AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2004, Volume 6, Number 4.

Op-Ed

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Global Health Equity

A physician describes his work with Partners in Health and his public health advocacy work in Haiti and encourages physicians to take health care equity to the global arena.

Paul Farmer, MD

Editor's note: This article is based on Dr. Farmer's remarks on November 24, 2003, at the Chicago Symposium on Medicine, Ethics, and Society, sponsored by the American Medical Association, Chicagoland Chamber of Commerce, Institute of Medicine of Chicago, and the MacLean Center for Clinical Medical Ethics. The editors thank Alice Yang, Dr. Farmer's assistant, for her help in preparing this article during a time of civil strife in Haiti.

Background: The Péligre Dam in Haiti

In 1983, the Haitian government built a hydroelectric dam that resulted in many farmers losing their land. They were growing their crops and then, as they tell it, one day "the water ate our gardens." Literally, in the middle of the day the water rose and the farmers left. The first time I heard this story I thought it highly improbable. After hearing it for a second, third, fourth, and fifth time, I realized they really meant it. There was never a proper resettlement plan, and the farmers just went up into the barren hills, a place where they couldn't grow food for their families, much less sell any surplus at regional markets. I was in medical school at the time, learning how to respect expert opinion, and then I was hearing the Haitians say: expert opinion, give me a break, experts are the people who gave us the dam in the first place. I looked at the official report issued by the company that built the dam: on paper it looked like there was a very reasonable resettlement program, but in fact it was the Haitians who were telling the truth and it was the report that was fraudulent. And that had a huge impact on me.

On Partners In Health's Beginnings In Haiti

We began thinking about what could we do—a couple of medical students and some village kids in their twenties who had never even finished high school. What could we do, without any sort of backing, that would make sense in this area, the Central Plateau of Haiti? We went from house to house and asked people what they would like to see done, and everybody said the same thing: we want a hospital. Whereas the experts said, no, don't build a hospital— it's not cost-effective, it's not appropriate technology, it's not sustainable.

So for a while our group did something that was very unwise, which was to stick with the beneficial but inadequate interventions that were deemed by the experts to be cost-effective and sustainable: promote immunization, family planning, hydration for diarrhea, a long list. We did all that. But then we decided to forge ahead. It took us a long time to do it, 10 years, but we finally built a hospital in Cange, which is what the Haitians had asked for all along. Now Clinique Bon Sauveur includes 104 beds, a referral center, 2 operating rooms, a blood bank, a women's health clinic, and a pharmacy.

The Nexus of Health And Human Rights

A sick child, Alcante, was brought to the clinic by his father. We went back to his house, we got x-rays for everyone in the family and did other tests. It was, of course, tuberculosis. His father was also sick. We treated them, and they both got better. But is that enough? The children in this family weren't in school, and the house they were living in should really be called a hut: dirt floor, rags for a roof. And there were 9 people living in it. We thought that was unacceptable, and so did they. Never in 21 years—not that I'm counting—have I ever encountered a Haitian patient or a family member who thought that abject poverty was an acceptable living situation.

So what do you do? What is the right thing to do? Partners In Health gets endless criticism when we say, "Well, there are many things that need to be done, and that includes schooling and housing and proper food and clothes and health care. Those are social and economic rights. Those ought to be birthrights of humans."

Nine months later, after treatment, Alcante is a normal, healthy kid who's doing well in school. And we built a new house for his family, a house with a tin roof and a cement floor.

The reason I bring this up is not to pat ourselves on the back. Instead, I'm posing the question: are we serious about human rights? If we are, how do we take the notion of health care as a right and schooling as a right and water as a right and make them real? How do we do that?

What Can Medical Students Do?

These struggles over health and human rights are never local. Ideas about equity can never be local or about any one community or nation—it has to be a global struggle. And, unfortunately, when I say global health equity, I find that people assume I mean international health, outside of the United States. But I never mean that. I'm always including the many people in this country who also don't have access to care.

So what can you do as a medical student? Spend some of your time engaging in these grand issues. If we can't provide equitable, quality health care in the most affluent places in the world, then we're never going to get these ideas off the ground in Africa or Haiti. But we can do it. You are the face of American medicine. I just turned 44 and I'm the old grandfather of our group, Partners In Health. People say to me, well, you guys now have so much prestige and clout. But to me we're still a group that was started by medical students just twenty-some years ago. So keep doing what you're doing. Improve our profession— it's a great profession. We have all these tools and technologies at our disposal that weren't available even 20 years ago. Now is the time to link the evidence-based medicine that we believe in, all of us, to the equity agenda. And we can't let the struggle be local or regional. We have to think globally and locally and act globally and locally, otherwise we are not serving equity in its broadest sense.

How Can Doctors Get Involved?

An interviewer once asked me: do you think of yourself as a physician or as a public health practitioner? I said, well, I think that I'm both, and that all of us in medical practice are both, and that these are arbitrary and unnecessary divisions. A good clinician, no matter what he or she is doing, has an impact on a population in an important way.

I believe it is best to ground policy in actual projects— to learn directly from patients. Back to the story of the dam in Haiti: it seemed a sensible policy on paper. I read all the reports that promised increased agricultural production below the dam and provided for a sound resettlement plan. But in reality it was a nightmare, and many, many people's lives and livelihoods were shattered. So I had this rather antipolicy experience when I was just starting out in my work.

Now I'm very involved in policy, of course, and it's incredibly critical, but I think I came at it with a good grounding in fieldwork. Before you make policies, try to spend some of your time with the victims—or beneficiaries, if they're lucky—of policy and then see how you think and feel. The more health practitioners—social workers and doctors and nurses and community health workers—who are involved with policy, and the more patients who directly influence their thinking, the better, and the more humane the policies will be.

Paul Farmer, MD, PhD, is founding director of Partners In Health; professor of medical anthropology in the Department of Social Medicine at the Harvard University Medical School; and chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women's Hospital, Boston, MA. For more information about Partners In Health, please go to www.pih.org.

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