PIH (Partners in Health)

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WHO LIVES AND WHO DIES: ANTHROPOLOGY & ACTIVISM

What is it like to be a passenger on a bus, or standing in a cheering crowd at the finishing line of a marathon, in the seconds after a bomb goes off, when you know you’re hurt but not where or how badly? What’s it like to be a child who finds a discarded toy and picks up what turns out to be a landmine? What’s it like to be giving birth at home, and see blood pooling between your legs, and look up at the ashen faces of a birth attendant, a midwife, a spouse? What’s it like to feel the earth tremble and see the roof and walls of your home or school fall towards you? More to the point, in terms of survival: what happens next? It depends. Not just on the severity of the injury, but on who and where you are. Death in childbirth, once the leading killer of young women across the world, is now registered almost exclusively among women living in extreme poverty, many of them in rural areas. Trauma is now the leading cause of death for children and young adults in much of the world. Who lives and who dies depends on what sort of healthcare system is available. And who recovers, if recovery is possible, depends on the way emergency care and hospitals are financed.

In the thirty years since I began my medical training in Boston, Massachusetts, I’ve cared for critically ill patients in Harvard’s teaching hospitals, as well as in Haiti, Peru, Rwanda and elsewhere in Africa. Study of healthcare financing was almost wholly absent from the curriculum at Harvard Medical School. But after working in rural Haiti I felt it was a necessary topic. I have seen patients grievously injured, often at the point of death, from a weapon or neglect or a weak health system or carelessness. Some died; those who had rapid access to a well-equipped hospital had a better chance of survival. I convinced myself, at first, that the differences in outcome must have been due to worse injuries, greater impact, more blood loss. But with time and broader experience, I was tempted to record the cause of death as ‘weak health system for poor people’, ‘uninsured’, ‘fell through gaping hole in safety net’ or ‘too poor to survive catastrophic illness’.

The people I lived with in the hills of central Haiti had a concise way of putting it: these were ‘stupid deaths’. It was to prevent such deaths that Partners In Health was founded in the mid-1980s, with the aim of providing care for the ailments, trivial or catastrophic, that afflicted the poorest, who were doing most of the stupid dying. PIH would also recruit and train others, whether as community health workers or nurses or doctors or managers, and generate knowledge about ‘healthcare delivery’: what’s the best way to treat Aids or cancer or drug-resistant tuberculosis in a squatter settlement in rural Haiti or a slum in Peru? How might we introduce trauma care, much of it surgical, where none exists? How might we prevent and treat malnutrition, which complicated most of the illnesses we diagnosed in children, without importing cheap food from subsidised US farms (which would further decrease the paltry incomes of local farmers, the parents of the malnourished)? How would we help the people who lived in these places, and had the most at stake, to get trained and qualified?

Our grandiose 1987 mission statement – most of us were still students – even promised to serve as ‘an antidote to despair’. Much of the despair we’d seen was generated by the ‘OOPS approach’ to sickness. ‘Out Of Pocket Spending’, a leading cause of destitution in countries rich, poor and in-between, was largely responsible for the stupid deaths we witnessed, since the care people paid for was expensive and mostly bad. PIH committed itself to the fight for healthcare as a human right. Such a right was in principle guaranteed by governments, even if they were unable, alone, to provide both healthcare and protection from destitution caused by a lack of health insurance. That meant PIH would try to help public health authorities to do their jobs, an aspiration dismissed as silly or worse by most other NGOs. We knew little about (and had nothing against) private health insurance, but we’d seen what it meant to be poor and sick or injured. The vast majority of Haitians had no insurance, public or private; they paid for their poor-quality healthcare, and inadequate education, with their own scarce cash.

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One afternoon in October 1988, I was leaving a friend’s house in Cambridge, Massachusetts in a self-important rush: a medical student also getting a degree in anthropology, I was headed back to Haiti, then experiencing a great political upheaval. My friend was one of the founders of Partners In Health, which we believed, even then, might make a difference in rural Haiti and beyond. But that’s not the reason I was in a rush: I was eager to correct the proofs of an academic paper (my first) before boarding an early flight to Port-au-Prince, where electricity and postal services were uncertain. The paper was on the political economy of health and illness in Haiti. I was also distracted (distressed, really) because three of the Haitian founders of PIH, all in their twenties, had recently died stupid deaths. The first of puerperal sepsis shortly after childbirth; the second of cerebral malaria in a psychiatrist’s waiting room after being misdiagnosed as psychotic; the third of typhoid fever, a rare infection where there is modern sanitation; it had eaten through his small intestine and he died as he was being rolled into one of the operating rooms of Haiti’s large, dysfunctional university hospital. My three co-workers, seriously ill, found themselves at the door of the House of No, even as they were working to dismantle it.

