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This document contains spoilers
From Haitian highlands to Russian prisons, follow the late Doctor Paul Farmer and the team at Partners in Health in their relentless pursuit of lifesaving care for those with greatest need around the world. They prove that with enough courage and compassion, even the greatest barriers can be overcome.
Beheading
Political violence
Challenging your world view
Comfort vs. Sacrifice
“The soldiers thought that Voodoo beliefs conferred a special, weird terror on decapitation. ‘Does cutting off a victim’s head have some basis in the history of Voodoo?’ I asked. ‘It has some basis in the history of brutality,’ Farmer answered.”
“I felt as though, in Farmer, I’d been offered another way of thinking about a place like Haiti. But his way would be hard to share, because it involved such an extreme definition of a term like “doing one’s best”
“The world is full of miserable places. One way of living comfortably is to not think about them, or, when you do, send money.”
Chapter 1 details Tracy Kidder’s First impression of Dr. Paul Farmer, describing an initial sense of discomfort at Farmer’s strong convictions. Have you ever been challenged by someone else’s convictions/beliefs in a positive way?
How can we make our strong convictions about advocacy encouraging for others?
Reflect on the quote “The world is full of miserable places. One way of living comfortably is to not think about them, or, when you do, send money.”
Do you think it is possible to live a comfortable life and truly face the reality of suffering? Does facing the reality of the world’s “miserable places” necessitate being uncomfortable?
Substance abuse (drugs and alcohol)
Homelessness
F-Word
Kindness
Generosity
Righteous Anger
“I felt I was in the presence of a different person than the one I’d been chatting with a moment ago, some whose ambitions I hadn’t yet begun to fathom.”
“At times, it seemed that [Farmer] could hardly contain his anger. He described giving antibiotics to an impoverished TB patient, then wrote: “When she received them, she soon began to respond - almost as if she had a treatable infectious disease.”
“The Paul Farmer who had written that book didn’t seem like the Paul farmer who worked at the Brigham. This one was shouting on every page.”
In what ways does our society dismiss the needs of people in poor, vulnerable, and marginalized?
How can we refute the idea that helping the poor is a lost cause or too resource-intensive?
A-word
Infant death
The nature of suffering
Poverty
Patient Care
If I took steps to become a doctor for those who don’t have medical care, it could be regarded as a sacrifice, but it could also be regarded as a way to deal with ambivalence” He went on, and his voice changed a little. He didn’t bristle but his tone had an edge: “I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent” page 24
“Comma was always directed at third parties, at those who felt comfortable with the current distribution of money and medicine in the world. And the implication, of course, was that you weren’t one of those. Were you?”
“You can’t sympathise with the staff too much, or you risk not sympathizing with the patients.”
“I’d feel sorry that so many Haitian children still died of measles…but I’d also feel that I could never be sorry enough to satisfy him. I’d end up annoyed with Farmer for a time, in the way one gets annoyed at others when one has done them a disservice.”
“...he begins not by telling her that sorcery doesn’t exist but that he knows sorcery wasn’t involved in this instance”. What can we learn from Farmer’s approach to beliefs about sorcery?
“Sorcery is, at bottom, the Haitians’ way of explaining suffering, but the allegations themselves can cause suffering.” How is suffering explained in your culture, and does that explanation ever contribute to suffering?
F-word
Structural violence
One health worker cited a Haitian saying: “Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.” page 34
“No other country in the world had been subjected to as much ‘idiotic commentary,’ he said, and it would have been hard to argue the point, given the fact that, for instance, the name of Haiti’s indigenous religion had long since become the synonym for crazy ideas and sheer luridness.”
“Most of the Haitian professionals on staff - the doctors, the nurses, the technicians - offered explanations that laid the blame in the minds of the patients, the kinds of explanations one often reads in scholarly journals.”
“The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medicines. Farmer said, “the only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it.”
“Politics, I supposed, was one means by which Haitian peasants avoided hopelessness. Many aid experts from prosperous places gladly expressed hopelessness on the Haitians’ behalf, Farmer would say.”
