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Dr. Paul Farmer on Rwanda’s Health Leap, Haiti’s Struggles & How Communities Can Repair the World

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Dr. Paul Farmer, an infectious diseases expert and a medical anthropologist, is known worldwide for helping to bring quality healthcare to some of the most impoverished areas of the globe. More than 25 years ago, Farmer helped found the charity Partners in Health to provide free medical care in central Haiti. Today, Partners in Health teams up with local groups to treat people with HIV/AIDS, tuberculosis, malaria and other conditions in Haiti and countries around the world. The South African Nobel Peace laureate, Archbishop Desmond Tutu, calls him “One of the great advocates for the poorest and sickest of our planet.” Farmer’s previous book, “Haiti After the Earthquake,” describes the massive suffering and ongoing recovery effort after the devastating January 2010 earthquake that killed hundreds of thousands of people. His latest, “To Repair the World: Paul Farmer Speaks to the Next Generation,” collects a series of commencement addresses that Farmer has delivered to graduating college students going back more than a decade. Throughout, Farmer urges them to confront global problems through an approach that has long guided his work: a tireless commitment to social justice and solidarity with the world’s poor. Farmer joins us to discuss why he thinks a community-based health approach can help fix the U.S. healthcare system, how Rwanda’s model has drastically improved the lives of its citizens, and how to tackle the massive health problems in post-earthquake Haiti.

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StoryApr 01, 2010Dr. Paul Farmer, UN Deputy Special Envoy for Haiti, on Haiti’s Challenges Following Catastrophic Earthquake and Years of Western Domination
This is a rush transcript. Copy may not be in its final form.

AARON MATÉ: For the rest of the hour, we are joined by a doctor whose name has become synonymous with global health and social justice. Dr. Paul Farmer is known worldwide for helping bring quality healthcare to some of the most impoverished areas of the globe.

More than 25 years ago, Dr. Farmer helped found the charity Partners in Health to provide free medical care in central Haiti. Today, Partners in Health teams up with local groups to treat people with HIV/AIDS, tuberculosis, malaria and other conditions in Haiti and countries around the world, including Rwanda, Russia, Peru, Mexico and Guatemala. Partners in Health recently finished construction on a new hospital in Haiti that, when fully operational, will be largest solar-powered hospital in the world.

Dr. Farmer is also chair of the Department of Global Health and Social Medicine at Harvard Medical School, and chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. In 2009, Dr. Farmer was appointed the U.N. deputy special envoy for Haiti working under former President Bill Clinton.

AMY GOODMAN: Dr. Paul Farmer’s longtime commitment to Haiti was chronicled by the author Tracy Kidder in the book Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. The South African Nobel Peace laureate, Archbishop Desmond Tutu, calls Dr. Farmer “One of the great advocates for the poorest and sickest of our planet.”

We last had Dr. Farmer on to speak about his previous book, Haiti After the Earthquake, which describes the massive suffering and ongoing recovery effort after the devastating January 2010 earthquake that killed hundreds of thousands of people. His new book is called To Repair the World: Paul Farmer Speaks to the Next Generation, a collection of a series of commencement addresses that Dr. Farmer has delivered to graduating college students going back more than a decade.

Dr. Farmer, I’m actually giving the commencement address at Hampshire College on Saturday, really looking forward to going up there, so I found this book very, very helpful. And the last speech you give, you talk about—I think it was to the Harvard Kennedy School of Government—you talk about accompaniment. What does that concept mean?

DR. PAUL FARMER: You know, I first got the idea—I heard it from Haitians 30 years ago. And we were trying to set up a decent tuberculosis treatment program. And we knew tuberculosis is a chronic disease, like diabetes. It has a cure, so it’s not like diabetes, but it takes many months to do so. And we thought we had free care at the clinic that we’d built there, and yet we had poor outcomes. Why? Well, we found out the reason was, of course, we needed to move the treatment out to the patients and their families, and that there were many hidden barriers just to get to the clinic.

