JUNE 8, 2013
PAUL FARMER has a new book out — a collection of graduation speeches he’s given in recent years, many of them at medical school commencements. It’s titled, To Repair the World, and it does not disappoint.
Farmer, who once, as a young physician, convinced the pharmacists at the Brigham and Woman’s Hospital to slip him tens of thousands of dollars worth of tuberculosis drugs to carry with him to the developing world, is a veritable giant in the field of global health. He is a professor at Harvard Medical School, an attending physician at the Brigham, and a co-founder of Partners In Health (PIH), which has worked in Haiti for more than 25 years, as well a dozen other countries.
Discussions of Farmer and his work justifiably start with Tracy Kidder’s 2003 biography of him, Mountains Beyond Mountains.
The book sketches Farmer’s nomadic early life, living with his family of eight on a houseboat as a high school student, and, before that, in a hollowed-out Blue Bird bus. It recalls his time as student at Harvard Medical School, where he lived in the rectory of a Catholic church and was known to classmates as “Paul Foreigner,” owing to the large share of time that he spent in Haiti. And it recounts his partnering with classmate Jim Kim, who now runs the World Bank, and the pair smuggling aforementioned tuberculosis drugs into Peru via suitcases — “Better to ask for forgiveness than permission,” Kidder cites as a rule of thumb for Farmer. PIH’s first microscope in Haiti was also “borrowed,” this time from Harvard Medical School, in an act of “redistributive justice,” in Farmer’s parlance. The tab for such redistributions was covered by one of PIH’s early benefactors, Tom White, a Boston construction magnet.
The Paul Farmer we find in To Repair the World is 25 years older, yet still tireless. His organization is now larger, but equally bold. And Farmer’s own recklessness, though perhaps still quietly manifest, seems to have sired a kind of calm evangelism — an awareness that, by convincing young people of their own agency to rebuild the world alongside him, he might leverage everything that he’s learned to bend the arc of justice still further.
The preface for the book is by Bill Clinton. But the foreword, by Jonathan Weigel, a former student of Farmer’s and the editor of the collection, is better. “[H]e made us feel like peers, partners, coconspirators,” Weigel writes of meeting Farmer. He recalls Farmer staying long after posted office hours to finish answering questions — a fact that meant “real” meetings were often delayed and flights were sometimes missed, which Weigel learned upon going to work for PIH. “Orientation,” Weigel writes, “consisted of a one-line Blackberry-typed email from the doctor himself: ‘It’s going to be Baptism by fire.’”
BRIAN TILL: Paul Farmer, you’ve just opened this incredible new hospital in Mirebalais, Haiti. It has 300 beds. It’s entirely solar-powered at peak daylight. And you’ve built it as an institution that will belong to Haiti, to the Haitian Ministry of Health. I think it’s sort of the dream of anyone who’s thought a lot about global health. How’s it going so far?
PAUL FARMER: It’s going great. It opened a few weeks ago. It’s just a beautiful facility and there’s just so much need and there’s great enthusiasm — not only among patients, but among the clinicians, the doctors, and the nurses. Most of them are Haitian, but there are a number of Cubans and Americans there, as well — colleagues of mine from Partners In Health and the Brigham. And they’re excited about working in proper infrastructure in the middle of central Haiti. So we have to draw on some of that enthusiasm and now push to roll out services and bring all of the hospital online in a way that captures that energy. I think that’s happening little by little.
BT: Tell me a little bit about how this hospital came to be.
PF: What Partners In Health was able to do, because of the nationwide interest in Haiti in the United States right after the earthquake, was draw on partnerships and friendships that reached into the building trades — the electrical workers, the painters unions, the carpenters unions — and beyond to a number of contractors and companies. We had as a supporter — a leader, really — a guy named Jim Ansara who built up a construction company in New England and then sold it. Afterwards he said, “I’m going to spend a lot of my time, the rest of my life, working on social justice issues and charitable, progressive causes.”
And he came down to Haiti and started working with one of my former students, Dr. David Walton, who was the program leader for building a proper facility in Mirebalais. Jim brought down scores of skilled laborers who knew how to build things and how to wire them and install amenities, like the wall-mounted gas you would find in a hospital in the United States. It’s the first public hospital in Haiti with a modern sewage treatment plant, which is critical because the country’s in the middle of a cholera epidemic.
