Building on the Legacy of Global Health Leader Dr. Paul Farmer 

Dr. Joia Mukherjee

[ Music ]

Marianne O’Hare: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter . This week we welcome Dr. Jo ia Muk h erj ee , Chief
Medical Officer for Partners In Health , an organization founded by Dr.
Paul Farmer to address deep disp arities in global health. He died
unexpectedly , leaving a huge legacy .

Dr. Joia Mukherjee: We should never think that we can provide health care as a human
right without massively looking at these unequal structures. And Paul
called that structural violenc e.

Marianne O’Hare: Now hear your host, Mark Masselli and Margaret Flinter.

Mark Masselli : We were all saddened by the recent death of Dr. Paul Farmer and the
co founder and chief strategist of Partners In Health. Dr. Farmer and
his colleagues, pioneered n ovel community based treatment
strategies that demonstrate the delivery of high quality health care in
resource poor settings. He wrote extensively on health, human rights
and the consequences of social inequal ity. He is even called a
modern - day Albert Sch weitzer

Margaret Flinter: Joining us to remember Dr. Farmer's contributions and to help us all
think about how to advance his life's work is Dr. Joia Mukherjee , the
Chief Medical Officer of Partners In Health , which has the wonderful
tagline of “ Injustice Has a Cure . ”

Mark Masselli : Well Dr. Mukherjee .

Dr. Joia Mukherjee: Thank you so much for having me.

Mark Masselli : Yeah. And really, we appreciate you taking the time to talk with us on
this really sad, sad occasion. And let's start with your personal
mem ories of Dr. Farmer . What sticks out in your mind?

Dr. Joia Mukherjee: Yeah, I mean, I was just talking with a friend, just before I joined you.
And I think what sticks out most is that Paul was incredibly funny and
fun to be around. And I think the reason that sticks out so much is
that the work of social justice is incredibly difficult. You have to not
only minister to the sick and the poor, but you have to really dive in
and recognize the history and the reasons for the injustice.

You know, justice itsel f is really a retrospective concept, you have to
understand that harm has been done and what those forces are. And
Paul's great gift was to do that hard work with so much lightness and
effervescence and he did that really through humor and love. And it
was so generously spread to everyone, we all have thousands of
inside jokes and pet names for one another. And I think that that
bound us together through really difficult times. And it shows the way
that you know contributing to social good can be actually j oyful, even

Dr. Joia Mukherjee

in the dark times. And I think that, to me, is what I've been really
coming back to over the days since learning of his death.

Margaret Flinter: That is an incredible legacy. And I'm so glad you raised that human,
very human component. Thank yo u for sharing that with us. You
know, one of the things we've come to understand is that Paul Farmer
reshaped our understanding of what it means to treat health as a
human right. And also the ethical and the political obligations that
follow once you recog nize that . Tell us a little bit about how
specifically did Dr. Farmer accomplish that goal?

Dr. Joia Mukherjee: Yeah, I think, you know, we live in a world that has deeply structured
inequalities along the lines of race, nationality, gender. And so when I
started and many of us, and the sea change, we all witnessed,
because of Paul's vision was, there was an acceptance of those
structural inequalities as normative and as unfixable. And so the
general thought was a country X has $3 per capita for health. And you
have to just do whatever fits in that sealing . Rather than asking, why
is that sealing there? How do we break through it? And then the most
important question of all what is it that the person in front of you
needs? So obviously chemotherapy never fel l under that sealing of $3 .
HIV treatment didn't . Palliative care . Orthopedic surgery.

So in accepting that inequality, that economic and social and racial
inequality, you will never achieve health as a human right . And so ,
what Paul challenges all of us t o do, even in death is to treat every
person as if you would your own family, you wouldn't say well, we
have $3 this is all we can do. In fact, I've seen impoverished people
walk miles expend huge amount of resources, sell their own assets,
home , animals, just to get care for a child. So the $3 is never enough.
And we should never think that we can provide health care as a
human right, without massively looking at these unequal structures.
And Paul called that structural violence. And indeed, it is violent. And I
think that is really his greatest contribution.

