Saturday, January 20, 2007

Paul Farmer Is Not God

I just finished reading Tracy Kidder's book about Dr. Paul Farmer, Mountains Beyond Mountains. I'd never heard of Farmer before reading it (apparently every pre-med everywhere, especially the Ivy League, worships the man) so at first I wasn't that impressed, but it was a pretty good read. He started an NGO Partners in Health that's built an awesome hospital in Haiti and he was instrumental in getting the world to take on drug resistant TB. But he seems to hate the notion of cost-effectiveness. Also, he's always right. For example, he went for a five-hour hike to visit one patient in Haiti and had this conversation with the author:
"But some people would ask, 'How can you expect others to replicate what you're doing here?' What would be your answer to that?"

He turned back and, smiling sweetly, said, "Fuck you."

Then in a stentorian voice, he corrected himself: "No. I would say, 'The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB.'" He was grinning, his face alight. He looked very young just then. "In other words, 'Fuck you.'"

Cute, very cute, comma. (Farmer supposedly ends sentences with "comma" when he means to end them with "..., asshole.") But it doesn't really answer the question about cost effectiveness. Someone in the book makes the point that if you have six million dollars, and can treat 90% of the people in one population with TB with half the money, it might be good to spend $3 million each in two locations and heal a lot of people rather than using $3 million to get the first 90% and then the other $3 million to treat the 10% that have harder cases. Another quandary follows:

Low-cost second-line antibiotics would soon be on their way to Russia, but at the moment various snafus had delayed their arrival. Other organizations, now intent on treating MDR in Russia, were still waiting for the inexpensive drugs. Farmer and Kim, by contrast, had gone to Tom White and asked for $150,000, and bought enough drugs, at high prices, to start treating a few dozen MDR patients in Tomsk right away. Why do that, why spend $150,000 now on drugs for thirty-seven patients if, by waiting a while, they could spend the same amount and buy drugs to treat a hundred? Well, Farmer said, project managers could afford to wait for low prices, but not all patients could.

No, seriously. What if you ran out of money, and then in the end you ended up saving fewer lives as a result? But there is something to be said for this kind of "build it and they will come" type attitude about donor money. Farmer's projects helped to bring down the price of MDR drugs, and maybe they would never have come down if somebody hadn't ignored cost-effectiveness and taken the plunge. I don't know. Hopefully I'm not just ragging on Farmer because I like to pick apart people that are morally superior. (Do I have any heroes that I don't try to bring down? Maybe Cal Ripken Jr. and my friend Scott Williamson.) And maybe I shouldn't think Oprah's lame for spending so much money on just one school (especially since she's spent a lot of money on other less publicized good works.) Maybe I'd be cooler with Farmer if I'd ever met him or heard him speak to get his side of the story (I'm the only Mormon I know that likes John Krakauer and I'm OK with ultra-runner/self-promoter Dean Karnazes solely because they seemed nice when I met them in person.) Or maybe it's just that public health is not my personal shtick. Who knows. The book was definitely worth reading.


  1. I read Mountains Beyond Mountains and found Farmer's moral superiority (as portrayed by Kidder) totally of over the top. And the crazy admiration I've seen amongst some pre-meds (one in particular) also put me off a bit. But I did have lunch with him once (with about 8 other people), and he seemed really nice. And I read one of the books that he actually wrote, Infections and Inequalities, and I was very impressed.

  2. Agreed. What good is Oprah's $40 million dollar school if only 200 people can go there?

  3. Anonymous9:22 PM

    Paul Farmer is a language fluffing, lack of content speaker that is more concerned with his prestigious image than actually taking action.

  4. Anonymous11:01 AM

    Haha, seriously people? Making comments on the book content is one thing, surely it presents him as somewhat of a superhero, but let's read his actual literature before we make judgments about his views and his work. He has written over half a dozen books and published hundreds of academic articles. "Pre-meds" love him because he brings a compassion to medicine that has become convoluted with self-interest, I couldn't disagree more with the final statement, horribly mistaken and uninformed judgment.

  5. The author of this blog and a few of the anonymous (read: cowardly) commentators clearly have never read any of Paul Farmer's anthropological works or understand the impact the man has had in the world of infectious disease. Paul Farmer and PIH has decreased drug prices from hundreds of dollars a dose to less than a dollar a dose because of a mentality that cost-effectiveness is a cynic's way of passing the buck on the most desperate and needed patients throughout the world. And for those that don't like the fact that Paul Farmer uses brilliant language to describe his thoughts and works, get over your insecurities and use a dictionary. Farmer should not have to apologize for challenging your brain. Paul Farmer is not God. But he has done a lot of extraordinary things for this world.

    I hope the author rereads the book and perhaps "Pathologies of Power" as well. I think you missed Paul Farmer's passion and mission the first time around.