The Model of a Great Doctor

Infections and Inequalities: The Modern Plagues, by Paul Farmer (Berkeley: University of California Press 1999) ¹

In August 1986, Robert David was a nineteen-year-old resident of rural Haiti. When Robert began experiencing weight loss and a cough that left him short of breath, he was taken to a hospital in the city where he was diagnosed with pulmonary tuberculosis and began drug therapy treatment. In order to receive treatment at a public facility, Robert David had to travel into the city—a trip that took two hours by truck and more than a day by foot. Despite committed efforts to continue treatment, his condition did not improve and he sought treatment in a town closer to his home.

Though his new doctor observed organisms in Robert David's sputum, ² his course of treatment was never changed. After a year and a half of treatment that came at great financial sacrifice to his family, the symptoms continued. During this period, he experienced life-threatening massive hemoptysis, ³ but did not receive any medical care because his family could not afford it. Eventually, Robert David was admitted to a sanatorium in Port-au-Prince for six months, treated and discharged to complete his treatment regimen. However, due to difficulties caused by economic and political factors (a bombing destroyed a major pharmacy) he was unable to obtain medication and complete his treatment.

Despite this, he began to feel better and remained symptom-free for almost two years.

At that point, his bouts with night sweats and weight loss returned and he was once again admitted to the sanatorium. His symptoms persisted and, once again, he was unable to obtain the medications necessary to treat his condition. This occurred in January 1993.

After nearly seven years of battling tuberculosis, Robert David visited Dr. Paul Farmer's clinic in Haiti's Central Plateau. Farmer and his colleagues soon discovered that Robert David had developed a strain of tuberculosis that was multidrug resistant. Despite Farmer's efforts to import medications from the United States and Robert David's faithful adherence to the treatment regimen, Robert David's strain of tuberculosis proved resistant even to these new drugs. In December 1995, he died.

Robert David's story is one that is far too familiar to Paul Farmer. As a physician and anthropologist, Farmer has spent a great deal of his career dealing with infectious diseases among the poor and impoverished. He has written extensively "on the structural causes of TB program failure in poor communities; he has also worked globally to establish effective TB-control programs in settings of poverty." ⁴ Farmer serves as co-director of the Program in Infectious Disease and Social Change at Harvard Medical School, where he heads the International Working Group on Multidrug-Resistant Tuberculosis. Additionally, he shares his time as an attending physician specializing in infectious disease at Boston's Brigham and Women's Hospital and as medical co-director of the Clinique Bon Sauveur in rural Haiti. His fieldwork has also taken him to urban Peru where he directs a program that treats patients afflicted with multidrug-resistant tuberculosis (MDRTB). As a result of these many and varied experiences, Farmer has many personal stories and medical observations to share in his book, Infections and Inequalities: The Modern Plagues.

In 1882 the German microbiologist Robert Koch discovered the tubercle bacillus and the world learned the cause of tuberculosis. In the late 1940s, anti-tuberculosis drugs were developed and those who had access to such treatments could expect to be cured of the disease. Those who could not obtain the medications, however (typically the poor and minorities), continued to suffer from tuberculosis. ⁵ This resulted in the creation of the "TB-outcome gap" between the rich and the poor. ⁶ Not only did this gap develop in the United States, it also developed globally between wealthy and poor nations. ⁷ For this reason, many regarded tuberculosis as a disease of the past. Because...