Monday, November 05, 2007

Paul interesting article...

Many of you will know that the man Paul Farmer is somewhat of a hero for me (in the medical world). An anthropologist and doctor who spends half the year working from a clinic in rural Haiti, and part of the year working in Harvard, teaching in their medical school. He has been a voice for international health justice and helped get the WHO to support more just system of TB treatment. He also began the international medical development organisation Partners in Health. This is a small excerpt from an article he wrote for the University of Notre Dame magazine. Click HERE to read the full article.

If we fail to act
by Paul Farmer, M.D.

As a physician who has battled infectious diseases in Haiti, Rwanda and elsewhere, I know we are in the midst of a staggering wave of killing, one that brings to question all notions of moral values. The numbers alone are telling. Even if we consider only the big three infectious killers -- AIDS, tuberculosis and malaria -- we are faced with tens of millions of preventable deaths slated to occur during our lifetimes. A recent document from the United Nations suggests, for example, that more than 80 million Africans might die from AIDS alone by 2025. A similar toll will be taken, on that continent, by tuberculosis and malaria. Adding other infectious killers to the list, the butcher's bill totals hundreds of millions of deaths over the next few decades.

Have these numbers lost their ability to shock or even move us? What are the human values in question when we hear, and fail to react to, the news that each day thousands die of these maladies unattended? Where, amid all these numbers, is the human face of suffering? What values might guide our response to such suffering?

These are rhetorical questions, but not ones without answers. Much can be done to avert these deaths. Allow me to offer the example of Joseph, a patient of mine. On the afternoon of March 17, 2003, four men appeared at the public clinic in Lascahobas, a town in central Haiti, bearing a makeshift stretcher. On the stretcher lay a young man, eyes closed and seemingly unaware of the five-mile journey he had just taken. After the four-hour trip, the men placed their neighbor on an examination table. The physician tried to interview him, but Joseph was stuporous, so his brother recounted the dying man's story.

PhotoJoseph, 26 years old, had been sick for months. His illness had started with intermittent fevers, followed by a cough, weight loss, weakness and diarrhea. His family, too poor, they thought, to take him to a hospital, brought Joseph to a traditional healer. Joseph would later explain: "My father sold nearly all that he had -- our crops, our land and our livestock -- to pay the healer, but I kept getting worse. My family barely had enough to eat, but they sold everything to try to save me." Joseph was bed-bound two months after the onset of his symptoms. As he later recalled, "My mother, who was caring for me, was taking care of skin and bones."

Faced with what they saw as Joseph's imminent death, his family purchased a coffin. Several days later, a community-health worker employed by Partners In Health, a charity I helped to found, visited their hut. The health worker recognized the signs of tuberculosis and HIV and suspected the barely responsive Joseph might have one or both of these diseases. Hearing that their son might have one last chance for survival, Joseph's parents pleaded with their neighbors to help carry him to the clinic, since he was too sick to travel on a donkey and too poor to afford a ride in a vehicle.

Joseph was indeed diagnosed with advanced AIDS and disseminated tuberculosis. He was hospitalized and treated with both antiretrovirals and antituberculous medications. Joseph told his physicians, "I'm dead already, and these medications can't save me."

Despite his doubts, Joseph dutifully took the drugs. Several weeks later he was able to walk. His fevers subsided, and his appetite returned. After discharge from the hospital, he received what is termed "directly observed therapy" for both AIDS and tuberculosis, and was visited each day by a neighbor.

Joseph now speaks in front of large audiences about his experience. "When I was sick," he has said, "I couldn't farm the land, I couldn't get up to use the latrine; I couldn't even walk. Now I can do any sort of work. I can walk to the clinic just like anyone else. I care as much about my medications as I do about myself. There may be other illnesses that can break you, but AIDS isn't one of them. If you take these pills this disease doesn't have to break you."

What sort of human values might be necessary to save a young man's life? Compassion, pity, mercy, solidarity and empathy come immediately to mind. Thinking about Joseph's experience, and so many others, leads me to reflect on injunctions, first heard as a child instructed to read the Gospel according to Matthew, about "the corporal works of mercy." I'm sure I didn't pay much attention then. But three decades later, these injunctions -- feed the hungry; give drink to the thirsty; clothe the naked; shelter the homeless; visit the sick; visit the prisoners; bury the dead -- strike me as worthy goals for those seeking guidance in diminishing suffering, whether due to disease or to violence. As important for a doctor concerned about the right to health care, the corporal works of mercy are a reminder of the radical nature of the values necessary to promote basic human rights. We need the tools of our trade -- in this case, laboratory tests, medicines, health care workers -- to save lives. But we also must have hope and imagination to make sure proper medical care, a corporal work, reaches the destitute sick.....

...Human rights and corporal works of mercy

For millennia now, philosophers and theorists have sought to understand why violence occurs and why we fail each other in the face of unnecessary suffering. Anthropology and other social disciplines have also grappled with these questions. Such reflection takes on urgency in many of the places in which I've worked. In Haiti, Rwanda and even Boston, service to the destitute sick reveals the sharp limitations of what can be done to allay misery without a broad understanding of why some people have so little while others enjoy a peculiarly modern surfeit. Without a right to health care, for example, modern medicine and public health become commodities to be bought and sold. Such arrangements will never suffice if our goal is to relieve premature morbidity and mortality -- the primary obligation, surely, of a physician.

I have seen the utility, but also the limitations, of a human-rights model. Conventional human-rights frameworks, only a couple of centuries old, have focused on civil and political rights, and human rights advocates may point with pride to certain victories. But defeats are as common, and they're more glaring now than ever.

A young Haitian man lies dying of AIDS, but without a right to antiretroviral therapy, what hope is there for his survival? What hope is there if he obtains the necessary medications but has nothing to eat? Writing from rural Rwanda, or from Haiti, leads me to reflect on the corporal works of mercy. As I've confessed, I didn't pay much attention before. But I now know that these injunctions -- again, feed the hungry; give drink to the thirsty; clothe the naked; shelter the homeless; visit the sick; visit the prisoners; bury the dead -- strike me as worthy goals for those seeking guidance in diminishing suffering, whether due to disease or to violence.

There are spiritual works of mercy, as well -- reconciliation, forgiveness, comforting the afflicted, and praying for the living and the dead, to name a few. Cynics might argue, in the inelegant language of our day, that these are not readily "operationalized." These debates will go on, no doubt, indefinitely. But in the 21st century we cannot argue honestly that it is impossible to develop effective strategies for works of mercy. If we fail to link new human rights understandings to a broader movement for social justice, we will have no shortage of dead to bury. In that case, perhaps that is the only corporal work of mercy we will deserve to claim as our own.