Doctor Crusades for Developing World

Paul E. Farmer, a prominent doctor and medical anthropologist who will address this year’s graduating class at Harvard Medical School (HMS), often appears to be in more than one place at a time.

One day, the affable doctor will be teaching a class at HMS—where he is a professor of medical anthropology—or in attendance at Boston’s Brigham and Women’s Hospital (BWH). The next, he is treating patients and running a large clinic in the poor rural town of Cange, Haiti. In between, he may check on the medical programs he helped found in Peru, Siberia, Mexico and Guatemala.

And colleagues say that Farmer is also a formidable doctor when dealing directly with patients.

Marcelo Suarez-Orozco, co-director of the Harvard Immigration Project, says he has seen Farmer “perform literally a medical miracle.”

“He was extraordinarily instrumental in saving the lives of patients that were, according to the conventional wisdom, unsavable,” he says.

The Red Pill

On paper, Farmer is an infectious disease physician and a medical anthropologist—a man who strives to understand the social and cultural causes of illness as well as directly treating them. But out in the field, he is much more than an accomplished academic and a talented doctor.

Farmer says in an e-mail that his Class Day speech will center on “what it means for a young physician to take the red pill,” a reference to the popular movie The Matrix and its hit sequel. In the movie, taking a red pill means abandoning a reassuring fantasy world and throwing oneself into the gritty, disheartening realities of an ongoing war for justice.

And if anyone can be said to have taken the red pill in his professional life—to have unflinchingly faced the darkest face of human mortality in an immediate, hands-on confrontation—it is Farmer.

An average day at his Clinique Bon Saveur in Haiti involves treating desperately sick adults and children, “most of them TB or HIV patients with a bit of malaria thrown in,” he says. In the brief moments between patients, Farmer will confer with political leaders about grave issues of public health.

Outside the clinic, Farmer’s chosen locale looks grim. Horrifying pandemics decimate a population scarred by the poverty and terror that an ongoing U.S. embargo, years of a violent junta and marauding paramilitary forces have bred.

Early this May, an ambulance carrying five of Farmer’s colleagues in Cange was hijacked at gunpoint by uniformed men, apparently former members of the Duvalier dictatorship’s dismantled army. The men, it later became clear, had killed two security guards at a major power plant and shut down electricity for the island nation’s central region.

In his years in Haiti, constantly exposed to ill patients, Farmer casually mentions that he’s had malaria “a couple of times. Well, maybe more than a couple.” He’s also managed to contract “the usual diseases that goofy anthropologists or incautious students get,” though he has somehow avoided acquiring the drug-resistant tuberculosis he often treats.

To most, this life would be a chaotic nightmare. Haiti is the sort of place a starry-eyed student might visit, working there for a few months before beating a swift retreat back to a comfortable suburban practice in the States.

Instead, Farmer has spent the last 20 years staring down the world’s most urgent medical problems.

When Farmer first visited Haiti, a year after graduating with a bachelor’s degree in medical anthropology from Duke in 1982, he says he “had no clear idea of what I wanted to make of my life.”

But his indecision would not last long.

“I worked as a volunteer in a crappy clinic,” he says. “Haiti is the reason I went into infectious disease, because I saw so many people die unnecessarily of these diseases when I was a student.”

Once he had become closely acquainted with the woeful lack of medical treatment for Haiti’s poor—and gotten his medical degree from HMS—Farmer didn’t hesitate to attack these problems head-on.

“Rather than focus on something very simple that would be in-and-out, he asked people there what they really needed,” says Joia Mukherjee, the medical director of Partners in Health (PIH), the non-profit medical organization which Farmer and close colleague Jim Y. Kim founded in 1987. “And they said, ‘We need a hospital, because we’re very ill.’ So he built the hospital.”

The hospital was the Clinique Bon Saveur, which Farmer established in Cange in 1985. It is still going strong—and its services are still necessary for the ever-growing health problems of Haiti’s poorest.

