Just Fix It

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.”

-Dr. Rudolf Virchow

Paul Farmer, MD PhD, an infectious disease specialist and anthropologist who started a foundation to provide care to impoverished populations in Haiti and around the world, died suddenly of an apparent heart attack this past week, at age 62.

Dr. Farmer studied Haitian culture as a medical anthropologist before becoming a physician and a specialist in infectious diseases. Through his direct patient care activities and by developing a public health infrastructure in a remote area of central Haiti, he cultivated a deep understanding of the links between disease, poverty, and political power. He wrote several books on this topic, using patients’ experiences to drive home his arguments.

Biographer John Tracy Kidder in “Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man who Would Cure the World,” relates this story:

A TB patient from a village hadn’t shown up for his monthly doctor’s appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medications. Farmer said, “The only non-compliant people are physicians. If the patient doesn’t get better (because they don’t take medications as prescribed), it’s your own fault. Fix it.”

Of the many moving and interesting parts of Farmer’s life detailed in the book, this one sticks with me, because it is so at odds with how many of us think about “non-compliant” patients. Attributing failure of an intervention to non-compliance is a way for health care professionals to assign responsibility or blame to our patients for them not getting better, because they don’t follow our scientific advice. The alternative term “non-adherence” was initially used with an intent to look for underlying factors that could be impacted, but it has come to be used in place of “non-compliant” just to sound less judgmental, but with the same implicit intent and outcome. The clinician moves on to their next task, their next patient.

Dr. Farmer believed that an understanding of a patient’s culture is essential to build trust between the physician and the patient allowing a skilled physician to devise a way to form an alliance with the patient that will lead them, long after they feel better, to complete an antibiotic treatment for tuberculosis, to cure them of the infection. This is difficult work in many ways. It requires time spent listening to the patient, as well as mental creativity, and tenacity.

This belief is what drove Dr. Farmer, a handful of Haitian doctors, a larger group of community health workers, and the community health center/hospital he ran in Haiti, to uncompromisingly provide quality health care to an impoverished population about the size of Shasta County. No one in the region served by his health center had died of measles or tuberculosis in many years (unlike other areas of Haiti, where deaths from these diseases were sadly common).

Dr. Farmer said his role model, since his undergraduate years, was Dr. Rudolf Virchow, a 19th century German physician of many skills and interests. Dr. Virchow was known as both the father of modern pathology (with an understanding of the central role of cells in tissues and diseases), and also the father of the field of social medicine. Like Farmer, Virchow was an anthropologist and a scientist as well as a prolific writer on both scientific and socio-political topics.

The work that you do in your health centers and offices follows the same spirit of service to the most vulnerable members of our community. Let Farmer and Virchow inspire us to not accept mediocrity, bureaucratic barriers, or blame our patients for poor outcomes. We must develop a deep understanding of the cultures of the patients we serve, the system we are working within, and combine this with compassionate medical care to meet the challenge of caring for the individual patients before us.

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