Paul Farmer


Ebola Tipping Point? Dispelling Myths And, Possibly, Less Hysteria Over Virus

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone. (AP)

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone. (AP)

Has the national hysteria over Ebola peaked? Who knows. Maybe. There seem to be fewer front page headlines screaming about it; a new national poll finds most Americans are “positive” about the response by public health authorities; and today’s news is that more than 40 Dallas residents (all who had been in contact with the Liberian man who died of Ebola) were declared virus-free.

Still, education is the antidote to hysteria, so it’s worth reiterating some of the facts. Many of them can be found in this must-read commentary in the London Review of Books by Paul Farmer, the rock star Harvard infectious disease doctor and leading advocate for global health equity in the world’s most impoverished regions. Farmer, who is also a co-founder of the Boston non-profit Partners in Health, writes that despite some of the truly scary aspects of the virus, an Ebola diagnosis is not necessarily a death sentence:

The Ebola virus is terrifying because it infects most of those who care for the afflicted and kills most of those who fall ill: at least, that’s the received wisdom. But it isn’t clear that the received wisdom is right….

…the fact is that weak health systems, not unprecedented virulence or a previously unknown mode of transmission, are to blame for Ebola’s rapid spread. Weak health systems are also to blame for the high case-fatality rates in the current pandemic, which is caused by the Zaire strain of the virus. The obverse of this fact – and it is a fact – is the welcome news that the spread of the disease can be stopped by linking better infection control (to protect the uninfected) to improved clinical care (to save the afflicted). An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care – including fluid resuscitation, electrolyte replacement and blood products – the great majority, as many as 90 per cent, should survive.

And he adds this:

I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.

If you want to become more educated on Ebola and find out what you can do to support the global effort, Partners In Health/Engage and Harvard are sponsoring an Ebola teach-in Wednesday night in Cambridge with a panel of practitioners and public health experts. Continue reading

A Health Care Success Story In An Unlikely Place

When you think about countries that might be considered health care “success” stories, Rwanda probably isn’t at the top of your list. But that’s exactly how renowned doctor and humanitarian Paul Farmer describes the African nation (once among the poorest in the world) in a recent BMJ article covered in yesterday’s New York Times.

Since the 1994 genocide in Rwanda, which claimed up to 1 million lives, “the country has become a spectacular public health success story and could provide a model for the rest of Africa,” the Times’ Don McNeil reports.

Consider these statistics cited in the news story:

In 1994, 78 percent of the population lived below the poverty line; now 45 percent do. The gross domestic product has more than trebled. Almost 99 percent of primary-school-age children go to school.



With help from Western donors, the number of people getting treatment for AIDS rose to 108,000 from near zero a decade earlier.

Many doctors fled Rwanda before the genocide, and many were killed. Even now, the country has only about 625 doctors in public hospitals for a population of almost 11 million. But it also has more than 8,000 nurses, and a new corps of 45,000 health care workers, elected by their own villages, to do primary care for malaria, pneumonia, diarrhea, family planning, prenatal care and childhood shots.

Largely because of these workers, the country has high rates of success in curing tuberculosis and keeping people with AIDS on antiretroviral drugs.

Nearly 98 percent of all Rwandans have health insurance. Continue reading

What The Rich U.S. Health System Can Learn From The Poor

A trio of superstar health innovators have a message for the broken U.S health care system: broaden the definition of health to include basic life necessities, bring care to where people live and study how it’s done in poor countries where you can’t always rely on expensive tests and drugs to make people better.

The persuasive new report on “re-aligning health with care” is written by Harvard doctors Paul Farmer (co-founder of the medical nonprofit Partners in Health) and Heidi Behforouz (executive director of the Prevention And Access To Care And Treatment [PACT] program) and Rebecca Onie, CEO of the nonprofit Health Leads. In it, they argue that with some rethinking, the U.S. can deliver better care at a lower price.

They lay out the central problem here:

The health care system is in crisis, driven chiefly by escalating costs, suboptimal health outcomes, scarce primary care resources, and rising poverty. At the same time…a growing number of health providers around the globe have learned to deliver high-quality health care at low cost. Now we need to align our resources in the United States to bring this knowledge fully to bear in saving dollars and lives.

Sounds great, but how to do it? The key, they write in the Summer 2012 edition of the Stanford Social Innovation Review is to change the way we view the “product” of health care, the places it’s delivered and the providers who dole out patient care. Continue reading

Paul Farmer On Why The Global Fund Shouldn’t Die

Dr. Paul Farmer’s speciality, among others, is his clarity when articulating a moral imperative.

