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If you like Paul Farmer's story, you might also like:
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Paul Farmer
Paul Farmer
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Paul Farmer Interview (page: 4 / 9)

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  Paul Farmer

You've done so much work with this problem of multi-drug-resistant infections, such as tuberculosis, what we call MDR-TB. Could you talk about that specifically?

Paul Farmer: I'd be glad to, and I think that's important. I mean, look where we are. We're in South Africa. It's a huge problem in this part of the continent and it's not been acknowledged.

How did this come about? Is this a case where the solution to the problem became the bigger problem?

Paul Farmer: Did the solution become the problem? I think the answer is no. Everybody thinks that, but putting it that way allows me to lay it out. It's not just about TB. It's about staphylococcus, HIV and every kind of infection. In general terms, there's the bugs and there's us. And the bugs, these are human pathogens, they're the enemy, all right? And I'm sorry I can't be completely touchy-feely about that. These are bugs that kill humans. They're viruses, parasites, bacteria. I don't have anything against dams, and I don't have anything against microorganisms, unless they're pathogens to humans. That's the link here. If dams help people, I like dams. If bugs don't hurt people, I've got nothing against bugs. They're all over us and all around us. But these are pathogens that kill millions of people every year.

The general point is, humans in the mid-20th century began to develop an arsenal of anti-infectives that could kill bacteria, parasites and viruses. It took a long time, and it's still ongoing, but that's the basic development. In the mid-20th century, we started getting the weapons we needed to kill the bugs that were killing us. But what happens is the bugs fight back, and they develop resistance to the weapons. So -- and then let me give it -- before even talking about tuberculosis, 'cause it's very contentious. Why? 'Cause it's airborne, that's the main reason it's contentious. But take staph aureus. Everybody hears about killer staph. It's a terrible pathogen. In the mid-20th century, almost all of the staph could be killed by penicillin. Now, 95 percent in South Africa and in the United States, it's all resistant to penicillin. So the bugs can't really be killed by the drugs that we developed in the 20th century. So we're playing catch-up. Now that's the general issue. I mean, you look at malaria, you look at TB, you look at HIV, you look at bacteria, like staph. It's a general story.

The bugs are going to fight back. They're going to develop genetic mutations that will allow them to escape the killing by the antibiotics, the anti-infectives. So it's not just about one disease or another. So the question, the way you put it, which I think is the way most people ask, "Is the solution part of the problem?" And I would say, "No, that's not the problem. The problem is the way we use the solution." So go back to TB again. If we had had a way, in the mid-20th century, of delivering effective therapy for tuberculosis to everybody who needed it, then we would have had community health workers, and all these things that we have scrambled to development, I don't think we'd have the big problem we have today with drug-resistant tuberculosis, MDR-TB.

Why didn't we do that? Why do we have this big problem?

Paul Farmer: 'Cause we keep trying to do it on the cheap. What do I hear all the time in my work? "We can't pay community health workers 'cause it's not sustainable. It's too expensive." When what's really expensive is to not pay the community health workers. That's what's really going to get you in the end, to have cheap solutions for really complex problems. For example, in the United States, with HIV, with AIDS, if we would simply put in place good community-based care and actually pay community health workers, then we wouldn't have so much drug-resistant HIV. Same in South Africa. What we've tried to do in our work with the so-called public sector, with the Ministry of Health in Rwanda and Haiti, is to say, "Now let's do it the right way from the beginning. Let's start by making sure that people who are sick have access to care, and that it's supervised by community health workers who are living with them, in the same villages."

This conventional model is, the patient's sick, they go in to the doctor. But there are no doctors out in rural Haiti. There are now, but I'm saying that was not a viable model, and so we actually developed a different model, that turned out to be better then the standard model, because it actually delivered good community-based care. We say, "free of charge to the patient." Okay, maybe that's not the right term, "free of charge." 'Cause obviously someone's paying for it right? Someone's paying the labor costs for the community health worker, the diagnostics for the lab and the medicines. But if you don't want to see this drug resistance develop with the chronic infectious disease, then don't ask the patient to pay for it. Because when they have money, they'll pay for it, and when they don't, they can't. And then the treatment gets interrupted, et cetera, et cetera. The whole chain inevitably leads towards drug resistance.

