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April 2000
The Potential for Global Human Solidarity:
HIV Through the Eyes of a Physician on the Front Lines
The Satya Interview with Paul Farmer


Paul Farmer is an infectious disease physician and anthropologist who has worked in HIV and tuberculosis control in the Americas for over a decade. He is the author of several books including Infections and Inequalities: The Modern Plagues (University of California Press, 1999), and is co-editor of Women, Poverty, and AIDS (Common Courage Press, 1996). Farmer is co-director of the Program in Infectious Disease and Social Change at Harvard Medical School, where he heads the International Working Group on Multidrug-Resistant Tuberculosis (MDR-TB). He is medical co-director of the Clinique Bon Sauveur in rural Haiti and is an attending physician in infectious disease at Brigham and Women’s Hospital in Boston. In urban Peru, he is medical director of a community program treating patients with MDR-TB. He teaches social medicine and medical anthropology at Harvard Medical School. Catherine Clyne caught up with the doctor to ask some questions about his work in Haiti and Boston, and his views on poverty, affluence and HIV.

What kinds of therapies do you recommend to your HIV/AIDS patients? Do they differ between the U.S. and Haiti?
I recommend the same therapies for all humans with HIV. There is no reason to believe that physiologic responses to therapy will vary across lines of class, culture, race or nationality. Thus the justifications for different standards of care are merely economic ones. Since I do not believe that there should be different recommendations for people living in the Bronx and people living in Manhattan, I am uncomfortable making different recommendations for my patients in Boston and in Haiti.

At the same time, it is obvious that clinicians in Haiti are faced with different, and, in fact, greater, challenges when attempting to treat complications of HIV disease. For example, a patient who has a seizure in Boston—whether from Roxbury or Newton—will have a CT or MR scan of the head. But the only CT scanner in Haiti is in Port-au-Prince and has been out of commission for some years. So we are often called upon to make "empiric" recommendations. That is, sometimes we have to treat blindly, without the solid evidence that we are able to obtain in the U.S. But this is by no means tantamount to developing double standards for the poor, because we would very much like to have a CT scanner in Haiti and will work to see that this happens some day.

Personally, how do you deal with the marked contrast between your work at Harvard and in Haiti?
Well, this is a difficult question. There are days in Haiti when I feel discouraged by the lack of medications or diagnostic capacity. To remediate this discouragement, my co-workers and I seek to improve the quality of care that we are able to provide to our patients. In other words, I deal with the contrast by seeking to diminish it.

How well do you believe people in non-western countries understand the germ theory of infectious diseases? How much does religion, magic or malevolent spells have to do with their understanding of what the diseases are and why they get them?
In my experience as a doctor serving people in the U.S. and in what you term "non-western" countries, I have learned that very few patients in either setting understand the basic principles of infectious disease. I would hasten to add that many doctors also fail to grasp key issues in, say, how to use antibiotics or how to manage a complicated infectious disease. So no, most do not understand where infectious diseases come from. But in Haiti, it is clear that many patients who speak of sorcery also believe in the germ theory. That is, they understand that sicknesses such as AIDS may be caused by a microbe, but in addition they draw on a host of complex, multifactorial understandings of causation. It’s hard for me to say that these notions are less sophisticated than those I encounter among my U.S. patients.

What do you think is or should be the responsibility of affluent nations with regard to the epidemics of infectious diseases in poorer nations and their treatment/prevention?
It’s my view that these are fundamentally transnational epidemics, and not really contained by administrative boundaries. So the entire analysis is fraught to start with. But if you’re asking my opinion, I would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick. Or it can be based on an epidemiological approach: go where the disease is. But no matter how you slice it, the only way to deal with global public health problems is to move resources from places in which they are concentrated, where there is little disease, to those where resources are limited and shrinking. It is in these latter settings, of course, that one finds the greatest burden of disease.

What role do you think the pharmaceutical industry plays in the globally rising HIV infection rate? What roles do or should pharmaceutical companies have in a) public health prevention initiatives, and b) making drugs available to poor nations? In your opinion, are they doing enough?
Well, I don’t think that the role of the pharmaceutical industry is any different from that of other transnational corporations. The degree to which international business and finance bears responsibility for the structure of HIV risks has never really been seriously addressed by research, and so I’m reluctant to comment on this.

As to what role this industry should play, however, there is much to say. Since this industry is, at this time, the only source of medications for our patients, it is an error to think that its leaders do not need to come to the table to discuss this problem. Anyone interested in the care of patients in resource-poor settings is going to need to form partnerships with this massive and influential industry.

It is clear that the pharmaceutical industry is not, by any stretch of the imagination, doing enough to ensure that the poor have access to adequate medical care. Some would argue that this is a business like any other; I would argue a business that each year posts impressive profits in selling medications to the sick might have a special obligation to think of those who are both sick and poor. We cannot say that the industry’s leaders are unwilling to shoulder such a responsibility if we fail to challenge them to do so.

From your experience in Haiti, can you comment on how poor nations perceive the roles of western countries and pharmaceutical companies in the epidemics of infectious diseases among their people? Do they want or expect affluent nations to help? Do they blame western countries for their situation? Do they make connections between their suffering/mortality rates/lack of medical treatment and western countries?
Darkly. Yes. To a great extent, yes and yes. Let me flesh out my answers to these four questions. When I say darkly, I hasten to add that this is, not infrequently, a very accurate way of seeing the actions of the powerful. I’ve been impressed, over the last 15 years, with how often the somewhat conspiratorial comments of Haitian villagers have been proven to be correct when the historical record is probed carefully. At the same time, the fact the world’s poor are calling upon us to help is a marker, in my view, of the limitless potential of human solidarity. In fact, it seems to me that making strategic alliances across national borders in order to treat HIV among the world’s poor is one of the last great hopes of solidarity across a widening divide. In an era of failed development projects, and economic policies gone bad, I sometimes feel very lucky as a physician, since my experience in Haiti has shown me that direct services are not simply a refuge of the weak and visionless, but rather a response to demands for equity and dignity.


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