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Wednesday, May 28, 2008 FULL SHOW | HEADLINES
2008-05-28

Dr. Paul Farmer Challenges Profit-Driven Medical System While Bringing Healthcare to Poor Communities Worldwide

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Dr. Paul Farmer, Professor of medical anthropology at Harvard Medical School and is the co-founder of Partners in Health. He is also associate chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital in Boston. His books include Infections and Inequalities: The Modern Plagues, Pathologies of Power: Health, Human Rights, and the New War on the Poor and From Outrage to Courage: Women Taking Action for Health and Justice.

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Paul Farmer is not your ordinary doctor. In going to the poorest places on earth, he is not only treating patients, but challenging whole healthcare systems. More than twenty year ago, Dr. Farmer co-founded the charity Partners in Health to provide free medical care in central Haiti. Today, Partners In Health provides healthcare for people with HIV/AIDS, tuberculosis, malaria and other conditions in Haiti and eight other countries around the world. We spend the hour with Dr. Farmer on his work, his remarkable background and the challenges of pursuing healthcare with a social justice perspective. [includes rush transcript]

Transcript

This is a rush transcript. Copy may not be in its final form.

AMY GOODMAN: Paul Farmer is not your ordinary doctor. In going to the poorest places on earth, he is not only treating patients, he’s challenging whole healthcare systems. And the United States is not exempt from his analysis. The titles of his books reflect his diagnoses, from Infections and Inequalities: The Modern Plagues to Pathologies of Power: Health, Human Rights, and the New War on the Poor, as well as From Outrage to Courage: Women Taking Action for Health and Justice.

More than twenty years ago, Dr. Farmer founded a charity called Partners in Health to provide free medical care in central Haiti. Today, Partners in Health provides healthcare for people with HIV/AIDS, tuberculosis, malaria and other conditions in Haiti, as well as, well, more than eight other countries around the world, including Peru, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala and Boston.

Dr. Farmer’s success has made him a celebrity in the world of global healthcare. He’s a professor of medical anthropology at Harvard Medical School and associate chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital in Boston. Dr. Paul Farmer joins us today for the hour.

Welcome to Democracy Now!

DR. PAUL FARMER: Thank you. Thank you, Amy.

AMY GOODMAN: It’s great to have you with us. You’re giving the graduation address today, the commencement address at John Jay?

DR. PAUL FARMER: I am.

AMY GOODMAN: What are you going to be talking about?

DR. PAUL FARMER: I think I’m going to talk about how we can — how these young people can be part of a movement that’s nascent right now that we see before us, a movement that focuses not only on one problem, like environmental justice, but on social justice and inequality in general. I want it to be funny, of course, but —-

AMY GOODMAN: Social justice and healthcare, can you talk about how you combine the two?

DR. PAUL FARMER: Well, you know, it was, for me, an epiphany to go twenty-five years ago to go to Haiti, and I was lucky enough to end up in a squatter settlement of peasants who had lost their land to a hydroelectric dam. So the choices were very stark. You know, either health was a commodity that was bought and sold, or the people that I went there to serve, as a, you know, naive but well-meaning young person, were out of the picture. And so, you know, that began a lifelong fascination with rights, not just to the right to vote or other civil and political rights, but also the right to eat and the right to have access to healthcare.

AMY GOODMAN: Talk about how you decided on this place called Cange in central Haiti, how you found it, how you began to build the hospital system you have there?

DR. PAUL FARMER: As is often the case, and I try to encourage students -— I teach students, so I tell them, “Look, you never know what’s going to happen.” And it was really a series of serendipitous accidents. I met a Haitian priest, and he was working in a nearby town, and he told me about this squatter settlement where people were living in lean-tos. And he was focused on education and said “Look, you’re going to be a doctor. Why don’t you come and be part of this?” And so, that was twenty-five years ago.

AMY GOODMAN: But you had been other places in Haiti and kept saying it’s not poor enough. Now, Haiti is the poorest country in this hemisphere.

DR. PAUL FARMER: Well, you know, those are the kind of youthful statement — it was plenty poor there, the places I saw. A couple of places that I went, it was really not so much the level of poverty as the way the systems that were already in place were working, and that is that they had taken this model, which you’ve called and I’ve called neoliberal ways of seeing health. You know, you buy health services; they’re not a right. That was the way the whole system worked in Haiti in the church missions I visited, in the charities and even in the public system. And so, going to this place called Cange was a way to start from scratch, to be in from the ground up.

AMY GOODMAN: It’s not far from a dam. Can you explain the genesis of this dam and what it has done to the people of Haiti?

DR. PAUL FARMER: Well, the dam has been discussed since the times of slavery. You know, managing that river, the largest river through Haiti, there were plans years ago. It was during the American occupation from — the military occupation of Haiti, 1915 to 1934.

