 Good afternoon everybody and I want to extend a very warm welcome to all of you who have joined us here today for the 29th annual Dorothy J. McLean Fellows Conference on Clinical Medical Ethics. So many of you who are attending today are part of the University of Chicago community but I also want to welcome those of you including former McLean Center Fellows who have travelled a long way to join us for the conference and for today's special event and the awarding of the 2017 McLean Center Prize. I'd like to particularly acknowledge the role that Mark Siegler and Barry McLean have played in all of this. 29 years is a really impressive number and I've had the good fortune of attending this conference on a number of occasions and it seems to get better and more exciting every year. So the McLean Center Prize which is a $50,000 award is one of the largest prizes in bioethics. It was established in 2010 by the McLean family to recognise physician scholars who have made transformative contributions to clinical ethics and healthcare. And previous winners of the prize include a really impressive group of people including John Wenberg who is founder of the Dartmouth Institute for Health Policy and Clinical Practice. Dr. Peter Singer, former director of the Joint Center for Bioethics at the University of Toronto and who's now the CEO of Grand Challenges Canada. Dr. Susan Toll, founder of the Oregon Health and Science University Center for Ethics in Healthcare and the developer of the Pulse Model for End of Life Care. Laura Roberts, the chair of psychiatry at Stanford and Norman Fost, one of the country's senior pediatric bioethicists and founder of the University of Wisconsin program in bioethics. So I now have a great honour, the great honour of introducing the recipient of the 2017 McLean Center Prize in Clinical Ethics and Health Outcomes, Dr. Paul Farmer. So let me briefly summarise Dr. Farmer's illustrious career. In 1990 Dr. Farmer received his medical degree and PhD in anthropology from Harvard University and since then he has dedicated his life to improving healthcare for the world's poorest people. As a medical anthropologist and as a physician Dr. Farmer divides his time between academic activity at Harvard and his groundbreaking work in Haiti, Rwanda and around the world for Partners in Health. Dr. Farmer is a founding director of Partners in Health, an international non-profit organisation that since 1987 has provided healthcare services and has undertaken research and advocacy efforts around the world on behalf of those who are sick and living in poverty. Whilst a medical student Dr. Farmer worked with dispossessed agricultural workers in Haiti's central plateau. The book Mountains Beyond Mountains written by Tracy Kidder chronicles Dr. Farmer's experiences in Haiti that led to the founding of Partners in Health. Starting with a single clinic in the village of Kanje, Partners in Health efforts in Haiti have grown to a multi-service health complex that now includes a primary school, an infirmary, a surgery service, a training program for health outreach workers, a 104 bed hospital, a women's clinic, a pediatric facility. And over the past 25 years Partners in Health has expanded to 12 sites in Haiti and to programs in 10 additional countries around the world. Dr. Farmer has strong and clear views on ethical issues related to health care. In Tracy Kidder's book Dr. Farmer is quoted as saying, for me an area of moral clarity is, you are in front of someone who is suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it and you act. Viewing health care as a human right, Dr. Farmer has argued that the inequality of access to life-saving vaccines or HIV treatment constitutes a major ethical failure. Throughout his career Dr. Farmer has led by example and has been a fierce advocate for increasing access to life-saving treatments for the poor. In addition he has stressed that in order to improve health care and respond effectively to epidemics it is imperative to deal with the underlying causes of poverty. Partners in Health's work has become a model for health care systems in poor communities worldwide. Dr. Farmer and Partners in Health have pioneered novel community-based treatment strategies that deliver high quality health care in resource poor settings. In Rwanda Dr. Farmer and his colleagues at Partners in Health have applied this model and have helped to double life expectancy. Partners in Health currently supports the Rwandan government in providing services to more than 860,000 people in three hospitals, 42 health centres and employs more than 6,400 community health workers. Additionally Dr. Farmer has maintained his lifelong commitment to Haiti and continues to serve as the United Nations Special Advisor to the Secretary General on Community-Based Medicine in Haiti. In addition to this Dr. Farmer has written extensively on health and human rights and the consequences of social inequality. He has an impressive body of scholarly work that includes multiple important books and obviously scholarly articles. He is the recipient of numerous honours including the Margaret Mead Award from the American Anthropological Association, the Nathan Davis Outstanding International Physician Award from the American Medical Association, the Salk Institute Medal for Health and Humanity, the CDC Foundation Hero Award and a John D. and Catherine T. MacArthur Foundation Fellowship Genius Grant. In addition Partners in Health has been the recipient of the Hilton Humanitarian Prize. Dr. Farmer has received more than 30 honoree degrees from institutions including Princeton, Duke, Columbia, Northwestern and the University of Oslo. He is a member of the Institute of Medicine, the National Academy of Sciences and the American Academy of Arts and Sciences. I know of no physician who so clearly embodies the highest professional and ethical standards and aspirations of our profession. It's a great honour then for me to present the 2017 McLean Prize to Dr. Farmer. His lecture is entitled The Ebola Suspects Dilemma. Please join me in congratulating Dr. Farmer and welcoming him to the University of Chicago. Thank you. Thank you. Boy, I now know who I want to be my eulogist. I always thought it would be my mother