At the intersection of medicine and community-based health

September/October 2023 | Volume 22 Number 5

Photo courtesy of Gabriel Diamond Dr. Raj Panjabi visits a patient at home in Liberia.

Dr. Raj Panjabi served as special assistant to President Biden and senior director for Global Health Security and Biodefense at the White House National Security Council from 2022 to 2023. He also led the U.S. President’s Malaria Initiative and advised the WHO’s Independent Panel for Pandemic Preparedness and Response. A graduate of the University of North Carolina School of Medicine, he received a master's of public health in epidemiology from the Johns Hopkins Bloomberg School of Public Health, and trained as a clinical fellow at Harvard Medical School and Massachusetts General Hospital. He was an assistant professor at Harvard Medical School, an associate physician at Brigham and Women’s Hospital, and a faculty member of Harvard Kennedy School of Government. In 2007, he co-founded Last Mile Health, a non-profit that has partnered with ministries of health in Ethiopia, Liberia, Malawi, and Sierra Leone to make sure that more than 12,000 community and frontline health workers who serve over 12 million people in these countries have the necessary skills, supplies, salary support, and supervision. Born in Liberia, Panjabi fled with his family from civil war when he was 9.

What touchstones serve as guiding principles for you?

When I was a child, my father always said, “No condition is permanent.” We're not defined by the changing conditions that we face; we can choose how we respond. This lesson was reinforced by my experience during the civil war in Liberia as well as during the nights and the weekends when I helped at my dad at his clothing store in Winston-Salem, North Carolina. Whenever business was slow, I’d repeat those words to myself like a mantra: “No condition is permanent.” This advice helped me throughout my career in primary care, infectious diseases, and public health.

My second touchstone is one I learned about 20 years ago in Alaska, working my first job in public health in the Yukon River Delta, where the community health aides were instrumental in stopping or at least controlling a tuberculosis epidemic. I saw firsthand the value of investing in the people closest to the problem. And, later, I understood the need for a similar approach when I returned to Liberia 17 years ago and found utter destruction—50 doctors left in a country of 4 million people—and again during the Ebola outbreak of 2014-16, a time of real fear and mistrust. People ran from health centers rather than towards them. Knowing we had to meet people where they were, we looked beyond the walls of our health centers. The community workers became part of our medical team. After learning to identify Ebola symptoms, they, quite literally, went door to door, finding affected people, getting them into care, hunting down the virus, and helping to stop it in its tracks.

These two ideas—no condition is permanent and invest in people closest to the problem—continue to guide me.

Photo courtesy of Adam Schultz Dr. Raj Panjabi shakes President Biden’s hand in the West Wing of the White House.

What are your takeaways from the U.S. President’s Malaria Initiative?

When President Biden appointed me to lead the U.S. President’s Malaria Initiative in February, 2021, it didn’t surprise me to see so many countries using a community-based approach to work towards reducing mortality and morbidity of malaria, and, in some cases, eliminating it. They were bringing rapid tests and antimalarials to people’s doorsteps, and they’d refer people with severe disease to the hospital. So one of the first things I tried to do with the teams at USAID and CDC, which together implement the U.S. President’s Malaria Initiative, was to reverse a 15-year-old policy that said U.S. government funds could not be used to pay community health workers. I knew that these workers were central to launching a new strategy that I believed would prevent another billion malaria cases by 2025. It’s crucial to combine medicine with community-based efforts to distribute the fruits of modern science equitably.

Where did we succeed and where did we fall short in the global COVID-19 response?

The U.S.’s biggest successes are around demonstrating global leadership and mobilizing financing for the global response. Some $34.5 billion is estimated to have been spent on the COVID response by the U.S. and other countries. The U.S. contributed almost $20 billion of that, if you count $16 billion through multilateral organizations and funds used to deliver vaccines to countries (plus testing, treatment, oxygen, and other items). Some 70% of the global adult population has been vaccinated with the primary series, including 80% of the over-60 age group and 82% of health care workers. And as the variants evolved—from the very first strain to omicron and its subvariants—our ability to keep focus on genomic sequencing has been vital. This is progress.

But more must be done. The gap has been in terms of speed and equity. Africa still lags behind other regions—less than 30%, on average, are fully vaccinated in sub-Saharan Africa—and, generally, low-income countries around the globe are behind in vaccination, testing and treatment. To date, over 687 million vaccines have been delivered to over 116 countries, but we've got to do more to decentralize manufacturing so that countries and regions can make vaccines and medicines locally.

Tell us about the new pandemic treaty being negotiated at the WHO.

A lot of effort is going into strengthening implementation of the International Health Regulations. This critical treaty on pandemic preparedness and response has been around for decades, but we need stronger compliance with its goals, which include joint external evaluation of national action plans for health security and faster reporting of events like SARS-CoV-2. Separately, U.S. Ambassador Pamela Hamamoto has been leading a team across the Departments of Health and Human Services and State to prepare for upcoming negotiation sessions on the proposed pandemic accord at the World Health Assembly in May, 2024. We're in the middle of negotiations, in which we hope to highlight our COVID-19 lessons-learned—around speed, efficiency, and effectiveness of the response, and about equity.