And it just went on and on, this process of bringing in partners. Hewlett Packard built the IT backbone for the hospital. They assembled part of it in China, for Haiti. We all know we’ll have to build local capacity to manage some of the diagnostics and technological complexities of the hospital over time, but we are going to continue to draw on this partnership model to raise our standards and aspirations for public hospitals in Haiti.
We’re still feeling very humbled by the challenges. It’s not very easy to run a complex institution like a hospital, much less to use it to improve a public health system. It’s not as if we’re going to know how to provide all clinical and teaching services right away, any more than we know how to service all of the technology on site yet, but we can definitely make this happen with sustained partnerships and accompaniment.
BT: The hospital’s ambition is to be both a research hospital and a teaching hospital. The students you’re focused on training, are they mostly US medical students from Harvard and elsewhere, or are they primarily young Haitian doctors and people from elsewhere in the world?
PF: To turn the institution into a research hospital will actually require doing research, and right now we’re focused on the two other legs of that triad, that is service delivery and the training. The majority of those trained will of course be Haitian, and that would include nurses, physicians, and — we hope — all kinds of professionals that are really important to running a hospital, a lab, a pharmacy, et cetera. And just as the Cubans have trained a lot of Haitian physicians in the past, we’d like it to be open to training people from outside of Haiti, as well.
What we really need are teachers, and the resources to pay them. We need senior faculty, the attending physicians who run residency programs and other training programs. We’re going to need longer-term engagement to get them off the ground and get them running. It will happen though.
BT: One of the things that I’ve always wondered about with PIH is the question of scaling. In so much of the stuff you’ve written, there’s this humility about understanding the connections and relationships that have to exist on the ground to do this kind of work well. And the price tag I’ve seen so far for the hospital is astoundingly cheap — $15 million — which, in the scheme of the billions of dollars we work with in the field of aid, is quite small. Assuming the financial side isn’t the biggest obstacle, what strikes you as the largest impediment to this really being a model, and us collectively becoming ambitious enough to build teaching hospitals all over the world?
PF: The primary impediments are not always financial, as you said. So, say it costs around $20 million for a 200,000-square-foot campus. And that’s an exceedingly low price in any country in the world. You couldn’t do that in most places. And that gets back to the point about humility around partnerships. We didn’t even call this gathering three weeks ago at the hospital an opening of any sort, we called it a “celebration of partnership” — not to be hokey, but to make clear that we can’t build, much less run, such an institution without help from others.
But, if you think about just the challenge of building training programs, what do we have and what do we need? It’s clear to me there’s no lack of talent among young Haitians who want to be physicians or nurses or other clinical providers. That’s not the shortage.
It’s not that there’s an absence of resources in the foreign aid sector. Now, that doesn’t mean it’s actually getting to Haiti. It certainly doesn’t mean it’s focused on delivery of services or on long-term training. And as I’m sure you’ve seen, a lot of this so-called training that we do takes place in short little workshops in capital cities and in hotels. And that’s just not the way we train people in medicine.
You wrote about surgeons training in Cameroon, and you know that it takes years to become credentialed as a surgeon, for example. It often takes a decade. And it’s really hard to find funding for such endeavors in the way aid is currently delivered. And that’s wrong. Because you train clinicians to deliver quality care and to then learn from teams and from how their patients are faring. That’s how the teaching hospitals in Boston work. That’s how the good ones everywhere work.
So, if it’s not talent, and it’s not the money that’s already been designated for, let’s say, medical assistance or medical care in a places like Haiti, or Cameroon, or Kenya, then the problems are more in the way we conceive of aid. It’s too short-term and not focused enough on care delivery and on learning from delivery.
BT: This book is really a conversation with young people, and young doctors in particular. And, very broadly, they have an interest in global heath that really didn’t exist a generation ago amongst young physicians. And they also — I think largely — recognize this sort of two weeks in, vacation/service model of engagement isn’t working. But they’re also graduating with astronomical debt. So, for these young people trying to figure out how they can carve out a role for themselves where they can be engaged in global health but also pay off debt, meet familial obligations, et cetera, what advice do you have for them?
PF: Some of the advice I have for them is that they should lean on the institutions where they train, and that includes medical schools and teaching hospitals. Because there’s so much interest among students and young trainees, the institutions that want the best trainees are going to have to adopt new ideas about how to fund such training. Does our country need doctors? Yes, and their training is subventioned. Do we need global health doctors? This generation seems to think so, and our institutions need to catch up.
