05.05.10

Paul Farmer Is Revolutionizing Medicine

One of the most important doctors of our time has traveled the world changing public-health practices. Tracy Kidder celebrates Paul Farmer's new book, Partner to the Poor.

A few years back I wrote a book called Mountains Beyond Mountains. It has a subtitle: “The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.” I don’t much like subtitles and I didn’t add this one willingly, but I suppose it’s accurate enough. My book is mostly about one person, Paul Farmer, and, as we all know, the old saw that one person can make a difference in this world really isn’t the whole truth. Paul Farmer never wanted me to imagine that he alone was responsible for the early work of Partners in Health. In fact, I think that if he’d been the writer, he would have given equal time to all the people involved in the early days—to Tom White, and Jim Yong Kim, and Fritz Lafontant, and Ophelia Dahl, and Loune Viaud, and Todd McCormack, and Haun Saussy, and the rest of a cast of at least dozens. But I have to add that I couldn’t have written a book like that, and I’m glad I didn’t try.

“I’m interested in public health, too!” said Paul. “But what is the public? Is it a family, a village, a city, a country? Who are these people to say what the public is?”

I traveled quite a lot with Paul Farmer, and some of those trips were, collectively, like a harrowing of hell for me—to the famished, deforested Central Plateau of Haiti; to a periurban slum outside Lima, Peru, which, as the residents say, looks like the surface of the moon; to Moscow’s Central Prison, where what the doctors described as an “uncrowded cell” contained 50 patients coughing up drug-resistant TB bacilli. In those places, particularly, Paul Farmer showed me more reasons for despair than I’ve ever seen before, or indeed imagined. And yet it was the most exhilarating experience of my life. PIH was still pretty small then, back in 2000, and yet they were creating vivid proof that diseases that could be treated successfully in the developed world could also be treated successfully and economically in some of the poorest, most difficult settings imaginable. That was the moving thing for me. Seeing the proof.

We also went to less-difficult places. Havana, Cuba, for instance. We spent most of our week there in the company of a world-class infectious-disease doctor named Jorge Pérez Ávila, who all by himself—by example, as it were—corrected some of the prejudices I brought with me to Cuba. Years of bad publicity had left me imagining the place as gray and rather colorless, puritanically Stalinist. One night we ended up in the bar of a fancy hotel, renovated with European money. There we were fed dinner by the manager, a Cuban woman named Ninfa, a patient of Jorge’s. At some point, Jorge turned to her and said, in words like these, “Ninfa. That is such a lovely name. But how did your parents know when you were born that you would be so beautiful?” Ninfa smiled, and turned to me. “Jorge has a very special way with all his female patients,” she said. “We all want to sleep with him.”

I began to sense that Cuba was a place where one might be able to have a pretty good time. I already knew that Paul Farmer’s idea of a really good time was to visit patients. In Cuba, he did what he often did in other places where he had no patients of his own: He borrowed some from other doctors. Anyway, visiting patients also was Jorge’s idea of rip-roaring fun, so that’s what they did, while I tagged along. They visited Jorge’s patients, mostly women, most of whom were pregnant. And after a while I would say to Jorge, “Is this patient pregnant, too?” just to hear his answer, which was, invariably, “Yes, but it is not my pregnancy.”

I remember going on rounds with Paul and his students at the Brigham and Women’s Hospital in Boston many times—evenings that would stretch late into the night, nights that were always the oddest mix of the comical and serious, yet always a cheerful experience somehow, rounds at the Brigham with Dr. Farmer, maybe because every tool ever invented for repairing patients was right at hand.

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Former U.S. President Bill Clinton talks with Dr. Paul Farmer while touring the General Hospital in Port-au-Prince, Haiti Monday, Jan. 18, 2010. (Lynne Sladky / AP Photo)

I remember a fashion show that the TB patients at Zanmi Lasante in Haiti put on, to celebrate Paul’s birthday—I was sure that party would find its way into the book I was going to write, but it didn’t, perhaps because I was laughing so hard at one moment and felt so enchanted the next that I couldn’t take adequate notes. I remember Mamito, the matriarch of Zanmi Lasante, scolding me for something Paul had done about 15 years before—scolding me because Paul had asked me, really almost begged me, to intercede on his behalf and explain to her why we had gone on an 11-hour hike. I remember long treks and conversations with the wonderful, hot-headed Ti Jean, who built God knows how many houses for the poorest of Zanmi Lasante’s patients. Ti Jean once carried me across a river. Another time he fed me and Paul a dinner of guinea fowl and Barbancourt rum. I miss him. He had a habit of telling Paul to shut up when Paul dared to interrupt one of his discourses—and the interesting thing about those moments was that Paul actually would shut up.