but you've outdone her, Ken, and I appreciate it and it's great to be back. I am going to just use an example of a fairly recent dilemma which is the dilemma faced by people living in poverty who may have had, thought they had or thought by others to have or did have Ebola. But you'll see if you've listened to what every member of this previous panel has said that these are recurrent dilemmas and they're faced by all those as Han Saucy. By the way, can I just say, since we're at the University of Chicago, it's kind of cool that you have the smartest person in the world on your faculty and it's also kind of cool he's my best friend and you know Harvard could have fought harder you know but there you have it. But as Plato said, or as Han sometimes says, well as High Digger failed to note comma and then as you see from reflections from you know about from the Republic, meaning Plato's Republic, these are not new dilemmas. But as you've also heard from Renslow, progress can be very rapid in addressing them. Even in a place like the United States that has a patchwork barely poorly set up health insurance system, you still can see progress. You see the disparities that we need to attack in order to see real progress but you see progress. And that I hope explains my entrenched optimism. Others have said that it's explained by psychopathology. I don't care. I've got it. They often don't. They're the haters. Anyway, that's not a very ethical thing to say in front of them. It claims to endow this generous and wonderful award. But I'm going to start with a critical reflection on bioethics. And again, not the way it is practiced here and in many universities and by many, this last panel is a reminder that health disparities and thus social circumstances can be front and center in ethics and bioethics and medical ethics and often are. Now, what are the risk of alternative approaches to ethical dilemmas? Well, they're substantial. Every anthropologist says this, by the way. Context matters. But if we have to spend a lot of time arguing about that, that would be a sign of a lack of progress. The world that we live in, by the way, the last time I gave one of these lectures, it was too grumpy, my lecture. I don't think it went over well. Made for a nice written chapter, once edited by Han Saucy, but that is not my intention here to read out of paper. So this idea of living in the first world, a third world, is one, of course, that is not readily sustained by any kind of historical analysis, nor is it one that can be sustained with any rudimentary understanding of political economy, how the world works. Context matters. The first of these images is Haiti in 2010, but that's what parts of Rwanda and over the Congolese border looked like in 1994. It's what a lot of Sierra Leone or Guinea, to the north of Sierra Leone, looked like during their war. And the other, just as a reminder of the desert of the real, I thought people would chuckle at that. That's a line from The Matrix, but clearly I'm dating myself. My colleague, Katie, who helped me put the slides together, said desert of the real, where'd you get that? And I thought I was hip. The other one, so this is taken in 2010, this picture, and it brings up a lot of painful memories, I'm sure, for some of you, Evan among them who were there then. And the other is taken recently in the town of Harper in southeastern Liberia. And that's one of the places that Partners in Health has worked over the last three, almost four years in responding to the Ebola epidemic, which was really not ever just about one particular disease, but about the large-scale social conditions that are historically given and often economically driven that determine not only risk for bad outcomes, whether that be infection with a pathogen say, but bad outcomes once infected. And I'm not just talking about infectious disease, the same holds true for major mental illness, for diabetes, the list goes on, right? But that picture was taken recently, which, to me, it looks like the war was over last week or last month. But a lot didn't happen in the wars after the wars were ended in Liberia and Sierra Leone that could have altered the nature of our discussion about the Ebola suspect's dilemma in 2014. So most of those wars were over a decade or more before the onset of the Ebola epidemic, which is held to have started. Notice I say held to have started because we don't know. In the clinical desert, you don't have staff, stuff, space or systems to diagnose and care for people. And a clinical desert is almost always, by definition, a public health desert, right? So you do not have surveillance, reporting, et cetera. Any claim that we're confident about when and exactly where this started are probably overconfident. But in a decade between the time that ceasefires held and the beginning of the epidemic, there were billions of dollars of humanitarian assistance much needed, right? For example, if you look at that assistance and see that the majority of it was for peacekeeping troops, you would be quick to note. I hope that without peacekeeping troops, the war could not be stopped. It hadn't been stopped with a very large contingent of Nigerian forces and others from the West African economic community called ECOWAS, right? But those wars ground on and on and they were fueled by, again, the extract of trades. Blood diamonds, that's where this term comes from, right? So when we want to ask, well, why those three countries and no others? Because really, Nigeria, Senegal, Mali, Spain and the United States aside, where a significant transmission of Ebola did not occur, secondary cases, 99% of all the cases were in just those three countries. So why? Right? Because you can't ask a question in ethics without understanding at least something about what came before and places that are not, as anthropologists might say, ethnographically visible. 