“There’s a WL line - the ‘they’re poor but they’re happy’ line. They do have nice smiles and good senses of humor, but that’s entirely different.”
“I love WL’s, love ‘em to death. They’re on our side…but WL’s think all the world’s problems can be fixed without cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”
“We can spend sixty-eight thousands dollars per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international health community jumps on you for creating nonsustainable projects.”
Farmer stated, “WL’S think all the world’s problems can be solved without any cost to themselves.” How does this statement make you feel? What kinds of sacrifice are necessary for a better world?
Sometimes, blame for failed TB treatments is placed on patients not taking their drugs. Dr. Farmer tried something new; he gave everyone free medicine, but also gave some food, money for childcare and transportation, and home visits from his staff. Everyone in the second group was cured. What does this say about the reasons people stop taking their drugs?
R-slur
Family
Family History
Identity
“The way I tell myself the story is a little too neat. I’d like to be able to say that when I was young, I lived in a trailer park, picked fruit with Haitians, got interested in migrant farmworkers, and went to Latin America. All true, but not the truth. We’re asked to have tidy biographies that are coherent. Everyone does that. But the fact is, a perfectly discrepant version has the same ending.”
Paul Farmer had an eccentric childhood and his accomplishments have been unique. Do you see a correlation between the way Farmer was raised and how he’s chosen to live his life?
Sex tourism
Virchow
“Epidemics of the illness usually occur during social upheavals, in the ensuing overcrowding, poor hygiene, and malnutrition. In his report, Virchow expressed a fundamental law of epidemiology: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbance of mass life”
“Medicine is a social science, and politics is nothing but medicine on a large scale.”
“Physicians are largely attorneys of the poor, and the social problems should largely be solved by them”
“Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.” 61
“Physicians are largely attorneys of the poor, and the social problems should largely be solved by them”
Agree or disagree? What role can advocates and governments play? What can be done to lift this burden from the shoulders of those who already carry a great deal of the weight of social problems?
How can we move from compassionate bystanders to real allies of the people who need help in the world?
Car accident death
Graphic depiction of parasite in a baby
The “Mango Lady” dies because of an accident, but Ophelia and Paul reflect that her death also had causes that were not an accident. What could have been done to prevent deaths like hers, and who is responsible for preventing similar situations?
Why is it easier to look at her death as an accident?
Baby death
F-word
Some Haitians have a saying “God gives, but doesn’t share” what does this mean?
Many or all of us quietly and unconsciously benefit from inequality around the world. What responsibility do we have to solve this? Without taking guilt for what we cannot control, what can we change that we do control?
What are the costs and benefits of acknowledging divisions (be they national, political, cultural, religious, linguistic, ethnic, or racial?)
Closed-door sex scene
“A school could serve as a place for teaching lessons about health and for providing free meals to malnourished children without injuring their dignity. To build a school was to unite both the practical and the moral.”-91
Farmer goes out of his way to respect the things that are meaningful to the people he serves
Why is this perspective sometimes difficult for people? What are the benefits of this perspective?
“The fact that any sort of religious faith was so disdained at Harvard and so important to the poor—not just in Haiti but elsewhere, too—made me even more convinced that faith must be something good.” We see many times in the book well-meaning medical professionals ignoring the things that are important to the poor. Why is it important for medical professionals and other “outsiders” to honor the importance people assign to their own lives?
Guns
Political violence
How can political freedom like freedom of speech facilitate better health outcomes?
How did the close-knit relationships between the early members of PIH influence their work and impact?
How can we build and foster tightly-know communities of advocates? Does this community help you to become a better advocate?
Political violence
Graphic, but clinical depiction of tortured body
“Lives of service depend on lives of support”
Chouchou was a patient of Dr. Farmer’s who was brutally beaten and eventually murdered for his political beliefs. What can be done for patients like Chouchou? Is telling their stories enough?
