Ethics and Equity:
Current Challenges in International Health

By Paul Farmer

This lecture was presented as part of the 5th Andrew D. Hunt, MD, Lectureship to the College of Human Medicine, Michigan State University (Sept. 19, 2003). (Howard Brody, MD, PhD, provides the following synopsis of this lecture.)

I’m happy to visit the College of Human Medicine for the first time and honor the singular vision of Andrew Hunt and the other founders of this medical school. I’ll try to show how this vision matters for all of us today by using a specific example from the hospital and clinic where I work in central Haiti. But the issues this will bring up are broadly applicable, both around the world and here in the US.

These slides show a child with a swollen eyelid and face. She was brought to our clinic by a relative who looked to be about 20—like most of our patients, neither knew their exact age. You probably won’t recognize this disease, so I’ll tell you that it’s anthrax—this is how most cases of anthrax present to our clinic. The 20-year-old relative told us, “I think we have anthrax.” We immediately started simple antibiotics and could assure both of these women that they’d be cured. But the older woman told us that a man in their village had recently died of anthrax. We asked why this happened, since if he had come to our clinic, we could easily have treated him, too. She replied that he had not come because he did not have the money for public transportation. We calculated that the cost to bring him would have been about two dollars.

The people we treat live in a large squatters’ settlement. They are displaced peasant farmers who used to work the land in a fertile valley. The valley was then flooded by a hydroelectric dam built with US funding. The peasant farmers lost their land, but they received no water and no electricity. They describe themselves as living in “indecent poverty” and can specify what that means. Decent poverty, for instance, is having a tin roof and a concrete floor; indecent poverty is a thatched roof and dirt floor (a mud floor when it rains).

I want to describe to you today how we went about treating AIDS in our clinic. AIDS is hugely prevalent in Haiti. I first went to Haiti as a medical anthropologist to study Haitian culture. I found that they taught me a great deal. I am now in their debt for what they taught me, and my drive to provide decent medical care in Haiti is partly to repay that debt.

When we began, the public health experts told us to do a community survey to ask people what they needed. After that, you proceed to do what the public health experts said was best. We thought that was wrong—if you do a survey you should pay attention to what the people say. So we asked the displaced peasant farmers and they said, “We need a hospital.” So we did both. We did all the good public health things like immunizations and oral rehydration, and we also built a hospital, even though it took us 10 years.

The experts then said that it’s not cost effective to use anti-retroviral drugs to treat AIDS in settings of great poverty. There is no infrastructure, and the drugs are way too expensive. All that’s affordable and sustainable is preventive efforts. That, of course, means that people who already are infected will surely die.

The experts often do not realize how contradictory their own authoritative pronouncements are. In the same article you can read both that antiretroviral treatment programs won’t work because there is so much stigma attached to AIDS, and also that the reason that AIDS is stigmatized is that there’s no good treatment for it.

So we asked the Haitians again. We found out that the people at greatest risk already knew that AIDS was a sexually transmitted disease and what you needed to do to prevent it. When these things did not happen, it was due to two factors–gender inequality and poverty. So we decided that those issues had to be addressed head on.

We began a project we called the “HIV Equity Project” and for many years, the foundations and agencies that you would expect would fund such work gave us no money at all. Finally we got this project going by grafting it onto an existing project for community-based treatment of tuberculosis.…

We found that the “missing infrastructure” that the experts said doomed any treatment program consisted of community health workers. The tuberculosis program worked because a community worker saw each patient every day and saw that they took their medication. We found the same approach worked for antiretroviral drugs.

The prohibitive cost of these medications is not graven in stone on Mt. Sinai. When we started the program we had to pay $10,000 a year per patient for a common 3-drug regimen. Now with generics we have seen the cost fall to $300.

So when we added up the results we found that we had effective clinical outcomes, with reduced hospitalization and mortality rates. The stigma associated with AIDS has been lessened, which improves medical staff morale and increases interest in HIV testing and counseling–showing that treatment aids prevention rather than being in competition with prevention as the experts had said.

One of our very smart Haitian doctors was opposed to spending money doing expensive viral load blood tests (the US standard) on these patients. He suggested that instead we simply weigh them. The photos I’m showing you of typical AIDS patient before and after drug therapy illustrate the wisdom of his suggestion–we commonly saw people who looked as if they were dying gain 20 or 30 pounds in the first month of drug treatment. But we decided that the audience we were trying to convince is not Haiti, but rather the international scientific skeptics, so we shipped blood back to Boston and did viral load studies. We were able to show that our patients both gained weight and also had greatly reduced viral load.

There are a number of lessons from our experience. Modern medicine has wonderful tools. We do not yet have an equity plan–how to use these tools to reduce or eliminate the gaps in outcome between rich and poor. Every medical program needs an equity plan.

The poor are usually the real experts in what their problems are and what needs to be done. We should listen to them. They should not have to bear the burden of proof to document that what they need is “cost effective.”

We need a movement in the world today that includes the scientific experts, and the afflicted, and everyone in between to start to address these problems head on and to devote the necessary resources.

Paul Farmer, MD, PhD
Partners in Health and Harvard University
“Ethics and Equity: Current Challenges in International Health”
Author of Pathologies of Power: Health, Human Rights,
and the New War on the Poor (University of California Press, 2003)