70% of the market for diamonds from Sierra Leone and probably all diamonds are in the United States. Latex for rubber from Nigeria, the United States. And on the list goes, these are interconnected problems across time and across space. Now, if you're on a clinic's, a clinical, you know, a clinic consult, some of you in this room are clinicians who have been on a clinical consult team. I have, right? And when you're asked to reflect on a clinical challenge in an ICU say, I mean, you don't want to start giving a lecture on history and political economy, right? Because that's not the kind of ethical assistance that's required, right? We're talking about the quandary ethics of the individual and their families, right? In an ICU case or, I mean, any service, right? So to be so expansive is not very helpful clinically. But this is a university where we're all getting a chance to step back and say, well, when is the quandary ethics of the individual not the only ethical question? And indeed, the Ebola suspects dilemma is a great example. Now, after the wars ended there, and some may ask, well, why Guinea? Why Guinea? There wasn't a civil war in Guinea. Well, because a quarter of all Sierra Leoneans chose to fled north, they didn't choose to flee. But when they did flee, they chose to flee north to Guinea, a quarter of all the population of Sierra Leone. So Guinea was very much involved in these wars. And these wars rolled out the red carpet for Ebola. Also, what didn't happen after the wars rolled out the red carpet. And let me let me illustrate a little bit further. First of all, that's to make you guys laugh. It's like, it's like Wrensley's pictures of children from Thailand. I had to block out to protect the innocent. Now, again, think about the University of Chicago's monumental decision to address a local ethical problem, right, which is that in the third largest city in the United States, and one of the most beautiful. There is a trauma desert in the south side of the city, right? And without a trauma center, that's what a trauma desert means, right? It means that if you can show as as we heard in thinking about insurance in India, if you could show that someone's too far away from a hospital, there will be adverse outcomes, right, especially in when there is intentional or unintentional injury involved, that is trauma. So this becomes an ethical problem for a university. The best, if I may, the best university, I'm not allowed to say in the country, even though you have the smartest man in the world on your faculty. But anyway, the storied University of Chicago and for the city of Chicago. And I would argue that it was addressing this as an ethical problem, not a problem of public health planning, a problem of, you know, what would be sustainable cost effective, etc. It was addressed as an ethical problem. And now we're going to have a trauma center here, which I think is pretty wonderful. I would like you to take good care of these guys on the either side of that innocent child. Max and Dr. Selwyn Rogers, both of whom are here sitting together, good friends of mine, who will be leading this effort, but relying on all of you to help them address this as an ethical problem. Because if it only becomes one about a bottom line of one sort of the other, well, there will be no justification in those frameworks, which are, and this is partly in your fault, University of Chicago. These are the dominant, this is the dominant religion of our day, neoliberalism. So whether or not you use the term, and everybody in Haiti does as as Evan Lyon said, these are our teachers, the, you're soaking in it, Maj. The, well, I could also go with the Chinese, the Chinese premier who said, this is the sea we're swimming in, right? We're swimming in the sea, it will not suffice for the justification of very important endeavor. The justifications are moral and ethical, and they come from this broad base view of what is fair and what is just. Now ethics exercises, again, I've made the distinction between the quandary ethics of the individual. All of us are going to face those ethics, we should not be dismissive of them, right? But in order to contemplate, to step back into a university and to contemplate in a broader context, ethical problems, this kind of desocialization is not a good idea. I tried to get the lights dimmed a little. They are dimmed. Can you see these okay? My cool new slides, so so. I could beg for a little bit of dimmer lights. My modeling days are over. Plus I have a runny nose, so. So I already said that war rolled out the red carpet for Ebola, but we don't talk about war when we talk about Ebola or about lessons learned. And if it is, it's tacked on as some kind of hasty addendum, right? And I know because I've been a part of a number of these exercises about lessons learned from Ebola, right? It's history itself that will reveal how many times the same thing has happened before. We don't learn about the why would people fear a healthcare delivery system? Well, if that healthcare delivery system is postcolonial, and Liberia is also postcolonial, right? Then you can bet that it has a long tradition of what we might call control over care. That is, that it is disease control and not caregiving that have been the primary focus of public health interventions, whether they're colonial or postcolonial. So not understanding how things were in living memory. I'll give one example that by the way, the picture isn't even from, isn't even from Sierra Leone or Guinea, which were British and French colonies respectively. And that's from Liberia, which was an American colony or American pseudo colony settled by Americans, right? And the same kinds of conflicts that it was seen on either side of Liberia were the ones seen there as well. And there were conflicts between sellers who were seeking to control diseases, tardily in the case of Liberia in the eyes of a very racist and hostile world, but nonetheless heavily influenced by colonial examples from either side of them, the British, French, and of course, it had been descendants of white Europeans who had settled North America, right? So this history is not a good thing to erase when we're stepping back to take a look at the dilemmas. And then finally, who's going to look back to events that would allow us to understand, for example, why the Museum of African History in Chicago is named Du Sable, you know, after a Haitian, right? Whose forebears were displaced to a city called San Mar, where Evan and I have both worked quite a bit, it would end up in the 18th century in a place displacing Native Americans to found