F-word
Anti–Us military policy
Sex and Rape
Threats
How did Farmer's choice to treat any person in need both put him in danger and ultimately protect him from danger?
Do you think Farmer’'s approach to Haitian politics was reckless or wise?
Why do war and political instability lead to public health crises?
Meager incomes don’t guarantee abysmal health statistics, but the two usually go together. How can addressing poverty improve health outcomes? Can you do one without the other?
Why does poverty increase a person's likelihood of contracting active TB?
How do we find the strength to keep working despite setbacks and opposition?
How did the Peruvian Government's decision to treat people in the cheapest way possible lead to problems in Lima?
Why do one-size-fits-all solutions so rarely succeed in treatment, especially for tuberculosis?
How should we respond to those who claim that some patients have illnesses that are too expensive to treat?
Farmer toed the line between following and breaking the rules as he tried to test MDR patients in Peru. What would have been the consequences of absolutely following or ignoring the law in this situation?
What challenges can advocates, doctors, and patients face while persuading politicians with complex motivations and constraints? How can we be more persuasive/effective?
What risks did Farmer take as he tried to establish an MDR treatment program in Peru? Would you have taken the same risks given the same choices?
How should doctors, community health workers, and advocates find balance between caring for their own health and the health of others? Why is caring for their own health important?
“Don’t let perfect be the enemy of good”
“‘There are more billionaires today than ever before. We are talking about more wealth than we have ever seen before. And the only time I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people.’ The PIH project in Peru could be replicated, and some of what was needed were endorsements from “Academics with clout” and the support of ‘the TB community’”
In global health, there is a lot of talk about conserving resources, or using them wisely. Often, organizations choose to treat many mild cases, while abandoning the few severe ones. What are the merits of this strategy? What are the drawbacks?
Why are compromises so important when it comes to global health?
What change might today be considered impossible but perhaps just needs to be made possible before it can be successfully implemented?
Why is utilitarianism dangerous when it comes to discussions about healthcare? When can it be helpful?
Child Death.
F-word
Political Violence
Prostitution
Why do you think that Dr. Farmer was so resistant to moving to a more oversight role in PIH?
In chapter 20, Dr. Farmer talks about a child who had died under his care. Why do you think he took it so hard, especially after saving so many?
Sex
Concentration camps
Torture
Isolation
How can we learn from Cuba’s success in medicine? What factors helped prevent the health struggles the Haitian people encountered?
Dr Farmer told a story, “A woman in Cange said to me, ‘You want to stop HIV in women? Give them jobs’.” How would a job prevent HIV? Why does increased autonomy and independence also increase health outcomes?
Whom do we sometimes fail to consider with a hermeneutics of generosity? How might things change if we managed to use it more often? Are there problems that aren’t being solved because we are failing to use this approach?
Farmer and Kidder have a disagreement over whether Paris and Haiti could be seen as existing in different worlds. Farmer is adamant that they do not. Earlier in the chapter, Didi Farmer comments that the wealth of Paris was created with the slavery of her ancestors. Why is it important to consider these places as part of the same world?
F-word
A-hole
Ethnocentrism
Pg 228
“Massachusetts is a great state, it has a big TB lab, lots of doctors, lots of TB nurses, lots of TB lab specialists. It lacks only one thing. Tuberculosis.”
Pg 229
“ I think of myself more as a physician than as an American… We belong to the nation of those who care for the sick.”
Farmer’s ultimate approach in Peru was to treat patients without legal permission, and then to gain legal permission later. This strategy has some flaws. Do you think it was justified?What can be done to improve situations like this?
Why is it sometimes difficult to get well-meaning people to advocate for people who have committed crimes, and how can we make it easier for people with reservations about helping prisoners to get behind these efforts?
F-word
“It comes in handy in my line of work. To like people” 252
“Project managers could afford to wait for low prices, but not all patients could. ‘It’s going to take resources to stop this epidemic’...Their approach, especially toward money, was completely impractical, it seemed to me, and yet it appeared to be working” 253
“Paul is a model of what should be done. He’s not a model for how it has to be done. Let’s celebrate him. Let’s make sure people are inspired by him. But we can’t say anybody should or could be just like him.”