AMY GOODMAN: You know, as you bring that up, why don’t you give us a brief history of Haiti?

DR. PAUL FARMER: Ouch, ouch.

AMY GOODMAN: We live in a globalized world, but we know very little about other countries outside the United States.

DR. PAUL FARMER: Which is very astounding about Haiti, because Haiti and the United States are of course the two oldest nations in this hemisphere. And, you know, between 1776, when our nation was founded, and 1791, when the major slave revolts began and could not be stopped, Haiti was born really just shortly after our republic. But unfortunately, for the first sixty years of Haiti’s existence, of course, the United States refused to recognize that it even existed. Slaves could not govern themselves. Blacks could not govern themselves. Later on came gunboat diplomacy. And then, in the early twentieth century —-

AMY GOODMAN: The US Congress afraid to recognize Haiti -—

DR. PAUL FARMER: Especially the Southern states.

AMY GOODMAN: — because it would inspire slaves.

DR. PAUL FARMER: Exactly. In fact, the first time we sent an envoy was Lincoln sent an envoy. Frederick Douglass was the ambassador to Haiti. It was an amazing story. Eric Foner has written about this beautifully. But unfortunately even a great —-

AMY GOODMAN: Frederick Douglass, sent by...?

DR. PAUL FARMER: Frederick Douglass, sent by, I think, Lincoln, but that’s just my guess. It makes sense. But even as great a man as Frederick Douglass could not, you know, thwart the ambitions, the growing imperial ambitions, of our country. And so, US ships invaded Haiti continuously throughout the late nineteenth century. And then in 1950, citing the rather ludicrous notion of a German threat in Haiti, the Marines invaded. So for twenty years, until FDR pull them out, we ran Haiti, formed the modern Haitian army. And it was during that time that some more agribusiness ideas about how to build this dam came about.

And I’ll just say one thing about it. My assessment is not that they were evil-doers who were trying to, you know, dislodge the peasants. That’s the local word, by the way. The small plot farmers behind the dam, they were trying to generate controlled agriculture further downstream and also eventually hydroelectric power.

AMY GOODMAN: For?

DR. PAUL FARMER: For the city and [inaudible], not for these people who lost their land. By the way, the dam was built by Brown & Root, which, you know, became absorbed by Halliburton.

AMY GOODMAN: KBR.

DR. PAUL FARMER: So it is a familiar story, I’m sure, to your viewers -—

AMY GOODMAN: Kellogg Brown & Root.

DR. PAUL FARMER: — now that you have viewers in addition to listeners. But in any case, I ended up working with the people who lost their land. And —-

AMY GOODMAN: And when you say “lost their land,” you mean it was submerged under water?

DR. PAUL FARMER: Yeah. It’s still submerged, yeah. Their cemeteries, their gardens, everything, mills to grind sugarcane.

AMY GOODMAN: Where did they go?

DR. PAUL FARMER: They just -— the first time I heard this story, I couldn’t believe it, and I thought maybe my Creole wasn’t good enough back then. This was twenty-five years ago. They said we just grabbed our kids under our arms and went into the hills. And I said, how could you have a dam that large — this was the tallest buttressed dam in the Western Hemisphere when it was built, if I’m not mistaken. How could you have something that large built so close to your homes and not know what was going to happen? And they — you know, I had responses like, “Well, you know, these waters have flown by our gardens from time immemorial. How could a little span of concrete stop that?” So I heard the same story again and again, and I realized they really did leave the day the water rose. And so, the big lesson for me as a twenty-three-year-old, that the official versions in the reports might not match the versions of the people who suffered the consequences.

AMY GOODMAN: Now, the dam is called the Peligre. Doesn’t that mean “danger”?

DR. PAUL FARMER: Yeah, I think — it definitely means “danger.” The headwaters are in the Dominican Republic, so, you know, it’s from Peligro, I think, so, yeah. And it sure was dangerous for the people who lived behind it, because they lost everything.

AMY GOODMAN: So they became even poorer?

DR. PAUL FARMER: Squatters. A major — you know, if you look at nineteenth century accounts of Haiti, I’m sure the situation wasn’t rosy, but after slavery, Haitians refused pretty much any kind of corporal agriculture, and so that, you know, gave rise to the small-scale peasant farmers that dominated Haiti for a hundred years. And they didn’t have a lot of things that they wanted, but according to their stories, the ones I heard, they didn’t have hunger, either. So they lost their land. And, you know, that’s probably the bottom of the barrel, you know, sociologically. It’s people who are landless peasants. And that’s why they emigrate to the slums in the cities, because there’s more hope, even in an urban slum in Port-au-Prince than there is when you’ve lost your land, can’t feed your family.

