訃告
保羅.法默 (Paul Farmer . 1959-2022) 全球公共衛生先驅和公平倡導者。
作者:Amy Maxmen,資料來源:Nature | Vol 603 | 17 March 2022 | 387;財團法人台灣紅絲帶基金會編譯
「發生在窮人身上的事情永遠不會脫離強權的行為」,保羅·法默在他 2005 年出版的《權力病態》一書中寫道。作為一名醫生、醫學人類學家和活動家,法默畢生致力於倡導健康公平。作為在海地、秘魯和盧旺達等低收入國家提供免費醫療服務的非營利組織健康夥伴(Partners In Health, PIH) 的聯合創始人,他利用該組織的成果改變了關於如何治療結核病和愛滋病毒。在 COVID-19 大流行期間,法默和他的同事譴責疫苗壟斷,這有助於解釋為什麼在低收入國家只有不到 10% 的人完全接種了疫苗(P. Erfani 等人 BMJ 374, n1837; 2021)法默在盧旺達治療病人直到他去世,享年 62 歲。
1990 年,他在麻薩諸塞州波士頓的哈佛醫學院獲得人類學博士學位和醫學學位,後來在那裡教授全球健康和社會醫學。他的觀點是由他在美國的童年經歷和在海地的年輕成人經歷塑造的。它們深植於他對社會理論、政治理論和天主教「解放神學」哲學的了解。這項研究將他的思想集中在對窮人的系統性壓迫上。
法默的 12 本書和 200 多份文稿揭示了指導他行動的原則。法默認為,拯救生命所需的資金存在於當生命都是等值時。他批評了公共衛生領域中的政府和捐助者使用成本效益分析,去計算他們認為理所當然的醫療技術,係於何時對那些無法支付自己費用的人是有價值的。在 2003 年《世界衛生組織公報》的一篇社論中,他批評了公共衛生界的那些人,他們在貧窮國家推動的是愛滋病預防而不是醫療照護,因為它更便宜(P. Farmer Bull. World Health Organ. 81, 699; 2003)。當時,愛滋病的藥物價格非常昂貴——但並不需要如此,正如他所指出的那樣。兩年後,政策改變讓學名藥進入了市場,價格大幅下跌。
為了實現他對每個人都能獲得醫療保健之世界的願景,法默有時會違反規則。據《紐約客》報導,在 1990 年代 PIH 的早期,他和他PIH的聯合創始人 Jim Yong Kim ,從他們所工作的麻薩諸塞州波士頓的布萊根婦女醫院走私了價值約 92,000 美元的二線結核病藥物,給他們在秘魯的病人。 (PIH 捐贈者後來向醫院核銷了這些藥物費用)。多年後,法默和金支持了一項世界衛生組織雄心勃勃的倡議,該倡議旨在於 2005 年全球應有300 萬名愛滋病毒/愛滋病患者接受治療。他們明白捐贈者更願意其資助計劃僅侷限於關注單一疾病,而不是廣泛地關注醫療照護。
「法默的整個職業生涯都試圖讓人們相信健康照護是一項人權。」
然而,私下裡,他們想重組系統,法默的親密同事、伊利諾伊州埃文斯頓西北大學的人類學家 本頓(Adia Benton) 說。 「他們知道,要讓這麼多人接受愛滋病毒治療,你必須改變專利法,你必須改變製造業,你必須建立婦產科診所。他會爭辯說,除非有良好的產前護理,否則就無法應對母嬰傳播」,她解釋道。 「他們都是騙子」。
PIH 與大多數其他援助組織的不同之處在於,它不僅試圖建立診所,且還試圖在政府營運的服務機構內確保它可永續經營並網羅當地各層級工作人員。 「我就是一個活生生的證明」, 獅子山PIH分會 (PIH Sierra Leone) 的執行董事巴里(Bailor Barrie) 說,該分支機構於 2014 年伊波拉病毒爆發期間成立。Farmer 和 Barrie 相遇時,後者還只是哈佛大學醫學院農民班全球衛生專業的學生。 「他是我的老師、我的導師、我的同事、我的朋友。我叫他爸爸,因為他就像一個父親」,巴里說。 「我完全的信服」。
法默鼓勵科學家在研究疾病時,應考慮諸如種族主義、性別歧視和貧困等阻礙人們利用科學成果利益之能力背後的因素。儘管根除壓迫的根源是一項艱鉅的任務,但法默描述如果醫療計畫努力爭取公平,他們將會如何更好地運作(J. S. Mukherjee 等人 Lancet Glob. Health7, E410–E411; 2019)。在那篇論文中,他寫道,在他的秘魯團隊中接受每月小額津貼和食物以及免費結核病治療的人們中,如何有100% 的人治癒了這種疾病,相較於僅接受藥物治療的人中卻只有 56% 的人治癒了這種疾病。
本頓認為,法默的政治取向源於他在相對貧困中長大的經歷:他是六個孩子中的一個,住在車廂、船艙和帳篷裡。他曾在《倫敦書評》上寫道,他在 1988 年攻讀研究生時治療斷腿的醫療費用大約是他母親作為收銀員年薪的兩倍。他反映,他的大部分賬單都由哈佛的醫療保險支付,而這樣的醫療費用每年會使全世界大約 3000 萬的家庭陷入窮困潦倒——如果人們得到治療的話。 「三名 海地PIH 的創始人,在他們20 多歲,最近都死於愚蠢的死亡」,他寫道,因敗血症、瘧疾和傷寒等可預防和易於治療的疾病。
法默在他的職業生涯中試圖說服人們健康照護是一項人權。為此,他成為全球衛生領域的名人;他留下了一批致力於推進他的使命的研究人員。「他不僅僅是一個有遠見的人」,本頓說。「他也是彪炳顯赫的」。
Amy Maxmen 是加利福尼亞州奧克蘭市 Nature 雜誌的資深記者。
Nature | Vol 603 | 17 March 2022 | 387
譯註:國內天下文化曾於2005年出版介紹其生平的「愛無國界:法默醫師的傳奇故事」一書
Obituary
Paul Farmer (1959–2022) : Global public-health pioneer and equity advocate .