So we started working with community health workers, who were called “accompagnateurs” in the local parlance. And we thought, “Wow! This is a great idea for other problems that would go on beyond, you know, a short amount time in a hospital, in a clinic,” which is to say most of them, right? And so we started pushing for that model, brought it back to Boston, you know, to say, “We need this in Boston, too.” We have great hospitals like the Brigham, where I work, but in the shadow of the Brigham and the other Harvard teaching hospitals, people facing other problems—not the ones in Haiti, but housing instability, poverty, you know, racism, the problems that have made it difficult for some people in our cities—they need this, too.

So, that particular speech is to say, “Well, what about foreign aid? Do you think this ADD approach that we’ve seen after Haiti is a good way to approach foreign aid, where everything is so short-term, where there’s so much conditionality? Or might a more solidarity-inspired endeavor, like actually walking with your partner, be more relevant to the world we live in, riven by inequalities but by people who do want aid to work on both sides of that equation? That was a longer answer than you thought, but—

AMY GOODMAN: No, no, I expected that we wouldn’t get in another question. But—but that issue of accompaniment in a healthcare model—


AMY GOODMAN: —from Haiti to Rwanda, to here in the United States, what is wrong with our system? How would we change it to be the model you’re talking about?

DR. PAUL FARMER: Well, what’s wrong with our American system is that we don’t have—or there are many, maybe many, problems that are, some of them, being addressed. We have so much money going into the system, so we ought to have a good—we ought to have a good system. But one of the problems, and one I’ve obsessed with, is: How do you reach from a hospital to a community-based health center, and then on into people’s homes? That’s what we’ve had to learn in treating chronic disease. You know, when people said you couldn’t treat AIDS in Africa, you know, we said, “Well, that’s not true. I mean, here’s a model that would give you better results than in a sprawling American city. Or—and you could do it in a rural area. This is a model that could help you treat major mental illness, diabetes, etc.”

So, I think we made progress, and now what we need to do in the United States is find a way to train and license and reimburse laypeople who are community health workers to work in the home and with—or with patients wherever they live. Make it convenient for the patients. These treatments for one or two diseases at a time that people with chronic illness face, including elderly people, they’re difficult and annoying, and you have to go back and forth. Then you go to other countries, like China, which I don’t know very well, but when I was visiting hospitals in China, they were asking people with chronic disease to go get their prescriptions filled every two weeks, and they would come back and stand in long lines. And imagine if you’re frail or sick, and you’re asked every 14 days to go back to, you know, this overcrowded hospital to get your prescription filled. It makes no sense at all. And that’s the basic pathology of the American healthcare system. It doesn’t have a good community-based or home-based component. There are other pathologies, too, and they’re being addressed, I hope, increasingly.

AARON MATÉ: Well, you’ve lived and worked in Rwanda for a long time, and I’m wondering if you could talk about your work there and what you think we can learn from how Rwanda has transformed their healthcare system.

DR. PAUL FARMER: Well, you know, the work in Rwanda has been very uplifting for Partners in Health, for me, for our partners from Harvard, in part because we made a bet almost 10 years ago that if we could, as a collective, take this model—and I’ll call it accompaniment, but I’m not just talking about community-based care; I’m talking about rebuild a system that has hospitals, clinics and community-based care—if we could go to a place with great need, in terms—especially maybe in terms of infectious pathologies like malaria, TB, HIV, which we know a lot about in our team, post-conflict setting, maybe one even written off as hopeless, but with a government committed to rolling out basic services in health and education to poor people in rural areas, if we could find all that, we would see something miraculous happen in the course of a decade. And we did. That’s why we went to Rwanda. We went with the Clinton Foundation and other partners and worked with the Ministry of Health of Rwanda. And that—and it’s been the most rewarding decade in my life as a doctor just to see how—the reversal of fortune, how quickly it could happen.