what was later Chicago. Now, again, don't do this during rounds. That's not what I'm saying. I'm saying this is our chance to think through very difficult problems now to Ebola. So Ebola is from a is a phylo virus. Thank you. Now I knew you would do that. Now I did some caregiving for you as well earlier today. And now it's your turn. Caregiving, by the way, is is that was my transition caregiving. Caregiving is is what spreads Ebola. I'm just curious how many of you know that Ebola is spread by caregiving? Still a minority in a very, I think pretty substantial minority or there's a uncharacteristic modesty in University of Chicago, T speaking hall. So it is both of these viruses over these, this group of viruses, Marburg and and Ebola. Both of them are spread that way. Now what does that mean spread by caregiving? Well, the caregiving, first of all, is highly gendered, right? In much of the world. So the majority of caregiving for anyone with a serious or chronic ailment is the family. And inside the family, this is highly gendered, right? It's largely women and girls who are providing care for free, right? And so why is there more gender parody in Ebola cases, right? Because if it's a caregiver's disease, you're going to see majority women. Well, if you're Catholic, then you know that you could you could tell me, right? All the seven corporal works of mercy that you learned in CCD class, one of my friends said I could because she's a theologian, a Catholic theologian. But one of them is, you know, it's Feed the Hungry, Clothe the Naked. One of them is bury the dead, right? And burying the dead in this part of the world is is of course also the obligation of family just as it was in the United States until we outsourced that to a very expensive business endeavor. And now we all regard this as a given thing that we will not be washing the dead. We will not be clothing them and we will not be burying them. But in fact, that was the way of it in the United States as well. So those activities, that's what I mean by caregiving, you take you nurse the sick, you clean up after them. And then if you fail and many do, you bury them, right? That's the whole story. Now you heard many other stories about the spread of Ebola. So let me just say the first isolate the first outbreak that was identified again, you can't identify the cause of sudden death, febrile or otherwise, without the staff stuff, space and systems that you need, right? So ethical problem arises with the advent of any new technology. And Dr. Rana gave a good example of an ethical dilemma she's trying to make happen, right? Because the dilemma is there. Why is there so much eclampsia and preeclampsia in Haiti? And even more so, remember, there are two ways to think about risk, risk of infection, I said, and I said it didn't have to be a pathogen, but then risk of outcome. Not only is there more of it, outcomes are much worse. But there's a new technology. So we have an ethical dilemma and a human rights dilemma, right? Now returning to Ebola, 1976. This let's just say you're in a village in rural Congo. That's a big chunk of terrain right there, right? Former colony of Belgium. And you don't have staff stuff, space and systems there, right, to identify a new pathogen that would require electron microscopy, microscopy, and many or other tools, right? So there's an outbreak of sudden febrile death inside a hospital, a mission hospital run by Belgian nuns who are actually Flemish speakers, which even Han Saucy can't speak Flemish. Maybe you can actually. I bet he can. Now 100 bed hospital, how many doctors do you think they had there, the good sisters? Huh? One someone said. Zero. They had no doctors. Interesting definition for 100 bed hospital. Now you you don't have to ask questions about the motivations of these great ladies, right? It would be disrespectful, but also useful since we don't have a diagnostic tool for motivations. Do we Dr. Rana? Just say no. Well, what happened was they were using reusing syringes, the opposite of needle exchange, right? To do programs in villages that really didn't require syringes at all, prenatal vitamins. I mean, this happens all the time in so called third world medicine, right? Meaning medicine for poor people because we have the third world at home, which I already mentioned. So that means that not only were they using a different standard because they wouldn't have done that in Belgium, right? But they also were not. This is a nosocomial and iatrogenic, although iatrous, I think means doctor. Now I'm scared because Han's here and knows the meaning of every word. So however you would say nanogenic, Catholic boys aren't supposed to say that kind of stuff, right? How would you like to be the guy who told them the surviving nuns, right? Because a lot of their number died. There was no doctor to kill on staff, but one came in and he died and a couple priests died. This exploded in all those villages where they were doing unnecessary needle non exchange, right? How do they like to be the guy who explained that? Turns out a friend of mine who was an infectious disease fellow in 1976 in Antwerp who spoke Flemish, which only Flemish people speak by the way. Anthropologists are not supposed to use humor like that. He wanted to be involved in this outbreak and his boss said, who is an eminent infectious disease specialist, said, yeah, you can go and then he realized, shoot man, I cut my picture out of my passport for an urgent gym membership need. Who does that? Now he still got into the Congo because that's how post colonialism works first and he was the one to help explain to them what had happened, you know? That pattern and pathogen from an unknown animal host, probably a bat, a fruit bat, we don't know for sure, gets introduced into a circle of caregivers. That is, in this case, nuns, nurses, later doctors, but family members, and it spreads rapidly within a household and within social network, right? That's been the pattern every time for Ebola. And Marburg too, with the exception of the first case, and if Marburg sounds like a German city, that's because it is a German city. And because the first case, again, transmitted by through the offices of non human primates, lab monkeys sent from I think