It’s called primary healthcare for a reason

by Eric Boa

The COVID-19 pandemic emphasised the importance of health in the community

Nobody makes films about dentists. So said a friend commenting on the dramatic potential of dental care. Marathon Man, a film starring Laurence Olivier and Dustin Hoffman from years past, does have an excruciating scene involving a tooth extraction, but it’s an exception. General Practitioners (GPs), the bedrock of human healthcare the world over, also largely fall short on the scope for dramatic possibilities. And yes, there are also exceptions, including the venerable Dr Finlay’s casebook TV series and of course The Citadel, a novel by A J Cronin that is credited with bringing about the foundation of the National Health Service in the UK.

I’m sure there are other examples of GPs and family doctors at the throbbing heart of films, TV, books and so on; yet there’s a wider point to make about primary healthcare: it’s really rather dull. Sniffles, scratches, spots, aching joints, dicky tummies and generally feeling off-colour are the order of the day. Consultations are short and follow a set procedure. Air Ambulance helicopters are not about to land outside the GP practice. There will be no rush to deliver a replacement kidney to the front door, or indeed witness any of the other medical procedures or ethical dilemmas that make hospitals such, well, dramatic places.

Primary healthcare in the poorer parts of the world has a similar low profile. Hospitals have a status and magnetic allure that ensures a high profile and enduring importance to the world at large. In the ideal scenario people go in really sick, often at death’s door, and emerge cured after wondrous interventions by specialist doctors and their heroic teams of nurses. All the medical attention in Gaza, that apocalyptic landscape full of wounded and desperately unwell people, is on the hospitals. The unheralded challenges faced by doctors trying to treat people are deeply disturbing, and yet the true misery and suffering of the masses huddled on the Egyptian border will ultimately derive from a primary healthcare system literally shot to pieces.

I don’t want to dwell on a single conflict, one of many where poor sanitation, over-crowding and bodies weakened by malnutrition are susceptible to a barrage of diseases. All are proof that what really matters to the health of people everywhere at all times is having access to basic healthcare. I’m reminded of another example of the crucial importance of primary healthcare from visits to the serene war cemetery in Comilla, Bangladesh, beautifully maintained by the Commonwealth War Graves Commission. Any thoughts of the misery caused by deaths in fighting and the sacrifices made by many on the battlefields were sadly undermined when I was told that many had died from cholera. A lack of primary healthcare was the reason they failed to return home.

There are more recent timely reminders of how a lack of basic healthcare provision has failed us. The impact of an outbreak of Ebola in West Africa ten years ago was heightened by weak primary healthcare. The frontline defence against the spread of infectious disease is in the community. Early reporting of outbreaks and swift responses wouldn’t have stopped Ebola spreading but it would have made a huge difference. Fast forward to COVID-19 and the case for better and consistent funding for health clinics and community health workers is magnified beyond calculation.

There are good reasons why primary healthcare systems are underfunded and neglected. The low-key nature of the work doesn’t immediately suggest huge and sustained improvements to human lives, even if the evidence to the contrary is over-whelming. It’s not a glamorous or indeed rewarding job for ambitious doctors, either financially or in job satisfaction. Vaccinating a child doesn’t have the same visceral impact as saving a damaged leg or preventing a death. The Gates Foundation is one of the world’s largest funders of human health projects. They have an admirable record in helping to find better ways to prevent malaria and other communicable diseases. Gates is also heavily involved in developing vaccines. Despite these admirable commitments, they pay much less attention to healthcare provision. A friend who works for the foundation explained this pithily: We don’t do slogging.

Yes, setting up and maintaining networks of GPs, nurse practitioners, community health workers and the like is hugely complicated and demanding. Connecting primary healthcare to secondary and tertiary healthcare (hospitals) equally so. But you have to start somewhere, so let me briefly outline how this could be done. I’ll make it even more difficult and challenging by focusing on plant health. The story follows a similar trajectory to human healthcare, though with an important difference. Plant health is not an obviously critical part of our lives. Sure, we all depend on plants, and they are the reason why our planet exists and survives, but this is too vague a justification for consistent attention by policy wonks, governments and international donors. A good plant pandemic, to be mildly cynical, always helps, though even the advent of rapidly spreading pathogens causing death and destruction to major crops such as wheat* and coffee*, has done little to shift the focus of attention away from research to finding a cure to the drudge of providing timely and regular advice to the masses.

I once had vague aspirations to being a senior researcher on the biology and behaviour of plant pathogens, developing new ways to characterize the fungi, viruses, bacteria and other microbes that attack plants. For maximum professional kudos I would work on a big disease of a big crop. Instead, I began my research studies on an obscure disease of a rather ordinary tree, here in the UK. The pattern was set and a decade on from completing my PhD I’d worked on diseases of bamboo in Bangladesh and cloves in Indonesia. Fascinating but prosaic research, and not the making of a leading scientist. My thoughts of being the plant equivalent of a medical consultant had gone. Not that I was ever that interested in the minutiae of microbes.

Plant health clinic in Tajikistan

I discovered primary healthcare by accident. It began with ad hoc plant clinics run in local markets in Bolivia, and a chance opportunity to build on this early experience in Uganda and Bangladesh. Along with two key colleagues, Jeff Bentley and Sol Danielsen, we explored how to run plant clinics in other countries, notably Nicaragua. The challenges of establishing plant health clinics are remarkably like those of human health clinics. So much so that we began to look at the medical literature for hints and suggestions on how to proceed.

There was no doubt that plant health clinics were meeting an unmet demand from farmers. We didn’t have the resources, however, to establish permanent plant health clinics and so concentrated on creating a flexible model that would attract the attention and commitment of governments and donors. The roadblocks to progress were substantial, not least in engaging with a myriad of agricultural agencies and institutes. We attempted to answer key questions. What is a plant doctor and is this a full-time job? What are the costs of running clinics and who pays? How do we organise technical support?

Each country we went to posed new challenges as well as opportunities. We learnt that NGOs** were a quick way to start plant clinics, but government involvement was essential for long-term success. Responsibilities for providing support to farmers were shared by a variety of national and local bodies who didn’t always collaborate effectively but had great individuals working for them. General agricultural advisors were better plant doctors than research scientists (despite their PhDs and Doctor title). On a practical level, plant clinics needed good publicity and a location easily accessible to farmers. We developed short courses for plant doctors and wrote lots of fact sheets for farmers.

After 10 years of trying out plant clinics in 14 countries we were ready to go for a Gates grant. The Biggy: grand ideas, serious money. We had solid evidence of what worked and had an ambitious yet realistic plan to establish primary healthcare systems for plants in the global south. The prospects for getting a modest (at least by Gates’ standards) grant were good. We almost, almost succeeded. Our proposal was rejected. We were given elegant reasons why, but that earlier judgment on Gates, and indeed on other funders of primary healthcare still stands: We don’t do slogging.

* For those interested in learning more, see plant pandemic reports on wheat rust and coffee wilt :

www.researchgate.net/publication/365926332_Ug99_Stem_Rust_breaching_wheat's_defences

www.researchgate.net/publication/367074712_Coffee_Wilt_Disease_The_forgotten_threat_to_coffee

** Non-governmental organisations – the developing world is full of them.