Paul Farmer: One patient at a time

Paul Farmer remembers his patients and the lessons they’ve taught him, even the hard ones.

He remembers the Haitian women dying in childbirth who would never have died in Boston. He remembers the Boston AIDS patient whose recovery made him think, “Why can’t we do that there?” He recalls being part of a team that performed a Caesarean section on a mother having trouble giving birth, saving her and her baby and showing him that he could have an impact. He remembers the impoverished Peruvian tuberculosis patient whose resistant illness finally cleared up, showing Farmer and the world it could be done.

Over the past quarter century, it has been the patients – their ailments, their cures, and sometimes their deaths – that have shown him the way.

Farmer today is the Maude and Lillian Presley Professor of Social Medicine at Harvard Medical School and co-director of the Program in Infectious Disease and Social Change. He is the author of four books concerning health care in the developing world, and he is winner of a MacArthur Foundation “genius” grant.

But he is perhaps best known for his guiding role in Partners In Health (PIH), a nonprofit he founded with a small group of friends that has close ties to Harvard and is dedicated to providing modern health care services to the poor in some of the world’s most remote places.

Today, Partners In Health, through its Haitian partner organizations, Zanmi Lasante and the Haitian Ministry of Health, is Haiti’s largest health care provider. Outside of Haiti, Partners In Health is making care available in neglected, far-flung regions of the world from Russia to Peru to Southern Africa.

Farmer and his colleagues at Partners In Health have repeatedly expanded the imagination of international health officials about the provision of care to people in poor settings. When the integrated primary health care movement was thought dead, they successfully incorporated it into each of their projects. When the international experts said multi-drug-resistant tuberculosis was too hard and too expensive to treat, they did it anyway and their success changed international standards for how to treat the illness. When the conventional wisdom in the late 1990s said that AIDS drugs were too expensive and too complex to use in situations without established health care systems, they launched a program in Haiti that has eventually expanded to Southern Africa.

Today, they’re discussing how to spread their hard-won operational knowledge outside of Partners In Health and how to pass the baton to a new generation of health care leaders.

Farmer describes himself as one player among many whose efforts over the years have made a difference, and that’s certainly true. But Farmer’s influence and energy are felt strongly throughout the organization.

“Paul keeps us focused,” said Louise Ivers, an assistant professor at Harvard Medical School, infectious disease specialist at Brigham and Women’s Hospital, and physician with Partners In Health. “It’s his vision.”

That vision, Farmer said, began taking shape almost from his first visit to Haiti’s poorest region, the Central Plateau, in 1983.

That was the year Farmer arrived on the doorstep of an Episcopal priest named Fritz Lafontant in the town of Mirebalais. Lafontant, today a member of Partners In Health’s Advisory Board, recalls Farmer as a skinny kid in jeans carrying a backpack. Another American, a volunteer with a youth sports program, brought Farmer to Lafontant and asked if Farmer could stay with them.

Farmer, who grew up in Florida, was taking a year off from his studies. He had received his undergraduate degree from Duke University and was hoping to attend Harvard Medical School. He planned to spend a year in Haiti learning Creole, in hopes it would help him in work one day at a large, urban, public hospital in the United States.

Farmer began helping out at a small clinic in Mirebalais each day, meeting another Mirebalais-based volunteer named Ophelia Dahl, who would go on to become Partners In Health’s president, a post she holds today. They also began making trips to a tiny community named Cange, where there were no health programs at all.

Lafontant recalls Farmer pestering him each day for the mail, hoping his acceptance letter to Harvard Medical School had arrived. It eventually did and Farmer packed himself off to the United States and his studies in Boston. But he was profoundly changed during his year in Haiti and left determined to continue his work there.

“Haiti got inside my heart within the first month that I was there,” Farmer said. “I felt that I couldn’t just leave what I had seen. One of my conclusions was that I really didn’t have to choose between being a doctor in Haiti and a doctor in the United States. One’s right around the corner from the other.”

Farmer split his time between his studies and trips to Haiti, spending a few months at a time in each place. Together with Dahl, he continued working in Cange, a community made up of refugees who had fled fertile farmland along the nearby Artibonite River when a hydropower dam built in the 1950s flooded their homes.