Uganda via London to Frankfurt, Marburg and Belgrade, right? Non human primates are also second. So it got spread to lab workers not doing research, but trying to develop polio vaccine. After that caregivers disease, same way, those nursing them. Now, did I already skip ahead all that? Did I do that on purpose? In any case, it's the next slide. This is the other ethical dilemma, right? And that is, look at case fatality rate if you want to learn a lot about what we could do. I just said that's why we talked about a trauma desert in the south side of Chicago, right? It's because of different case fatality rates, or you could look at morbidity complications of too late therapy, often surgical therapy for people or victims of trauma, right? Case fatality rate is always something to pay attention to and to be very suspicious when you hear claims of causality about case fatality that are not related to social inequalities, right? Because if you look all throughout the 19th century and a Hans gonna know which centuries before that, you look at differential case fatality rate from tuberculosis in North America, it was all about race, right? You look about differential case fatality from smallpox. It was about race, right? It was about Native Americans being overwhelmed because of their immunological naivete, right? So structural violence, and since Renzo brought it up, I'm going to use it again, structural violence was not front and center in those long centuries of explanation of differential mortality, but it needs to be. Now, I'm obviously trying to make an argument that the Ebola suspects dilemma, which is, do I seek care? Or do I not? Everybody seeks care. The question was, where would they seek it? And what would be available? Right? This picture is taken during the recent epidemic. And that is what was passing as an Ebola treatment unit, right? I would submit to you that an Ebola treatment unit or an ETU that looks like this has no T in the ETU, that a community care center that looks like this has no C in the CCC, right? And that people are not dumb, right? And there was a lot of reason for folks who fell ill with a fever from these three countries, whether it be in the cities or in the rural reaches in the east where it was held to have started under the eaves of a receding forest, that they got not only mixed messages from the supposed health communication experts that descended on them, right? They also had very good reason to doubt that they would find real care and real treatment in these units, right? And if you look back over history as we did not, you would find that exactly the same thing began in the late 19th century and endured all the way up to the wars, that is control over care. And it's very striking the tenor of the objections in the early 20th century toward the end of colonialism. And just to give one little example from another historian medical historian, his name is Myron Eckenberg, he wrote about the history of plague control in Senegal, right? And there's a plague epidemic. It's just I hope ending soon in Madagascar. But in Senegal, he interviewed men, elderly men, this is in the 80s, maybe the 70s when he did his field work about their history, the experience of plague control. And they had a lot of memories of a control over care approach, that is isolation, mandatory fines for having rats or mice in your house, destruction of housing, deportation, the list goes on, right? What they didn't remember was any kind of care. And when American soldiers, GIs, showed up in 1945, they were bearing two things, among others, weapons, for example, they also had DDT and antibiotics, which cure the plague, right? But the French said, no, we don't, we don't need that. We'll take the DDT, you can keep the antibiotics. Right? So that's control over care. And it was very much what was done from the Pastorian Revolution in the late 19th century through to the end of colonialism, at least in African colonies, and I believe in many others, Han will know. Now, case fatality rate in 1967, in Yugoslavia, or Central Europe, right, Hamburg, Marburg, Belgrade, was 23%. So even without knowing what it was that was sickening these lab workers and then their caregivers, they said, well, we might not know what it is, I'm sure we'll find out. Let's just apply the standard of care that we have. You lose a lot of, the symptoms of these diseases, both of them are what? Fever already said, nausea, vomiting, diarrhea, so sometimes massive fluid losses. And it's true that they hadn't been measured before. But that's called eyes and nose in American Hospital, ins and outs, right? It's not rocket science. If you have someone losing 10 liters of fluids and electrolytes a day, right, which some of my friends did when they got Ebola, my people I know, then, and you're vomiting, then, you know, you need the kind of care that you get in a trauma center, massive rehydration through large bore IVs. And I'm the surgeon, my surgeon buddy here would always make sure that was a central line, right? Now we'll go back to the therapy that occurred in this recent epidemic. First, I want to talk about those mixed messages and the, obviously I'm saying the bowl of suspects dilemma is, do we seek care? Or do we trust our mother and our grandmother and our grandfather, the traditional healer? Do we turn over the dead? Or do we trust these people enough, right? Perfectly legitimate set of questions if you're from the clinical desert, especially the war torn clinical desert, which by the way is pretty much the only places that Ebola epidemics occur in war torn clinical deserts, right? So what did what did we tell them the experts on infectious disease? By the way, I will say what somewhat defensively, I'm, you know, I've been interested in Ebola for a while. I can prove that because of my the cover of my best selling book, Infections and inequalities is a mass grave of the Ebola victims on it. That was 20 years ago. And my my publisher said, you know, Paul, I don't really think this is a good marketing strategy. And she was right. So Ebola, everybody who's an infectious disease doctor, did I mention I'm an infectious disease doctor? Did Ken mention that? We're all interested in because it has a terrible case fatality