To be very clear, what is happening on the ground level that is creating this drug resistance? What is it about healthcare and the infrastructure?

Paul Farmer: You're right to push me on this. I've studied this my whole life, and this is my reading of it. I think this is what's happened. Of course we wouldn't have drug-resistant disease if we didn't have antibiotics. We would, but they'd be naturally occurring mutations that didn't add up to much in human populations. So it is true that the challenge of antibiotics is what created drug resistance to start with, and spread it through human populations, that's true. But I would say there are other causative factors here. For example, the model of care that I described. You have someone who pays. If they have money, they pay for the treatment. Is that the right model for public health? I don't think it is for infectious disease. In fact, I don't think it's right for a lot of things.

Healthcare in the United States is very expensive, and part of the problem is it's very expensive to give bad medical care to poor people in a rich country. Think about that. It's expensive to give bad medical care to poor people in a rich country. We're in Cape Town, so let's just talk about Cape Town. You look at the massive teaching hospital here, or the beautiful university, but you know, the idea that some people, because they're poor here, are not going to try and get good medical care for their family, that's absurd. Of course they are. Women who live in poverty love their children just as much as anybody else does. So you're going to have all of this engine of really effective connections, and families are going to push people to try and get medical care. But if it's a commodity that you buy, then when you're poor, you buy it sometimes, you can't buy it at other times. That's not a good model for public health response, I would say.

Paul Farmer Interview Photo
So a lot of people figured this out around tuberculosis back in the 20th century. They said, "Oh, we made a mistake here, selling these drugs." So they took the drugs out of the pharmacies and put them in the hands of public health officials. I think that was the right thing to do. The problem is, in the world, we don't have that system set up in enough places so that everybody who has tuberculosis has access to diagnosis and care. Instead, they don't know what they have. They cough. They go get a chest X-ray. They pay out of pocket for that. They're told one thing. Maybe they get good advice, maybe not. But that system, globally, is not set up very well yet.

Isn't that the definition of bad medical care?

Paul Farmer: Yeah, but the doctors and nurses who are delivering bad medical care aren't doing it on purpose. If they don't have a system behind them, what can they do? In The New York Times Magazine last week, the last page, there's a one-page essay. It's about an American woman in India. She has had a problem with a malignancy, a cancer, in the past. And she's told by her American doctors, "You can go to India, as long as you have some screening now and again." So she hooks up with this doctor, and he is this cheerful fellow who really has nothing to work with. And at the end of that one-page essay, they go and visit this Indian woman who's dying of cancer. And he's saying to her, "Be of good cheer," and the American said, "It seemed cruel, but that's all he had, was words." And that's it.

The doctors and nurses who are delivering mediocre medical care are not doing it 'cause they want to. They're doing it because they don't have the tools of the trade, the system behind them that they would need to provide good medical care. You know, in all the years that I've spent working in Haiti and Africa -- which is now 25 years, and Latin America -- versus, say Harvard, I tell you, I don't think that these young professionals in Africa are any less committed, even though I would have said that 15 or 20 years ago. They're not less committed to medicine and to people's health. They just don't have the systems and tools that they need. One of the biggest epiphanies for me in working in these different places is, if you can set it up so that young African professionals, nurses and doctors and social workers and people in Haiti, et cetera -- if they can actually do their work, they're happy to do it. People talk about the brain drain. One of the best ways to respond to brain drain is actually give these young professionals the tools that they need to serve the poor, 'cause they're surrounded by the poor. I think that's a big part of what we need to do in global health, is to make sure that we don't make the mistake, say as young Americans -- I'm not young any more, but -- of saying, "Oh, it's all about us going in and saving the day." It was never about that. It's always about building systems, and building teams, and building partnerships that will last.

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So drug resistance is, in a way, a big challenge to the "healthcare as commodity" approach to healthcare, which is this sort of garden-variety approach. If healthcare is something you buy, what if you're poor and you have an airborne disease? What if you have influenza or tuberculosis or swine flu? Who knows? If we don't take that as a public health problem, it's just a private problem, and then it's going to be out-of-pocket expenses, and it's not going to be the right response to these kind of problems. Same thing for malaria, and on and on it goes.

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This page last revised on Sep 28, 2009 20:07 EDT