This article is from the (RED) edition of The Independent, guest-edited for 16 May 2006 by Bono. Half the revenue from the edition will be donated to the Global Fund to Fight Aids.

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.

Sport
Club legend Paul Scholes is scared United could disappear into 'the wilderness'
football
News
A model of a Neanderthal man on display at the National Museum of Prehistory in Dordogne, France
science
News
Dawkins: 'There’s a very interesting reason why a prince could not turn into a frog – it's statistically too improbable'
newsThat's Richard Dawkins on babies with Down Syndrome
Sport
Malky Mackay salutes the Cardiff fans after the 3-1 defeat at Liverpool on Sunday
footballFormer Cardiff boss accused of sending homophobic, racist and messages
PROMOTED VIDEO
Have you tried new the Independent Digital Edition apps?
News
ebooksAn evocation of the conflict through the eyes of those who lived through it
Sport
Rodgers showered praise on Balotelli last week, which led to speculation he could sign the AC Milan front man
transfers
Life and Style
life – it's not, says Rachel McKinnon
Arts and Entertainment
Eye of the beholder? 'Concrete lasagne' Preston bus station
architectureWhich monstrosities should be nominated for the Dead Prize?
Arts and Entertainment
Arctic Monkeys headline this year's Reading and Leeds festivals, but there's a whole host of other bands to check out too
music(who aren't Arctic Monkeys)
News
Lizards, such as Iguanas (pictured), have a unique pattern of tissue growth
science
Extras
indybest
News
Anna Nicole Smith died of an accidental overdose in 2007
people
Life and Style
food + drink
Arts and Entertainment
'The Great British Bake Off' showcases food at its most sumptuous
tvReview: Bread-making skills of the Bake Off hopefuls put to the test
Independent
Travel Shop
the manor
Up to 70% off luxury travel
on city breaks Find out more
santorini
Up to 70% off luxury travel
on chic beach resorts Find out more
sardina foodie
Up to 70% off luxury travel
on country retreats Find out more
Have you tried new the Independent Digital Edition apps?
Independent Dating
and  

By clicking 'Search' you
are agreeing to our
Terms of Use.

iJobs Job Widget
iJobs General

Software Developer - Newcastle - £30,000 - £37,000 + benefits

£30000 - £37000 per annum + attractive benefits: Ashdown Group: .NET Developer...

Trainee Recruitment Consultant

£20000 - £25000 per annum + OTE £40,000: SThree: SThree Group have been well e...

Digital Project Manager/BA

£300 Per Day: Clearwater People Solutions Ltd: An experienced Digital/Ecommerc...

Creative Content Executive (writer, social media, website)

£30000 - £35000 Per Annum + 25 days holiday and bonus: Clearwater People Solut...

Day In a Page

Middle East crisis: We know all too much about the cruelty of Isis – but all too little about who they are

We know all too much about the cruelty of Isis – but all too little about who they are

Now Obama has seen the next US reporter to be threatened with beheading, will he blink, asks Robert Fisk
Neanderthals lived alongside humans for centuries, latest study shows

Final resting place of our Neanderthal neighbours revealed

Bones dated to 40,000 years ago show species may have died out in Belgium species co-existed
Scottish independence: The new Scots who hold fate of the UK in their hands

The new Scots who hold fate of the UK in their hands

Scotland’s immigrants are as passionate about the future of their adopted nation as anyone else
Britain's ugliest buildings: Which monstrosities should be nominated for the Dead Prize?

Blight club: Britain's ugliest buildings

Following the architect Cameron Sinclair's introduction of the Dead Prize, an award for ugly buildings, John Rentoul reflects on some of the biggest blots on the UK landscape
eBay's enduring appeal: Online auction site is still the UK's most popular e-commerce retailer

eBay's enduring appeal

The online auction site is still the UK's most popular e-commerce site
Culture Minister Ed Vaizey: ‘lack of ethnic minority and black faces on TV is weird’

'Lack of ethnic minority and black faces on TV is weird'

Culture Minister Ed Vaizey calls for immediate action to address the problem
Artist Olafur Eliasson's latest large-scale works are inspired by the paintings of JMW Turner

Magic circles: Artist Olafur Eliasson

Eliasson's works will go alongside a new exhibition of JMW Turner at Tate Britain. He tells Jay Merrick why the paintings of his hero are ripe for reinvention
Josephine Dickinson: 'A cochlear implant helped me to discover a new world of sound'

Josephine Dickinson: 'How I discovered a new world of sound'

After going deaf as a child, musician and poet Josephine Dickinson made do with a hearing aid for five decades. Then she had a cochlear implant - and everything changed
Greggs Google fail: Was the bakery's response to its logo mishap a stroke of marketing genius?

Greggs gives lesson in crisis management

After a mishap with their logo, high street staple Greggs went viral this week. But, as Simon Usborne discovers, their social media response was anything but half baked
Matthew McConaughey has been singing the praises of bumbags (shame he doesn't know how to wear one)

Matthew McConaughey sings the praises of bumbags

Shame he doesn't know how to wear one. Harriet Walker explains the dos and don'ts of fanny packs
7 best quadcopters and drones

Flying fun: 7 best quadcopters and drones

From state of the art devices with stabilised cameras to mini gadgets that can soar around the home, we take some flying objects for a spin
Joey Barton: ‘I’ve been guilty of getting a bit irate’

Joey Barton: ‘I’ve been guilty of getting a bit irate’

The midfielder returned to the Premier League after two years last weekend. The controversial character had much to discuss after his first game back
Andy Murray: I quit while I’m ahead too often

Andy Murray: I quit while I’m ahead too often

British No 1 knows his consistency as well as his fitness needs working on as he prepares for the US Open after a ‘very, very up and down’ year
Ferguson: In the heartlands of America, a descent into madness

A descent into madness in America's heartlands

David Usborne arrived in Ferguson, Missouri to be greeted by a scene more redolent of Gaza and Afghanistan
BBC’s filming of raid at Sir Cliff’s home ‘may be result of corruption’

BBC faces corruption allegation over its Sir Cliff police raid coverage

Reporter’s relationship with police under scrutiny as DG is summoned by MPs to explain extensive live broadcast of swoop on singer’s home