¡Salud!

WHERE IS HE NOW?

Paul Farmer, MD, PhD, is an attending physician in infectious disease and Chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital (BWH) in Boston. He is also Presley Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medical School and Medical Director of the Clinique Bon Sauveur charity hospital in rural Haiti. Dr Farmer is Founding Director of Partners in Health, (founded in 1987), a non-profit organization providing direct health care services and which undertakes research and advocates on behalf of those who are sick and living in poverty. Dr. Farmer has published extensively about health and human rights, and social determinants of health, including Pathologies of Power. He is the subject of the Pulitzer Prize-winning book by Tracey Kidder, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World (2003).

Among his many awards is a 1993 John D. and Catherine T. MacArthur Foundation “genius award” recognizing his work. Since filming ¡Salud!, Dr Farmer won the Austin College Leadership Award in February 2007, the $100,000 prize of which he plans to give to Partners in Health. In November, 2006, Dr Farmer presented ¡Salud! and led the discussion session following at Harvard University screening.

On working with Cuban doctors in Haiti and the importance of the public sector:

In central Haiti, where we'd been working for over 20 years, one of the most significant problems we've had has been recruiting medical specialists, particularly surgical sub-specialists – there are almost none in rural Haiti serving the rural poor. Pediatricians even, are only sporadically serving the Haitian poor. So we knew for years that we were going to have a hard time recruiting and retaining specialists. We tried the obvious routes, recruiting Haitian specialists. But there wasn't a lot of interest in living in the middle of rural Haiti in places where maybe there's not electricity or hot water and their families don't feel comfortable. For middle class professionals, this is not really a big part of their professional ethic...so we started campaigning early on for help from Cuban physicians. And we said we would like a senior surgeon and an experienced pediatrician. The express purpose of the exchange [was] that the Cuban physicians and other health professionals were going to go in and help strengthen the public sector. Which is exactly what they needed to do. Unfortunately, if you look at medical assistance and international health, there really isn't enough focus these days on strengthening the public sector.

It took us many years to figure this out. We'd been here 10 years working, real hard work, yeoman's work, trying to deliver basic health services to poor people in central Haiti before we asked ourselves 'well what have we done to beef up the public sector?' And that's a long time to ask that question. But then we decided we hadn't done enough, and that all of our expansion would only be in the public sector [which] is the primary guarantor of health and education to the poor.

Anyway, we asked for a pediatrician and a surgeon, and we got them. The surgeon had been practicing for 30 years, all over the world. He could do anything. Any kind of emergency surgery, general surgery; he was very broadly experienced. The pediatrician had been a pediatrician for 27 years. And one of the things I admire, was their tremendous work ethic...The presence of these two very mature physicians, with a lot of public health experience, really served to raise the level of care all across the hospital and the system.

You know, it's easy in a place like Haiti for groups like ours to say 'we're doing great. We've built an OR, and we've put in a blood bank.' But you know you can always do better. And the Cubans came in and the surgeon would say, 'the OR schedule's not right,' or 'we can't follow this case with that case.' And he would just be very demanding. Sometimes we'd throw up our hands and say 'now what have we done wrong?' But it had an enormous impact over the two years. In a very Cuban manner, he made a list of every single procedure he did in those two years. And I forget, it was some huge number. It was well over 1,000 cases. And he was a good teacher. The same with the pediatrician. She also raised the level of care in the pediatric inpatient unit. There's no substitute for that in medicine...for having experienced people pass on their way of delivering care to others – to trainees, to those who are younger or less experienced. But the wonderful and almost magical thing about the two of them – and about their successors – is their work ethic and their professional ethic.

The most important contribution Cuba has given global health has been its example…the idea that you can introduce the notion of a right to health care and wipe out the diseases of poverty. For example, you get universal vaccination with oral polio vaccine to every citizen who needs it and one day, there goes your polio epidemic. Or your endemic polio. And that's kind of a cheap example, because it's much harder to take on chronic illnesses and put in place an infrastructure to deliver primary health care. But the best thing that Cuba has given to the world has been the power of its own very stirring example, especially to poor countries, that they could do it; that they could really put in place a comprehensive public health and medical system.

And then there are other contributions…certain vaccines, technologies, and South-South programs to help other countries. And I think those have been important too, but not as important as the example of their own success.