Let me put it this way, perhaps rhetorically: you’re telling me we can send a rover to Mars, and we can’t solve student indebtedness so that they can do the kind of things they want as physicians? It’s absurd, right?
Harvard and the Brigham, where I work, have put lots of money into this kind of training. So far it’s been private, philanthropic dollars. But we started 10 years ago the first residency in global health and internal medicine, and that’s one of the reasons there’s so many applicants to the Brigham program, because a lot of them decided they want to do this as a part of their lives. And it might not be for 12 months a year, but it’s not gong to be two weeks either.
BT: There’s this sort of post-disaster, recovery-and-relief mode that dominates a lot of what we do in foreign aid. And I want to ask you about the Interim Haiti Recovery Commission (IHRC), which you were involved with. It had the brilliant idea to try to coordinate efforts, almost simply by the power of labeling. The idea was to certify which projects fit into a broader plan, and which were more of the traditional, a thousand points of light, chaotic and wasteful efforts — the kind of thing that resulted in 93 percent of the total aid to Haiti never actually reaching the country. What are the most important lessons you think we should take away from that period and that work?
PF: Well, some of them aren’t so heartening. IHRC was hard to do because there are so many institutions that are used to doing it another way. I mean, the “points of light” approach must be benefitting some people, right? There are certainly some contractors that benefit from it, including NGO contractors.
But that approach doesn’t benefit the Haitian public sector, including the Haitian Ministry of Health. That’s pretty clear. You couldn’t really have a massive rebuilding effort without more attempts at coordination and without making one consummate plan. That’s what I think Rwanda tried, and has had success doing. They weren’t rebuilding and recovering from a natural disaster, but from a social disaster, a war and a genocide.
And they tried to gather some of the big players, big international NGOs and smaller ones, too. Also the various aid agencies. And the Rwandans said, “We’re going to rebuild the health system, or rather build a proper health system, and you all need to get on board and support this plan.”
But people are used to working in silos, and the Haitian public sector was badly damaged in the earthquake. Its physical infrastructure and a lot of staff were injured or killed. So making the argument that we needed to invest in the public sector, and that private sector dollars should go into that, became even harder. But you have to try. How can you have public health without a public sector?
Inside a lot of those institutions, which after all are run by humans, there are plenty of people who want to see reforms move forward. You know, lower overhead, more local capacity building, more local procurement, more coordination with the public sector and with other NGO’s: there are people who really want to see this happen. Clearly there are others who aren’t as eager, but the question really is: how can we push levers and pull levers at every level to move a coherent vision forward?
BT: There’s this mind-numbing moment in your Haiti book where you write about how decimated the hospital was in Port-au-Prince after the earthquake. A huge portion of the staff had died and it was struggling to stay operational. You write about how hard it was to convince the Red Cross — which had millions of dollars sitting in coffers at this point — that it should step in and pay salaries for doctors, nurses, and janitors — all the people you need to run a hospital. And it took you leveraging Bill Clinton to persuade them that this was important to do.
PF: But they did it. Notice that they did it. And they’d never done it before. And we’re still talking about that now. I just ran into them at the Mirebalais celebration of partnership. High-ranking officials. And we keep working at that — how can we get more of this private money to support public institutions?
BT: Ten years from now, where do you want Partners In Health to be?
PF: Well, 10 years from now, I would hope PIH will protect and improve the delivery platforms that it’s built with its partners in Siberia, Malawi, Rwanda, Lesotho, Haiti — I hope that we can protect the delivery platforms that we’ve built and continue to integrate them into the public sector. Second, I hope that we can improve the quality of healthcare that we’re delivering there. Third, I hope that every service project is leveraged fully with a training effort that focuses on local capacity building.
And fourth I hope that we can learn things through delivery and training. So, when I say research, I’m not saying PIH will do another randomized clinical trial with placebo, although I’m glad when they happen ethically. But what Partners In Health is focused on doing are trials in justice and equity. That is, if we have somewhere in the world a type of medical intervention that improves clinical outcomes, our research is about: how can we put those innovations to work for poor people, too?
BT: What are you afraid of, Paul Farmer?
PF: Tarantulas. I don’t really know why. Their venom really isn’t that strong. But, yeah. Tarantulas.