This article originally appeared June 1, 2013, on ASCO Daily News.

Paul Farmer, MD, PhD—physician, medical anthropologist, and an ardent champion for health care for people living in poverty—will share his insights on global health and cancer care at this morning’s Opening Session (9:30 AM–12:00 PM, North Hall B1). Dr. Farmer is the Kolokotrones University professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School; chief of the Division of Global Health Equity at Brigham and Women's Hospital; and the United Nations special adviser to the Secretary-General on Community-Based Medicine and Lessons from Haiti. An expert in infectious diseases and a leader in the movement for global health equity, Dr. Farmer is committed to delivering high-quality health care to those who most need it and who cannot afford it—a commitment that started early and has never waned.

Dr. Paul Farmer

As an undergraduate at Duke University, Dr. Farmer used prize money from an essay competition to visit Haiti, where he witnessed firsthand how the poorest of the poor lived in the country’s Central Plateau region. He proved to be an unconventional medical student, using many of his holidays and vacations to bring medicines to the poor in Cange, an extremely poor squatter settlement in the region, and returning to Harvard for labs and exams. By the time he received his medical degree and doctorate in anthropology in 1990, Dr. Farmer had seen and treated more diseases associated with poverty than many U.S. doctors might see in their lifetimes. In Cange, Dr. Farmer realized that delivering effective health care to the poor cannot be achieved solely by improving access to drugs. He helped establish a first line of defense, which included disease prevention programs, a protected water supply, and improved sanitation infrastructure, and helped train members of the local community as community health workers to help care for patients in their homes, accompany them to the clinic when necessary, and overcome barriers to accessing treatment.

In 1987, at age 27, and even before he received his medical degree, Dr. Farmer cofounded Partners In Health (PIH) and its sister organization in Haiti, Zanmi Lasante (ZL), which treats all patients who arrive at the clinic and works with partners to build schools, water and sanitation systems, and houses for the poor. In Cange, Dr. Farmer and his colleagues at ZL particularly concentrated their efforts on treating tuberculosis (TB) and other infectious diseases. Today, PIH/ZL operates clinics and hospitals at 12 sites across Haiti’s Central Plateau and lower Artibonite, including a new national teaching hospital in Mirebalais, built and operated in partnership with the government of Haiti. ZL is the largest nongovernment health provider in Haiti.

PIH/ZL started as a two-room office, one-doctor clinic in Cange, working closely with a growing network of community health workers. Today, it has sprouted into an international organization that currently has 14,000 employees and manages dozens of hospitals and clinics across the world; a process which evolved in small steps at first, followed by giant strides later.

Dr. Farmer and PIH became leaders in global health when they entered the debate on the ethics of treating AIDS in settings like Haiti and sub-Saharan Africa. Despite the prevailing international opinion, PIH provided incontrovertible proof that AIDS can be effectively treated among the poorest of the poor. PIH worked with pharmaceutical companies, the International Dispensary Association, the Clinton Health Access Initiative, and other partners to increase access to antiretroviral treatment for HIV. In Haiti, ZL's HIV Equity Initiative was one of the world’s first projects to use antiretroviral therapy to treat people with HIV in resource-limited areas.

In the mid-1990s, PIH's sister organization in Peru, Socios En Salud, provided a model for treating multidrug-resistant TB in Carabayllo, a shantytown on the outskirts of Lima. Socios En Salud’s successful treatment and cure of TB and MDR TB in difficult settings changed international protocols and standards of care. This was a turning point for PIH and for the global health equity movement. In 2001, the Open Society Institute invited PIH to take over primary responsibility for clinical care at a TB project in Tomsk, Siberia.

In these efforts to treat HIV and TB, PIH showed that the accepted standard of care, which treated patients in the developing world differently than those elsewhere, was inadequate and grossly unfair. Dr. Farmer and PIH faced the daunting task of delivering expensive and complex interventions in settings of poverty. Delivering services to all who need them, “not selling services to those who cannot afford them,” was fundamental. Dr. Farmer believed in the mantra “better to ask forgiveness than permission,” and was able to connect the resources of Boston academic medical centers to rural communities in Haiti and elsewhere, helping to ensure that the fruits of science benefit all.

Over the course of the next decade, PIH’s work expanded to rural Rwanda, Lesotho, Malawi, Mexico, Kazakhstan, Boston, and the Navajo Nation. Dr. Farmer and PIH have received numerous awards and recognitions. In 1993, Dr. Farmer received the John D. and Catherine T. MacArthur Foundation Award (also known as the “Genius Grant”) and used the monetary award to found the Institute for Health and Social Justice, PIH's research and advocacy arm.

Q: What influenced your interest in administering health care to the very poor?