rate. But then again, we're not so sure that it needs to be that way. Right? And again, that is what we should be asking about every pathogen or pathogenic force. Does it have to be this way? Eclampsia, major mental illness, right? Diabetes, HIV disease. The list goes on. Now here's some of the messages that I saw my first, my first trip to Sierra Leone was in the summer of 2014 in the company of surgeons. And if you want to have a really good time, go somewhere with 100 surgeons. And as physiologists, they're kind of cool and collected compared to the surgeons. This was for a Lancet, a Lancet commission on the care of surgical disease for the, you know, what do you want to call them? The poor will do for me. And it's a term that's often, I've often heard from people living in poverty. So this, these Lancet commissions, by the way, when you talk about context matters, whichever anthropologist says, take opioids. Right? We have a crisis in the United States, an opioid crisis, as Renzo said. Well, there's an opioid crisis in Sierra Leone also. And that is that there are no opioids. Right? So if we always apply this kind of our experience, or our problems and project them to others is also a very significant ethical trap. Because having been on another Lancet commission that recently, without palliative care that just came out a couple of weeks ago, telling you a number of people wanted us to tone down the message about the crisis of opioids. And a number of us and particularly our colleagues from Africa said, please don't confuse your situation in the United States with the situation in the clinical desert. And we have an opioid crisis and it's no opioids. No morphine. Right? So this was another Lancet commission and it was about surgery. And as the first, the first, it was kicked off, the Lancet commission was kicked out off at Harvard Medical School. And there are three meetings usually three plenary sessions for these things. I'm sure it can has been involved in them. And the first one was at Harvard Medical School. And the third one, for financial reasons I won't go into, but it was cheap was Dubai. Harvard Medical School, Dubai, and this is about surgical disease and its management in the, you know, resource poor world. Not a good plan. So we said, let's go to the clinical desert for the second meeting. That's where we can have a clear, clear headed discussion about this problem as an ethical problem, as an analytic problem, how many people don't have surgical care? Right? In India, where we heard proximity to a hospital doesn't mean you're going to get in or a small amount of distance from a hospital doesn't mean you're going to get good care like the trauma desert of the south side of Chicago. So this is the thing about I've learned this is it's not so bad to be in charge of the finances. I was horrified when I thought I would be a department chair. It's kind of good to control. I'm looking at the dean because there were calls for us to cancel the meeting. The venue wasn't safe. Right? Freetown, the meeting was in June, and it was at the end of May. I know this because I knew someone who was an Ebola hemorrhagic fever expert Sierra Leonean. Right? So I knew what was going on. You knew in March that if it's in Liberia and in Guinea, it's going to be in Sierra Leone. Right? If you look at the map, you'll see why. But after that, in May, it was documented in Sierra Leone and there were some calls for us to change the venue. And I got to say, you know what? Ebola isn't spread through medical conferences. That's Legionnaires disease. We're not moving. I was an autocrat for a minute. A tiny autocrat. Anyway, it felt good and we didn't change the meeting. And I only knew I only knew for Sierra Leoneans. Oops, I was already on them. These are three of the four. Student of mine, Byler Berry, known for 10 years. He was at Harvard Medical School, doing a master's degree at the time. I had been his mentor. He started a community based organization in Eastern Sierra Leone right hard against the diamond mines, which by the way, back to GDP growth. Sierra Leone had the highest rate of GDP growth in the world in 2013 and was a clinical desert, right? Because India can have massive and sustained growth in GDP. But that doesn't mean at all that it will be translated into equity in an ethical manner, meaning invested in a safety net. It has not, right? Sierra Leone, Liberia and to a lesser extent Guinea, same story. Really rate high rates of GDP growth again through the extractive trades, very low rates of investment of the public dollar or private dollar. I mean, out-of-pocket expenses finance it, but very little investment in health care systems. Byler Berry, in the middle, Martin Salia, a surgeon who participated in the conference. And then Humar Khan, the fellow I knew, the infectious disease doctor, the specialist in hemorrhagic fevers. By November, two of them were dead of Ebola, right? Now, back to the quandary ethics of the individual. In both of their cases, Martin Salia and Humar Khan, the quandary ethics of the individual arose for very different reasons. And this could be the subject of an entire discussion. And I will only talk about Humar Khan. But the medical ethicists and everybody in the fellows who's gone to the McLean Center will recognize this. Maybe you'll even know the story. In July, so shortly after we left, the epidemic was devastating. The eastern parts of all three countries had already moved into the urban areas long previously. There was no stopping it in a clinical or public health desert. And people were fleeing, right? And then you heard all the stories about, well, it's because they're superstitious. They don't believe Ebola is real. They're eating bushmeat. They're fondling bats. Whatever it was, that's not what was going on, right? A pathogen is introduced every time it's a zoo analysis from an animal. But this is all being spread human to human in the course of caregiving, right? So to make it clear. But even when these two fellows fell ill, right? That cover of Newsweek, bushmeat, backdoor, that was honor about the week that Humar Khan fell ill. And he knew of course exactly what it was. He said, God, I hope it's malaria, right? But since a number of his close