AMY GOODMAN: Explain how you set up this health clinic in Cange.

DR. PAUL FARMER: Well, of course, I worked with a lot of people, most of them Haitians. Now that that team has grown to — I just came back from Haiti, just got here yesterday. We started with a small group of young people my age going from village to village asking people in their homes, “So what is it you would see as an appropriate healthcare system?” And some people kind of laughed at us, saying, “Well, what do you” — you know, and a little but archly — “Well, what do you think?” You know, and they would usually say, though, “A hospital. We want a hospital.”

And we had in mind, you know, a system of a small community health clinic and a system of satellites. And they wanted a hospital. They wanted a good hospital, a hospital — someone said to me in 1984, where if you have trouble having a baby, you could actually have someone save your life. I knew just what that mean, of course — meant, of course. And, you know, over the years, with a lot of help from people, mostly in Haiti, but North America, we built a hospital, and it’s a big hospital now.

AMY GOODMAN: Primarily treating what?

DR. PAUL FARMER: Well, you know, we primarily do not treat infectious diseases, although I think we have a reputation of taking on AIDS, TB, malaria. But we treat whatever comes in, a broken arm, obstructed labor, you know, the things that you see out in the rural countryside in Africa or Haiti.

But in the mid-’90s, I must say, just shortly after we built — finished — we built the hospital in a very difficult time, during a coup, and those were very hard years, ’91 to ’94. You were already involved in reporting on that. But we did get the hospital done, and by the mid-’90s, we once looked to see, OK, how many people in this hospital have AIDS or HIV infection. And it was up to 40 percent at one point. So we said, at that time — I was going between Harvard and Haiti. I was being trained as an infectious disease specialist at Harvard, and, you know, it’s right around the corner to Haiti. So I’d get off the plane on one side, and I’d be begging my American patients, “You’ve got to take these pills, these AIDS cocktails,” and I’d get off on the other side, and they’d be begging me for the same medicines. So we spent a couple of years saying there’s got to be a way to deliver the same services to people living in Haiti. And, you know, it took a long time to get that support. We started in 1998. And we actually called it, somewhat sassily, the HIV equity program, because we knew it would be a fight for equity from the beginning, and we knew it would be a fight for basic rights, as well.

AMY GOODMAN: How did you do it? So you’re bringing these extremely expensive cocktails —-

DR. PAUL FARMER: That’s right.

AMY GOODMAN: —- down to Haiti.

DR. PAUL FARMER: Yeah, well, you know, I have to say, some of the first donations that we received were from American patients, AIDS patients, and also nurses, doctors. Later on, we had concessionally priced pharmaceuticals from Big Pharma. And what we knew needed to be the goal for a project to be brought to scale in Haiti was to get the generic manufacturers involved. And by that time, we had been working, you know, for fifteen years and had faced other similar problems with other diseases and had a network of consociates in the generic industries, in the procurement, drug procurement — nonprofit drug procurement, and also friends in the pharmaceutical industry. So, because there were so many activists in the United States, especially in Europe, pushing for this, and a lot of other organizations — Doctors Without Borders, for example — this movement moved —- you know, went forward.

AMY GOODMAN: Where did you get the generics?

DR. PAUL FARMER: India, mostly. India is the largest producer, I’m quite sure, of generic antiretrovirals, drugs for AIDS.

AMY GOODMAN: And what was the response in this country of Big Pharma, of the big pharmaceutical companies?

DR. PAUL FARMER: Well, you know, they had taken a beating in the press. And so -—

AMY GOODMAN: Thanks to the AIDS activists.

DR. PAUL FARMER: Thanks to the AIDS activists, and you know — I mean, I, myself, were I a PR flak in that industry, would not have counseled them to sue, you know, Ghana for — or to bring a lawsuit against South Africa.

AMY GOODMAN: Explain what you mean.

DR. PAUL FARMER: Well, you know, when generics were brought in, the initial response of some of the industry was to bring lawsuits against African countries. I mean, and this happened again recently with Thailand, as you may recall. This is just last year. And it was an unwise move as a PR move, certainly, because the sympathies of a lot of people did not lie with the pharmaceutical industry, but rather with these emaciated people who were just trying to survive.

And so, by the time the Global Fund, which became one of the first multinational funders of AIDS prevention and care, came about — that was 2002 — the pharmaceutical industry was not in its combative stance with us anymore. And I think, in fact, you know, as far as I can tell, pharmaceutical industries are still peopled by people. So, you know, we can bring them on board. We can move them forward. But we have to have a strategy that involves generic medication.

AMY GOODMAN: And the response of the pharmaceutical companies that they need to charge these high prices for research and development?

