Africa's medicine man

To his patients, he's simply 'Dr Paul'. To the people working in Aids-ravaged communities, he's a revolutionary - and an inspiration. Jeremy Laurance hears why

The man who is known to his patients as Doctor Paul is at it again: building hospitals in war-torn parts of the world, training health workers and then setting about the real work of transforming communities.

Paul Farmer is a professor at Harvard Medical School, a specialist in infectious diseases and the author of more than 200 papers. He has been lauded with medical honours. But much of his time is spent thousands of miles from Harvard working at the front line of the war against poverty.

His latest venture is in Rwanda, the tiny but most densely populated country in Africa, which was destroyed by the genocide of 1994 and is now ravaged by Aids. He and his colleagues run Partners in Health, a charity that he founded nearly 20 years ago. With $3m (£1.6m)from the Clinton Foundation and other donors, they have just restored an abandoned hospital in the south-east of the country near the Tanzanian border at Rwinkwavu. Rooms once deserted and full of bullet holes and blood are alive again, buzzing with doctors and nurses offering care to the sick and comfort to the dying.

"There is nothing I like more than building a hospital - that's what I call a good pastime. We have probably built a dozen around the world. I think it's exciting to see good results. That inspires me," he says.

Farmer is more than 6ft tall, long- limbed, and, at the age of 46, still seized by the injustice of a world in which the poor are denied the same rights to medical care as the rich. Home is a hut with a cement floor and a tin roof on the Caribbean island of Haiti, a focus of the Aids epidemic, where, as a raw young medical student in his twenties, he started Partners in Health, which has now become his life.

He has spent half his time over the past year in Rwanda, where he is starting work on a second hospital at Kirehe. This year, the charity is expanding into Lesotho and Malawi. Before Rwanda, he was involved in projects in Peru, Siberia and a deprived area of Boston, close to Harvard. But Haiti is where it all began.

Farmer had gone straight from college to work as a doctor's assistant in a hospital on Haiti in 1983, and was so struck by the inadequacy of the care available that he resolved to do something about it. He was 24 and met Ophelia Dahl, the daughter of Roald Dahl, who was then 18. Together they set up a community health centre that has since grown into a medical complex called Zanmi Lasante, which serves a population of one million peasant farmers on the central plateau, the island's poorest region.

To build Zanmi Lasante, Farmer set up Partners in Health in 1987. He was 28 and was later joined by Dahl, who is now the charity's executive director. In the early years, Partners in Health was funded almost entirely by Tom White, an Irish-American developer who had made a fortune in the construction industry and decided to give most of it away. As the charity has grown into the global, multimillion-dollar operation it is today, others have stepped in: the Bill and Melinda Gates Foundation, the Clinton Aids initiative, the UN Global Fund.

On Haiti, seven further hospitals followed Zanmi Lasante, all built by Partners for Health and all, unusually, owned by the government. Other government clinics and hospitals have been built or extended in Peru, in Siberia and now in Rwanda.

It is this that distinguishes Partners in Health from other charities working in international development. It does not bring aid to the dispossessed by helicopter. Instead, it does the unfashionable, unglamorous work of public-sector development "in partnership with" national governments. Exactly what it says in its title.

Farmer says: "A lot of NGOs prefer to build their own projects. The public sector is left to fall apart and then the saviours come in from abroad. Working with the public sector is difficult but far more rewarding. To be sustainable over decades, a project has to be picked up by the ministry of health."

Farmer has an eight-year-old daughter who is at school in Paris, where she lives with her mother, Didi Bertrand, who Farmer wooed and married a decade ago. Bertrand is the daughter of the local schoolmaster in Haiti. It is a complicated life.

He is a Catholic who subscribes to the doctrine of "liberation theology". His father was a schoolteacher and he and his siblings led a frugal life living in a bus and a boat. He has few material possessions, little interest in clothes, and a portion of his monthly salary is paid direct to his own charity. His credit card is consequently often over the limit and refused. Tracy Kidder, who wrote a book about Farmer, Mountains Beyond Mountains: the quest of Dr Paul Farmer, a man who would cure the world (Random House, 2004), quoted a bookkeeper at the charity who told him: "Honey, you are the hardest-working broke man I know."

He had wanted to work in Africa for a long time, but finding the right project - and the right place - proved difficult. Negotiations with the Ministry of Health in Rwanda took three years. "We were interested in poverty reduction. We wanted to be involved in rebuilding the infrastructure. We didn't want to run another Aids project."