Mark Masselli : Well, what a nice conceptual model and really framing up sort of the
focus of the organization Partners In Health . And I guess it's perhaps
an inflection point. I don't know where you al l are. But I'm wondering
if you could share with us where do you go from here? And how do
you keep Paul's promise moving ahead? And can we assume the focus
will remain on community health in countries where you serve and
not quote parachuting in strategy w hen disaster strikes?

Dr. Joia Mukherjee: Yeah, yes, you can assume that we will stay and double and triple
down in the communities and the countries we work in helping both
the communities and the public system. I mean, Paul, really believed
in the public provision of health care, not charity alone. But that, you
know, the right to health depends on the public provision, strong
governance, and community participation, this is really the dialectic of

Dr. Joia Mukherjee

human rights, that that is so critical. And, and so you k now, we will be
doing that.

And one of the things I've been saying a lot is that Paul really left us a
roadmap, he wrote about what he wanted all of us to do, he spoke
about it, he taught it, and he modeled it in his own practice. And so I
think we're ver y clear that our job is always taking care of the poorest
of the poor, but at the same time, strengthening government
systems, working with communities, and teaching the next
generation.

And, you know, he died in a university, where we have worked
together with partners on the ground, the University of Global Health
Equity in Rwanda, teaching our first class of clinical medical students,
he had been there for six weeks. And we know that one of the most
important things to Paul and to all of us, in fact, is to really continue
to provide formalized long term treatment to improve health care,
not only for people, but to assure that their providers are local people
who speak their language , who are from their communities.

And so that is what we are committed to doing, care for the sic k,
training the next generation, and working to build robust public
systems and engage communities.

Margaret Flinter: Well, I think a great example of that w as some of his work throughout
this COVID pandemic. And we remember that one of his major ac ts
was really pushing the Biden administration to drop intellectual
property barriers that prevented pharmaceutical companies from
sharing their technology and I am sure that COVID is not the only
example. We could look at this, maybe share with our li steners, why
that still matters? And where does that effort stand today , in a
broader way, as you talked about making sure these treatments ar e
equitably available to people?

Dr. Joia Mukherjee: Yeah, thank you for that question. Margaret. Paul , strongly believed
that there should be goods in the public common , for things like
health, for education, you know, and when we see what's happening
with the, you know, a vaccine apartheid, as many are calling it, you
know, they're still less than 10% of people on the African continent
vaccinated. We know that Om ic ron probably came from un vaccinated
populations as did Delta, as will the next variant.

So most importantly, to us, it is moral for everyone to have the fruits
of science, not for those fruits o f science to be again, put along the se
structured lines of inequality. But in addition, it's in our global
interest, to work together and collaboratively to end a pandemic, not
in a nationalistic way. We cannot be a fortress. We know that. And so,
you know , Paul felt very strongly that the scaling up of vaccine
production, he was very committed to the plant that is starting to

Dr. Joia Mukherjee

produce vaccines in Rwanda. He had just visited there on his last trip.
And through collaboration with pharmaceutical companies, wit h
governments that we should really expand massively to 22 billion
doses actually, the availability of the mRNA COVID vaccine .

Mark Masselli : You know, I will pull the thread on the word collaboration, because
it's interesting that he advocated for working with existing power
structures, even if they were disliked, such as with the World Bank.
But he also felt all right, getting comfortable with dis comfort. And
how do you and your organization square these two beliefs?

Dr. Joia Mukherjee: Yeah, well, P aul h ad a term that we've all come to be very familiar
with and use a lot, which is the notion of pragmatic solidarity, you can
be in solidarity with the poor and really kind of despise the power
structure, really be questioning this structural violence in thes e
structured inequities. And yet, when we come face - to - face with
someone suffering, we need to get whatever tools we can to help
them. And so the pragmatic solidarity says you can critique and work
on these bigger systemic changes , but to deliver care , to save , to
pa lliate , you've got to do whatever it takes to get to that.

And so that is our notion is to stay -- remain honest critics , but also try
to collaborate, to get the work done at the very human level that it
needs to be done. And we've been able to do that. Sometimes it's not
easy. Sometimes we have to have, you know, different strategies. But
at the end of the day, the most important people to us are the most
impoverished people who are sick.