DR. PAUL FARMER: Well, I understand that, but it’s not like they have a market in Burundi now and that they’re going to lose patients because Rwanda is using generics or Haiti. None of those people fit into the market, as construed by major corporations. Maybe they wanted them to be part of their customer base, but they weren’t. So we’re just saying, you know — we’re not spending a lot of our time arguing with the pharmaceutical industry, but rather saying, “Look, we’re physicians, we’re nurses; it’s our job to make sure that these patients get the meds they need.”

AMY GOODMAN: We’re talking to Dr. Paul Farmer. He’s a professor at Harvard Medical School, and he is the head of Partners in Health that has clinics in over ten countries around the world — we’ll talk about some of them — in Mexico, in Guatemala, in Rwanda, where he lives, in Lesotho, in Haiti. And we’ll also talk about the United States, healthcare here. This is Democracy Now!, democracynow.org, the War and Peace Report. We’ll be back in a minute.

[break]

AMY GOODMAN: “Haiti” by Arcade Fire. They’re a Canadian band who talk about Partners in Health while on tour and donate money from ticket sales. Paul Farmer, how does it work?

DR. PAUL FARMER: Well, I have to admit, I didn’t know much about — I don’t know that I had ever been to a rock concert. And I got to meet this really great group of young people from Canada and the United States, and through a connection — actually, the lead singer is Haitian, and she grew up in Canada. And they read some of the books that I had written. And they knew, of course, about Haiti. And so, they decided, with their new album, if you look at it, it says on the bottom their address, and it says just underneath it www.pih.org. But if you look more closely, at their tours, a dollar of their every American tour went straight to Partners in Health, and a euro of their every European tour. So, yeah, one of our major donors is a rock band. I think it’s pretty cool.

AMY GOODMAN: Well, this is Democracy Now! [...] We are talking with Dr. Paul Farmer, who is a professor of medical anthropology at Harvard Medical School, co-founder of Partners in Health. He is associate chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital in Boston. But all of that time I spent talking about that, he spends much more time around the world. He established the first clinics for Partners in Health in Haiti and has expanded to nine other countries, including Malawi and Lesotho and Rwanda and Russia, Mexico, Guatemala, Peru.

But I want to talk about the food riots, and we’ll talk about why Dr. Farmer would have any views on this. The United Nations recently announced plans to form a top-level task force to address the global food crisis. Aid experts say soaring global prices for food and fuel threaten to push a hundred million people worldwide into hunger. This is President Bush addressing the food crisis last month.

    PRESIDENT GEORGE W. BUSH: In terms of the international situation, we are deeply concerned about food prices here at home, and we’re deeply concerned about people who don’t have food abroad. In other words, scarcity is of concern to us. Last year, we were very generous in our food donations, and this year we’ll be generous, as well.

AMY GOODMAN: Haiti is one of the places hardest hit by the food crisis. Prices of rice, beans, cooking oil have doubled in the past few months. Two-thirds of Haitians live on less than a dollar a day. 47 percent are undernourished. We recently spoke with Reverend Jesse Jackson, who had just returned from Haiti. This is some of what he had to say.

    REV. JESSE JACKSON: I talked with President Preval. They want for this year 360,000 tons of rice, 180,000 tons of wheat, and then cooking oil, so they can survive until they can get their farmland moving again, because we dropped our subsidized rice on them. Not only did we drop subsidized rice on them, they had to buy rice from us, as it were. And so, they took a double hit. But they really are capable of being an exporter of rice, an exporter of sugar. So they now need, beside the emergency food and water and medicine, they now need tractors and irrigation system, and they can begin to come back again. And we, I think, can do no less.

AMY GOODMAN: Dr. Paul Farmer, the food crisis?

DR. PAUL FARMER: Well, you know, I had not seen that, because I was in Haiti last week. And, you know, there’s nothing that I would disagree with in terms of what Reverend Jackson said, but there’s a lot more to be said.

I was in Haiti in 1986.

AMY GOODMAN: This is Duvalier time?

DR. PAUL FARMER: This is right after. And it was, you know, in February that the family dictatorship fell, and I was there before and after. And I didn’t know anything about economics or food security, and I was already in medical school and perfectly happy, you know, with what I was doing in medicine, and — but I was going, as I said, back and forth between Harvard and Haiti. And in one year, the deals that were cut that year with the international financial institutions — they’re the classic ones that now I know about and you know about, but I didn’t know about as a medical student — and that was, you get rid of your trade barriers, but we won’t. I don’t know if they actually say "but we won’t," but they don’t.

So what happened is that in one year — and I’m not exaggerating, and other people are experts on this — but in one year, as a witness, I saw the destruction of the rice industry in Haiti, so that — and then, astoundingly, Haiti, once the largest producer of sugar in the world, you could see bags of Domino Sugar from Florida, you know, in Haiti.

