Posts Tagged 'paul farmer'

Story for the day

From Never Again? Reflections on Human Values and Human Rights, the Tanner Lectures on Human Values, given by Paul Farmer:

Joseph, twenty-six years old, had been sick for months. His illness had started with intermittent fevers, followed by a cough, weight loss, weakness, and diarrhea. His family, too poor, they thought, to take him to a hospital, brought Joseph to a traditional healer. Joseph would later explain: “My father sold nearly all that he had—our crops, our land, andour livestock—to pay the healer, but I kept getting worse. My family barely had enough to eat, but they sold everything to try to save me.” Joseph was bed-bound two months after the onset of his symptoms. He became increasingly emaciated and soon lost all interest in food. As he later recalled, “My mother, who was caring for me, was taking care of skin and bones.”


Faced with what they saw as Joseph’s imminent death, his family purchased a coffin. Several days later a community health worker, employed by Partners In Health, visited their hut. The health worker was trained to recognize the signs and symptoms of tuberculosis and HIV and immediately suspected that the barely responsive Joseph might have one or both of these diseases. Hearing that their son might have one last chance for survival, Joseph’s parents pleaded with their neighbors to help carry him to the clinic, since he was too sick to travel on a donkey and too poor to afford a ride in a vehicle. At the clinic, Joseph was indeed diagnosed with advanced AIDS and disseminated tuberculosis. He was hospitalized and treated with both antiretrovirals and antituberculous medications. Like his family, however, Joseph too had almost lost faith in the possibility of recovery. He remembers telling his physicians, early in the course of his treatment, “I’m dead already, and these medications can’t save me.” Contemplating a photograph taken by Dr. David Walton as Joseph began his treatment (figure 1), one can understand readily why he had given up hope. Despite his doubts, Joseph dutifully took his medications each day, and he slowly began to improve. Several weeks later, he was able to walk. His fevers subsided, and his appetite returned. After discharge from the hospital, he received what is termed “directly observed therapy” for both AIDS and tuberculosis, visited each day by a neighbor serving as an accompagnateur. After several months of therapy, Joseph had gained more than thirty pounds (figure 2).


A couple of years later, Joseph frequently speaks in front of large audiences about his experience. “When I was sick,” he has said, “I couldn’t farm the land, I couldn’t get up to use the latrine; I couldn’t even walk. Now I can do any sort of work. I can walk to the clinic just like anyone else. I care as much about my medications as I do about myself. There may be other illnesses that can break you, but AIDS isn’t one of them. If you take these pills this disease doesn’t have to break you.” What sort of human values might be necessary to save a young man’s life? Compassion, pity, mercy, solidarity, and empathy come immediately to mind. But we also must have hope and imagination in order to make sure that proper medical care reaches the destitute sick. Naysayers still argue that it is simply not possible, or even wise, to deliver complex medical services in settings as poor as rural Haiti, where prevention should be the sole focus. Joseph’s story answers their misgivings, I feel, both in terms of fact (you can successfully treat advanced AIDS in this setting, and because good treatment serves to strengthen prevention programs) and in terms of value (it is worthwhile to try to do so). Certainly Joseph and his family would agree, as would thousands of other Haitians who have benefited from these services.


Paul Farmer’s Baccalaureate remarks at Princeton

In case you missed it, check out Paul Farmer’s Baccaulareate speech at Princeton, delivered on June 1, 2008.  Farmer provides a vision for what the world will be like in 2028 if we are able to continue building a broad-based social movement for human rights.

A few good excerpts (make sure you check out the full text):

Medicine, certainly, will be transformed and improved, but that’s just the beginning. Our economy will be green, in this utopian vision, our carbon footprint tiny compared to the bad old days when oil hit, in 2010, $250 a barrel, provoking, at long last, a serious commitment to alternative, clean fuels that are truly clean as opposed to advertised as such. So too for India and China, which by 2020 became the world’s largest economies. The planet’s population will have grown, of course, but at nothing like the rates we’re seeing now: the human herd will no longer be culled by epidemic disease or by war. For the first time in a century, the Amazon rain forest will be growing, not shrinking.