Margaret Flinter: Well, Dr. Mukherjee, I know education i s a huge interesting concern
of yours. And we know you as the author of the widely used textbook
and introduction to global health delivery practice, equity, human
rights, and we understand somehow you've also found the time to get
a second edition, coming out with a focus on pandemic. So what will
our readers learn from you about this incredible time in our recent
history?

Dr. Joia Mukherjee: Yeah, thank you for mentioning that. It's, it's something I think a lot
about it this time. And I've Oh, yeah, the second edition is out. I think
one of the reasons I was asked to write a second edition is, so many of
the principles in the first edition of the textbook is how do you build
the staff? How do you improve the systems? How do you look at drug
supply, all wi th, with a mindset that you want equity as the e n d result.
And what we saw in the pandemic that was so jarring is that is the
failures of even the richest country in the world, the United States.
And I think trying to understand that it's not just about mo ney or
inputs, it's about systems that are designed with equity in the first
instance. And so a lot of it is talking about how do you look at equity?
How do you think about collaboration with people from different
cultures, different countries? How do you put the poorest people

Dr. Joia Mukherjee

first ?

Had we done that in the United States, we probably would not have
the pandemic that we do. And indeed, when Partners In Health was
asked to support the Public Health Department in the S tate of
Massachusetts, our big, I think m ost important contribution is to do
contact tracing, not so much. But for each person we talked to, we
said, these are the things you need to do to protect yourself and your
family. Can you do it? And if the answer is n o, then you need social
support, food , eviction support, you know, all of these things. That is
how you build a program with equity, if you're just telling people
information, that's ne ver going to be an equity focused program. And
so a lot of the work in the second edition is to say, how do we in a
pandemic recognize what has happened with these structured
inequities? And how do we fight to deal with that worsening inequity
at a time such as this?

Mark Masselli : Well, that's such an important note of having that lens of equity as a
focus and also translating that past , its importan ce, but into really
practical terms. Clearly, there's a noticeable feeling of relief across the
United States right now as Om ic ron variant seems to be waning, but
how do we keep Americans alert to the pandemics reall y continuing
threat in other parts of the world that have a lack of vaccines and
treatment? And we know this is a global need , and I think Americans
tend to perhaps be narrow in their focus about what it means to have
a solution here.

Dr. Joia Mukherjee: T hank you. I mean, I think if there's one thing that I and many of my
colleagues and certainly Paul, lose sleep or lost sleep over in our lives
is h ow do we get people to care about our shared humanity? I mean,
in COVID, you'd think that even just the fact that it's a threat, a
continuing threat to all of us would work , but we see if that doesn't
work , t hat's not enough. And what I've seen, in Ebola and HIV and the
other pandemics and epidemics I've worked on is the threat of
contagion just tends to kind of serve to otherize people , build more
walls, close the airports, right.

Whereas trying to bring forth our shared humanity, this is a mother,
this is a friend, this is a person whose life has infinite value. That I
think is the way we have to go. And I don' t see a lot of leadership in
that space right now from the global north, but I do see it from, you
know, the global south from African leaders, you know, like Cyril
Ramaphosa in South Africa, like President Kagame in Rwanda. And so
trying to think about ho w do we foster that .

And what gives me hope, is young people, you know, people under
25, they really understand this in a very different way. I don't know if
it's their connections across boundaries. They're, more tuned into the
world as their peer group a nd so it's my hope that that will help us

Dr. Joia Mukherjee

sort of promote this.

Margaret Flinter: Well, we couldn't agree with you more about our just incredible pride
in our young generation coming up and the work that they are doing,
and going to do, but one of their ch allenges as it's been a challenge,
I'm sure for your organization has been at any point in time, so much
going on in the world right now. What we are witnessing and what
people are experiencing so many challenges, how do you prioritize ,
w here you're going to devote your efforts of people and resources? Is
it even right to talk about prioritization? Or does the most urgent kind
of triage rise to the top of the list, just share with us a little bit about
how your organization approaches that?