There’s also a need for more political leadership, not only during pandemic responses, but also for pandemic preparedness and prevention. In September there was a first high-level meeting of heads of state at the UN whose participants agreed on the world's first political declaration on pandemic preparedness and response. This is important, because another COVID-19-like novel respiratory-transmitted pathogen could lead to another pandemic again soon—in 25 years, say, as some modelers estimate. While these negotiations continue, we have taken immediate action. The U.S. has put forward two major global health security initiatives. One is to more than double the number of U.S. global health security partners from about 19 to more than 50. That's a commitment the president has made. We also want another 50 countries supported by other partners down the line. Our second initiative is working with the G-20 and G-7 to stand up The Pandemic Fund, which focuses on supporting low and middle income countries, and seeks to strengthen epidemic and pandemic prevention and preparedness at the World Bank. Currently, this fund has almost two billion dollars in seed financing from about 17 countries and three major philanthropies.

What should be Fogarty’s priorities in terms of pandemic preparedness?

First, it's worth acknowledging just how much Fogarty has already achieved in terms of keeping people safe in other countries—and at home. One example is Dr. Christian Happi, the former Fogarty Trainee who was first to detect a SARS-CoV-2 strain in Nigeria; another is Dr. Sikhulile Moyo from Botswana, also a Fogarty trainee who’s been credited with first detection of the omicron variant in southern Africa. I hope Fogarty will build on this tradition of investing in trainees, because it’s always the folks working in everyday health systems who are called to act during emergencies.

What needs more attention is the step preceding development of vaccines and therapeutics—we need safe, rapid, localized clinical trial capacity. In the context of a biodefense strategy, the target goal is 100 days to develop and authorize a vaccine, 130 days to manufacture it at-scale, and 200 days to work with partners so that anyone around the world at-risk can get it. Pathogen-specific testing needs to be available within 30 days or less from an identified biological incident. We also need to repurpose existing therapeutics and hopefully prove them effective within 90 days and then develop and authorize novel therapeutics in 180 days. And, what’s needed to achieve each of these separate goals is a commitment to stand up clinical trials within 14 days of the next biological incident.

The technical know-how is there, and the funding must be there, too. Some $10 billion was spent towards biodefense priorities in 2022, but we need to be even bolder if we’re to unlock the scientific potential we possess. In fiscal year 2024 the president has requested congressional approval of additional financing towards pandemic preparedness and biodefense.

How do we keep preparedness alive barring a global crisis?

One of the more effective ways is by thinking about preparedness and response as outputs of a muscle. Muscles get stronger by using them, so we can build our preparedness muscles by using our existing response muscles that we use to tackle HIV/AIDS, malaria, tuberculosis, and other infectious diseases globally. Take the countries in Southeast Asia that receive research dollars for malaria and HIV. Vietnam did well early in the COVID-19 pandemic, partly because they'd been building their health systems to combat epidemics. 

We’ve also got to do better at telling the story of how we are stopping infectious disease outbreaks faster. Uganda stopped its 2022 Ebola outbreak in less than 100 days, which was faster than had been done in the past. This kind of progress is important and helps people understand the value of advance planning and prevention.

How do we get out ahead of misinformation and disinformation?

There's no silver bullet—that’s the first thing we need to acknowledge. Investing in communities is an antidote to the plague of mistrust we face in public health. Whether it’s a community health worker in Liberia or a church leader in the U.S., local actors have lived experience and expertise that we in government or the policy community often lack. They may not have medical or public health degrees, but they work in the marginalized communities that are at highest risk of suffering from misinformation and disinformation, so they are the ones who best understand how to convey health and science information.

I remember talking with a community health worker in Liberia, who’d gone door to door to find patients during the Ebola epidemic. I asked, “Why did you step up?” And she said, “It's simple. I love my community, and my community loves me.”

We also need to teach more science at the earliest levels of school, so people become more literate in science and statistics.

Finally, we've got to put our words where the problem is and then put our money there, too. We need to say that pandemic policy is not just about investing in products, we need to invest in people—in a stronger public health workforce. Whether it's in the U.S. or other countries, it’s exciting to create public health jobs in local communities, local economies.

More information

• Last Mile Health
• National responses to covid-19: drivers, complexities, and uncertainties in the first year of the pandemic
  BMJ, 2021
• Biden-⁠Harris Administration Announces Expansion of Global Health Security Partnerships and Releases Annual Progress
  White House Fact Sheet, November 29, 2022
• The Pandemic Fund
• Adopting Landmark Declaration, General Assembly Calls for Strengthening High-level International Coordination to Improve Pandemic Prevention, Preparedness, Response
  United Nations news, September 20, 2023

Updated October 17,  2023

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Related Global Health Research Topics

• Global health security