Chapter 10 … There are no accidents. The Paul Farmer Story

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In 1983, a young anthropology graduate from Duke University named Paul Farmer set off for Haiti. He had done research on Haitian migrant workers at Duke and become deeply interested in their home country. He wanted to become a doctor and an anthropologist and thought he might sample a bit of both by going to Haiti and volunteering in health clinics.

While there, he boarded a bus with a new friend, Ophelia Dahl. Ophelia, the daughter of movie star Patricia Neal and author Roald Dahl, was just 18 at the time, and looking for a calling in life. As they navigated the rough, unkempt roads of Haiti, Paul leaned out the window and waved happily to all who greeted them, which Ophelia found nerdy but beautifully innocent and charming. Then they came upon an overturned bus on the road. Mangoes destined for the market were scattered everywhere as people meandered about making sense of what had just happened. A woman lay lifeless, with a strip of cardboard covering her body.

Paul went stone silent. Ophelia tried to comfort him by saying, “It’s just an accident.” But Farmer was “seeing big” like an anthropologist. He saw that the neglected road was no accident. The worn shocks of the bus were no accident. The overloading of the bus with peasants going to market with their mangoes was no accident. These were all a result of poverty, and Farmer could see through this poverty the past 400 years of history in Haiti. He saw the 17th century slave colony of France, the brutal and bloody fight for independence, the French demand that Haiti pay back $21 billion for their “lost property” (the slaves who were now the citizens of Haiti being asked to pay for themselves), and the environmental collapse that came from trying to pay those debts. So when he saw the woman who was riding in a worn-out bus over a torn-up road to sell mangoes at an market desperately impoverished by 400 years of history, lying dead on the side of the road, he turned to Ophelia and responded, “It is never ‘just an accident’.”

This peculiar view of the world, that there are no pure accidents, is also an empowering one. Paul Farmer and Ophelia Dahl would soon recruit the young anthropologist Jim Kim to their cause and set out to provide the best healthcare possible to the world’s poor.

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Thirty years later, their efforts would be celebrated as “the friendship that changed the world.” And it all started by applying the anthropological perspective of seeing your own seeing, seeing small, seeing big, and seeing it all to realize that there are no pure accidents. If the message building from the preceding chapters was “We make the world,” the message of this trio has been, “We can do better.”

“Tout Moun Se Moun”

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During one of his first trips to Haiti, Farmer shadowed an American doctor. He was enamored with his competence, talent, and care, and saw him as a great role model. But he was soon disenchanted to find out that this American doctor had no intention of staying in Haiti. “I’m an American, and I’m going home,” the doctor said. Farmer kept pondering the conversation and hanging on those words, “I’m an American,” wondering how it is that we come to classify ourselves into these exclusive categories, thus limiting our responsibilities and allegiances to others.

That night, a pregnant woman suffering from severe malaria came in and crashed into a coma. She needed a blood transfusion, but the only place to get blood was far away in the capital city, and the blood would cost money.  Farmer ran around the hospital gathering money and came up with fifteen dollars. The woman’s sister took the money and set off for the city, but returned empty handed. She did not have enough money for the bus and the blood. The pregnant woman, a mother of five, died.

The sister was distraught, sobbing and crying. Through her tears Farmer heard her say, “You can’t even get a blood transfusion if you’re poor.” And then she kept repeating, “Tout moun se moun. Tout moun se moun.” We are all human beings.

Tout moun se moun. Driven by such words, Farmer dedicated himself to serving all humans as humans. He turned his attention to those who had been most neglected by the world. He set off for Cange in the central highlands of Haiti, the poorest of the poor in the poorest country in the Western hemisphere.

Structural Violence

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Cange was the perfect place for Paul Farmer. From the mountain road entering Cange, there is a beautiful vista of an expansive blue lake framed by the steep mountainsides. But Farmer, who could see that same scene through the eyes of local Haitians, with the benefit of an anthropological lens to see the bigger picture, saw that this was no simple beautiful mountain lake. It was, despite the deceptive calm and tranquility of the mountain lake, one of the many reasons for the extensive poverty of Cange, and it was no accident.

The lake was artificially created by a dam project led by the U.S. Army Corps of Engineers to provide irrigation and power to Haiti. However, the recipients of the water and power were not the poor of Haiti, but American-owned agribusinesses and the Haitian elite living downstream.

The lake swallowed up the best farm land of Cange and destroyed people’s homes. Farmer called the people who had to evacuate the valley “the water refugees,” and they were some of the most poor and destitute in a country full of the poor and destitute. Instead of farming in the once-fertile valley the river ran through, the people were forced onto the steep mountainsides where water would not hold. They tried to farm anyway, which led to devastating erosion. Pushed beyond malnutrition toward famine, virtually everything green was consumed and used up, so that today Cange is a shocking glimpse into a world that has suffered true environmental devastation.

Paul Farmer frequently writes and speaks about the dam near Cange as an example of structural power and the structural violence that can result.