A: The effort to deliver high-quality health care to all who need it is both an intellectual challenge and a moral obligation. Physicians are trained to follow the pathologies that they seek to treat. For an infectious disease specialist like me, that means working among the poor. While I was an undergrad at Duke, I had the honor to learn from a nun named Sister Julianna, who advocated for poor migrant farm workers in North Carolina. Working with Sister Julianna in the fields sparked my interest in understanding the social and political structures that engender oppression and inspired me to take my first trip to Haiti. I have also been inspired by theologians like Gustavo Gutierrez, whose commitment to a “preferential option for the poor” has deeply influenced my practice as a physician and as an advocate for the oppressed. Accompanying patients in places like Haiti, Rwanda, Peru, and Boston has been a reminder of how important this work for health equity is—and a constant motivation in itself.

Q: Jim Kim, a cofounder of PIH, is now World Bank President. How does the World Bank partner with PIH to achieve its mission?

A: When we first had the idea for Partners In Health—and that “we” includes not just Jim and Ophelia [Dahl] and Todd [McCormack], but also Tom White and Father Fritz Lafontant and so many others—it was entirely based on the concept of partnership. At our sites today we work alongside not only thousands of community health workers, but also architects, agronomists, and economists. As for the World Bank, their stated mission is “a world free of poverty.” After working Jim for 30 years, I know how deeply committed he is to that mission and am excited to see how the World Bank moves forward under his leadership.

Q: How do partnering organizations assist in or complement PIH’s vision?

A: Partners In Health has always relied on partnerships—it is part of our name and part of our strategy. From the beginning, we have worked closely with many partners to care for our patients and help them get all of the services that they need. Cancer care is a good example. We worked closely with the extraordinary clinicians—and I’m including physicians, nurses, pathologists, and laboratory specialists here—and leadership at the Dana-Farber/Brigham and Women’s Cancer Center to develop the public Butaro Cancer Center of Excellence in Rwanda, built in collaboration with the government of Rwanda. We partnered with architects at MASSDesign and even made common cause with a NASCAR driver—Jeff Gordon’s Children’s Foundation has been a key partner in the Cancer Center. We are grateful to all of them and would not be able to do our work without many partnerships.

Q: What are the deciding factors in where you expand PIH’s efforts?

A: The most critical factors, from the very outset, have always been need (where is the burden of disease greatest?) and gap (where are needs not being met?). In the mid-1980s, Haiti was the poorest country in the western hemisphere (and it remains so today), and also had some of the highest rates of HIV infection in the world. We went to Peru because of the gap: the growing burden of drug-resistant tuberculosis was being largely unaddressed. We went to Russia—to Russian prisons to be exact—for the same reason. Our most significant expansion in the past decade has been in Rwanda, which had a very high burden of disease but also a strong commitment from the public sector to combat it. That is where our model can be most successful.

Q: How can the PIH model for infectious diseases be replicated in cancer?

A: Many of the cancers we see are not strictly “noncommunicable”—I’m thinking of how much Kaposi sarcoma we see at our sites in rural Africa, or how much cervical cancer we see in rural Haiti. So the dichotomy between communicable and noncommunicable—like the “dichotomy” between prevention and treatment—is often a false one. The PIH model is not focused on a single disease, but rather on working in partnership with national governments to build comprehensive systems of care. All of the work that we’re able to do—administering a chemotherapy regimen, safely delivering a breech baby, setting a broken bone—is dependent on infrastructure, training, and resources: what we call the “system of care.” This model links community health workers, local clinics, and hospitals supported by a feedback loop of research, training, and service.

Q: PIH has reached 2.5 million impoverished people across 10 countries, yet you’re quoted as saying, “I go to bed worrying about the promises we’ve made, and I get up each morning thinking we haven’t made enough promises.” Why?

A: There is much suffering in our world, and so much of it is caused by inequity. Partners In Health actively seeks to deliver high-quality care—the fruits of modern medicine—to the poorest of the poor and the most vulnerable. We are committed to this mission, and we’ve achieved a lot in the past 25 years. There is still, of course, a great deal of work to be done. Many people are still dying of preventable, treatable diseases. There are always new challenges (and new pathogens). Our work will not be a success when we reach most of the people in need, but all of them.

Q: What message will you have for health care professionals treating cancer during your lecture?

A: Cancer is everywhere and we need to treat it where we find it. Eighty percent of the burden of disease in your specialty falls on the developing world. The pathologies are the largely the same, and the treatments can be the same, too. The diagnostic and therapeutic advances of the past half-century have been astounding, particularly in oncology. The challenge, of course, is delivery. So we need to meet it. We need to deliver high-quality care, and we need to deliver on our promise to care for patients to the best of our ability and training.

References

  1. Partners in Health. Accessed at www.pih.org.
  2. Kidder T. Mountain Beyond Mountains. The quest of Dr. Paul Farmer: a man who would cure the world. New York: Random House, Inc, 2003.

 

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