Here he is on the opinion page of yesterday’s New York Times making the case to keep The Global Fund for Aids, Tuberculosis and Malaria (which has itself been injured recently by financial troubles of various kinds) alive.

Farmer, of course, is a Harvard infectious disease doctor and a cofounder of Partners In Health, the global health nonprofit, which has received support from The Global Fund in several countries. Farmer cites four reasons why The Fund matters, including its spillover benefits to other health and development areas, and its substantive investments in local health systems. Continue reading

Advocates Pressure Congress To Fund Global AIDS Programs

Pressure is rising on the U.S. to continue funding for global AIDS treatment

“Save Millions More Lives.”

That’s the subject line in a letter being sent to more than 184,000 supporters later today from the global health nonprofit Partners In Health.

The letter begins this way:

We’ve never done this before.

We’ve never asked you to contact your Members of Congress, but the situation is dire. Today is World AIDS Day and the poor we serve need your help.

PIH, along with other international health organizations and donors, has made enormous gains against HIV/AIDS over the past decade. These gains led to 6.6 million people receiving HIV/AIDS treatment. But today we’re at significant risk of seeing our progress stall or even stop. Continue reading

One Year Later: Cholera Keeps Rising In Haiti, Vaccine On The Way

Cholera has killed more people in Haiti in one year than in all other countries in the world combined in 2010

Cholera has killed over 6,500 Haitians in the past year, and nearly half a million people — about 5% of the country’s population — have been treated for the disease since it was detected in 2010, according to the nonprofit, Partners in Health. Indeed, cholera has killed more people in Haiti in one year than it did in all other countries in the world combined in 2010.

Yesterday, Dr. Paul Farmer, co-founder of the group that has been working in Haiti for 25 years, spoke to reporters about the need to greatly intensify efforts to stop the epidemic, and mount a more comprehensive response, including vaccinating about 100,000 Haitians with a cholera vaccine that is “safe, proven, effective.”

(The cholera vaccine, never before used in Haiti, will be rolled out beginning in January, PIH says.)

Here’s a bit of what Farmer said on the call (transcribed by PIH) which you can listen to here.

On the Need for a More Integrated Approach:

“What we’re calling for, a year into the epidemic, is a prompt integration of these prevention and care and treatment measures, including: chlorinated water at the household or village level, hand washing and hygiene measures, building up systems that haven’t previously had them, improved case-finding, treating with oral rehydration salts and finally integration of oral cholera vaccine.”

On Stopping the Water Insecurity:

“Some years ago, PIH and many sister organizations began talking about the right to water. We did so because those of us who are clinicians, we can sit in our clinics and work in our hospitals and wait for people to come in sick with complications of water-borne diseases, or we can work with public authorities and appropriate NGO partners and others to build real water security in Haiti. We’ve been sounding that drum for some years now.”

Continue reading

Case Studies, Now Online, Grapple With Global Health Dilemmas

For anyone interested in global health, fixing big problems in poor countries or just getting a sense of how the folks at Harvard Business School think, check out these newly accessible, free (for students and educators, at least) case studies that deal with thorny health care delivery dilemmas in poor regions of Rwanda, India, Haiti and throughout Africa.

The 21 studies range in scope and geography, for instance, Multi-Drug Resistant Tuberculosis Treatment in Peru (a classic) to Botswana’s Program for Preventing Mother-to-Child HIV Transmission.

The case study model was pioneered at Harvard Business School to help students simulate a decision-maker role in examining various issues in the financial and corporate world. But a few years ago, the renowned doctors and medical anthropologists who launched the non-profit Partners in Health — Paul Farmer and Jim Kim, now president of Dartmouth — began to apply the case study method to public health problems in poor countries in collaboration with Harvard Business School’s Michael Porter.

Medical and other students needed some kind of out-of-classroom experience dealing with health issues among the poor, the thinking went, and short of getting on a plane, the cases provided detailed, real-life problems — and in some cases, solutions. And though some of the studies might appear dry — perhaps you’re not fired up about Building Local Capacity for Health Commodity Manufacturing: A to Z Textile Mills Ltd. — I’ve had the privilege of sitting in on classes with all three of these guys and I can say it’s truly inspiring and intellectually gripping. Never, ever dry. (In fact, the A-Z Textile case study is the amazing story of a local Arusha, Tanzania maker of insecticide-treated bednets to prevent malaria and the misaligned incentives that brought them, sadly, down).

All 21 cases were developed jointly by the Global Health Delivery Project, a collaboration between Harvard’s medical and business schools, the Brigham & Women’s Hospital and Partners In Health.