Dr. Joia Mukherj ee: Well, you know, we have the feeling in our very name Partners In
Health is that there is no movement that can happen alone, right, that
there is no social movement ever that has been a homogeneous
group. And so we want to do what we do well, which is t ake care of
the sick. But we invite other people to join us, we have close
collaboration with the Equal Justice Institute that is work ing on, you
know, death penalty, reform, and cases . We have close collaboration
with Mass Design, which is an architecture group.

We've worked with prison reformers. And so I think if we think that
the goal is a better and fairer world, it's going to take lots of different
kinds of organizations with whom we are always delighted to make
common cause, you know, some of my grea t friends and fellow
travelers, you know, from my life have been HIV activists. You know,
so I think the way we look at it, and what I tell young people that I
teach, is do what you do well , do what you do with a passion. And
then try to find collaborators from different walks of life to share that
journey.

And, you know, I am a doctor, and so I try to do doctoring. I also have,
you know, I'm a reasonably good speaker. So I end up in front of, you
know, crowds, but there are people who are phenomenal at try ing to
do financing, and they're working on that. You know, there are people
who know a lot about water and sanitation . The re are people know
about peacemaking. And so, you know, that's my view of the world
that we all have a part in it, and can work toget her.

Mark Masselli : Well, that's a great vision. Thank you, Dr. Mukherjee for all that you're
doing. And we appreciate your insights into the life and work of Dr.
Farmer and also the incredible impact that Partners In Health is
having around the globe. And thanks to our audience for joining us in
this important talk and you can learn more about Conversations on
Health Care a nd sign up for our e - mail at chcradio.com . Again, thank
you so much .

Dr. Joia Mukherjee: Thank you so much . Thanks for having me.

Dr. Joia Mukherjee

Mark Masselli : At Conversations o n Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy . Lori Robertson is an award winning journalist and Managing
Edito r of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.
Lori, what have you got for us this week?

Lori Robertson: In late January the Food and Drug Administration pulled its
auth orization of two COVID - 19 antibody drugs because the
treatments are highly unlikely to work against the Omicron variant.
But Governor Ron DeSantis of Florida misleadingly claimed the
decision had been made “ without a shred of clinical data ” to support
it.

There may not be data from patients, but lab studies strongly suggest
the treatments will not help Omicron infected people. Since late
January , the Centers for Disease Control and Prevention has
estimated Omicron accounts for nearly all the Coronavirus in fections
in the country. The manufacturers of both antibody drugs in question,
Eli Lilly and the biotech company Regeneron said in statements that
they agreed with the FDA and found the decision appropriate.

The agency said that it would allow the use of t he drugs again if
another variant comes along that is susceptible to the treatments. The
FDA pointed health care providers to treatments that are expected to
be effective against Omicron. Those include two newly authorized
antiviral pills, the antiviral, R emdesivir and a different monoclonal
antibody treatment manufac tured by Vir Biotechnology and
GlaxoSmithKline.

On February 11 th , the FDA authorized a new monoclonal antibody
manufactured by Eli Lilly, that does retain activity against the Omicron
variant. That means that while the agency revoked the authorization
of two monoclonal antibody treatments, there are two other
monoclonal antibody treatments that are authorized for use against
Om ic ron . The state of Florida and its Republican governor however,
we'r e critical of the FDA ’ s late January move to revoke the
authorization for some antibody drugs. DeSantis said in a January 25
tweet that the decision had been made “ without a shred of clinical
data ” , calling the drugs life saving treatments.

Again, while th ere may not be studies in people demonstrating that
the two antibody treatments are now useless, there's an abundance
of other data including from the companies that suggest these drugs
have little if any ability to fight off the Omicron variant.

Since Sep tember, the federal government has been supplying COVID -
19 monoclonal therapies to states based on the COVID - 19 caseload
and how much a locale has been using the drugs. These synthetic

Dr. Joia Mukherjee

antibody treatments target the spike protein of the SARS CoV - 2 - virus
an d can prevent it from entering cells.

