The Moral Medical Mission: Partners In Health, 25 Years On

How the global health organization grew from makeshift clinics to a state-of-the-art cancer center in rural Rwanda, and what lies ahead (Hint: Still more mountains) 

Construction on Mirebalais National Teaching Hospital, 30 miles north of Port au Prince, Haiti, will be complete in early 2013.

People as enormously successful as Dr. Paul Farmer and Ophelia Dahl often temper discussions of their accomplishments with lines like, "Who could've imagined we'd make it this far?"

So it could initially feel like a discontinuity of character when the intensely modest founders of Partners In Health -- the international organization that directly serves 2.5 million people in 10 countries -- go a little bit Kanye West, offering no such disclaimer. They realized long ago that their organization would become what it is today, because it needed to.

For Farmer and Dahl, it's not about swagger -- it's about meliorism. A belief that the world can be made better by human effort. Before you begin to confuse their resoluteness for arrogance, Farmer will tell you, "It's not rocket science to think out social justice strategies."

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Cofounders of Partners In Health, Dr. Jim Yong Kim (now President of the World Bank), Ophelia Dahl, and Dr. Paul Farmer. Cofounders Tom White and Todd McCormack are not pictured.

If you could go back to the 1980s and tell the twenty-something versions of Dahl (now President and Executive Director of Partners In Health) and Farmer (now Chief Strategy Officer) -- as students treating patients with malaria and tuberculosis in a provisional "clinic" in rural Haiti -- that by 2012 they'd have a pediatric cancer center in Rwanda and be treating HIV in sub-Saharan Africa with higher medication compliance rates than in parts of the United States, they probably would've given you little more than a straight-faced, "Cool."

It's been almost ten years since Tracy Kidder's biography Mountains Beyond Mountains told the story of Farmer, "the man who would cure the world," and Dahl as they traveled to and from a rural village in Haiti with a small group of Boston colleagues, providing medical care and, in so doing, established what would become Partners In Health. The impact of the organization is only now being realized in the capacity they saw that it could.

"We never fell for the idea that you can intervene with simple, inexpensive tools alone," Farmer told me.

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Paul Farmer in Cange, Haiti

Dahl added, "You have an entire field of public health where the most compelling and dominating arguments revolve around things like cost-effectiveness rather than effectiveness. It's like those bumper stickers: If you think education is expensive, try ignorance. If you think that it's cost-effective to only give oral rehydration to patients in dire need -- the key is bringing groups of people together to build a good, modern teaching hospital."

"A lot of times," Farmer told me, "our younger colleagues here at Harvard will say, 'You're treating a lot of patients with, say, congestive heart failure;' or 'When did you start treating cancer?' The real answer is as soon as you open your doors to whomever feels sick, you see problems that are way more complex than what our public health colleagues at the time in the 80s were accustomed to treating."

Partners In Health celebrates its 25th Anniversary this week, marking the occasion with a Manhattan gala. Ben Stiller and Arcade Fire will be in attendance, among the celebrities lending their cred to the cause. And they have a lot to celebrate.

The coming Spring will see the opening of the Mirebalais National Teaching Hospital in Haiti, 30 miles north of Port au Prince, just three years after the earthquake that killed over a quarter million people. At 300 beds, it will be the largest public teaching hospital in Haiti and the essence of what PIH believes health care in Haiti is capable of achieving. The hospital will house the only CT scanner in any public facility in Haiti. It will be staffed both by local physicians as well as faculty from Harvard's Massachusetts General Hospital and Brigham and Women's Hospital. The operating rooms will have cameras linked to international expert surgeons who can consult for advice in real time from around the world.

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Mirebalais National Teaching Hospital

Perhaps most importantly, the Mirebalais hospital will house a training program for local physicians, aimed largely at compensating for the exodus of doctors out of Haiti. Farmer notes that training local care providers has become the core of the PIH model. Teach a man to perform neonatal cardiac surgery, and he'll save lives for a lifetime.

Kidder's biography of Farmer is also titled after a proverb -- a Haitian one that translates: "Beyond mountains there are mountains." According to Kidder, it's "sometimes used to express the idea that opportunities are inexhaustible, and sometimes as a way of saying that when you surmount one great obstacle you merely gain a clear view of the next one."