“The Anthropologist Within”

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Farmer enrolled in a program at Harvard that allowed him to pursue a degree in anthropology while simultaneously earning his doctorate in medicine. He knew that if he was going to serve the world’s poor, he would need the anthropological perspective to understand the broader cultural environment and issues impacting their health outcomes.

Throughout his training, he continued to spend most of his time in Haiti. His professors were not against it, as he was providing important medical care to people who needed it, and it proved to be a fruitful place to apply what he was learning in graduate school.

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His work had a profound influence on anthropology. In one of his first essays, “The Anthropologist Within,” he argued that the traditional manner of practicing anthropology as an impartial observer made him feel restricted in his ability to help solve the many problems surrounding him in Haiti. Since that article was written in the early 1980s, anthropologists have become much more active in their work, and are more likely to actively participate in providing solutions to local problems rather than standing idly by as impartial observers.

But Farmer was struggling to make a big impact in Cange. He needed money to complete his vision of building a free hospital providing outstanding medical care to the poor. His essay caught the eye of Tom White, the owner of a construction company in Boston who was interested in donating money to feed the poor in Haiti. In fact, he planned to give away every last dollar of his substantial fortune before he died. In Paul Farmer, he thought he had found someone who could make sure his money was well spent.

With the first $1 million donated by White, Paul Farmer established Partners in Health/Zanmi Lasante. The plan was not to simply support Paul Farmer in Haiti, but instead to create “partners in health” by training community health workers throughout rural areas of Haiti.

“O for the P”

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As the three friends – Farmer, Kim, and Dahl – set about crafting the core goals for Partners in Health, they continually came back to the idea of “O for the P,” short for “preferential option for the poor.” The “preferential option” refers to the idea that poor people should not just get the bare essentials of healthcare, but they should be given preferential treatment as those most in need, and that they should receive the same top-quality “preferential options” that the wealthy receive. Tout moun se moun – we are all human beings – drove every aspect of their operating philosophy.

While this might seem like an obvious and uncontroversial goal, it ran against the operating consensus of other development professionals, as well as the top global aid organizations such as the World Health Organization. The standard consensus at the time was organized around the idea of “cost effectiveness.” Instead of providing the “preferred option” the scarce resources available to development projects should be used to maximize benefits to the most people.

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“O for the P” opened up a serious controversy. Imagine a fairly common scenario that one might face in rural Haiti or any other impoverished area. A patient has a complicated case of TB that will cost $5,000 or more to cure. Ordinary cases of TB cost just $200 to cure. Do you cure the one for $5,000 or do you cure 25 ordinary cases for the same amount? The principle of cost effectiveness would suggest that you cure the 25, not the one.

But Farmer, Kim and Dahl were taking a longer view. They so strongly believed that the highest quality healthcare should be available to all that they decided to go down that long, hard, unexplored path of providing the best for everyone, in hopes that they might be able to attract more money, lower costs, and ultimately save even more lives than they could by following the traditional model of “cost effectiveness.”

The Structural Power of Medicine

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The key barrier to O for the P was the cost of medicine. When they first decided to try to treat the most complicated cases of TB, the treatment drugs could cost as much as $60,000 for just one patient. With such high prices, the World Health Organization (WHO) would not recommend the drugs, since it goes against the logic of cost effectiveness. And since the WHO would not recommend the drugs, generic manufacturers would not produce them. These three factors create an interlocking triad in which prices are high, so the WHO will not recommend it, so generics will not produce it, so prices stay high – a vicious cycle that continues as people all over the world continue to die while drugs are readily available that could save their lives.

Jim Kim took the lead on trying to break through this vicious cycle that kept prices so high. As he did, he kept encountering a prevailing supporting myth for why the drugs were not being made more available: ‘Poor people are poor because they are stupid and lazy.’ They are lazy, so they do not deserve the drugs. Their lives are not as highly valued as those of the wealthy. And they are stupid and will likely misuse the drugs, build resistance to the drugs, and cause further harm.

The WHO and development professionals who held these views were not as prejudiced as you might think. They formed their opinions based on experience. They came into their careers idealistic and full of hope, but constantly found their carefully crafted plans fell apart in practice, and treating TB was especially difficult. To properly treat TB, the patient must take the proper drugs and keep taking them after the symptoms have cleared in order to ensure that the TB does not recur or get passed on to others. Unfortunately, when people do not complete the drug sequence, the TB can develop resistance to the cheap drugs, and an outbreak of multi-drug resistant TB can take hold.

Paul Farmer saw the same patterns, but he refused to blame the patients.  In part, this was because he lived particularly close to them and immersed himself in their lives.  Actually living with people in extreme poverty had taught him that they were anything but lazy or stupid.  He knew there were other challenges keeping them from taking their prescribed medications.

So Farmer expanded the prescription.  His new prescription was not just for drugs, but also for regular visits from community health workers who would travel throughout rural areas to check up on the patients and make sure they were taking all of their drugs. And as a third element, he even prescribed money – a cash stipend so that they could pay for good food and childcare while they were sick. His studies had shown that the poor were not stupid, they were simply constrained and forced to make trade-offs while they were sick in order to make ends meet. A small cash stipend of just $5 was enough to let them rest properly and pay for help until they were fully recovered.

