Paul Farmer is
an infectious disease physician and anthropologist who has worked
in HIV and tuberculosis control in the Americas for over a decade.
He
is the author of several books including Infections
and Inequalities: The Modern Plagues (University
of California Press, 1999), and is co-editor
of Women, Poverty, and AIDS (Common
Courage Press, 1996). Farmer is co-director of the Program in Infectious
Disease and Social
Change at
Harvard Medical School, where he heads the International Working
Group on Multidrug-Resistant Tuberculosis (MDR-TB). He is medical
co-director
of the Clinique Bon Sauveur in rural Haiti and is an attending physician
in infectious disease at Brigham and Women’s Hospital in Boston.
In urban Peru, he is medical director of a community program treating
patients with MDR-TB. He teaches social medicine and medical anthropology
at Harvard Medical School. Catherine Clyne caught up with
the doctor to ask some questions about his work in Haiti and Boston,
and
his views on poverty, affluence and HIV.
What kinds of therapies do you recommend to your HIV/AIDS patients?
Do they differ between the U.S. and Haiti?
I recommend the same therapies for all humans with HIV. There is
no reason to believe that physiologic responses to therapy will vary
across lines of class, culture, race or nationality. Thus the justifications
for different standards of care are merely economic ones. Since I do
not believe that there should be different recommendations for people
living in the Bronx and people living in Manhattan, I am uncomfortable
making different recommendations for my patients in Boston and in Haiti.
At the same time, it is obvious that clinicians in Haiti are faced
with different, and, in fact, greater, challenges when attempting
to treat
complications of HIV disease. For example, a patient who has a seizure
in Boston—whether from Roxbury or Newton—will have a CT or
MR scan of the head. But the only CT scanner in Haiti is in Port-au-Prince
and has been out of commission for some years. So we are often called
upon to make "empiric" recommendations. That is, sometimes
we have to treat blindly, without the solid evidence that we are
able
to obtain in the U.S. But this is by no means tantamount to developing
double standards for the poor, because we would very much like to
have
a CT scanner in Haiti and will work to see that this happens some
day.
Personally, how do you deal with the marked contrast between your
work at Harvard and in Haiti?
Well, this is a difficult question. There are days in Haiti when
I feel discouraged by the lack of medications or diagnostic capacity.
To remediate this discouragement, my co-workers and I seek to improve
the quality of care that we are able to provide to our patients. In
other words, I deal with the contrast by seeking to diminish it.
How well do you believe people in non-western countries understand the
germ theory of infectious diseases? How much does religion, magic or
malevolent spells have to do with their understanding of what the diseases
are and why they get them?
In my experience as a doctor serving people in the U.S. and in
what you term "non-western" countries, I have learned that very
few patients in either setting understand the basic principles of infectious
disease. I would hasten to add that many doctors also fail to grasp
key issues in, say, how to use antibiotics or how to manage a complicated
infectious disease. So no, most do not understand where infectious diseases
come from. But in Haiti, it is clear that many patients who speak of
sorcery also believe in the germ theory. That is, they understand that
sicknesses such as AIDS may be caused by a microbe, but in addition
they draw on a host of complex, multifactorial understandings of causation.
It’s hard for me to say that these notions are less sophisticated
than those I encounter among my U.S. patients.
What do you think is or should be the responsibility of affluent
nations with regard to the epidemics of infectious diseases in poorer
nations and their treatment/prevention?
It’s my view that these are fundamentally transnational epidemics,
and not really contained by administrative boundaries. So the entire
analysis is fraught to start with. But if you’re asking my opinion,
I would argue that a social justice approach should be central to
medicine
and utilized to be central to public health. This could be very simple:
the well should take care of the sick. Or it can be based on an epidemiological
approach: go where the disease is. But no matter how you slice it,
the
only way to deal with global public health problems is to move resources
from places in which they are concentrated, where there is little
disease,
to those where resources are limited and shrinking. It is in these
latter settings, of course, that one finds the greatest burden of
disease.
What role do you think the pharmaceutical industry plays in the globally
rising HIV infection rate? What roles do or should pharmaceutical companies
have in a) public health prevention initiatives, and b) making drugs
available to poor nations? In your opinion, are they doing enough?
Well, I don’t think that the role of the pharmaceutical industry
is any different from that of other transnational corporations. The
degree to which international business and finance bears responsibility
for the structure of HIV risks has never really been seriously addressed
by research, and so I’m reluctant to comment on this.
As to what role this industry should play, however, there is much to
say. Since this industry is, at this time, the only source of medications
for our patients, it is an error to think that its leaders do not need
to come to the table to discuss this problem. Anyone interested in the
care of patients in resource-poor settings is going to need to form
partnerships with this massive and influential industry.
It is clear that the pharmaceutical industry is not, by any stretch
of the imagination, doing enough to ensure that the poor have access
to adequate medical care. Some would argue that this is a business
like
any other; I would argue a business that each year posts impressive
profits in selling medications to the sick might have a special obligation
to think of those who are both sick and poor. We cannot say that
the
industry’s leaders are unwilling to shoulder such a responsibility
if we fail to challenge them to do so.
From your experience in Haiti, can you comment on how poor nations
perceive the roles of western countries and pharmaceutical companies
in the epidemics of infectious diseases among their people? Do they
want or expect affluent nations to help? Do they blame western countries
for their situation? Do they make connections between their suffering/mortality
rates/lack of medical treatment and western countries?
Darkly. Yes. To a great extent, yes and yes. Let me flesh out
my answers to these four questions. When I say darkly, I hasten to
add
that this is, not infrequently, a very accurate way of seeing the
actions of the powerful. I’ve been impressed, over the last 15 years, with
how often the somewhat conspiratorial comments of Haitian villagers
have been proven to be correct when the historical record is probed
carefully. At the same time, the fact the world’s poor are calling
upon us to help is a marker, in my view, of the limitless potential
of human solidarity. In fact, it seems to me that making strategic alliances
across national borders in order to treat HIV among the world’s
poor is one of the last great hopes of solidarity across a widening
divide. In an era of failed development projects, and economic policies
gone bad, I sometimes feel very lucky as a physician, since my experience
in Haiti has shown me that direct services are not simply a refuge
of
the weak and visionless, but rather a response to demands for equity
and dignity.