“What happens to poor people is never divorced from the actions of the powerful,” Paul Farmer wrote in his 2005 book Pathologies of Power. A doctor, medical anthropologist and activist, Farmer devoted his life to advocating for health equity. As a co-founder of Partners In Health (PIH), a non-profit organization that provides free medical care in low-income countries including Haiti, Peru and Rwanda, he used the group’s results to change global guidelines on how to treat tuberculosis and HIV. During the COVID-19 pandemic, Farmer and his colleagues denounced monopolies on vaccines that help to account for why fewer than 10% of people have been fully vaccinated in low-income countries (P. Erfani et al. BMJ 374, n1837; 2021). Farmer treated patients up until his death in Rwanda, aged 62.
In 1990, he earned a PhD in anthropology alongside a medical degree from Harvard Medical School in Boston, Massachusetts, where he later taught global health and social medicine. His views were shaped by his own experiences as a child in the United States and as a young adult in Haiti. They were deepened by his knowledge of social theory, political theory and the Catholic philosophy of ‘liberation theology’. This study focused his thinking on the systemic oppression of poor people.
Farmer’s 12 books and more than 200 manuscripts reveal the principles that guided his actions. The money needed to save lives exists if lives are valued equally, Farmer argued. He criticized the public-health field for cost-effectiveness analyses used by governments and donors to calculate when medical technologies that they take for granted are worthwhile for those who cannot pay for them themselves. In an editorial in the World Health Organization Bulletin in 2003, he criticized those in the public-health community who pushed for HIV prevention rather than care in poor countries because it was cheaper (P. Farmer Bull. World Health Organ. 81, 699; 2003). At the time, HIV drugs were astronomically expensive — but did not need to be, as he pointed out. Two years later, policy changes allowed generics to enter the market and prices fell drastically.
To achieve his vision of a world in which everyone has access to health care, Farmer sometimes bent the rules. In the early days of PIH in the 1990s, he and co-founder Jim Yong Kim smuggled some US$92,000- worth of second-line tuberculosis drugs out of Brigham and Women’s Hospital in Boston, Massachusetts, where they both worked, to their patients in Peru, according to a profile in The New Yorker. (A PIH donor later reimbursed the hospital for the drugs.) Years later, Farmer and Kim threw their support behind an ambitious World Health Organization initiative to treat three million people with HIV/AIDS by 2005. They understood that donors prefer to fund programmes that focus narrowly on a single disease, rather than on health care broadly.
“Farmer spent his career trying to convince people that health care is a human right. ”
In private, however, they wanted to restructure systems, says Farmer’s close colleague, Adia Benton, an anthropologist at Northwestern University in Evanston, Illinois. “They knew that to get this many people on HIV care, you’d have to change patent law, you’d have to change manufacturing, you’d have to build obstetrician–gynaecology clinics. He’d argue that you can’t take care of maternal-to-child transmission without good prenatal care,” she explains. “They were hustlers.”
PIH stands apart from most other aid organizations in that it attempts not only to build clinics but also to ensure they remain sustainable by operating within government-run services and enlisting local staff at every level. “I am a living testament to that,” says Bailor Barrie, the executive director of PIH Sierra Leone, a branch established during the Ebola outbreak in 2014. Farmer and Barrie met when the latter was a global-health student in Farmer’s class at Harvard Medical School. “He is my teacher, my mentor, my colleague, my friend. I call him Pa because he is like a father,” Barrie says. “I am devastated.”
Farmer encouraged scientists studying diseases to account for forces such as racism, sexism and poverty that hinder people’s abilities to take advantage of the fruits of science. Although rooting out the sources of oppression is a tall order, Farmer described how medical programmes could work better if they strove for equity ( J. S. Mukherjee et al. Lancet Glob. Health7, E410–E411; 2019). In that paper, he wrote about how 100% of people who received small monthly stipends and food alongside free tuberculosis treatment from his team in Peru were cured of the disease, compared with only 56% of those given the drugs alone.
Benton suggests that Farmer’s political orientation stemmed from his experience of growing up in relative poverty: one of six children, he lived in a bus, a boat and a tent. His medical care for a broken leg as a graduate student in 1988 cost about twice his mother’s annual salary as a cashier, he once wrote in the London Review of Books. He reflected that most of his bill was covered by Harvard’s medical insurance, whereas such health costs impoverish some 30 million households each year around the world — if people get care at all. “Three of the Haitian founders of PIH, all in their twenties, had recently died stupid deaths,” he wrote, of the preventable and easily treated diseases of sepsis, malaria and typhoid fever.
Farmer spent his career trying to convince people that health care is a human right. For this, he became a celebrity in global-health spheres. He leaves a legacy of researchers committed to carrying his mission forward. “He wasn’t just a guy with a vision,” Benton says. “He was brilliant.”
Amy Maxmen is a senior reporter for Nature in Oakland, California. Nature | Vol 603 | 17 March 2022 | 387