Just to give you some numbers, the life expectancy in Rwanda has probably doubled over the last 10 years. And the declines in mortality, especially among children, women in childbirth, declines in mortality among those who already have tuberculosis, malaria and AIDS, these are the steepest declines ever recorded in human history. Something—

AMY GOODMAN: So explain exactly what you did.

DR. PAUL FARMER: Well, we worked with the Rwandans, as did many other people, and I’m not suggesting that, you know, we were—there are many other groups. But the key is working with the public sector. After all, eventually, if people have a right to healthcare, it will be the public sector and not non-governmental organizations or universities from the United States that will confer those rights. So we worked to build a system. And the system stretched, as I said, from community health workers to clinics, where the majority of care is given—those are run by nurses—to having in every district a hospital. Partners in Health ended up building or rebuilding three of the 30 district hospitals, and including even starting a cancer center, probably the first cancer center in rural Africa anywhere.

But it all fit into a system, and the vertical—they’re called vertical programs in public health. So, an AIDS program or a family planning program, those are vertical programs. What the Rwandan government and authorities said is: “We want those vertical programs to strengthen our health system, our Rwandan national health system.” And we did do that. And we were pushed to do that. And the result is—I think that’s why that decline is more steeper in Rwanda than in other places and why it’s the only country in sub-Saharan Africa on track to meet all of the health-related Millennium Development goals.

AMY GOODMAN: We’re going to break and then come back to this discussion, and of course we’ll go south to look at Haiti. This is Democracy Now!,, The War and Peace Report. Back in a minute.


AMY GOODMAN: Our guest is Dr. Paul Farmer. He’s been working in Haiti and around the world for decades. Twenty-five years ago, Dr. Farmer helped found the charity Partners in Health, which provides care to those living in poverty in central Haiti as well as other places around the world. And he’s written a new book called To Repair the World: Paul Farmer Speaks to the Next Generation. Dr. Paul Farmer is the department chair of Global Health and Social Medicine at Harvard Medical School and chief of the Division of Global Health Equity at Brigham and Women’s Hospital, where many of the victims of the Boston Marathon bombings were brought. Can you talk about the significance of that? And then we’ll talk about Haiti.

DR. PAUL FARMER: Well, I think, in my view, they’re related topics, and not just because I work at both the Brigham and in Haiti. First of all, there’s a reason that everyone who made it to a hospital, like the Brigham, survived. You have in a place like that an incredible set of options to help people who are seriously injured or seriously ill. You have redundant systems, in the sense that—if you have, as happens with an earthquake or a bombing, everybody shows up at once, you need redundant systems, meaning you need backup teams and backup teams. So you can’t have, like we have all over the Third World, the power suddenly goes out. You know, the generator dies. You know, that’s never going happen at a place like the Brigham. There is so much capacity there that it’s no wonder—in my experience, it’s no wonder that people did really well, the patients did really well, once they got there.

And it’s a reminder. You know, every time something like this happens in our country, in our affluent country, we get a chance to think how much humans need safety nets. And that’s what we’re trying to build in Rwanda and Haiti. And if you don’t have—you know, if you have only a community health system and no hospitals, and someone is injured, then that—the person who’s injured is out of luck. Or that could be a minor injury, you know, a minor injury that could be fatal because there’s no hospital. If you only have the hospitals and no community-based care, you don’t do well with chronic disease management. And so, what we’ve been trying to do in Haiti, Partners in Health and the Ministry of Health and many partners, has been to rebuild some of the destroyed capacity for hospital care and teaching in the rural area, decentralizing from Port-au-Prince and the quake zone, and we’ve done that.

AARON MATÉ: Can you compare, though, Haiti to Rwanda? I mean, is it safe to say that your group is an exception to the rule in Haiti? In which—in your case, you work with community groups. Money actually goes to Haitians. But, overall, so much aid goes into the hands of foreign workers and foreign NGOs.