Along with a number of associated outpatient clinics, the 40-bed Clinique treated more than 50,000 impoverished patients in 2000, dealing mostly with victims of AIDS and drug-resistant tuberculosis—and all for free.

Farmer’s colleagues say his efforts have not always met with approval from western nations.

For several years, he locked horns with the United Nations’ World Health Organization (WHO) over its program of treatment for extremely poor patients with drug-resistant tuberculosis—a program which Mukherjee says amounted to letting such patients die on the grounds that treating them would not be “cost-effective.”

“The field of international public health is a mess because of no funding,” Farmer says. “So of course people in this arena have set their sights low. Our own view was that we need to raise more money rather than lamenting the lack of it and setting standards lower for poor people.”

In essence, Farmer was fighting to convince the WHO to reinterpret what they saw as a hard bottom line and trying to impose his personal, hands-on approach on an entire system.

But Farmer did not give up, raising money through PIH and proving that financial considerations could be overcome when the far more important concern of human life was at stake—even when those lives belonged to the profoundly poor people that medical organizations had often neglected in the past.

Today, the incoming Director-General of the WHO is Jong-Wook Lee, who Farmer says “is a great man” who strongly values the health of the poor.

And Mukherjee says PIH representatives—including Kim, Farmer’s closest associate—will have a strong advisory role in the WHO’s immediate future.

Coming Back to the Ivory Tower

And at the end of a tough week in Haiti, Farmer still manages to pack up and return to Cambridge.

This year, Farmer taught two courses at HMS—and his dedication to academic work is not diminished by his busy life on the front lines of infectious disease, students say.

“He really puts his abilities to good use and challenges his students to look at medicine and issues from a different perspective,” says Robert R. Stavert ’03, who took Farmer’s course, “Poverty, Culture and Infectious Disease,” this spring.

Most importantly, many say, Farmer’s dedication and vision constantly rubs off on those who work and study with him.

According to Howard H. Hiatt ’46, professor of medicine at HMS and former dean of Harvard’s School of Public Health, Farmer and Kim “are really pied pipers,” leading hordes of new medical professionals like themselves into the world.

His skill in the classroom is the result of an intense life of the mind.

Suarez-Orozco cites an “intellectual abstraction and elegance” in Farmer, mentioning grand-scale discussions that Farmer has engaged in with University President Lawrence H. Summers.

Farmer says that Harvard’s leader “strikes me as an ideas person.”

He does not think his own ideas are entirely acceptable to everyone in the academic community, though.

“I’m sure that some of my views, particularly on things like the right to health care and the sorry job we’re doing in equity of access to care, are regarded as extreme by some,” he says.

Still, Farmer feels at home here.

“I have never felt silenced at Harvard,” he says.

Where Everybody Knows Your Name

When those who know Farmer speak of him, it is not uncommon for the word “saint” to come up, and many colleagues marvel at not only his remarkable accomplishments but also his sustained sunny outlook on a usually-dispiriting situation.

“A lot of times those of us who work in this become discouraged by the forces that are maintaining poverty and racism; lots of times people turn away because they feel there’s nothing we can do, it’s something that’s always going to be because it’s human nature,” says Heidi Behforouz, who has worked with Farmer on PIH’s only domestic project, in inner-city Boston. “I think Paul expects more of human nature.”

And with hundreds of press mentions and a glowing New Yorker profile published in 2000, Farmer has attained celebrity status in the medical world.

But Farmer says he objects to his colleagues’ elevated laurels.

“What do I think of it?” he says. “I think it’s wrong. I’m no saint.”

Farmer says he gets no satisfaction from his fame.

“It’s helped our cause, but I do not enjoy this status,” he says. “Not at all. Because the focus should be on the problems at hand—the suffering of the destitute sick—and not on the lives of those who are engaged in addressing them.”

—Staff writer Simon W. Vozick-Levinson can be reached at vozick@fas.harvard.edu