A broad-based movement to acknowledge historical truths will have led not only to the abolition of war but to the forgiveness of “odious debt” in many countries. By 2028, the decades-long trend of increasing social inequalities will have been reversed, and four of the world’s five fastest-growing economies will be in Africa.

Medicine and health will have flourished during the first quarter of the 21st century. The United States will have a world-class national health system, introduced in 2009, with universal coverage implemented by 2012. Healthcare costs will have fallen even as the average citizen lives longer, better lives. “Social safety net” will no longer be a dirty word.

But is it crazy to wish for these kinds of improvements? Is it crazy for the class of 2008 to wish for something better than what has gone before?…Imagine a commencement speaker in the early nineteenth century, exhorting young Americans or Britons to abolish slavery as the affront to God that it surely was and is. Imagine an address in the early 20th century in which the speaker pushed universal suffrage, arguing that an adult is an adult, regardless of race or gender. Imagine a speaker in 1993—not so long ago—arguing that apartheid in South Africa was an insult not just to the notion of human rights but to modernity itself. Imagine a country like ours looking back from 2028 and thinking it quaint that not that long ago a woman or a black would not likely be elected as head of our country…A world in which every child has the right to go to school. A world in which clean water is not a privatized commodity to be sipped from bottles but rather part of the earth’s bounty, for all its inhabitants?

We may be leaders of this movement but must also be humble participants. Some have not been as quick to see the boundaries and dimensions of this movement. That’s because it’s fluid, as all real social movements are. It’s a chaotic movement, just now coalescing, but with the promise of lessening the hurts and insults of an unequal world.

Top 3 Debates in Global Health

Victor Roy has a great post up on GlobeMed‘s Article 25 Blog about 3 major debates common in the global  health community: 1) horizontal vs. vertical design of health programs, 2) the prevention vs. the treatment of disease, and 3) paternalism vs. measuring the effectiveness of international aide $$.

I think that the debate of horizontal vs vertical health programs is nicely summed up by the back and forth correspondence between Dr. Paul Farmer and Laurie Garrett published in Foreign Affairs‘ discussion of how to best promote global health. Garrett is a strong critic of the “stovepiped” models of providing disease specific, large scale funding citing evidence that it can pull vital resources away from underfunded primary health care efforts. Farmer tends to agree with Garrett in that western dominated funding of programs that ignore the social underpinning of suffering and disease are not nearly as effective as those that engage grassroots leaders and address fundamental human rights. However, he cautions us not to be so quick to dismiss the good that can come from using disease specific aid and diverting it to programs that work towards achieving more broad health equity goals.

The influx of AIDS funding can indeed strangle primary care, distort public health budgets, and contribute to brain drain. But these untoward or “perverse” effects are not inevitable; they occur only when programs are poorly designed. When programs are properly designed to reflect patients’ needs rather than the wishes of donors, AIDS funding can strengthen primary care. PIH has shown this throughout central Haiti, in eastern Rwanda, and in the mountains of Lesotho, and is going to use the same model in southern Malawi. In each of these settings, we work under the aegis of the Ministry of Health (and, in three of them, with the Clinton Foundation) in order to promote the notion of health as a human right. In some cases, programs have to be built from scratch; in others, it is necessary to rebuild public infrastructures damaged by war, neglect, or the misguided advice of outside experts.

Farmer et al. has been tremendously effective in developing a model that is able to take foreign funding – which in many contexts has at best shown modest results and at worst (as Laurie Garrett discussed) negatively impacted people’s health – and transform it into a vehicle for equity. Hopefully PIH‘s model and evidence of success will act to catalyze a change in international aid from a force propagating structural violence to a force restoring human dignity and rights.

I’ll try to add some comments about debates #2 and #3 as well as the wild card – public vs. private models in global health – in the coming days. Stay tuned!


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