitimate critique, every time something happens to us, shame on us if we don't look at history and the lessons that we should have learned. And shame on us if we don't learn new things. The temptation as you know from your own clinical work and programmatic work is, you know, everything is just going at such a rapid clip in the middle of one of these crises and it's so easy just to try and get by and to not look back at lessons learned. I just believe, as you do, that we have to step back sometimes and ask questions like the ones that you ask in this podcast. 

PD: And that's exactly what we're doing this series, you know, we're trying to answer your call to go deep and to go long and to respond to your call to think about what these changes could be to our human social architecture. What do you think it's going to take to turn it around? I mean like how bad does it have to get? Is it just, you know, as long as we have toxic leadership we're just resigned to suffering, I mean, where's the bottom? 

PF: Well I think toxic national leadership, uh, that a lot of scholars going forward will be asking that question. Now on the other hand, I'm also an informed optimist, for example I'll bet when we look back to our early discussions early in the Covid-19 era, that we talked about the tools that would come along and help us, and those include obviously a vaccine, better diagnostics, right, but also maybe reinvigorated leadership and humbled leadership. People are willing to say not just Ôhow bad does it have to get?Õ but also Ôwhat are we going to do to really amp up our response?Õ You know, what's the difference between a mask mandate and widespread uptake of masks, those are cultural differences. They're probably around things like leadership, an example. And of course again I always go back to the material, they're around supply, they're around supply chains, but really I think we're going to be stuck with thinking about these matters at least for the coming years, and again, when it happens again with something else, it'll be the same set of questions. The question is are we going to be able to learn lessons and really work them into our policies and practices so that our not only our suffering diminished, but our vulnerability to suffering is diminished.

PD: Keep remembering.

PF: Yeah keep remembering. We have to keep remembering, I mean even in talking about racial injustice in the United States. You know, what strikes me is that for many Americans George Floyd's murder was almost like a revelation, and captured by happenstance on a cell phone, and obviously only people who are shielded from that kind of aggression can think of that as a revelation, right. There are plenty of other people who live in fear of this and so again, keep remembering. Keep remembering that we have a history, since the beginning of the Republic in the case of the United States, of structural racism and worse. Undoing it is going to require remembering and acknowledging and then coming together to do something better. I mean I feel like you and I got to see that process in person in Rwanda, compressed into a very short period of just a few years, you know, of saying we're going to remember, it's going to be very painful, it's going to be contested, but we're going to do it collectively, and on a community by community basis. It's going to spread all across this country as we work from the grassroots up to understand, you know, what has happened here in Rwanda, and what we're going to do differently. I don't really have that experience as an American. I didn't have it when I was a child growing up in Jim Crow Alabama, or moving to Florida, in part to escape Jim Crow Alabama. I never had it as a curious medical student or undergraduate or graduate student. It's not something I've ever seen, where you see a very broad agreement that remembering and acknowledging is important to the next step, which is repair.

PD: And that active caregiving, which both of us were part of especially at the community level, at the village level, was so important to helping to stitch together that social fabric. 

PF: I'm so glad that you brought that up because it's another antidote to cynicism, or even discouragement, is to think what can we do on a daily basis? Caregiving. And that's not just for doctors and nurses right, that's anyone. Indeed in your work in Rwanda and elsewhere the majority of people engaged in caregiving are not healthcare professionals, the majority. And so we can all do that, we can all show that we care about each other. And so again I go into the next few months with a great deal of optimism, again, even though we're in a very difficult situation here in the United States and in many other places as well.

PD: My thanks to Dr Paul Farmer and Dr Joia Mukherjee. You've been listening to Reimagine: a podcast from the Skoll Centre for Social Entrepreneurship at Oxford University's Sa•d Business School. Do you want to see things differently? Don't miss a beat. Subscribe to Reimagine wherever you get your podcasts. And if you like what you hear, take a moment to juice up those algorithms and rate and review us. Find me on twitter @PeterDrobac, and to learn more about social entrepreneurship and the Skoll Centre, visit reimaginepodcast.com. From Oxford, I'm Peter Drobac and you've been listening to Reimagine: a podcast about people who are inventing the future.