Paul Farmer

Overview


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Dr. Paul Farmer

Paul Farmer, medical doctor and medical anthropologist, is well known for his human rights-based approach to global health care. Currently holding the highest honor at Harvard University, Kolokotrones University Professor, Farmer is well esteemed for his work in Cange, Haiti, where the flagship clinic of Partners in Health (PIH), Clinique Bon Sauveur, is located. Boston-based non-profit organization PIH was co-founded in 1987, and currently operates 49 clinics in 11 countries worldwide, providing free primary health care to the poor through local community-health workers and national support, all while addressing the root problem of poverty. To this day, Clinique Bon Sauveur remains the largest hospital in Haiti.

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PIH clinic locations


Research & Work


Infectious diseases such as HIV/AIDS and Tuberculosis dominate the majority of Farmer’s studies. A year after opening the clinic in rural Haiti, Farmer noticed the diffusion of HIV throughout Haiti’s Central Plateau, watching as HIV went from being a “city sickness” only threatening those in capital city Port-au-Prince in 1984, to an illness which filled the courtyard of Clinique Bon Sauveur full of ailing rural women waiting for care[1]

Farmer adamantly claims that HIV is a disease of the poor, striking those who are made most vulnerable in inegalitarian societies. HIV never strikes “randomly,” instead follows “steep gradients of inequality.” [2] The poor are the least able to overcome this situation due to limited financial and medical resources, and thus suffer worsened health outcomes altogether. Inspired by Liberation Theology, Farmer advocates for health care rooted in social justice and providing “preferential option for the poor.” [3]

Structural violence, a term borrowed from John Galtung, is used by Farmer to describe the historical and economic policies, structures and forces that limit the agency of the poor. [4] This violence can be indirect or covert, but always results in “extreme suffering” due to its creation of “structured risk,” leaving those at the margins most likely to carry the burden of this suffering. [5] Its economic, historical, political and legal burden stops “individuals, groups, and societies from reaching their full potential.” [6] The violence element of this concept often remains “invisible” to those it most affects, making its circumstances seem “ordinary” to those who suffer the most. [7]

Farmer rights against “immodest claims of causality” made by those studying or working with HIV infected persons. These claims place the blame of HIV infection onto individuals, their risky behaviors and cultural differences while ignoring political, economic and historical structures which create concentrations HIV in resource-poor areas. [8] This type of victim-blaming suggests an “exaggeration of personal agency,” and fails to consider the structural limitations that prohibit individual choices, often meaning the sacrifice of their own health to meet financial and personal needs. [9]



A Case Study

Farmer tells the story of Acéphie, a young woman born into structural violence in the town of Kay in Haiti’s Central Plateau, where a number of peasant farmers have been displaced following construction of a hydroelectric dam in 1956. At age 19, Acéphie began contributing to the household income by selling produce with her mother at a market an hour and a half away by foot. When a military captain who held one of the few paying jobs in the area began giving attention to Acéphie, it was of little importance that he was married with children; Acéphie saw only an opportunity for financial security, and a “way out." Strangely, after their sexual encounters ended, the captain grew ill and mysteriously died.

At 22, Acéphie traveled to Port-au-Prince to take a position as a maid, one of the few viable options for work for young women in Haiti. Soon, Acéphie fell in love with Blanco, a man with a similar background, and she became pregnant. Unfortunately, her employers found a pregnant maid “unsightly” and fired her, sending her back to Kay where she found herself raising a child alone.

Not long after, Acéphie was diagnosed with AIDS. Acéphie blames her work as a servant for her AIDS diagnosis. Had poverty not placed her family in such despair, Acéphie may not have engaged with the captain, a married man, for the chance at financial security. Had job options been available in Kay, with her family, Acéphie’s life would have been different. Acéphie illness and eventual death came from the restraints due to poverty, historical unrest and honest attempts to keep her family afloat.[10]

Arguments Against "Cost Effectiveness"

Farmer and his partner Jim Yong Kim often speak out against criticism that their treatment in resource poor settings are not cost-effective. Kim directs another PIH clinic in Lima, Peru, alongside community partner Socios en Salud. Not long after its creation in 1996, Kim and Farmer began to notice a number of patients were not being cured of their TB infections despite their strict adherence to the Directly Observed Therapy Short course (DOTS) regimen. DOTS patients are observed taking their medications daily, and are able to discuss any potential problems they may be having with their treatment.

In an effort to determine why patients were not being cured of their infections, sputum from these incurable patients was sent to the Massachusetts state lab. Results showed that a highly resistant strain of TB, termed Multi-Drug Resistant TB (MDR-TB) was present in Lima. Yet when Farmer and Kim brought this to the attention of the Peruvian government, they deemed these infections too costly to treat; only non-drug resistant cases were to be treated, the others would be left to die. Both Farmer and Kim, who saw this response as a human rights violation, sought out to prove that MDR-TB cases were worth treating, and that it could be done successfully. An overwhelming triumph resulted: 85% of patients with MDR-TB were cured. Due to these successes, both Farmer and Kim have been a powerful force in helping to lower medication prices worldwide, making treatment to even the most challenging diseases worthwhile and efficacious.