AMY GOODMAN: And explain how that works.

DR. PAUL FARMER: Well, the deal was, we’re going to let you into — we’re going to give you credits — the international financial institution will give you loans and — but in order to do this, you have to undertake these series of — you have to privatize certain things, you have to lift trade barriers. It’s a classic formula that now I know — didn’t know then, but it’s called structural adjustment. So Haiti got — you know, after this thirty years, twenty-nine years of dictatorship, was shoved into this mold, and it destroyed the small agricultural industry.

AMY GOODMAN: Was the rice free that came — supposedly free that came from the United States?

DR. PAUL FARMER: Well, there was also that. There was also that. So that’s what Reverend Jackson is talking about: food aid. And then, I believe his words were “they need this to get their farming back on track.” But the farming is not off track because of local considerations. It’s off track because of international trade associations and agricultural subsidies in the United States and Europe.

And, you know, there’s no way — I don’t — you know, again, I’m a doctor, but as a layperson, I don’t see any way that we can take on food insecurity in Haiti. We can do our part. We can take care of malnourished children. We know how to treat them and make them survive. We can help malnourished adults medically. We can help local farmers. But until we get to that third part, of fair trade, which is going to require a movement and a coalition and lots of people who are saying, “Look, we cannot have unfair trade subsidies in the rich countries demanding that poor countries remove all protection of their farmers.” And now, of course, the farmers in Haiti are small plot farmers, by and large, and the beneficiaries of subsidies here are agribusiness.

AMY GOODMAN: So the farmers get wiped out in Haiti because of the subsidized rice coming in, and then when there is a crisis, when the food prices soar, there’s no Haitian farmers or there’s not enough Haitian farmers to make up the slack?

DR. PAUL FARMER: Or the land has gone fallow, or the irrigation ditches have gone, because, you know, how can — there’s no way that they can undercut the prices of the staples coming from the subsidized rich world, which is for Haiti is the United States.

AMY GOODMAN: Dr. Paul Farmer, think pig. That’s, talk pig. Talk about the pigs of Haiti.

DR. PAUL FARMER: Oh, pig. For a minute , I thought you said “Talk big.” I said — I was thinking we were.

No, you know, the pig story — it sounds funny to your listeners, but it was another one of those epiphanies for me. In right around the end of the dictatorship — Duvalier was still there — there was a threat of swine flu, which I believe came from the Dominican Republic or Cuba, I’m not sure where. It wasn’t in Haiti, in any case. But the decision was made by the overlords of Haiti, who were largely from my country, that every single pig on the island would be wiped out and then restocked, you know, with Iowa pigs.

AMY GOODMAN: These are Creole pigs.

DR. PAUL FARMER: Creole pigs is what the Haitians call them.

AMY GOODMAN: Were taken away.

DR. PAUL FARMER: They were taken away —-

AMY GOODMAN: And killed.

DR. PAUL FARMER: And it was pretty complete, you know. It was a thorough job. We got -— I would drive in a public vehicle from Port-au-Prince to the city in central Haiti, and we would be stopped and searched for pork products. I mean, that’s how serious they were about it.

And then, you know, we said — we lined up for pigs, too. You know, now we’re working —- at this point now, we have a clinic, schools, we’re working up there, facing food problems, especially around the time that kids start school again, because families would use the pigs as a bank. They would sell the pig to buy school supplies and uniforms or to take care of a funeral expense or whatever. So that’s what the pigs functioned as much for the people I served, the really poor, as a bank. So that was wiped out in one year, too. And so, we said, OK, we want to be part of this new pig project. And -—

AMY GOODMAN: Where they’d give American pigs.

DR. PAUL FARMER: They gave American pigs.

AMY GOODMAN: Pink pigs.

DR. PAUL FARMER: Pink. Very pink.

AMY GOODMAN: What do they call them? I remember being down there. Were they princess pigs?

DR. PAUL FARMER: They were — I think that’s their real names, actually, I’m not sure. But the Haitians just called them, you know, “cochons blancs,” you know, “white pigs.” You know, “blanc” means “foreigner” also, so “foreign pigs” is technically the translation. But they were big, and they were pink. And we could raise them in our program to become these giant little rhinoceros-sized pigs. And the idea, of course, was to distribute them to community councils, you know, other romantic ideas like that, and then they would have litters, and they would be distributed, and everything would be happy. But it didn’t work.

AMY GOODMAN: They require tremendous care.

