By RUTHANN RICHTER

Paul Farmer, MD, PhD, can speak eloquently to academic audiences about global health equity and human rights, but he seems equally comfortable in the backwaters of Haiti, where his clinic patients park their donkeys down by the river.

That was readily apparent last week, when Farmer brought his unusual blend of medicine to Stanford during a two-day visit as part of the university-sponsored event, "Haiti Week."

Farmer, a Harvard professor of medicine and anthropology, talked about the growing disparity between the world's rich and poor and the need for greater equity in medical care -- a principle he has applied in community-based, shirt-sleeve projects in Haiti and Peru.

Farmer began treating some of Haiti's poorest patients while a student at Harvard medical school more than 20 years ago. He ultimately established a model medical care system in the rural village of Cange, where he lives, and did groundbreaking work in tuberculosis that led to changes in the worldwide protocol for treating multi-drug-resistant disease.

"Rarely are there single individuals who can change the world, but he is doing that," Philip Pizzo, MD, dean of the School of Medicine, said in introducing Farmer to an audience of some 250 people in Fairchild Auditorium Friday.

Farmer described his "HIV Equity Initiative" in Haiti, a conceptually simple project in which community health workers, known as "compagnateurs," visit their HIV-positive neighbors daily to ensure that they take their antiretroviral drugs. The drugs are provided free because AIDS is considered a public health emergency, he said.

Paul Farmer (right) chats with medical school dean Philip Pizzo prior to a Friday talk at Fairchild Auditorium. Farmer is internationally recognized for his human rights work, particularly in providing relief to Haitian AIDS patients. Photo: Visual Art Services

The program doesn't rely on changes in CD-4 counts, the usual standard in Western medicine, to follow a patient's progress. A simple scale tells whether the patient has gained weight, while health-care workers can easily determine whether the patient is spending more or less time in the hospital or doing more in the way of daily activities, Farmer said. Some 6,000 HIV patients are being followed under the program and all have shown improvements, including weight gain, he said.

"Even in Haiti, which has been wracked by turmoil, no patient missed any doses of antiretroviral or TB meds during this [political] mess -- and that's because of this community-based care that's part of this equity plan," he said to applause.

In a stark demonstration of the effectiveness of the approach, he showed photos of a downcast young man, reduced to a skeleton, seated next to his mother; five months later after receiving antiretroviral therapy, the man is robust and smiling with a child on his hip.

"Going through this a few times can change your life," Farmer said. "Going through it hundreds of times can make you downright militant."

Farmer said he recently ventured to Africa, the beginning of his involvement in the HIV epidemic that is sweeping sub-Saharan African nations. He displayed a graph showing a steep decline in life expectancy among HIV patients in five nations in the region, starkly contrasted with a steep rise in life expectancy for HIV patients in the United States--just one example of gross inequity in medical care.

"This has been a major social catastrophe by any criteria. I was in Lake Victoria and saw lots of children and older people, but not many young adults because HIV has wiped out a generation," he said. Then he paused and wondered out loud, "What is the social cost of inaction? There must be some cost to not doing the right thing."

Farmer showed a slide of himself in a sea of young African faces at a school he visited in Kenya. There he said he met a 15-year-old boy who had dropped out of school to take care of his seven orphaned brothers and sisters.

"When I go to Africa, I think if we only had an equity plan to keep children from becoming orphans," he said.

Farmer also spoke the day before to an overflow crowd in the Bechtel Conference Center on the main campus, where he talked about access to medical care as a basic human right. He showed the same slide of disparate life expectancies among HIV patients in the United States and Africa.

"It's a human rights issue. When you have one pathogen that can reduce life expectancy in a single generation, that constitutes a human rights problem," he said.

Farmer's visit to Stanford was sponsored by the School of Medicine and the Stanford Institute for International Studies, which are working together on issues of global health. "Haiti Week" was organized in large part by Ralph Greco, MD, the Johnson and Johnson Professor of Surgery, who has been making regular visits to Haiti for nearly 30 years to provide surgical care and train local medical staff, as well as Stanford residents.