If the name Paul Farmer isn't immediately recognizable, the highlights of his famous story probably are.

He was the brilliant kid from Brooksville who grew up in a converted school bus and houseboat. He's the Harvard-educated doctor who, starting in Haiti, built a multinational organization on the radical idea that poor patients deserve the same care as rich ones.

He's the writer and activist who for years has railed against what he called the injustice of U.S. foreign aid programs.

Soon he may be running these programs.

According to the Boston Globe, Farmer is a finalist for a State Department job, either as administrator of the U.S. Agency for International Development or coordinator of all State Department global health initiatives.

Though this is not a sure thing, even his candidacy indicates how far the international aid establishment has come around to Farmer's way of thinking, health care experts say.

And if he actually gets the job, said Matthew Kavanaugh of the AIDS advocacy group Health GAP, it would a "game-changing'' move that shows President Barack Obama "is very serious about taking U.S. foreign aid in a new, smart, very bold direction.''

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The United States is expected to spend $37 billion in foreign aid in the coming fiscal year, and its existing programs have done a great deal of good, such as helping to eradicate polio and spread literacy, according to a 2008 report from Oxfam America.

But U.S. assistance policies have one large, underlying flaw, the report said: Most of it is tied to American business and political interests, as required by the 1961 Foreign Assistance Act. This has justified, for example, exporting cheap American rice that undermined Haiti's farm economy.

"Food aid … tied to U.S. business interests but not to food sovereignty or to addressing our oldest neighbor's ecological disaster, is a sorry case in point,'' Farmer said in a recent address to graduates of Columbia University's School of Public Health.

Federal agencies also have a long history of pouring money into large nongovernmental organizations that operate too independently, Farmer has said, weakening federal governments and local institutions.

Even worse, USAID doesn't seem to require these organizations to produce results, said Gregg Gonsalves, a veteran health care activist with the International Treatment Preparedness Coalition.

"It's become this lumbering bureaucracy that subcontracts its work out to these big nongovernmental organizations … and it's lost sight of its core values.''

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Farmer, on the other hand, never has, Gonsalves said. The organization he helped found, Partners in Health, made its name by treating poor patients with expensive AIDS and tuberculosis medicine at a time when most other aid groups considered this unsustainable.' Farmer is also known for requiring "measurable outcomes'' for Partners in Health programs, meaning proof they actually work, Kavanaugh said.

"Frankly, that would be a big change for USAID,'' he said.

Partners in Health also works with, rather than independently of, the governments of the 10 countries where it operates, said medical director Joia Mukerjee. For example, all but one of the 11 hospitals that the organization has built or refurbished in Haiti have been turned over to the Ministry of Health.

Farmer's advocacy and example have already helped change a lot of minds, Kavanaugh said.

His organization's use of community health care workers has been widely copied, and its protocol for treating drug-resistant tuberculosis has been adopted by the World Health Organization. The Bush administration tacitly acknowledged USAID's problems, Kavanaugh said, when it created the multibillion dollar President's Emergency Plan for AIDS relief as a separate agency in 2003.

A bill to reform the Foreign Assistance Act has been introduced in the House of Representatives. And even longtime staffers of USAID would welcome Farmer's "effective inspirational leadership,'' said Kenneth Mayer, a professor at Brown University and an adviser to the Center for Global Health Policy and Advocacy. "I think a lot of them felt like children in an abusive family during the Bush administration.''

Some consider Farmer a perfect fit for the job because his organization's approach to aid has been almost as broadly based as the federal government's, addressing contaminated water, inadequate shelter and other maladies that contribute to disease.

Working alongside bureaucracies in poor countries has prepared him for the political challenge of the State Department. And, most importantly, Gonsalves said, Farmer's ideals are what global aid should be all about.

"He can provide a vision of generosity that people can believe in," he said. "This is a chance to really lift people up and show them that America is still a generous place.''

Dan DeWitt can be reached at dewitt@sptimes.com.