DR. PAUL FARMER: You know, they were — they required — I mean, even getting sprayed, hosed down, because it was hot and things like that. Of course, people have no water. And the kind of food they required, the Creole pig had adapted, been there for probably centuries. And, you know, they didn’t survive. I mean, they may have in some parts of Haiti, but again, it was a personal epiphany for me, because I learned then about why Haiti is a graveyard of development projects. And there’s just so many efforts in Haiti — reforestation, agricultural efforts. And, you know, I was there last week, as I said. And it’s not — it’s adding up to so much less than the sum of the parts.

AMY GOODMAN: And yet, you say that in some places in Haiti they’re getting better healthcare than the United States.

DR. PAUL FARMER: Well, you know, I believe that’s true. I mean, I know it’s true. It’s not really an assertion. For chronic disease — and AIDS would be a good example — you need to take — and diabetes, insulin-dependent diabetes is another — you have to take a medicine every day. You know, whether that be an antiretroviral cocktail or insulin, you have to take it every day.

And the system that we built up in the ’80s, really confronting another disease, tuberculosis, relied very heavily on community health workers, who we trained and, more to the point, we paid. You know, we thought, you know, do we expropriate the labor of the poor, or do we actually pay them, like someone like I would get paid a fortune to do consulting work like this. And we said no, no, no, it’s clear they have to be our employees and coworkers. So it worked great. And it worked great for tuberculosis. It worked great for other chronic diseases. And when AIDS came along, what we did was to say, well, clearly, we need to take the same system, which is free diagnosis and free care to the patient, because this is a public health problem, and they have a community health worker, you know, visiting them.

And so, what I see in this city, for example, in New York, I’m told they’re contemplating adopting this model. I hope it happens. What we did was to bring the Haiti model up to Boston. You know, and I got in a little bit of trouble with some of my colleagues. They were saying, “Well, all we’re trying to do is raise Harvard levels of care up to Haiti levels,” because the outcomes were much better, because they weren’t lost to follow-up. That’s medical jargon. But, you know, in the United States, you get someone who’s really sick with a chronic disease — either of those two diseases I mentioned, for example, would be true — and then they’re sent home, but they don’t have the appropriate support in, as they say here, in the community. And so, then they get sick again. They go back to the emergency room. Maybe they don’t have insurance, maybe they don’t speak English, maybe they have housing insecurity — this is the United States — but like Haitians, they have social problems, and our medical system doesn’t deal with those problems well. And so, the care can be better in Rwanda and Haiti than what we’re seeing here.

AMY GOODMAN: We’re talking to Dr. Paul Farmer, who heads up Partners in Health in ten countries around the world, also a professor at Harvard Medical School. Many books he has written and had a book written about him by Tracy Kidder, who won a Pulitzer Prize, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. This is Democracy Now!, democracynow.org, the War and Peace Report. We’ll be back with Dr. Farmer in a minute.

[break]

AMY GOODMAN:

Our guest for the hour is Dr. Paul Farmer, professor of medical anthropology at Harvard Medical School, was the founder of Partners in Health. You’re no longer the head?

DR. PAUL FARMER:

No, Ophelia Dahl, another founder, is the head of Partners in Health. Well, you know, that’s a great thing — well, I sound self-congratulatory — but the group that started Partners in Health, we’re all still together. We all work together still to this day. I mean, so you have a lot of specialization now. I was talking about generic drugs. Jim Kim, another founder, became an expert in that arena. And so, it has happened. Back in the day, when I had to worry about pigs, you know, those days are different now, because we have other people on our team who are experts in this arena.

AMY GOODMAN:

Dr. Farmer, I want to ask you about Rwanda, where you live now with your wife, who’s Haitian, and your kids, and the clinic. But first, I want to go back to your own personal history, where you grew up and, well, your rather unusual abodes, where you lived with your family. How many brothers and sisters do you have?

DR. PAUL FARMER:

I am one of six children, the runt of the litter, and I’m not that small. I’m six feet tall. But I only say that because for many years we lived in a bus.

AMY GOODMAN:

In a bus.

DR. PAUL FARMER:

In a bus. And it was — my favorite part about it, in retrospect, is that it was one of those buses that was used in American cities to do mobile tuberculosis screening. So it had an area where there was a space for an x-ray machine.

AMY GOODMAN:

Were your parents involved in healthcare?

DR. PAUL FARMER:

No, my parents were involved in looking for a way to take eight people on a vacation that didn’t involve a plane, because they couldn’t afford airfare. So —

AMY GOODMAN:

And this would take care of rent, too?

DR. PAUL FARMER:

And this would take care of rent. Well, my father pulled that off on us later. He didn’t tell us, “Oh, this is not just a vacation; it’s home.” He tricked us. But —

AMY GOODMAN:

In what state did you [inaudible]?

DR. PAUL FARMER:

Well, this — he bought it in Alabama, and we lived in Florida. And so, I grew up in Florida mostly. And after the bus came the boat, another one of my dad’s experiments.

