Global Health Ideas

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“The Right to Sutures” – Paul Farmer’s keynote address at APHA

apha-2006.jpgPaul Farmer gave the second of two keynote addresses at today’s opening of the APHA (American Public Health Association) Annual Meeting – the first was from Helene Gayle, now President and CEO of CARE International. In reporting on his address, I have quoted him as directly as possible, and where appropriate.

The theme of this year’s conference is “Public Health and Human Rights”, and as it is in one of Paul Farmer’s backyards (Boston), he was a well-suited speaker. The overall message was an extension of his 1999 article “Pathologies of power: rethinking health and human rights” (American Journal of Public Health, Vol 89, Issue 10 1486-1496). In short, he argued “prevailing orthodoxies” in public health center around the “crude” concepts of sustainability and cost-effectiveness, while the focus should be on social and economic rights. “[Sustainability and cost-effectiveness] are tools we need, not religion.”

The more practical message was that we need to address more immediate, material concerns, such as food, clean water, drugs, and medical supplies – much of which can be considered “wrap around services”.

“There should be a right to sutures. There should be a right to sterile drapes. There should be a right to anesthesia … We will need gloves, sutures, drapes, and hot, clean water. This is uncharted territory for human rights groups. We here are ready to talk about gender inequality, but to few of us are ready to buy generators, sutures, or [operating room] lamps … [This] may not seem sexy to people commenting on health and human rights.”

I was delighted to hear his talk touch on such “unglamorous” issues as supply chain and procurement.

He is still very committed to his ideology of providing equivalent technology to poor people. While this is certainly the most effective and ethical approach in many cases – as he has demonstrated to the rest of the world – it is unclear that this is always in the best interests of poor people. I argue not from the point of “cost-effectiveness”, but rather of “effectiveness”. Take for example his advocacy for clean water and infant formula in Rwanda. A colleague who is an expert on breastfeeding reported that people at this year’s International AIDS Conference were highly critical of this approach because of the increased potential for infant deaths from diarrheal diseases. Significant, comparative research over the last few years has shown that while formula is effective for PMTCT (prevention of mother to child transmission) of HIV, breastfeeding results in fewer overall infant deaths. One key is the lack of access to clean water, which results in diarrheal disease, while another is the protective nature of the breastmilk itself. Farmer’s response, no doubt, would be that Partners in Health will provide all the clean water necessary. Achieving this for small communities will be difficult, but not impossible – achieving it at a large scale will take considerable time. In the short-term, breastfeeding seems to be a much safer bet.

Several nursing colleagues and I went to dinner in Chinatown, where we discussed Farmer’s talk. The consensus was that Farmer often makes it seem as if nothing positive is being done in the sphere of international health.

Despite some concerns about his ideology, he provided a strong, persuasive, and needed message. His quote from a young Kenyan doctor, lamenting about working conditions and supplies, sums it up best: “I did not go to medical school to become a mortuary attendant.”


Written by Jaspal

November 5, 2006 at 8:18 pm

One Response

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  1. The first time I saw Paul Farmer speak was in 1999, to a standing room only crowd. And every time since then has been a similar experience. Although some people disagree with him and his tactics it is good to see leadership in public health and someone that can truly inspire people into action.

    It is amazing since that point in time how much public and global/international health has caught on since then. Schools of Public Health (SPH) are opening up left and right and divisions or departments of global health are being started at many academic institutions. On the one hand I question the growth of SPHs across the US but it is good to see people in general paying more attention to the field.

    A testament of Paul Famers pull, all freshman and transfer students at the University of Washington will be reading the book about him. It has been selected as the “common book”. It is the first time one book will be assigned to all incoming students at UW:


    November 7, 2006 at 11:40 pm

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