Applying that proverb to Farmer's work remains poignant these years later, typified by PIH's work in Rwanda. As Partners In Health made inroads against endemic infectious diseases like malaria and drug-resistant tuberculosis, they saw people living longer, and they were able to turn their attention to the next thing that took over where those diseases left off.

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Neonatal unit at Butaro Hospital, Rwanda

"Rwanda has plenty of cancer, but didn't have a single oncologist," Farmer recalled. "When we started working in Rwanda in 2005, in a public sector facility, we saw cancer every day. We saw more AIDS, TB, and malaria, but now the mortality from those have dropped substantially and life expectancy has gone up pretty dramatically. As people live longer and do better, you see more cancer. So you have to adjust and stay ahead of the curve."

And so they did. On July 28 of this year, Partners In Health, working with the Rwandan Ministry of Health, the Jeff Gordon Children's Foundation, and the Dana-Farber Cancer Institute, opened the Butaro Cancer Center of Excellence in Rwanda, which includes the first comprehensive pediatric center in rural Africa.

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Neonatal unit at Butaro Hospital, Rwanda

For Dahl, looking back on 25 years, the work is really about this sort of transformation. "Be it transforming a sick person to a well person, or a parking lot into a clinic -- the transformations became amplified as we grew our partnerships. You see that most NGOs work alone -- when there are thousands of NGOs in Haiti, and simply forming partnerships, connecting to local and national government, makes things much, much more efficient."

Beyond the partnerships and the belief that they can and should achieve what they have, Farmer cites the tenacity of the initial group of volunteers in Haiti in the 80s.

"We were working with a group of young people, our age, just doing a community assessment. Of that original group, all in their 20s, one of them died of cerebral malaria, one died on the operating table of a perforated ileum from typhoid, and a third died about 9 or 10 days after child birth of Semelweiss' puerperal sepsis -- which I was then studying at Harvard Medical School. So one of the things I was always most proud of was that we didn't back out, that we didn't turn away, as these problems took the lives of our colleagues."

Experiences like that inform Farmer's apparently limitless ambition. His first comment on the cancer center in Rwanda was: "It's a beautiful place. Of course every time you build something like that you think, 'How could we have done this better?'"

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A patient at the Cancer Center of Excellence in Rwanda

How much better could this sort of work be done? What can we look for in the next 25 years of Partners In Health?

Dahl says, they'll be "expanding, creating all sorts of partnerships." Looking at the huge burden of disease, "the need and the opportunity is enormous. But we also have enormous interest ... I'd like to think the work is on a path for exponential growth."

According to Farmer, "There are two ways to expand: geographically -- which has been very gratifying -- but the real mode of expansion for us is going to be through others."

Farmer notes that "Where joblessness is the status quo, building new hospitals and health centers and schools can actually bring disappointment to some, in that everyone wants to work there. It's usually not because they want a better job, but because they want a job. Before joining us, the majority of PIH's 15,000 employees never held a salaried job in what economists term the 'formal sector.'" Farmer frequently describes the thought barrier of being "socialized for scarcity." The gist is that, especially in people who are used to operating with finite, limited resources, something given to others means something taken away from (or, at least not available to) themselves. Farmer adds, "The assumption is that if someone else gets a job, even someone in their own family, then they will not. This sort of limited-good, zero-sum thinking is to be expected among the poor, but is unacceptable from those who seek to attack poverty."

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A Partners In Health community worker in Peru, 2009

In the past year alone, Partners In Health has also been involved in places like Nepal, Liberia, and Mali, where Farmer has visited and worked in students' projects. "We're trying to envision: What would an NGO look like if every service project were fully leveraged by a training effort for local people? One of the biggest problems with the global health movement in the U.S. over the last 10 years is there's not enough attention paid to making sure we focus not just on training our own students and residents, but our peers from Haiti to Africa."

In the meantime, Farmer -- the man who Kidder described as not sleeping more than "an hour or two most nights" -- Dahl, and the rest of the Partners In Health crew should take some time to reflect on their organization's tremendous accomplishments on its 25th anniversary, before taking on the next mountain. 

If you'd like to donate, volunteer, or otherwise work with PIH, absolutely do.

All photographs courtesy of Partners in Health