In November 2004, they were taken to a town in the north of the country to look at a hospital that was functioning but in need of help. Farmer said: "It was clean and it had a working X-ray machine. We said, 'This looks easy.' In response, the minister of health banished us to a non-functioning hospital in the most rotten corner of the country."

When Farmer and his team arrived in Rwinkwavu, in May last year, there were 400,000 people living in the area and no doctors. The "hospital" was a collection of one-storey buildings, unoccupied for almost a decade, on a campus that had once served a Belgian mining company.

"As soon as we showed up, patients started flocking to see us. We had to rebuild while treating them," says Farmer.

Three doctors came with him, and "little by little" they started hiring nurses and community health workers. Today, they have 150 staff, there are 100 beds and the hospital is "rocking", Farmer says. They have trained scores of local community health workers and are treating more than 1,000 HIV patients with antiretroviral drugs (ARVs).

The community workers are crucial to this. The problem with ARVs is that they can make patients feel better quickly, but they must be taken for life. If they are taken intermittently, resistance can develop, which some experts fear could trigger a second wave of an even worse HIV epidemic. ARVs also will not work if the patient is starving through poverty or afflicted by other illnesses that undermine their immune systems.

The community workers go into people's homes and observe them taking the drugs, ensuring at the same time that they have adequate food and treatment for other conditions. This is modelled on the strategy known as Dots-plus (Directly Observed Therapy Short course) for drug-resistant tuberculosis, plus the extras necessary - second-line drugs, extra nutrition - that are essential for the treatment to succeed.

Dots was developed in response to the rising tide of TB cases worldwide, which began in the Sixties after decades of decline. Dots-plus, which deals with the emerging problem of drug-resistant TB, was first described by Farmer and colleagues in a paper in the British Medical Journal in 1998. It has since been adopted by the World Health Organisation and the UN Global Fund and has become the standard approach to the treatment of drug-resistant TB.

The contribution of the community health workers in Rwinkwavu goes beyond supervising the medical treatment. "What they are doing is so much better than expected," says Farmer. "You might call it spreading solidarity. They are involved in rebuilding the community. After what the country has been through, having them out there being neighbourly is a good thing." This vision underpins Farmer's work and that of Partners in Health. To cure disease, you have to address the conditions that give rise to it. In Haiti, Farmer's charity fought pneumonia not only with antibiotics but also by helping people to replace their thatched roofs with tin (which keeps out the rain better). In Peru, it treated TB not only with the drugs isoniazid and rifampicin but also by training residents of Lima's shanty towns to help diagnose and treat their neighbours.

"Those experiences taught me how central poverty is to disease," Farmer said. "We are not going to get at poverty in Africa without attacking disease, and we are not going to get at disease without attacking poverty."

Plague on a continent: Aids in Africa

* By the end of 2005, 40.3 million people worldwide were living with Aids. An estimated 25.8 million of them were living in sub-Saharan Africa, where 95 per cent of the world's Aids orphans live.

* Last year, 4.9 million people were newly infected, including 700,000 children, and 3.1 million people died of HIV/Aids-related illnesses.

* Ninety-six per cent of people with Aids live in developing countries, the majority in sub-Saharan Africa.

* Average life expectancy in sub-Saharan Africa is 47 years. Without Aids, it would be 62.

n An estimated five to six million people in poor countries will die in the next two years if they do not receive antiretroviral (ARV) treatment. At the end of 2005, only one in 10 Africans who needed antiretroviral treatment were receiving it. Many were not even receiving treatment for opportunistic infections.

* Treatment and care needed includes HIV/Aids prevention, counselling and testing, nutritional management, prevention and treatment of opportunistic infections, and, of course, access to ARV drugs. Money needs to be invested in education, training and healthcare resources as well as drugs.

* Botswana is the first African country to trial ARV therapy on a national scale. The project has not yet been a complete success, because of problems with resources and healthcare infrastructure, but Botswana believes it can provide a comprehensive HIV/Aids care and treatment programme similar to Brazil's.

* The price of ARV medication has plummeted in recent years, in part because of greater competition between pharmaceutical companies, but also because patent rules have been relaxed to allow the distribution of generic drugs in some of the poorer parts of the world.

* The drugs are still not cheap, however, and the cost of treatment is well beyond many public health systems. Foreign aid, therefore, is still needed.