New England Journal of Medicine
December 19, 2013  Vol. 369 No. 25
http://www.nejm.org/toc/nejm/medical-journal

Shattuck Lecture
Chronic Infectious Disease and the Future of Health Care Delivery
Paul E. Farmer, M.D., Ph.D.
http://www.nejm.org/doi/full/10.1056/NEJMsa1310472

Excerpt
More than four decades after one U.S. Surgeon General reportedly declared it “time to close the book on infectious diseases,” drug-resistant pathogens have diminished the effectiveness of once-potent therapies.1 In the past three decades, newly described pathogens, including the human immunodeficiency virus (HIV), the severe acute respiratory syndrome (SARS) virus, and the H1N1 influenza virus, have caused pandemics, while old scourges from tuberculosis to cholera have persisted or resurged. Simultaneously, rising life expectancy and rapid social change have led to an increasing burden of chronic diseases for which we have effective therapies but inadequate innovation for delivering them efficiently to the neediest people — the so-called know–do, or delivery, gap.

As compared with discovery science and randomized trials, the 20th-century biomedical paradigm viewed care delivery as scientifically uninteresting — too messy for serious scrutiny, like the observational and qualitative methods that elucidate it. Yet understanding how and why care delivery does or does not happen and how to improve it may now represent medicine’s most important task.2

In settings of poverty, the delivery gap can be a gulf, especially in the case of chronic illness. In the rural villages and small towns in Rwanda, Malawi, and Lesotho, where the nongovernmental organization Partners in Health has worked over the past decade, adherence to daily regimens may seem unlikely. But rapid progress can be made toward closing the gap, as we had learned in rural Haiti. Work with local, national, and international partners to develop health systems able to respond to both acute and chronic disease shows that we can, with adequate resources, improve care delivery, sharply reducing morbidity and mortality. I believe that the lessons from 25 years of responding to the acquired immunodeficiency syndrome (AIDS) and other chronic infections have implications for the chronic afflictions now recognized as leading causes of premature death and disability in places rich and poor (a slide show is available with the full text of this article at NEJM.org)…