I just finished reading the most fantastic book. Entitled “Mountains Beyond Mountains” it is written by Tracy Kidder and follows the life (thus far) and work of Dr. Paul Farmer. This book has renewed my faith in humanity and in medicine, which I didn’t think was possible. Farmer is, well in simplest terms he’s an infectious disease doctor and Brigham and Women’s hospital in Boston. This job title does not begin to describe the work he does in treating HIV, AIDS, TB and MDRTB (Multi-Drug Resistant Tuberculosis) in Haiti, Peru, Russia, and Boston and the influence he and his organization Partners in Health have had on global health and poverty. Much has been written by him and about him and I’m not going to write about specific things he has done. I’m going to write about why I can’t shake the impression his world view has had on me.
In Haiti he’s Doktor Paul. My dear Haitian friend, when I ask him if he has met Farmer, says “Of course! He is Haitian!” And that is how the people of Haiti feel about him. He is, to quote my friend again, “Beyond words.” You see, Paul Farmer really thinks that all humans are interconnected, that one life is not worth more than another, that cost-effective strategies for the global war on poverty don’t apply to the patient he’s looking at right now. That we SHOULD be uncomfortable with the disparities between rich and poor. That we SHOULD be ambivalent about our places in life. But it’s not just that he “cares about poor people” in some general way. Plenty of people wave their hands around and spout about how “something needs to be done in x third world country and how we have so much and they have so little and isn’t it awful why don’t I send Mr. Farmer 50 bucks for his wonderful work”. Farmer’s interest is ultimately in the individual, and focusing on the individual gives him the drive to intervene in a concrete way in places like Haiti.
Here are two examples of this philosophy. Farmer will walk 11 hours to follow-up on a single TB patient that hasn’t been seen in the clinic recently. He doesn’t view this as a waste of time. He once approved a $20,000 flight to the US for a Haitian boy dying of a rare but treatable form of cancer. When asked if he didn’t think this money might have been better spent on a larger number of people in a smaller way, and why this boy and not another, he will say something like “Because this boy and his mother were in my clinic. They needed help and I could help.” He doesn’t view this as a waste of money. The general consensus among world health experts is that it isn’t cost-effective to aggressively treat HIV and MDRTB in poor countries. Farmer disagrees. I did anesthesia for a week in the jungle in Mexico where the anesthesia machine had holes and little old ladies re-sterilized gloves and hung surgical drapes on clotheslines. It was hard not to think “What’s the point? This is such a drop in the ocean”. Farmer would view that week as a great success because 20 people who needed my help got it.
One thing that strikes me about Farmer is that he still loves his work at the Brigham. He either does not see or is immune to the many hassles, waste, and general BS that have become part of daily life in high-tech hospitals. I don’t understand this. I would think that someone who has seen as much suffering as he has would be angry and offended by the excesses of American medicine. I spent 4 hours sitting in an OR yesterday giving anesthesia to a beautiful 19-year-old who wanted a nose job. That makes me crazy. And maybe he is angry. But it is channeled in such a way that he is able to use the resources of his hospital to further his work elsewhere. And he still manages to keep the focus on the individual. Duke, Harvard, the Brigham, professorships, Fulbrights, Gates foundation grants, all his intellectual and societal gifts are channeled toward the individual. Most of the frustrations with health care reform, health insurance, computerized records, etc. comes from the elimination of the importance of the individual. Protocols and Meaningful Use requirements deny the uniqueness of the individual. Cost-effective quality measures consider populations, not people. If we can keep the focus on the patient in front of us, the world can change.
Doktor Paul. Beyond Words.