How can ordinary people work together to provide the kind of health care that Paul Farmer provided?
The pursuit for equitable and effective health care leads Paul to make some questionable decisions. He works outside of the law. He pays bribes. He consorts with leaders in questionable or unpopular authoritarian regimes. He puts himself and others in dangerous situations. Some people may be less likely to support him because of some of these methods. Do the ends justify the means? Do you think at any point he goes too far?
Graphic depiction of illness
Starving babies
“I think he was transmuting anger into something that felt better, a dream of ending the disparities, at least the medical ones, that separated Boston and Cange” 261
“Equity is the only acceptable goal” 261
“They died of Haiti” 262
“It’s through journeys to the sick that we identify needs and problems” 283
How does a focus on equity as the only acceptable goal influence Partners in Health and the work they do?
How do we find hope to keep pursuing equity even when it feels out of reach?
F-word
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we win. I don’t dislike victory.”
“We’re used to being on a victory team, and actually what we’re doing in PIH is make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.” 288
"If we could identify losers like John, and not waste our time and energy on them, then we'd be all good, as they say in the States. Right? But the point of O for the P is that you never do that. You never risk that. Because before you turn your back on someone like John you have to be really really sure, and the more you learn about John's family the more you realize that the whole family, their whole-I mean, they're basically extinct, right? He was the last kid. They're extinct. His mother's bloodline is just gone. It sounds Darwinian, but you know what I mean. Shit, man, how can you be an O for the P doc and be willing to take that risk without all the data you can get? Every patient is a sign. Every patient is a test. Like this guy we just saw. The guy's living in dirt, the guy who needs Canadian crutches? You realize how much shit I'd get for that, Canadian crutches in rural Haiti?"
"Because they're not appropriate technology?" "Yeah. Now you can see the critiques revealed for what they are. But I have to limit the amount of time I put into explaining all that Or it just sucks your soul dry” Page 290
“Long ago in North Carolina, Farmer watched the nuns doing menial chores on behalf of migrant laborers, and in the years since he's come to think that a willingness to do what he calls "unglamorous scut work" is the secret to successful projects in places like Cange and Carabayllo. "And," he says, "another secret: a reluctance to do scut
work is why a lot of my peers don't stick with this kind of work." In public health projects in difficult locales, theory often outruns prac- tice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large, like MDR. "If you focus on individual patients," Jim Kim says, "you can't get sloppy." That approach has worked for PIH. And I can imagine Farmer say- ing he doesn't care if no one else is willing to follow their example. He's still going to make these hikes, he'd insist, because if you say that seven hours is too long to walk for two families of patients, you’re Saying that their lives matter less than some others', and the idea that some lives matter less is the root of all that's wrong with the world.” 294
“That’s when I feel most alive… when I’m helping” 295
“Farmer taps into a universal anxiety and also into a fundamental place in some troubled consciences, into what he calls "ambivalence," the often unacknowledged uneasiness that some of the fortunate feel about their place in the world,” 295
“Meanwhile, other definitions than the usual, of what can be done and what is reasonable to do in medicine and public health, have spread from him. They're still spreading, like ripples in a pond.
How does one person with great talents come to exert a force on the world? I think in Farmer's case the answer lies somewhere in the apparent craziness, the sheer impracticality, of half of everything he does” 296
Why would some people consider the question about spending the money on a child’s life polite, but about the question about whether a doctor’s salary is exorbitant impolite? What similar biases might we unknowingly hold that may impact the amount of money we consider putting towards life-saving efforts?
How do we balance risk and investment, when people’s lives hang in the balance? What if we could know before we started whom we would be unable to save? Would it change our behavior toward them?
A lot of the successes recounted in this book come down to people choosing to expand what is reasonable to do in health care into the realms of what others might call impracticality. Why does this approach work? Why is it so important to Farmer?
Questions from back of book