friends had already died in the hospital where he worked, the nurses, he knew what it was, right? So he thought, I do not wish to die in my own hospital, which is likely going to be closed down anyway, right? And he went east towards a unit that's set up by the world's largest medical humanitarian organization in a place called Kailam, right? Now he should have gone west and gotten the hell out of the clinical desert, many on a plane. This is the only expert in hemorrhagic fevers. He was going to spend the 2014-2015 academic year at Harvard on sabbatical, young guy, 39, you know, a champion for health and social justice in the country. And he goes the wrong direction, right? And couldn't get a ride out. Now, the ethical dilemma, inside a refrigerator, just a few hundred yards from where he lay being encouraged to drink coconut water, right? Which is not going to save you if you have enough nausea and vomiting and fluid losses. Inside a refrigerator are three vials of an experimental therapy called ZMAP. Now the historical, the world political economic system having been set up in proximity to West Africa, not geographic proximity, but that being the epicenter of the world global economy for some hundreds of years. And I mean Upper West Africa, right? That was set up hundreds of years ago, so it won't surprise you to learn that that was a Canadian company publicly financed that had made this new therapy, again, not tried in humans, tried in nonhuman primates. And there it was in that refrigerator. Now I would say that having a conversation about whether or not any experimental therapies should be used in the middle of medical emergency, I get that, right? Although I just don't think that's a ranking ethical problem. The ranking ethical problem was how did the world disparities get to be this way, the world disparities get to be this way, and how is it that all these nurses and doctors, the professional caregivers are dying, about to die or dead, you know, when they had so few to start with. But the big fight that went on over three days of conference calls between the World Health Organization, the headquarters, European headquarters of the the humanitarian organization, experts from the CDC, everybody had an opinion. It's interesting, though, that as far as I can tell, whom our cons opinion was not solicited, right? And some of the humanitarian doctors said, if we give an experimental therapy to a medical VIP, and not others, we quit. Now, again, I just hadn't thought of it that way, you know, that there was a great unfairness in contemplating giving an experimental therapy three vials to that region's one of the only experts they had and on hemorrhagic fevers. That's not the way I would have labeled the ethical dilemma. In any case, he did not receive it. He died three days later, and is buried not far from where he worked as a physician. The vials of ZMAP were airlifted to Liberia where they went to two Americans who survived. Now, whether or not they survived because of ZMAP, which I think unlikely, I think they survived because they were airlifted out to receive supportive and critical care. That's what you'd get in a trauma center, critical care, right? And it's not surprising, A, that in the deaths in the district where Humarkon worked, 15% of all the people who died were medical professionals. Now you think 15% of the population of Kenema district is medical professionals, right? And at the end of the epidemic, the case fatality rate among people my age and younger, a lot younger, was the same at the end of the epidemic as it was at the beginning. Meanwhile, not one of the Americans who fell ill died of Ebola, and that's because they got airlifted out of the clinical desert, including, as I said, a couple of friends of mine and a volunteer for partners in health. Now, why talk so much about health professionals? Doesn't matter. Caregivers, as I said, the majority of caregivers are not health professionals. And did Ebola spread through the back door of chomping on chimpanzees in Sierra Leone. There are chimpanzees in Sierra Leone, although I noticed they call them baboons there. It wasn't a good thing to say. Actually, those aren't baboons, those are chimps. I know how to keep my tongue. I know how to listen, as Evan said. So no, they didn't get Ebola that way. This young woman over here, that's her partner. They had a little baby. That's her best friend. Her grandfather, traditional healer. Her father lives with her in Freetown, goes to help his father when he falls sick. The old man, the traditional healer, dies. The younger man goes back home to Freetown. He's still sick. His daughter takes care of him. Her best friend, which is in, as does her partner. He helps bury the man. They all get sick with Ebola. Their baby dies. And other people in their family got sick as well. Everyone had a story like this. A story not of eating bushmeat or chomping on vats or whatever, but of providing care in the clinical desert. So that's why the ethical problems that we talked about today, health disparities, are not about the quandary ethics of the individual, unless it's an accumulation of the quandary ethics of the individual, which is what Vercow described in Silesia. And we can do that too, but not without a social justice underpinning for ethical considerations. For example, undeclose. How many emergency responses have we been involved in? I mean, collectively in this room. I can tell you that after the earthquake in Haiti, about half of all American households donated earthquake relief. And from the city of Chicago, I can tell you a lot of people chose Partners in Health to support and still do, which is why we were able as Partners in Health to do something different from the usual emergency response. By emergency response, I mean after war, after a so-called natural disaster. After the so-called unnatural disaster of war ended in Sierra Leone, Liberia, and Guinea in the sense of some of the refugees were repatriated. This did not happen. So the creation of a clinical desert requires war and unjust what Renzo was good enough to call structural violence, which by the way, I totally stole that from the liberation theologians. Not a very original thought. Health systems strengthening. What's