Champion Of the Poor

By Philip Elmer-DeWitt / Rwinkwavu

When Paul Farmer first went to Haiti in 1983, he was studying medicine and anthropology and hoping to become a doctor for the poor, perhaps in Africa. He eventually became America's most celebrated doctor for the poor, made famous by Pulitzer-prizewinning author Tracy Kidder in his 2003 book, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.

But it wasn't until this spring--22 years later--that Farmer, now 46, made it to Africa. He was invited by the Clinton Foundation and the government of Rwanda to do for this tiny East African country, still trying to pull itself together after 1994's genocide, what he and his team had done for Haiti.

What Farmer and his Boston-based charity, Partners in Health (P.I.H.), did in Haiti--the poorest, most disease-ridden country in the western hemisphere--is build a showcase public-health system that each year delivers high-quality medical care to 1.3 million peasant farmers, about one-sixth the country's population. There he also helped rewrite the protocol for treating multi-drug-resistant tuberculosis and pioneered several medical practices at the time deemed hopelessly quixotic--such as giving impoverished AIDS patients first-line antiretroviral drugs (ARVs)--that have since been widely adopted.

When Farmer arrived in Rwanda, the Minister of Health called a meeting and asked him where P.I.H.'s doctors wanted to set up shop. The minister in charge of HIV/AIDS, who knew Farmer's work, answered for him: "Just put them in the worst, most rotten part of Rwanda, and they'll flourish."

Six months later, it's clear the AIDS minister was right. The site that Farmer's team was assigned--an abandoned hospital in a rural province with a population of 340,000 and no doctors--is drawing patients from miles around--women in brightly colored skirts, men in tattered work clothes and children in whatever happens to fit. (It's not unusual in rural Rwanda to see what appears to be a 5-year-old girl in a ruffled dress and discover when she squats down that she is a he.)

In the wards, the beds are filled by patients with AIDS, TB, malaria, typhoid, cholera, malnutrition and anemia. Some will die. Most will be cured. All will be treated with as much care and attention--if not more--as is afforded wealthy patients at Harvard Medical School and Boston's Brigham and Women's Hospital, where Farmer has joint appointments. He calls this approach the "preferential option for the poor."

Any Western-trained physician who has practiced even briefly in a poor country is acutely aware of how inequitably money and medical care are distributed in the world. Farmer, who grew up in a Florida trailer park, has developed what Kidder calls a "comprehensive theory of poverty," which Farmer elaborates on in books that are surprisingly angry for so gentle a man. In Pathologies of Power (2003), his most recent, he argues that the only antidote for the "structural violence" that keeps the poor too sick to climb out of the hole they are in is to treat health care as the most basic human right and do whatever it takes to deliver it.

Farmer is, above all, a gifted clinician, and he developed in Haiti something he calls "the P.I.H. model," a formula for administering first-class health care in dirt-poor settings. Every AIDS or TB patient is assigned a paid health worker, or accompagnateur--generally a friend, relative or neighbor--who will handle the drugs and make sure they are taken on schedule. The patient is also given what the doctors hope will be enough food for a family of five. "You can't take these meds on an empty stomach," Farmer explains, "and you can't treat a wasting disease like AIDS or TB without calories." The extra rations are to avoid situations in which the sick have plenty to eat but their families starve.

The effectiveness of the model is evident when Farmer does checkups on AIDS patients after their first few weeks on ARVs. Hadija, 11, pretty in a pink dress, has gained nearly 7 lbs.; she shyly admits that her diarrhea has cleared up. Clementine, 35, a genocide widow with two children, has gained 9 lbs. but complains that pain from shingles makes it hard for her to work. Damascene, 14, has put on an astonishing 22 lbs., but Farmer senses that something's wrong; the boy's belly is distended with fluid. He gives the accompagnateur 2,000 francs (about $4) for transportation to return for further tests. The next day he drains Damascene's belly and diagnoses TB that has moved beyond the lungs. With proper treatment, says Farmer, the child will live long enough to have children of his own.

Partners in Health began enrolling AIDS patients in Rwanda in June and by last month was treating more than 300 with ARVs. It is on track to reach 1,000 by next spring--but that's just a fraction of the estimated 250,000 HIV-positive Rwandans who need food, housing, clean water and schools as well as medicine. The Global Fund subsidizes the drugs, but donors are reluctant to pay for the calories, arguing that food aid is never-ending and "unsustainable." Farmer, ever the optimist, is undismayed. "You start down this slippery slope," he says, "but it's a slippery slope that leads to better health care for poor people, so I say, Let's slide down it."