This month, we are pleased to release the second issue of "PIH Reports," a regular series that examines PIH programs and interventions around the world and provides guidance for those interested in implementing similar initiatives. Below, Dr. Paul Farmer introduces the latest edition and reflects on patient-centered accompaniment in Tomsk, Russia, where PIH has worked for more than two decades to improve access to care and social support for vulnerable patients. Click here to download the full issue of PIH Reports.
This issue of PIH Reports introduces the Sputnik Program. Most readers would associate this term with the satellite of 1950s fame. But the word has also come to mean, in Russian parlance, “life partner” or “special friend”—someone around whom one’s life revolves. This need not have romantic connotation: as I was writing this, in Tomsk, a couple of Russian friends noted that, here in Siberia, extreme weather reminds people each year of the need for collaboration, of looking out for one another. Serious illness is another reminder. And so “Sputnik” became the name of an effort designed by PIH/Russia to help patients adhere to a difficult course of treatment for drug-resistant tuberculosis.
I’d like to mention three reasons we think Sputnik merits the support of every member of the PIH community.
The first: MDR-TB is one of the most pressing health problems of our times. By some estimates, there are half a million new (“incident”) cases of MDR-TB each year. It’s an airborne disease and cannot be hidden away or ignored or declared “incurable.” Curing extensively drug-resistant TB requires what can only be described as grueling treatment. We need new and better therapies: safe, effective, tolerable, and faster-acting. But the Sputnik experience shows us that when patients are the center of all of our efforts—when our attentions and resources revolve, like satellites, around them—we succeed, even though our treatments are imperfect. Cure rates are high if patients receive, each day, the medicines and the social support required to complete therapy.
A second reason to support Sputnik is that the poor and marginalized don’t live only in poor countries. In Tomsk, over 80 percent of beneficiaries, mostly young men, are unemployed; almost as many are chronic abusers of alcohol. More than a third have histories of drug abuse, and close to half have hepatitis, much of it caused by hepatitis C virus (HCV). Rates of HCV and HIV co-infection are even higher in prisons, and 38.4 percent of Sputnik’s beneficiaries have been incarcerated (the PIH team met some of them in prisons, once the setting of runaway epidemics of MDR-TB). Most of this group, in other words, meet anyone’s definition of poor and marginalized, and a diagnosis of drug-resistant tuberculosis has sapped their physical strength as well as their political clout. AIDS activists have taught us that too few poor or otherwise marginalized people afflicted by such infections make enough noise. Surely this air-borne disease is a reminder that we all move in the same or related orbits.
The Sputnik experience in Siberia serves as a reminder that the goal of clinical care, and of health systems, is to revolve around the patients.
Third, the notion of accompaniment can be applied to improve clinical outcomes and to strengthen our response to new and difficult problems in medicine and public health. The thinking in public health is too short-term; clinical care, even more so. How might we link Sputnik’s lessons about patient-centered accompaniment to the challenges now before us? If HCV infection is suddenly curable, what is our “equity plan” to deliver treatment for patients like those encountered within the Tomsk penitentiary system or cared for through Sputnik? We need an integrated approach to delivering effective health care, setting aside resources to respond to new problems, and to deploying new tools for old problems. We need, most of all, long-term commitments to health equity.
In the popular imagination, “Sputnik” will always be a Soviet satellite. But this is precisely why the term was used to describe PIH/Russia’s efforts to address the needs of those deemed incurable: the very notion of revolving around someone other than oneself has been too often devalued, even in medicine and public health. The Sputnik experience in Siberia serves as a reminder that the goal of clinical care, and of health systems, is to revolve around the patients.