The success rates before Farmer’s intervention were dismal. Afterward, the success rate soared to nearly 100 percent. When he published the results, it became a model for others all over the world. He had shown what could be done by working with the people and creating a broad coalition of local leaders and community health workers.

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With their success, they decided to push harder against the structural power that was keeping the cost of drugs for more complicated forms of TB so high, and launched a project in the shanty towns outside of Lima, Peru where there was an outbreak of Multidrug Resistant TB (MDR). Farmer held to his same prescription: drugs, regular visits, and a cash stipend. The problem was that the drugs were $15,000 per patient.

The World Health Organization and other development professionals pushed back. It was not cost effective to treat people for $15,000 each. It was not sustainable. Tout moun se moun, Farmer thought, and they set off to find a way.

With their background in anthropology, Farmer and Kim know that price is a social construction. There is no inherent quality of the drugs themselves that make them worth $15,000. So they set about changing the structure to lower the cost. Jim Kim, with his passion for policy and transforming bureaucratic structures, threw himself into the problem. He had to find a way to convince generic manufacturers to produce the drugs, which would drive down the cost. But the WHO would not recommend the drugs due to their high cost, and because of their concerns about poor people and poor regions not having the knowledge and resources to properly administer the drugs.  They were stuck in a structural stalemate: the WHO would not recommend the drugs due to their high cost, the high cost was due to the WHO not recommending the drugs.

To convince the WHO, Kim promised them that Partners in Health would set up a “Green Light Committee” to create standards and require training to ensure that the drugs would be administered responsibly.  The Gates Foundation bought in and offered $45 million to support the initiative.  With the WHO on board, Kim went to the generic manufacturers, who agreed to make the drugs. Prices fell 97%. 750,000 lives were saved.

It was an amazing feat. Jim Kim was trained as a medical doctor and hoped that one day he would save lives—and here he had just saved 750,000 lives.  He took what he had learned in the pilot programs in Peru and found a way to bring that same care to hundreds of thousands. He had recognized a configuration of structural power that was causing great structural violence, and changed the structure.


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Aids in Africa

By 2001, their money was running out. Tom White was determined to die without a dollar to his name, and he was nearing his end. They had created an effective treatment for TB that was spreading throughout the world, and they were having great success treating AIDS in Haiti at a time when much of the world thought that treating AIDS among poor people would not be “cost effective” or “sustainable.”

At that time, thirty million people in Africa had AIDS, and only 50,000 of them were receiving treatment. The Partners in Health model was working in Haiti, in circumstances similar to those in many African countries. This made people hopeful, and The Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) was launched, raising millions of dollars to combat AIDS.

The WHO was brought on board, the generic manufacturers started producing the drugs, and the cost of treatment plummeted. “Anti-viral drugs can extend life for many years,” President of the United States George Bush announced in his State of the Union address later that year, “And the cost of those drugs has dropped from $12,000/year to under $300/year, which places a tremendous possibility within our grasp … Ladies and Gentlemen, seldom has history given an opportunity to do so much for so many.” He proceeded to ask Congress to dedicate $15 billion over the next five years “to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.” His request was greeted by a jubilant standing ovation, delivered from both sides of the political aisle.

Jim Kim, Paul Farmer, and Ophelia Dahl were astonished. In just twenty years of deeply dedicated service to their calling, they moved from working and struggling outside the system to being insiders.

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A few years later, Jim Kim was nominated and elected to be the new President of the World Bank, an opportunity to use tremendous wealth and power to bring better health and well-being to the world.

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In the years to come Paul Farmer would join Dr. Agnes Binagwaho in Rwanda to set up a healthcare system that had been torn apart along with the country after the devastating genocide of 1994.  They sought not only to create a functioning system, but a world-class system that could expand on the original vision of a preferential option for the poor. They offered expansive treatments, created a country-wide network of well-trained health workers connected through a cellular network.  They even opened a cancer center and founded the University of Global Health Equity.  They tackled AIDS with the same prescription Farmer had always preferred: the proper drugs, follow-ups by health workers, and a cash stipend to cover expenses while sick. While many still saw the treatment (and especially the stipend) as radical, the results spoke for themselves.

From 1995 to 2015 Rwanda had the steepest decline in child mortality recorded in any place at any time.

Today, Farmer, Kim, and Dahl continue to build a global network of people dedicated to a preferential option for the poor.   And this includes educating the next generation of health professionals and advocates who can lead the way.  You can learn how you can get involved here. (Links to an external site.)

Former ANTH101 student and TA Garrett Wilkinson with Jim Kim and other future health professionals at Partners In Health.


Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, by Tracy Kidder

Bending the Arc: A Friendship that Changed the World. Documentary Film.

Partner to the Poor: A Paul Farmer Reader

To Repair the World, by Paul Farmer

Reimagining Global Health by Paul Farmer, Jim Kim, Arthur Kleinman and Matthew Basilico

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