Criticism


Structural violence, Farmer’s principal explanation for the negative health outcomes among the poor and disadvantaged, is criticized by Bourgois and Scheper-Hughes as being “too much of a black box,” limited by its simplicity and failure to explicate local understandings. [11] Fassin says his use of structural violence only considers the global aspects of poverty, and not how it “operates in the daily lives of the people with whom the anthropologist works.” [12] Others, below, also argue that the broad approach taken with structural violence may not allow for local explanations of health phenomena.

Reviews of Farmer’s books rave about his impressive knowledge and ability to analyze the complicated, historically rooted problems Haiti is suffering from today. Blogger Ben Brucato, in his critique of Pathologies of Power, claims Farmer fails to consider the impact that globalization, modernization and the Westernization of biomedicine may have on the health of Haitians. While Farmer vehemently argues for modern health treatments for all, he neglects the fact that many of these health issues are due to modernization. [13] Additionally, by advocating for health as a human right, Farmer is arguing for universal medicine, which is problematic for its lack of local consideration. [14]

His 1994 book The Uses of Haiti, discusses the role of the U.S. and other international countries had in creating the tumultuous history of Haiti. Bob Corbett, former professor at Webster University and Haiti scholar, believes Farmer’s suggestion is too deterministic, and that it is necessary to consider multiple elements when reconstructing Haiti’s past. [15] Mainly, Corbett states that Farmer leaves Haitians themselves out of the creation of their history, painting a picture “in which Haitians don’t matter.” [16]

Biography


Born in Massachusetts on October 26, 1959, Farmer is one of six children. His childhood interests in animals included drawing reptiles and amphibians, even starting a herpetology club in the fourth grade. [17] Farmer lived a humble childhood, spending much of his youth living without running water in a bus and in the helm of a boat in rural Florida. [18] His biography, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, was written in 2003 by Pulitzer Prize winner Tracy Kidder.

Farmer attended Duke University for his Bachelor of Arts in medical anthropology, which he received in 1982. After, he pursued a PhD in anthropology while completing medical school for internal medicine, graduating in 1990. His dissertation resulted in the book AIDS and Accusation: Haiti and the Geography of Blame in 1992. He is now married to his wife, Didi, and together they have three children, daughters Catherine and Elizabeth, and son, Sebastian. [19]

Professionally, Farmer currently serves as the UN Deputy Special Envoy for Haiti alongside Bill Clinton. This work is profiled in his latest book Haiti After the Earthquake, published in 2011. Farmer juggles a hectic schedule of traveling to work in PIH clinics, teaching courses in social medicine and global health at Harvard, serving as the Chief of the Division of Global Health Equity at Brigham and Women’s Hospital located in Boston, and editing the journal Health and Human Rights. [20]

Awards


  • Carter Award for Humanitarian Contributions to the Health of Humankind from the National Foundation for Infectious Diseases
  • Salk Institute Medal for Health and Humanity, the Duke University Humanitarian Award
  • Margaret Mead Award from the American Anthropological Association
  • American Medical Association’s Outstanding International Physician (Nathan Davis) Award
  • Heinz Award for the Human Condition
  • Skoll Award for Social Entrepreneurship

Major Publications


  • 2011 Haiti After the Earthquake. New York: PublicAffairs.
  • 2010 Partner to the Poor: A Paul Farmer Reader. Haun Saussy, ed. Berkeley: University of California Press.
  • 2008 Challenging Orthodoxies: The Road Ahead for Health and Human Rights. Health and Human Rights 10(1):5-19.
  • 2008 Mother Courage and the Future of War. Social Analysis 52(2):165-184.
  • 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  • 2004 Political Violence and Public Health in Haiti. New England Journal of Medicine 350:1483-1486.
  • 2003 Suffering That is ‘Not Appropriate at All’ Revista 3(42):42-47.
  • 1999 Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press.
  • 1994 The Uses of Haiti. Monroe, ME: Common Courage Press.
  • 1992 AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press.