Cuban physicians are trained differently. They're trained to understand the communities they’re serving, [making] home visits for example, knowing their neighbors, who are also their patients. This is largely gone from American medicine. In Cuba, it’s the rule; it's included in the body of knowledge you have to learn as a physician, in addition to whatever pathophysiology and clinical medicine you have to learn, you have to know about public health. You have to know about community health.

In order to respond to complex health problems among the poor, you need a public health system. And that’s been the strong point of the Cuban training program: even the clinicians – even the sub-specialist clinicians – are expected to know something about public health. A urologist, say or an ophthalmologist. They’re expected to know something about public health and I think that, along with the fact that Cuban health care is considered a right not a commodity, has really transformed health care on that island.

Cuba was way ahead of the pack with their focus on prevention and health promotion. Prevention and promotion are highly regarded and are also worked very much into the curriculum from the beginning of medical school and throughout training. So even if you're a surgeon you're expected to know about health promotion and about preventive medicine.

Among the many Cuban doctors I've had the chance to work with, or teach with, or visit patients with, I think there's a really high level of commitment to the profession and obviously to the patients. And I wonder how that is maintained when the material rewards for being a physician in Cuba or international volunteer are not great? The financial reward for being a physician in Cuba is really modest. The rewards have to be elsewhere. There is a great deal of prestige in Cuban medicine inside Cuba...the respect accorded a Cuban physician is really…it's almost extreme. What I've seen [are] very warm exchanges between physicians and patients. Very, very, warm. At the same time, there's a great deal of respect for what the physician's opinion is, a real belief in the ability of modern medicine to solve problems...It's touching to see that not only is access to modern medicine pretty much universal in Cuba, people really believe in it. And they'll follow the recommendations of physicians whenever they can. And so it's this strange paradox where you have not much in the way of financial rewards, [but] lots of prestige nonetheless, and lots of respect.

I think most people like the idea of a right to health care. They might not put it in rights language. They might not say, 'everyone should have a right to health care.' They might say, 'well, if you're sick, you have the right to be taken care of.’ I've really never met anyone that said, 'you know I actually don't believe the sick should get access to care.'

[But] that’s what cripples international health right now: people are not accustomed to saying, ‘the patient has a right to this service whether he or she can pay for it or not.' This is the least we can do. Make sure everybody has clean water, or everyone gets this vaccine. That’s not in fashion anymore. Obviously it is in Cuba. But if you look at schools of public health for example in the United States, what they’re teaching things called rather vaguely, “health care reform” or “cost recovery” or “sustainability.” None of these are strategies about health care as a right. And indeed, if you go to an American school of public health and start talking about the right to health care, you’re kind of smirked at.

If had to choose the top challenge [to global heath], I would put the right to health care at the top of that list. Because I think, if you say, ‘we aspire to have health care as a right and not a commodity — something you have rather than something you buy. It’s yours because you’re human.’ If we could push that forward as the #1 priority, other things would follow.

All of the professional bodies I belong to support the right to health care…I can't think of a single exception in my professional life. All the students I teach, the faculty at the medical school, the people I come in contact with across the country — all support the right to health care.

So why are we so ineffective? One reason is this lack of dramatic challenge on a daily basis. We live in a very rich country where even the dregs of our medical care are still good — they’re just delivered inappropriately or tardily…I'm ashamed to say that I think it's going to be the economic crisis that's going to drive the right to health care. It's just so expensive to do medicine in the United States these days, that I think that's what's going to rectify this. I hope I'm wrong.

If you want to be a real supporter of these schools in Cuba – or wherever they may be – make sure you create jobs that allow the graduates of these schools to work equitably for poor people. That's what they most need – a transformation not of them, but of their home countries. And you know Cuba is obviously not in a position to transform their home countries…What they're trying to offer is to train the doctors. Now, what do the rest of us do? Because we need to make sure that these jobs exist, so these graduates can be good, humane, and equitable physicians.

The issue is still going to be: Is health care a right or a commodity? Because if you [train] these kids and send them back to places where health care is just a commodity, then they're going to face the same problems that everybody else does. They'll just have better training. And it's not going to solve the problem. Cuban medical training is not going to solve the problem of the rest of Latin America. It will solve one problem, which is the health care personnel crisis. But the other crisis that's getting ignored is that health care is not a right, it's something you buy...And there's a real risk here: unless we have a concerted effort to make health care a right among the poor of Latin America...until there are fair systems for financing health care, the full promise of those students is not going to be realized.