AMY GOODMAN:

You lived on a boat?

DR. PAUL FARMER:

I lived on a boat, I did.

AMY GOODMAN:

And where did he get the boat?

DR. PAUL FARMER:

He got it in a sealed bid from the US government. It had been a boat called a “liberty launch” from the USS Saratoga that took people to shore. It’s fifty feet long. So all it was, it looked like a giant rowboat. And my father bought it. He was the lowest bidder. And then, suddenly, he announced, as was his wont, “We’re going to live on a boat.” He actually said he was going to be a fisherman, and we rolled our eyes and said, “Yeah, right, Dad.”

AMY GOODMAN:

Is this why you’re always traveling, because you feel like the journey itself is home?

DR. PAUL FARMER:

I don’t think so. I’ve been asked that before. But I think I’m traveling because we get drawn into hotspots of disease where we have expertise. So that’s how we ended up in Peru and Russia, is because we already knew a lot about tuberculosis, and it wasn’t from the tuberculosis bus. It was from medical school and taking care of lots of patients. And that led us to Peru, where there was an outbreak of drug-resistant tuberculosis. And we have an incredible Peruvian team. They’ve helped us in Africa now, and just as the Haitians have helped us in Africa. Our Haitian team is, you know, helping to run these projects in Africa. But in any case, that led us to Russia.

AMY GOODMAN:

Your wife is also in medical anthropology?

DR. PAUL FARMER:

She is, yeah.

AMY GOODMAN:

And she lives in Rwanda now with your children?

DR. PAUL FARMER:

She is the director of community health for our efforts there.

AMY GOODMAN:

Explain what you did in Rwanda.

DR. PAUL FARMER:

Well, Rwanda has been, in many cases, the best experience we’ve had in our twenty-five years, because things that you need that I didn’t understand twenty years ago, you know, to make — to bring good comprehensive system to scale. What I mean by “comprehensive” is, I’m not talking about an AIDS program or a TB program or a maternal mortality program, I’m talking about comprehensive healthcare for poor people. And to bring that together, you need a lot of political will. You need farsighted people at the top. And so, at the same time that the Clinton Foundation asked us to go to Rwanda, the government of Rwanda, the Ministry of Health of Rwanda, asked us to come and try and do this rural model that we developed so extensively in Haiti in rural Rwanda. And so, we were sent to two districts where there was no functioning district hospital, and that was in 2005.

AMY GOODMAN:

Or more specifically, just in researching what you did there, you were brought to an area where you said, “No, no, no, this is not poor enough.”

DR. PAUL FARMER:

That time, it is true. We went to a town in northern Rwanda, and we went to a hospital that was clean, and it had an x-ray machine, and it had three physicians, a big hospital. It needed more than three physicians. But we went back to the city and said to the minister, you know, you could send us somewhere more difficult. And so we ended up in an abandoned hospital, abandoned since the war and genocide. And, you know, it was —

AMY GOODMAN:

Since 1994, that killed almost a million people in ten days?

DR. PAUL FARMER:

Exactly. And in addition, about 60 percent of the people living in this region were resettled refugees or internally displaced people. So it was a real mess socially, but we had some things going for us that we did not have in Haiti. I mentioned already we had great leadership at the top in Rwanda, a lot of support locally, because these people had been without medical care. There was no doctor. It was, you know, probably 400,000 people in those two districts, zero doctors. And then we also had the Haitians. You know, we had been working with our Haitian colleagues for sometimes fifteen, twenty years, and they came over with us to help set up the program. And they did that in Lesotho, too. So, you know, people talk about solidarity, which is fine, but until it’s linked to actual pragmatic solidarity that is actually doing something, well, that’s just less fine. So this, I think, was a really good thing.

AMY GOODMAN:

In Russia, you’ve worked with TB resistance in the prisons?

DR. PAUL FARMER:

Yeah, yeah. We worked with — that actually was another really very good experience. And people said, “What?” You know, “Working in Siberia has been a pleasant experience?” But I’ll tell you, it’s not what I expected. And we found in the prison where we worked, which is in a place called Tomsk, which is in western Siberia — and it’s a vast place, it’s the size of Germany or Poland, and there’s only a million people living there. So there’s a lot of logistic challenges to working — I hate to say this — but working outside the prison.

But inside the prison, we found there to be, you know, good, humane medical personnel. And I talked to one of the doctors when I first went there, and she said to me, “You know, we know what to do to take care of these patients with drug-resistant tuberculosis. What we don’t have are certain medications.” So it was very different from working in Haiti or some of the other places we’ve worked. They did know what to do in many ways. And so, one of the things that we did was to say, OK, we’re going to help rehab the lab, set up the drug procurement.