Online Resources



Further Reading


  • Farmer, Paul E., Bruce Nizeye, Sara Stulac, and Salmaan Keshavjee 2006 Structural Violence and Clinical Medicine. PLoS Medicine 3(10):e449
  • Castro, Arachu and Paul Farmer 2005 Understanding and Addressing AIDS-related Stigma: From Anthropological Theory to Clinical Practice in Haiti. American Journal of Public Health 95:53-59.
  • Fraser, Hamish S. F., Darius Jazayeri, Patrice Nevil, Yusuf Karacaoglu, Paul E. Farmer, Evan Lyon, Mary Kay C. Smith-Fawzi, Fernet Léandre, Sharon S. Choi, and Joia S. Mukherjee 2004 Treatment in Rural Haiti. British Medical Journal 329:1142-1146.
  • Sonya Shin, Jennifer Furin, Jaime Bayona, Kedar Mate, Jim Yong Kim, and Paul E. Farmer 2004 Community-based Treatment of Multidrug-Resistant Tuberculosis in Lima, Peru: 7 Years of Experience. Social Science and Medicine 59:1529-1539.
  • Walton, David A., Paul E. Farmer, Wesler Lambert, Fernet Léandre, Serena P. Koenig, and Joia S. Mukherjee 2004 Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural. Haiti Journal of Public Health Policy 25:137-158.
  • Farmer, Paul, Mary C. Smith Fawzi, and Patrice Nevil 2003 Unjust Embargo of Aid for Haiti. Lancet 361:420-423.
  • Mitnick, Carole, Jaime Bayona, Eda Palacios, Sonya Shin, Jennifer Furin, Felix Alcántara, Epifanio Sánchez, Madeleny Sarria, Mercedes Becerra, Mary C. Smith Fawzi, Saidi Kapiga, Donna Neuberg, James H. Maguire, Jim Yong Kim, and Paul Farmer 2003 Community-based Therapy for Multidrug-resistant Tuberculosis in Lima, Peru. New England Journal of Medicine 348:119-128.
  • Farmer, Paul, Fernet Léandre, Joia S. Mukherjee, Marie Sidonise Claude, Patrice Nevil, Mary C. Smith-Fawzi, Serena P. Koenig, Arachu Castro, Merecedes C. Becerra, Jeffrey Sachs, Amir Attaran, and Jim Yong Kim 2001 Community-based Approaches to HIV Treatment in Resource-poor Settings. Lancet 358:404-409.
  • Farmer, Paul and Jim Yong Kim 1998 Community-based Approaches to the Control of Multidrug-resistant Tuberculosis: Introducing ‘DOTS-plus’. British Medical Journal 317:671-674.
  • Farmer, Paul, Margaret Connors, and Janie Simmons, eds. 1996 Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence. Monroe, ME: Common Courage Press.

References


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  1. ^ Farmer, Paul 1999 Infections and Inequalities: The Modern Plagues, updated edition. Berkeley: University of California Press. Kindle edition.
  2. ^ Farmer, Paul 1999 Infections and Inequalities: The Modern Plagues, updated edition. Berkeley: University of California Press. Kindle edition.
  3. ^ Farmer, Paul 1999 Infections and Inequalities: The Modern Plagues, updated edition. Berkeley: University of California Press. Kindle edition.
  4. ^ Farmer, Paul 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  5. ^ Farmer, Paul 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  6. ^ Farmer, Paul E., Bruce Nizeye, Sara Stulac, and Salmaan Keshavjee 2006 Structural Violence and Clinical Medicine. PLoS Medicine 3(10):e449
  7. ^ Farmer, Paul E., Bruce Nizeye, Sara Stulac, and Salmaan Keshavjee 2006 Structural Violence and Clinical Medicine. PLoS Medicine 3(10):e449
  8. ^ Farmer, Paul 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  9. ^ Farmer, Paul 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  10. ^ Farmer, Paul 2003 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
  11. ^ Farmer, Paul 2004 An Anthropology of Structural Violence. Current Anthropology 45(3): 305-325.
  12. ^ Farmer, Paul 2004 An Anthropology of Structural Violence. Current Anthropology 45(3): 305-325.
  13. ^ Brucato, Ben 2011 Review of “Pathologies of Power” by Paul Farmer. http://www.benbrucato.com/?p=125, accessed April 15, 2012.
  14. ^ Brucato, Ben 2011 Review of “Pathologies of Power” by Paul Farmer. http://www.benbrucato.com/?p=125, accessed April 15, 2012.
  15. ^ Corbett, Bob 1994 Review of The Uses of Haiti. http://www.webster.edu/~corbetre/haiti/bookreviews/farmer.htm, accessed April 16, 2012.
  16. ^ Corbett, Bob 1994 Review of The Uses of Haiti. http://www.webster.edu/~corbetre/haiti/bookreviews/farmer.htm, accessed April 16, 2012.
  17. ^ Kidder, Tracy 2003 Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. New York: Random House, Inc.
  18. ^ Kidder, Tracy 2003 Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. New York: Random House, Inc.
  19. ^ 2012 Paul Farmer, MD, PhD http://ghsm.hms.harvard.edu/people/faculty/farmer/, accessed April 15, 2012.
  20. ^ 2012 Paul Farmer, MD, PhD http://ghsm.hms.harvard.edu/people/faculty/farmer/, accessed April 15, 2012.