The Physician as a Public Health Leader
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control.
– Universal Declaration of Human Rights, Article 25
I argue that equity is the central challenge for the future of medicine and public health.
– Paul Farmer
Paul Farmer, MD, PhD, has dedicated his life to focusing on the inequality of healthcare for the most vulnerable members of our society. In addition to serving the poor 1 patient at a time, Farmer forces us to look at structural violence, which is disproportionately realized by the poorer and weaker members of our planet.
Introduction
Farmer (born October 26, 1959) is a physician, medical anthropologist, and health advocate who strongly believes the biggest challenge facing medicine in the 21st century is “harnessing science to help the sick and the destitute sick.”1 He holds the positions of the Presley Professor of Medical Anthropology at Harvard Medical School and chief of the division of social medicine and health inequalities at Boston’s Brigham and Women’s Hospital.
He is a founding director of Partners in Health, an international charity organization that provides direct healthcare services and advocates on behalf of the sick and poor. Farmer is also medical director of a charity hospital, the Clinique Bon Sauveur, in rural Haiti. His life story was superbly written and introduced to the public in Mountains Beyond Mountains by Pulitzer Prize winner Tracy Kidder. Farmer is the winner of the MacArthur Foundation Genius Award and the Margaret Mead Award for his contributions to public anthropology.
Farmer exemplifies an expert mastery of the art of caring—one that is worthy of emulation. He was chosen for inclusion in this series of guest editorials because of the personal sacrifices he has made to serve the poor, as well as his efforts in educating others about the inequalities in housing, nutrition, and healthcare inflicted on the destitute poor by those in power. His attention to the inequality of healthcare to the most vulnerable members of our society, and his efforts to alleviate this disparity, are nothing less than admirable.
The Clinician–Patient Relationship
In my mind, practicing excellence in the art of caring by attempting to master the clinician–patient relationship evokes an image of a one-to-one interaction between the healer and his or her patient. Farmer gained his fame not by seeking it, but by purely promoting a better way of providing health to an underserved subsection of society—those who are without the basic necessities assumed, even expected, to be available in many parts of the world. Farmer argues that “anyone who wishes to be considered humane has ample cause to consider what it means to be sick and poor in the era of globalization and scientific advancement.”1
Basic Human Care
In 2006, Farmer won the 2006 J.I. Staley Prize for outstanding work in anthropology for Pathologies of Power: Heath, Human Rights, and the New War on the Poor. Here, he notes that the most basic of human rights—the right to survive—is being denied to the most vulnerable of our world’s population. Freedom from want is the human right most applicable, and unfortunately most denied, to many of his patients.
Physicians, nurses, and physician assistants of course need access to medicines and supplies to physically practice medicine and nursing, yet he challenges us to be more active in social and economic rights as a logical extension of care of the patient. This rhetoric comes from someone who has witnessed this inequality firsthand, which only serves to make his story all the more compelling.
Farmer’s life story, like so many of the subjects of past guest editorials (eg, Hippocrates, Maimonides, Osler, Nightingale, Schweitzer, and Pellegrino), is what provides the human experience and foundation for his argument. He has travelled to the poorest communities on the planet and lived side by side with those he serves. Whereas humanism advocates for focusing on the individual, Farmer might argue that you must not forsake the public health of a community for the individual patient.
As physicians, we are responsible to both the individual and society; although this relationship sometimes manifests in dilemma, it should never be far from the healer’s mind. He would certainly proclaim that the rich and powerful—or perhaps the clinician who exists in a relatively powerful role in relation to the vulnerable patient—must not forsake the poor and weak. Farmer calls for involvement by globally advocating for equitable healthcare for those who cannot effectively speak for themselves. This must be a principle by which the true healer lives his or her life.
Inhumane Treatment
Farmer describes the many ways that the powerful take advantage of the poor. For example, he notes “cruel and unusual punishment” that is inflicted upon prisoners who suffer from tuberculosis (TB) in many parts of the world. By denying inmates proper medical care, we are inevitably contributing to increased morbidity and mortality rates. TB transpires in prisons at rates 5 to 10 times the national average. And with increasing rates of TB evolves the extremely treatment-resistant strains. Drug-resistant tuberculosis is viewed, therefore, as a special form of punishment for these inmates, as they must suffer through progression of a more intense and life-threatening illness than a person given proper care.
Farmer and his colleagues were invited to the Soviet Union as TB specialists in an effort to help curb this disease, which at the time was the primary cause of death in Soviet prisons. The group worked to not only improve the health for the individual patients, but also improve the prisons and society as a whole. Overcrowding, poor ventilation, and a lack of financial resource allocation to treat multidrug-resistant strains all contributed to the TB epidemic.