And just to give you one figure that comes from this one prison, the case fatality rate, the number of people diagnosed — these are mostly young men — diagnosed with TB who died was 24 percent, which is terrible. I mean, that’s far worse than Africa with treatment, or Haiti; we were getting down to two percent in our area. And so, we knew it was something other than noncompliance or the usual patient-blaming kind of explanations. It was drug-resistant TB. And when we introduced the right labs and the right drugs, the mortality fell to almost zero, and very quickly, in the space of two years.

AMY GOODMAN:

Before we get to the end of the broadcast, I want to come back here, because your analysis is not just a medical diagnosis, but it is an analysis of the healthcare system, and that’s ultimately what you’re challenging. So we’re in a presidential year. Healthcare is a critical issue, as long as you’re not watching the media, where you hardly see it discussed. But what do you think of the healthcare system in this country? What has to be done? How do you think — what do you think of the candidates and what they’re representing?

DR. PAUL FARMER:

Well, my diagnosis of our healthcare system’s problems is that it’s very expensive to give bad medical care to poor people in a rich country, very expensive to give bad medical care to poor people in a rich country. And I can give example after example from my own clinical experience working in, you know, the best hospitals I’ve ever seen in the world. And like I said, when they’re in the hospital, things go OK. But we do not have a good safety net. We don’t have a good primary healthcare system.

And to get into the hospital, the uninsured — 47 million people, maybe 50 — they have to pass through an emergency room, waste time, and things happen to them there that probably shouldn’t, because they’re primary healthcare problems, they’re in an emergency room. And then again, on top of that 47 million, probably just as many Americans are poorly insured and can be thrown into destitution by serious illness. So, you know, there’s 100 million Americans who are in — are not — they don’t have health security. They don’t know that a devastating illness could not wipe out their savings or make them lose their home. They may know that. I hope they do.

AMY GOODMAN:

What does the term single-payer mean to you?

DR. PAUL FARMER:

I think it’s a good idea. I mean, again —

AMY GOODMAN: If someone doesn’t understand it, in a sixty-second quote...

DR. PAUL FARMER:

Single-payer means, to me, that there’s a national health insurance program that is not divvied up, you know, state-by-state. You know, I was reading about Oregon yesterday on the plane on the way up here, and they’re talking about a lottery to see who’s going to get health insurance. Of the people who applied, it’s going to be some tiny little fraction. Using a lottery to allocate health insurance doesn’t seem to me like a great idea. In Massachusetts, where much has been made of universal access, what’s really happened is that medical insurance is made mandatory, which is different from a national health insurance program or a social safety net. And, you know, I don’t mean to be ideological about this. I’m not. I’m just saying we live in a country that is putting out 16 to 17 percent of our GDP for healthcare and not getting the returns that we need. And from the analyses that I read, having a national health program would cut out some of these unnecessary expenses. I think that’s a sound analysis.

AMY GOODMAN:

And you’re a voting participant in this society. What do you think of what the candidates are offering?

DR. PAUL FARMER:

Well, you know, they’re — well, I’m not going to talk about the Republican likely nominee, because I don’t think that’s going to be much of a difference. The Democratic nominees are not really shaking the foundations of this system. Whether they will or would if they could, I don’t know. But again, the right to healthcare is different from mandating. You know, car insurance is mandatory right? So you’re not supposed to drive a car — and if you get pulled over when you don’t have insurance, you could have your car impounded. That’s not a great approach to healthcare and insurance. And I don’t think that’s going to be enough.

And so, I’ll be a goodwill participant. And other people I mentioned — my colleague, Jim Kim, who is a real policy guru — we have people on our team — I included — who will participate in trying to be active members of a society that needs a national health insurance program. I mean, I don’t know — I’m sure that the path forward is going to be very complex. But a lot of times people say, well, it’s much more complex than that. You know, there’s also a simplicity to it; it’s we don’t have a social security net for the ill or those likely to become ill .

AMY GOODMAN:

Finally, Dr. Paul Farmer, thirty seconds. For young people, young doctors, young people in the medical profession, nurses, what do you have to say to them today?

DR. PAUL FARMER:

You know, they’re my retirement plan. There’s a great generation of young doctors and nurses and other frontline workers, social workers, who are — they understand the need for a movement more than we did. We need a movement that’s not just run by people who are experts, but the citizenry. And that’s what I’d say. Be part of a movement to push forward social justice, and that will lead us on healthcare, as well.

AMY GOODMAN:

Dr. Paul Farmer, thank you very much for being with us for this hour, professor of medical anthropology at Harvard, one of the founders of Partners in Health, which has now spread to ten countries in the world…and growing?

DR. PAUL FARMER:

We’re growing.

AMY GOODMAN:

That does it for our broadcast. Their website is pih.org.

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