Earlier clinical trials showed the antibody cocktails which are either
infused intravenously or injected under the skin reduced the risk of
hospitalization or other negative outcomes in high risk outpatients .
That led the FDA to authorize them for non hospitalized patients with
mild to moderate COVID - 19 who are at high risk for developing severe
disease. As with any COVID - 19 treatment, the monoclonal are not a
substitute for vaccination. But the shape of the Omicron var iant spike
protein is different. And some of the antibody treatments can't
neutralize the Omicron variant very well, if at all, as numerous lab
studies have shown.

For instance, a January Nature Medicine study found the Regeneron
and Eli Lilly antibody com binations lost all neutralizing activity against
an Om ic ron virus taken from an infected American. But as we said a
different monoclonal from Eli Lilly has now been authorized for use
against Omicron. Regeneron is preparing to begin clinical testing of
ano ther antibody treatment. That's my fact check for this week. I'm
Lori Robertson, Managing Editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and as a project of the Annenberg Public Policy
Center at the University of Pennsylvania . If you have a fact that you'd
like checked, email us at chcradio.com . We'll have FactCheck.org’s
Lori Robertson check it out for you here on Conversations on Health
Care.

Mark Masselli : Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. One in five
Americans will suffer a diagnosable mental health condition in a given
year, and most often do n't seek treatment. For those with serious
mental health conditions the consequences can be devastating.
Seeing a rise in mobile apps aimed at behavioral health entering the
marketplace, a University of Washington researcher Dror Ben - Zeev
thought a compara tive effective analysis study would be a good idea.

Dror Ben - Zeev : My team and I conducted a three - year comparative effectiveness
trial , now w ith the objective of having a head - to - head comparison
between a mobile health intervention for people with serious mental
illness called FOCUS and a more traditional clinic based group
intervention called W RAP or Wellness Recovery Action Planning. So
it's conducted at a clinic setting , people with similar diagnoses. So the
study really gets at some of the core differe nces between mobile
health and clinic based care. Is there something about the mobile
health approach that would make it more accessible or less accessible
when people find it less engaging over time?

Dr. Joia Mukherjee

Mark Masselli : More than 90% of the mobile A pp group en gaged in the online
program, which was a series of text messages, offering coping
strategies and self monitoring of s ymptoms, along with weekly call - ins
wit h a behavioral health clinician.

Dror Ben - Zeev : The second thing we wanted to see is after people co mplete care,
what are their subjective ratings of their experience and treatment?
Are they satisfied with both interventions? Are there differences in
their levels of sat isfaction? And probably the most important piece of
the study are the clinical outcome s. So we measure to see whether
involvement in both interventions for a 12 - week period, would that
create some sort of difference in psychiatric symptoms severity and
quality of life, and 90% of the individuals who were randomized into
the mobile health ar m actually went on to meet a mobile health
specialist to describe the A pp to them and train them how to use it
and use d the intervention A pp that's assigned to them at least once.
Whereas in the clinic based arm, we saw that only 58% of the
participants as signed to that clinic based intervention ever made it in
for a single session.

Mark Masselli : Both groups of patients saw roughly equal results from their
completed treatment, but the mobile group was more likely to
engage in therapy. Ben - Zeev says this su ggests that mobile therapies
may provide a useful tool for clinicians having trouble getting those
with serious mental health issues, to engage with the clinical
interventions .

Dror Ben - Zeev : The group dynamics, the fact that there's a sense of shared
expe rience and perhaps even normalization of some of the
experience that on its own is quite potent for people, right. And so we
know that the very existence of a group can be quite helpful. But for
others, the interaction is anxiety provoking, just making it to the clinic
to engage in that interaction is logistically complex. When it comes to
the clinical outcomes, in both intervention arms people improved,
both in terms of reduction in their symptoms and the distress
associated with symptoms and improvements in their recovery.

Mark Masselli : The results of this study were published in the Journal of Psychiatric
Services , a targeted mobile A pp aimed at facilitating access to clinical
care for those experiencing serious mental illness symptoms, proving
equally e ffective and managing the condition improving access to
intervention for behavioral health needs. Now that's a bright idea.

Mark Masselli : You've been listening to Conversations on Health Care. I’m Mark
Masselli

Margaret Flinter: And I'm Margaret Flinter .

Mark Masselli : P eace and health .

Dr. Joia Mukherjee

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
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