Champion Of the Poor

When Paul Farmer first went to Haiti in 1983, he was studying medicine and anthropology and hoping to become a doctor for the poor, perhaps in Africa. He eventually became America's most celebrated doctor for the poor, made famous by Pulitzer-prizewinning author Tracy Kidder in his 2003 book, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.

But it wasn't until this spring--22 years later--that Farmer, now 46, made it to Africa. He was invited by the Clinton Foundation and the government of Rwanda to do for this tiny East African country, still trying to pull itself together after 1994's genocide, what he and his team had done for Haiti.

What Farmer and his Boston-based charity, Partners in Health (P.I.H.), did in Haiti--the poorest, most disease-ridden country in the western hemisphere--is build a showcase public-health system that each year delivers high-quality medical care to 1.3 million peasant farmers, about one-sixth the country's population. There he also helped rewrite the protocol for treating multi-drug-resistant tuberculosis and pioneered several medical practices at the time deemed hopelessly quixotic--such as giving impoverished AIDS patients first-line antiretroviral drugs (ARVs)--that have since been widely adopted.

When Farmer arrived in Rwanda, the Minister of Health called a meeting and asked him where P.I.H.'s doctors wanted to set up shop. The minister in charge of HIV/AIDS, who knew Farmer's work, answered for him: "Just put them in the worst, most rotten part of Rwanda, and they'll flourish."

Six months later, it's clear the AIDS minister was right. The site that Farmer's team was assigned--an abandoned hospital in a rural province with a population of 340,000 and no doctors--is drawing patients from miles around--women in brightly colored skirts, men in tattered work clothes and children in whatever happens to fit. (It's not unusual in rural Rwanda to see what appears to be a 5-year-old girl in a ruffled dress and discover when she squats down that she is a he.)

In the wards, the beds are filled by patients with AIDS, TB, malaria, typhoid, cholera, malnutrition and anemia. Some will die. Most will be cured. All will be treated with as much care and attention--if not more--as is afforded wealthy patients at Harvard Medical School and Boston's Brigham and Women's Hospital, where Farmer has joint appointments. He calls this approach the "preferential option for the poor."

Any Western-trained physician who has practiced even briefly in a poor country is acutely aware of how inequitably money and medical care are distributed in the world. Farmer, who grew up in a Florida trailer park, has developed what Kidder calls a "comprehensive theory of poverty," which Farmer elaborates on in books that are surprisingly angry for so gentle a man. In Pathologies of Power (2003), his most recent, he argues that the only antidote for the "structural violence" that keeps the poor too sick to climb out of the hole they are in is to treat health care as the most basic human right and do whatever it takes to deliver it.