that? We ought to just call it Beyonce because it is so boring a term, right? But it's really important to have a health system. And anybody who's been hit by a car shot by a gun, ingest something intentionally unintentionally that could kill them, or has a child who's acutely ill, you know, anybody knows that you need a health system, right? And to after war, you don't have one at all very often. And therefore, strengthening it really means building it. That did not occur after the wars, right? Training. I mean, how do we train a doctor? Last time I spoke here and talked about the trauma center, the clinical desert. So the way we train a surgeon, or a surgical nurse, or, you know, is it takes years to do that, right? For Selen Rogers, we're talking about a decade after finishing medical school. And so it is with all subspecialist surgeons, right? You don't do it by giving a weekend long workshop funded by your favorite international development agency to show a bunch of PowerPoint slides. At least I would recommend that you not see a clinician who has that kind of training. Which in the United States before the Flexner Act, Flexner report of 1910, that's exactly how medical training occurred. You get an MD at Harvard Medical School without working in a hospital. I may be exaggerating about Harvard Medical School, but just for effect, you know. And that that reform closed down a lot of medical schools, but made it the training, you know, and nursing was already better training, but made the training at least clinical. But the way we invest in development work, and in a lot of global health work alas, in training is just so superficial that I would say it's unethical, because it eats up a lot of money, right? And research, why you'd say, well, why would you conduct research in the middle of an emergency? Well, wouldn't you like to know if there were a vaccine that could work against Ebola? Wouldn't you like to know if a cholera oral vaccine could reduce rates of new infection? Wouldn't you want to know, you know, the kind of questions that Dr. Rana, they answer those questions that she asked? When you want a rapid diagnostic for Ebola? So actually, this is a time that a university should be investing in what it does best, which is training other people, generating new knowledge. And if you're in a clinical facility, like a trauma center affiliated with the University of Chicago, taken care of the critically ill and injured. That's what we should be doing. And this really is my close. So after the earthquake, after Ebola, rather, all of these pledges made, I mean, you heard there's billions of dollars pledge. Oh, yes, they were pledged. I was there at the UN hearing it, and taking notes. And then you just went back and said, Well, what happened to the pledges? Were they kept? The majority of them never, never reached West Africa. When I say the majority, the great majority of them, right? So what do you think that does to the local population and its trust for the health care system and the international do-gooders like me? I would say it further erodes that trust, right? Because that's the talk of the town and the city and the country is where did all those billions of dollars go? All right? Well, they didn't go into this. Now, after the earthquake, which as I said, was pretty traumatic for a lot of people, including some of us in this room. The same things happen, right? First of all, the academic medical centers of Haiti, such as they were, were destroyed in the earthquake. Right? This is the nursing school. I can tell you that none of the third year and Evan and I have extremely painful memories of these young women and they were mostly women. Almost none of the third year class survived. Neither did their faculty, right? If at this time, you could not say this is the time to rebuild a university medical center that does direct service delivery, that does training and that generates your knowledge. If you couldn't say it, then when would you say it in Haiti? And the fact that this idea was derided by experts, right? Experts in what? In global health, in development, right? It wasn't derided by our Haitian colleagues to say nothing of patients. It wasn't derided by people who said, gee, I don't know. It was derided by people who said, I do know and this is not a priority. It's not sustainable. It's not cost effective. It's not a priority. Again, if it's not a priority after this, it will never be a priority. And I have shown this before. So we said we're going to build a proper medical center, academic medical center, not to replace clinics or community health workers. Again, this is another thing you see all the time. It's pitting one good intervention against another. One good deed against another. Well, if you're doing this, you can't do that. The quandary ethics of the individual will always come back, right? If I'm hit by a car, I would like to be cared for in a trauma center. And in fact, I was hit by a car as a Harvard medical school. And no one leaned over to me as I lay in the street and said you should have looked both ways before you crossed the street. I should have. It was my fault. I heard my mother saying, Oh, PJ, Paul Jr. Why don't you look both ways, right? I was scolded by the chief orthopedics residents because she was tired, right? But she didn't say you should have looked both ways. She said, Oh, my God, you're messing up our schedule. Now we got to get to the OR right away because she just had a fat embolus. Right? I had good care, right? The Ebola Suspect Salema was there could never be any chance that there would be good care in those places. And that won't happen until we do this. So this staffed up space and this is the place. Dr. Rana mentioned it as HUM. I was thinking, wow, she thinks everybody knows what she's talking about HUM. Did you? This is University Hospital of Mirabalé. So I want to thank you for inviting me back to this university. Universities are great places to think. And these examples offer us great places, great things to think with. And that these challenges before us, whether on the south side of Chicago or in Rwanda or in the middle of an Ebola epidemic, these must remain and are ethical dilemmas. Thank you very much for having me back.