Farmer calls for protective public policies to help those who are victimized by this inhumane treatment. Furthermore he warns, “Transnational TB epidemics will at least remind the affluent few that as long as those epidemics remain out of control, no one is really safe.”2
Commercialized Healthcare
Farmer believes that “the commodification of medical care is one of the biggest human rights issues facing the ‘modern’ world today.”3 When the term “patients” substituted by “clients,” we see the commercialization of healthcare and the shift of the physician from healer to service provider. Farmer notes that clients (not patients) indeed are customers—someone who pays for their services. When they are viewed as such, the service in question is being defined as a commodity and not a right.
For example, cancer care is almost unknown among the world’s bottom billion. Through his organization which bridges resources across the globe, Famer shares the story of how an impoverished Haitian woman was fortunate to undergo a mastectomy by a volunteering Cuban surgeon and subsequently have her cancerous growth analyzed by pathologists at Brigham Women’s Hospital. She later received chemotherapy donated by benefactors. This woman survived because of the efforts of Farmer and his colleagues as they reached above and beyond to bring her in contact with the necessary care.
Several years ago, Partners in Health was featured in a photographic exhibit called “Structural Violence: A View From Below,” which featured a bare-chested portrait of the same woman and revealed an extensive left mastectomy scar. One of the exhibit’s guests expressed her displeasure with an entry in the guestbook that mentioned the photo was inappropriate. Farmer theorizes that the guest’s comment conveys an honest but unfortunate misunderstanding of intention and focuses on a superficial display of “inappropriateness” rather than seeing the beauty in this woman’s survival—the fact that so many resources came together through the work of these physicians and overcame societal shortcomings to save her and others like her. The comment speaks to an instinct that many in our society possess, which is to avert our gaze from things that make us uncomfortable.
Those who must face structural violence every day encounter precious little in the way of support for the right to food, water, housing or medical care… We need to rehabilitate a series of sentiments long out of fashion in academic circles: compassion; indignation on behalf not of oneself but of the less fortunate; empathy; and even pity.3
It is extremely important to acknowledge Farmer’s call for the promotion of public health improvement. As Dr Martin Luther King Jr. once proclaimed, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”
We cannot relegate our duty to our patients at large. In this age of globalization, we are more easily connected to those who are in need of healthcare throughout the world. As such, our ideal goals of improving social and global health are indeed reachable in a way that they were not for many centuries.
Furthermore, I pursue a call for greater advocacy for those who are victims of inequality of healthcare. But do not feel intimidated by this—I do not think that anyone of us should feel guilty for practicing “conventional medicine” and serving our patients faithfully in areas where access to healthcare is better than other parts of the country or world. I do, however, think we are challenged to face the harsh reality that there are many others who are not getting the care they deserve and that perhaps we can do more to alleviate this disparity.
Despite much advancement in medical and communication technology, this is still no easy task. You do not need to relocate to another country in order to be a consummate healer. I am encouraged with the wisdom of Schweitzer who, as noted previously, recited that anyone can “have a Lambaréné.”4 The truth is that you are needed right where you are. ■
Richard Colgan, MD, is the vice chair of medical student education and clinical operations, as well as a professor at the University of Maryland School of Medicine, Department of Family and Community Medicine in Baltimore, MD. He is the author of Advice to the Healer: On the Art of Caring.
References:
1. Review of lecture by Dr. Paul Farmer. Harvard Public Health Now. 2004 Sep 17. www.hsph.harvard.edu/now/sep17/ program.html. Accessed May 29, 2014.
2. Farmer P. Pathologies of Power: Health Human Rights, and The New War On The Poor. Berkeley, CA: University of California Press, 2005:195.
3. Farmer P. Suffering that is “not appropriate at all.” Revista. 2003;3:42-47.
4. Association Internationale Schweitzer Lambarene. Biography. www.schweitzer.org/2012/en/work-and-life/biography-long. Accessed May 27, 2014
Additional Resources
1. Kidder T. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure The World. New York, NY: Random House Trade Publications, 2004.
2. Farmer P. Pathologies of Power: Health Human Rights, and the New War On The Poor. Berkeley, CA: University of California Press, 2005.
3. Farmer P. Infections and Inequalities: The Modern Plagues. Berkeley, CA: The University of California Press, 1999.
4. Farmer P. The Uses of Haiti. Common Courage Press, 1994.
5. Farmer P. AIDS and Accusation: Haiti and the Geography of Blame. California Series in Public Anthropology. Berkeley, CA: University of California Press, 1992.
6. Partners in Health, Boston, MA, can be found at www.pih.org.