Then there were the christenings of patients’ newborn babies—in Peru, for instance—with Paul in the role of godfather. This summer in Rwanda, I learned that this happens in Africa, too. And I found myself thinking, This is pretty cool, the guy has godchildren all over the world, more godchildren than a Mafia don.

I remember quite vividly watching Paul testify in a grubby little courtroom in New York City—the INS was trying to deport a Haitian man with AIDS, and Paul was testifying to the effect that sending this man back to prisons in Haiti was tantamount to torture. The district attorney seemed like a pretty tough cookie, but after listening to Paul describe conditions in Haiti, she stopped putting up any fight at all and started asking him questions that seemed calculated to injure her case. Periodically, as I recall, this prosecutor would exclaim, “Good God! I had no idea it was that bad!” And I also recall that, on the way to the courtroom, Paul started worrying that his necktie was too flamboyant to wear before a judge. He insisted I give him my much more conservative tie. I still have the fiery red one that he gave me in return, though I do not wear it.

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A nurse checks the pulse of a patient at Dr. Paul Farmer's Zanmi Lasante Hospital in Cange, Haiti, Sept. 20, 2006. (AP Photo)

Finally, there was a night in Moscow. A congenial dinner with a famous personage in public health. By day Paul had been arguing with him. The fight had to do with milk: Paul wanted Russian prisoners with TB to get a glass of milk each day, and the public-health expert didn’t think this was necessary. I drank a therapeutic amount of Côtes du Rhône at dinner. Afterward, walking down a snowy Moscow street in the dark, I needled Paul a little. I may have recited a line I heard many times from people in the business of international health, which goes like this: “Doctors are very nice. They think the patient in front of them is the most important thing. But we care about something more important, which is the health of populations.” I repeated something like that and then said of our dinner companion, “He’s interested in public health.”

“I’m interested in public health, too!” said Paul. “But what is the public? Is it a family, a village, a city, a country? Who are these people to say what the public is?” He was smiling. I think he’d had a therapeutic dose of Côtes du Rhône, too. His tone was jocular, but by then I knew that jocularity was often the tone in which he disguised statements of great importance to him. And I’ve been turning that statement over in my mind ever since, The Moscow Statement, as it were.

Partners in Health doesn’t have all the answers as to how to go about fixing the dreadful poverty and disease that afflict billions of people today. I don’t think anyone in the organization ever said they did. And even if they did have all the answers, they couldn’t bring the terrifying pandemics of AIDS and TB and malaria under control all by themselves, any more than Paul Farmer could have created and nurtured Partners in Health all by himself. But they have shown the world that it is possible to control those diseases and to redress some of the underlying causes that have turned those diseases into pandemics. In some cases, with multidrug-resistant TB, for instance, they have given the world precise prescriptions, and they have made it possible for poor countries to use those prescriptions—largely thanks to Jim Kim, who figured out how to drive down the prices of the necessary drugs by about 90 percent.

But what they have done above all, I think, is to present both a rebuke and a challenge to the United States and the other wealthy countries and to offer all of us a real kind of hope, hope backed up by fact. They have done this, I believe, by paying attention to the needs of individual patients, in Haiti, Peru, Russia, Boston, and now Africa. It has been individual patients, people just like you and me, who have taught them how to treat a family, a village, a city, a country, maybe the world.

Reprinted with permission of the University of California Press and Tracy Kidder.

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Tracy Kidder has won the Pulitzer Prize, the National Book Award, the Robert F. Kennedy Award, and many other literary prizes. He is the author of Strength in What Remains, Mountains Beyond Mountains, My Detachment, Home Town, Old Friends, Among Schoolchildren, House, and The Soul of a New Machine.