April 2008

Meet Our Featured Guest Columnist:
Dr. Paul Farmer

is the founding director of Partners In Health, an international aid organization that combines research, training, advocacy, and direct health care services to help people living in some of the poorest areas of the world. Partners In Health empowers local communities by training local residents as doctors, nurses, and outreach workers and allows the views of local residents to shape the actions of the organization. Dr. Farmer developed programs to provide treatment for tuberculosis and HIV patients in Haiti at a time when many argued that these diseases were too expensive to treat in impoverished communities.

Q: What does "health and human rights" mean to you?

A: Social and economic rights, which include the right to health care, have been termed the "neglected stepchildren" of the human rights movements and held up in opposition to the political and civil rights now embraced, at least on paper, by many of the world's governments. So striking is this division within the rights movements that some have come to refer to social and economic rights--that is, the right to health care, clean water, primary education, a decent livelihood, and other basic entitlements--as "the rights of the poor."

Though the privilege of working with colleagues, students, and patients in impoverished settings around the world, I've come to see access to health care, access to jobs, and not starving to death as fundamental human rights. One need only read the Universal Declaration of Human Rights: articles 25 and 27 speak directly to these ideals:

Article 25: (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Article 27: (1) Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.

Q: What experiences led you to a career providing health care in some of the world's poorest regions?

A: Understanding the connection between my country of origin and Haiti--and then, later, other countries--and recognizing that these are stories of proximity and not distance was an important realization for me. We are connected to Haiti in important ways, as well as to other places where there is violence and poverty and suffering.

As a college student, I got involved in migrant farm worker issues. Some of the workers were Haitians, and they living under such bad conditions that I was forced to ask why they would leave their home country to be treated so badly here. I wanted to be able to respond to a challenge a migrant farm worker posed to me: "If you want to know why I left Haiti, you should go there and find out for yourself." So, between college and medical school, I went to Haiti, and what I saw there was so compelling that I never left. In fact, Partners In Health grew out of that initial personal commitment to a few villages in rural Haiti.

Q: How can an individual person make a contribution to global health?

A: I think we should regard the condition of our lives, of modernity in the 21st century, as different. Consider medicine: no one would confuse the early 21st century with the mid-20th century. No one would deny that only 60 years ago the practice of modern medicine was completely different from and far inferior, in most ways, to what it is now. Look at the information revolution or the advances in diagnostics and therapeutics, for example. But the tools and the fruits of modernity are largely controlled by us--people with access to resources such as education, computers, and modern medicine.

Those are my two premises. One: modernity is different. Two: the fruits of modernity are unevenly shared. That leads me to answer the question in a very specific way. We should acknowledge our privilege and acknowledge the fact that the fruits of modernity are not shared equitably, and then ask the strategic question: How can we share them? The list is pretty much infinite. You can work on drug development, or raise money for Africans living with HIV, or lobby for universal health care in the U.S., or study international food aid, or coordinate policy forums or film screenings relevant to the questions that you ask. You could make a contribution to the remediation of inequalities and unnecessary human suffering in dozens of ways. In my experience, one of the things that people need to do is to figure out what appeals to them personally. Find out what you like to do and what you are good at, and then do it--ideally with like-minded colleagues--in a humble but persistent way.

Q: What specific health projects have been especially rewarding to you in Haiti, and what lessons can your work in Haiti teach us?

A: I was lucky enough to make my first trip to Haiti almost 25 years ago; Haiti has been the best teacher I've ever had (and that's saying a lot). Working there taught me several things: that all enduring, good work is done by teams (no doctor can be effective alone); that public health and public infrastructure is always important (even the biggest and most beautiful mission hospital cannot serve the people of an entire region, much less a nation); that community-based care relying on local health workers is the secret to success for programs for chronic diseases, including AIDS and tuberculosis; that some services should not be sold, even for the tiniest price, because there will always be some who cannot pay, and the ones who cannot pay are precisely the people we came to serve in the first place. These are also the people who are, often enough, hungry. There's only one treatment, we learned, for that affliction: food.

With these hard, if seemingly obvious, lessons came great success for the projects we undertook in Haiti. Over the past decade, our work there expanded rapidly whenever we held true to our principles. What was in 1985 a tiny clinic now serves, through the public sector and with the help of an army of community health workers, nearly two million Haitians annually. Over the past two years, Partners In Health has launched new projects in Rwanda, Lesotho, and Malawi in conjunction with the Clinton Foundation and the governments of each of those countries; we believe that the lessons we've learned in Haiti are now serving us well in rural Africa, the epicenter of the AIDS epidemic.

Q: Can you explain why HIV and Tuberculosis affect the poor disproportionately?

A: Large-scale social forces, such as racism, sexism, political violence, poverty and other social inequalities, are rooted in historical and economic processes and impact disease distribution and risk, access to health care, and treatment outcomes. I've referred to these social forces as 'structural violence,' which predisposes the human body to pathogenic vulnerability by shaping the risk of infection and subsequent disease reactivation. After infection, structural violence also determines who has access to diagnostics and effective therapy. Drugs that could stop or slow down epidemic disease are not available in the places where they are needed most, where these diseases take their highest toll. And so the uneven distribution of medical and technological advances contributes to increasing the "outcome gap," shaping the incidence and prevalence of infectious disease at the individual and social levels.

Often, public health experts recommending policy for poor countries believe that the high cost of treatment, the lack of infrastructure, and patients' inability to adhere to treatment render disease control and treatment impossible. Our own experience in providing health and social services in Haiti, Peru, Russia, and Africa suggests that this is simply not true. Relieving health inequalities depends ultimately on addressing basic social ills. We can address the lack of basic tools, from diagnostics to therapeutics; the lack of healthcare workers; and the absence of community-based models of care in locations far from laboratories, doctors, or nurses. And we can also tackle broader obstacles to well-being, such as a lack of roads and cultural and linguistic barriers. In so doing, we hope also to contribute to the basic goal of alleviating poverty.

Q: What are the challenges in treating multidrug-resistant tuberculosis?

A: Multidrug-resistant tuberculosis (MDR-TB) is defined as strains of TB resistant to the two most powerful antituberculous medications, isoniazid, and rifampin. MDR-TB is more difficult and more expensive to treat than its fully susceptible counterpart, often requiring18-24 months of therapy with four to eight different medications, including daily injection for at least 6 months. These drugs are complicated to dose and have a wide range of side effects that are often difficult for patients to tolerate. Infection control is also an important consideration.