Even though the dam had closed its floodgates decades earlier, Farmer and Lafontant said the situation of the people at Cange was still pretty grim in 1983. They describe a squatters’ settlement of people made landless by the dam, existing in utter poverty in a denuded, treeless landscape. Their homes were simple lean-tos, with the only significant structures being the church and school started by Lafontant. Food was scarce. The children were shoeless and in rags.

Farmer and Dahl decided as one of their first activities to train a cadre of community health workers, laying the groundwork for the community-based model of care that Partners In Health promotes today. They sent the workers to Darbonne, south of the capital of Port-au-Prince, for training and then into the surrounding villages.

“[Farmer and Dahl] were giving all this support in the community,” Lafontant said. “They knew every small community up every small hill.”

Life in Cange was tough on everyone, Lafontant said, recalling nights spent sleeping on the ground and in his car. Farmer once told Lafontant he wanted to take a leave from medical school and stay to continue the work in Haiti. But Lafontant told him not to, that he would be a bigger help once he finished his medical training.

In 1985, they founded the Clinique Bon Sauveur in Cange, and, in 1987, officially christened a nonprofit organization, called Partners In Health, to support their Haitian activities.

“We knew it had to . bring together incredibly disparate organizations, so we called it “Partners In Health” because we knew it had to be about partnership,” Farmer said.

Partners In Health was founded by a handful of people who Farmer knew almost from the start of his activities in Haiti. In addition to Farmer and Dahl, other founders include businessman Tom White, and Farmer’s college roommate, Todd McCormack, both of whom serve on PIH boards today. The fifth founder was Jim Yong Kim, to whom Farmer was introduced during his Harvard Medical School admissions interview by Arthur Kleinman, Esther and Sidney Rabb Professor of Anthropology, professor of medical anthropology, and professor of psychiatry. Kim today heads Harvard Medical School’s Department of Social Medicine and the Harvard School of Public Health’s Francois-Xavier Bagnoud Center for Health and Human Rights. He serves as chief of Brigham and Women’s Hospital’s Division of Social Medicine and Health Inequalities and as co-director of the Program on Infectious Disease and Social Change.

Farmer counts himself lucky that all the founders remain not only engaged in the organization, but good friends as well.

“I think forming these working relationships that are stable and durable over time is very important. I’m not sure we would have understood that in the 1980s, but now I think of it as a huge strength that all the people who started the work are still together,” Farmer said.

The organization’s solid core and dedicated staff have been a boon during the challenges and struggles along the way. One low point came in 1991, when things had been going well for a while. Farmer had finished his medical training and was finding that he could divide his time between teaching, research, and writing in Boston and his work in Haiti. The clinic had grown so much that PIH had plans for a hospital. In addition, he said, Haiti had elected its first president ever, Jean-Bertrand Aristide, giving an aura of hope after decades of Duvalier family dictatorship.

Then, in 1991, a violent coup not only removed Aristide from office, but spread unrest across the country. Thousands of people were killed and hundreds of thousands became refugees.

“It took a great toll on our work,” Farmer said. “I never had a moment when I felt that I would get out of this work. But there were some very difficult times.”

Today, with Partners In Health in nine countries around the world and teaching and research duties at Harvard, Farmer spends a significant amount of his time traveling. Despite the long flights and long hours, he said he remains inspired by the work. Wherever he travels, however, he still thinks of Haiti as his home.

“This is where I feel I grew up, in the sense of being a physician and someone engaged in public health,” Farmer said, sitting in his office at the Clinique Bon Sauveur, today a major medical center. “This is home for me, more than anyplace else.”

When asked about the future of his work, Farmer says that being able to see the future is the great thing about being a teacher. Students at both Harvard Medical School and Harvard College, where he teaches an undergraduate seminar, are excited about issues of global health and health care equity. He also sees the future in the faces of young staffers who work with Partners In Health, many of whom are still early in their careers and have dedicated their professional lives to improving the health situation of the poor.

“I think I can see 10 to 20 years in the future just by looking at our students and trainees,” Farmer said, adding, however, that he doesn’t plan on quitting anytime soon. “The work is still inspiring. It’s very exciting for me.”