Thought you all might be interested in this since we had Paul Farmer here
earlier this year...
> Health Care for the Poorest as a Central Human Right
> March 29, 2003
> Paul Farmer, a Harvard Medical School professor and
> anthropologist, has helped revolutionize the world's health
> establishment's view of health care for desperately poor
> people sick with complex diseases like AIDS or
> drug-resistant tuberculosis by arguing that they can be
> treated. In a new book, "Pathologies of Power" (University
> of California), Dr. Farmer, who has worked and lived in
> Haiti for the past 20 years, criticizes human rights
> advocates and bioethicists for giving short shrift to the
> health problems of the poor. Patricia Cohen spoke with him.
> You argue that the greatest bioethical challenge today is
> the lack of health care for the poor, yet bioethicists and
> human rights advocates ignore this question.
> The ethical dilemmas that are the primary focus of
> conversation in the literature or on hospital rounds are
> often about an embarrassment of riches. Making choices that
> involve options. How long should we continue life support?
> What constitutes brain death? Should we perform liver
> transplants for people who are alcoholics? Of course these
> are serious problems for families facing grave decisions
> for their loved ones. But in Haiti and in other similar
> places it's about no options, about lack of access to just
> the basics: vaccines, clean water, food, treatment for
> tuberculosis or AIDS.
> What changes have resulted from your arguments that the
> most destitute can be successfully treated?
> There has certainly been a shift in terms of rhetoric and
> even analysis. AIDS is the case in point. It's terrific
> that people are questioning the logic that complex care
> can't be provided in these dirt-poor communities. The
> received wisdom about AIDS is also being challenged because
> approaches that did not include care have not worked very
> well in settings of great poverty. That said, we're
> certainly not at the point where it's conventional wisdom
> to say, yes, we very much need to make sure that people
> living with both poverty and complex diseases have access
> to the care they need. In Africa alone there may be up to
> 30 million people living with H.I.V., and it's estimated
> that fewer than 1 percent of them are on effective therapy.
> Of course, I can imagine you're thinking what about Bush's
> comments recently, and it would be very shortsighted not to
> see that as a major shift. But now we need to see that the
> money follows the pledges.
> Why are you so critical of the human rights movement?
> It's an insider, loyalist critique, since we're part of
> that movement. The human rights community has focused very
> narrowly on political and civil rights for many decades,
> and with reason, but now we have to ask how can we broaden
> the view. Civil and political rights are critical, but not
> often the real problem for the destitute sick. My patients
> in Haiti can now vote but they can't get medical care or
> clean water.
> You mention drug-resistant tuberculosis in Russian prisons
> as an example of how legal problems are only one aspect of
> human rights.
> You have all these young guys dying in prisons, and the
> prison doctors and nurses are the ones saying, "We can't
> have these young men dying of TB on our watch." I heard
> that directly in prisons all over Russia. But the
> international human rights community was spending most of
> its energy yelling at the Russians for prolonged pretrial
> detention. And it turns out that a number of people,
> including humanitarian groups from Europe and the United
> States, were giving the patient-prisoners the wrong
> medicines - cheaper drugs to which these epidemic strains
> were resistant. The only way to do the human rights thing
> is to do the right thing medically.
> As you often point out, though, even medical care is not
> I joke around with my friends that after I did my
> infectious-disease fellowship, I had to go do my tin roof
> fellowship and then my dirt floor fellowship and then my
> clean water fellowship and then my girls' tuition
> I went to a little town in rural Haiti a few months ago,
> and the village council told me their AIDS prevention
> project was to add another year to the local junior high
> school in the village because when kids go away to high
> school, they get pregnant or acquire H.I.V. Who knew that
> you couldn't get involved in H.I.V. prevention without
> worrying about whether or not kids had an extra grade in
> their village?
> As overwhelming as it is, though, looking back on those 20
> years, our own group, which is very small and underfunded,
> has helped build a hospital, open up new clinics and
> schools, done many water projects, supported equal access
> to schooling for poor girls and even managed to launch a
> program to use the most modern AIDS therapies in places
> where there are no roads or electricity or ready access to
> Does your devotion to the poor sometimes give people a
> moral inferiority complex?
> Sometimes, and I actually find it more than a little bit
> painful. I'm not an austere person. For me, an area of
> moral clarity is: you're in front of someone who's
> suffering and you have the tools at your disposal to
> alleviate that suffering or even eradicate it, and you act.
> I'm not recommending this work for everybody, but it's hard
> to turn back once you've seen it, and I've definitely seen
> How did you end up choosing this path?
> My father was not a very orthodox guy. We actually lived in
> a tuberculosis bus for 10 years. Back in the 60's, the
> public health service did TB screening with mobile X-ray
> machines. Then they sold them in public auction, and my
> father, then a schoolteacher, bought one and moved in his
> eight family members.
> When we were growing up in the campground, we were all sort
> of embarrassed by it, but I think all of us now feel
> grateful to my parents for having liberated us from
> middle-class expectations. This makes my biography sound a
> little too neat. I mean we grew up in a TB bus and I became
> a TB doctor. We worked picking citrus for about a
> nanosecond before my father admitted we could never make
> enough for us to live on, and years later I worked with
> Haitian migrant farmworkers. But it can be too neat and
> still true, right?
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