·         renowned global health advocate,

·         medical anthropologist,

·         cofounder of Partners In Health, and

·         chair of the Department of Global Health and Social Medicine at Harvard Medical School.

·         U.N. Special Adviser to the Secretary-General on Community-based Medicine and Lessons from Haiti.

The most publically influential anthropologist since Margaret Mead and her mentor, the “founding father” of U.S. anthropology, Franz Boas. 

·         Seeing the world from the perspective of the planet’s poorest. Unlike many doctors (and anthropologists for that matter), Farmer has lived for decades with his patients, first in Haiti and later in communities from Rwanda to impoverished neighborhoods in Boston.

o   “It took me a relatively short time in Haiti,” Farmer writes of the beginnings of his career in his 2003 book Pathologies of Power, “to discover that I could never serve as a dispassionate reporter or chronicler of misery. I am only on the side of the destitute sick and have never sought to represent myself as some sort of neutral party.” 

·         Farmer’s work is unflinchingly committed to social justice, global equity, and the idea that health care is a human right, beginning with what he calls “the most basic right . . . to survive.” Like his medicine, Farmer’s anthropology is thus an anthropology in service to the poor.

o   Importantly, this does not mean an anthropology of the poor. Farmer is well aware that “writing of the plight of the oppressed is not a particularly effective way of assisting them.” After all, anything one might say is likely to be used against them. 

o   Instead, Farmer is interested in studying and exposing the “processes and forces that conspire” to constrain the agency of the poor and that cause poverty, disease, and suffering.  

·         Interest in the root causes of poverty and the diseases has led to his analysis of “structural violence.”

o   Drawing on the work of Norwegian sociologist Johan Galtung, Farmer calls attention to powerful forms of everyday violence, like poverty, hunger, and poor health, that can be just as deadly as the violence of bullets and war but that tends to be caused by social forces, political and economic institutions, and the decisions of policymakers.

§  The root causes of a Haitian contracting HIV/AIDS are to be found not in personal irresponsibility but in the displacement of a village by a dam planned and funded by powerful actors in Washington, D.C.; by the impoverishment the dam created; and by the long-term impoverishment of Haiti through centuries of subjugation at the hands of the United States and European powers dating to the days of slavery.  

·         Farmer’s is a bio-sociocultural-political-economic-historical anthropology.  

o   His work as both an anthropologist and a physician revolves around the lives of individuals suffering amid powerful structural forces. He combines an empathetic understanding of people’s lived experience and how people make meaning in their lives with a political, economic, and historical analysis of the large-scale forces that shape individual lives. Coupled with an appreciation for the biological vectors of disease causation,

·         His tireless commitment to creating positive social change and to using his anthropological and medical skills to help improve the lives of the poor.

o   (When told he should spend more time with his wife and child in Paris, Farmer responded, “But I don’t have any patients there.”)

·         Community based and sustainable health care development.

o   Farmer and Partners In Health, emphasize working in solidarity with those they serve; training Haitians and others to become doctors, nurses, and community health care workers; and building sustainable health care infrastructures designed to be part of public health care systems. 

o   Haitian counterpart organization Zanmi Lasante

§  IMPACT (according to Kidder in Haiti)

·         Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area [in central Haiti].

·         Vaccinated all the children

·         Greatly reduced both local malnutrition and infant mortality.

·         launched programs for women’s literacy and for the prevention of AIDS

·         Reduced the rate of HIV transmission from mothers to babies to 4 percent—about half the current rate in the United States.

·         When Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau.

·         In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988.

·         Partners in Health (PIH) has accomplished far more since its inception.

o   serves some 2.4 million people in 12 countries, in settings that include post-genocide Rwanda, Peruvian slums, and Russia’s prisons.

o   In devastated post-earthquake Haiti, PIH recently inaugurated a 300-bed, state-of-the-art, solar-powered university teaching hospital that represents the country’s largest post-earthquake reconstruction project.  

·         PIH and Farmer reject conventional public health wisdom about what’s “possible” in the provision of health care in impoverished settings.

o   They reject arguments that treatments available in wealthy countries like the United States aren’t “cost effective” in settings like Haiti.

o   Guided by the radical idea that all human lives are equal, that PIH should provide the same quality of care to the poor that the wealthy want for their own family members, that health care is a human right, PIH and Farmer demand nothing less than a “preferential option for the poor.” 

“That goal is nothing less than the refashioning of our world into one in which no one starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended,” Farmer says in an National Public Radio “This I Believe” essay. 

“Of course such a world is a utopia,” Farmer continues, “and most of us know that we live in a dystopia. But all of us carry somewhere within us the belief that moving away from dystopia moves us towards something better and more humane. I still believe this.”