Paul Farmer On The Haiti Earthquake

A young Haitian girl with cholera symptoms

The world gave a collective gasp of horror 18 months ago when word came of the devastating earthquake in Haiti. Now Paul Farmer, the doctor whose name is synonymous with bringing better health care to Haiti, has written a book on the aftermath, “Haiti After The Earthquake.” It’s described as “Paul Farmer’s written account of the earthquake, the root causes of the devastation it wrought, and the relief and recovery efforts of Haitians and those who came to their assistance.”

He’s scheduled to talk about it on “Fresh Air,” aired on WBUR today at 1 p.m., and his Boston-based organization, Partners In Health, just sent word that the staff would be running a five-week summer reading and discussion series on the book, here.

Dr. Evan Lyon of Partners In Health writes:

In the book, Paul and co-contributors—among whom I feel privileged to count myself—reflect not only on the lives saved and lost, on the challenges encountered and overcome, but also on the century of underdevelopment and internecine politics that have plagued Haiti. Continue reading

Embrace The Idea of ‘Accompaniment,’ Paul Farmer Tells Kennedy School Grads

While we’re highlighting inspirational commencement speakers, here’s Paul Farmer, the renowned doctor and co-founder of the humanitarian group Partners In Health, telling graduates of Harvard’s Kennedy School of Government to embrace the notion of “accompaniment” in their future endeavors, The Harvard Crimson reports.

Farmer speaks of the term broadly in his address, but its origins are close to his heart: decades ago, in Haiti, he helped mobilize a cadre of community health workers, or “accompagnateurs” to help treat and care for the sick and dying in their own neighborhoods and towns. This model of using local health workers as a central component of any medical support team has been replicated in communities around the world: in Rwanda and Peru, for instance, and more recently in the poorest neighborhoods around Boston. In Haiti alone, Partners In Health trains and employs over 2,000 Haitians as accompagnateurs, and these health workers were critical during last year’s devastating earthquake and subsequent cholera outbreak.

“All that I have to offer you today turns about the notion of accompaniment,” [Farmer] said to the audience. “It is an elastic term, but here it means sticking to a task until it is deemed completed by the person that you are accompanying.”

Farmer acknowledged that the concept could initially appear unrelated to government, but said that it has far-reaching implications. He asked graduates to consider the potential increase in the effectiveness of humanitarian aid that is executed according to the notion of accompaniment.

“Many of you here will be soon leading foreign contractors and NGOs—if you are not already—and you will need to help these organizations find a way to accompany our developing partners and intended beneficiaries away from deprivation and suffering,” he said.

“Just because we can’t tangibly measure the value of accompaniment, doesn’t mean that we can’t use it in the service of the common good,” Farmer added.

In Case You Missed It: Foot Soldiers Of Health Make Housecalls

A health worker visits a young boy at home to remind him how to use his asthma medications

I wrote a piece Friday about an ambitious new program that deploys community health workers to the homes of poor, chronically sick people in order to improve these patients overall health — mental, physical and otherwise. (And since many of our loyal followers appear to check out on Fridays, I’m revisiting it here, in case you missed it.)

These health workers, part nagging mom, part medical fixer, part guide through daunting insurance and social service bureacracies, do what ever it takes to connect patients to better health: they help with transportation and child care, advise on mental health problems and promote asthma and diabetes management. They can feel like a close aunt, or sister, talking to a new mom about post-partum depression, for instance, and when necessary, a health worker might even pick up a sponge, to help a patient learn how to clean the house.

The goal of the program, Network Health Alliance, is clear: better care for the patient and lower cost to the system by reducing expensive emergency room visits and hospitalizations and enveloping people more fully into a primary care setting.

In an odd twist, the concept of community health workers originated in poor countries like Haiti, as part of a more integrated health system promoted by the renowned doctor, Paul Farmer:

Here in Massachusetts, this wealthy medical mecca of high-tech hospitals, community health workers are part of an experiment to use low-tech lessons learned in the poorest of countries, Haiti. As the state, and the nation, begin to revamp broken parts of the health care system, the need for these health workers, who fill a critical gap by supporting families in their homes, is clearer than ever before, says Partners In Health co-founder Paul Farmer, the doctor famed for developing a cadre of such workers in Haiti. “There has been more discussion about the need for innovation in this arena this year than ever before,” he said. We are finally acknowledging that “it is very expensive to give bad medical care to poor people in a rich country.”

If you want to learn more, read Atul Gawande’s excellent story on “Hot Spotters” in The New Yorker, and Tina Rosenbeg’s piece in The New York Times about a program that uses health workers to support AIDS patients in New York City.

And listen to Radio Boston, which is planning to air a segment on community health workers Tuesday at 3.