DR. PAUL FARMER: Well, there—we may be not unique, but we’re trying to be different in two ways: yes, that the money goes to Haitians, meaning Haitian employees, but we’re also working to support the Haitian public authorities. You can’t have public health without working with the public sector. You can’t have public education without working with the public sector in education. So the privatization that we talk about in our writings or on shows like this, it happens insidiously, too, when NGOs work with contractors, as you suggest, only, but also when they don’t work with the government, the public sector. And that happens even more insidiously, because people think, “Well, I work with a community organization or community groups. That should do it.” Well, really? Not to build a safety network or social protection—it really requires working with both sides.

So, yeah, we’re trying to bring—to bring ourselves, to make ourselves do work that way, to build local capacity, even if we’re doing something grand like building a teaching hospital. And that teaching hospital—if I could just mention one example that isn’t straightforward, we did not have in Haiti the skill to build a lot of the guts of the hospital—you know, how you would have wall gas in the walls—or the finishing work. If you want a table to look like this one, you know, or the machinery that you guys are—contraptions you’re using here, that production capacity doesn’t occur in Haiti. We went back to the unions—for example, the electrical workers, the painters, the carpenters—in the United States, and they came down and helped build the hospital as volunteers. But they helped transfer skills to Haitian craftsmen and craftswomen, too. So it really was a teaching hospital before we ever saw the first patient.

AMY GOODMAN: I wanted to ask you about the cholera outbreak that erupted in Haiti in October 2010 that killed about 8,000 people, sickened about 620,000 people. Most independent studies say the outbreak originated with a battalion of Nepalese troops who were part of the U.N. peacekeeping mission after Haiti’s devastating 2010 earthquake. But the United Nations has never formally acknowledged responsibility or apologized. Attorneys for thousands of Haitian cholera victims announced a lawsuit against the U.N. in 2011. And earlier this year, the United Nations finally responded by announcing its refusal to pay compensation. A U.N. spokesperson cited immunity under the U.N.’s own rules.

MARTIN NESIRKY: In November 2011, a claim for compensation was brought against the United Nations on behalf of victims of the cholera outbreak in Haiti. Today the United Nations advised the claimants’ representatives that the claims are not receivable, pursuant to Section 29 of the Convention on the Privileges and Immunities of the United Nations. The secretary-general again expresses his profound sympathy for the terrible suffering caused by the cholera epidemic and calls on partners in Haiti and the international community to work together to ensure better health and a better future for the people of Haiti.

AMY GOODMAN: The U.N. spokesperson. Dr. Paul Farmer, your response?

DR. PAUL FARMER: Well, I mean, my response is probably going to be as a physician and an anthropologist, as we did immediately after the earthquake, as my colleagues and I did, saying, “What are the complementary steps that we could take to slow cholera and then eradicate it? And how are we going to save lives in a setting with this kind of water insecurity?” And there are important—it is important to understand that we haven’t really succeeded in achieving even those complementary steps in the public health and medical arena, to say nothing of the water and sanitation arena, which is going to require building massive municipal water capacity across that country, like we have in this one and like the Rwandans are trying to do in theirs.

Those projects are also part of reparations. You know, when I talk to patients—I kind of think of everybody as a patient or potential patient, so watch out—but when I talk to patients who are living in poverty, they really do talk about reparations. “We need housing. We need healthcare. We need water. We want our kids in school.” And, you know, I think that among the various interventions we could make, we’ve got to remember that—those pragmatic—

AMY GOODMAN: So, should the U.N. be responsible for that?

DR. PAUL FARMER: I think the U.N. is responsible. I think the world is responsible. I think that everybody who in the past tried to move Haiti out of the fraternity of nations during the 19th century and failed to recognize its legitimacy as a nation, I think the French who made extorted money from Haiti, are responsible. I think—I could go right through the list, you know? And I do think—I do believe, as you’ve read in this book and others, that I believe in that kind of assessment of responsibility.

The question is, again: What are the mechanisms by which we may offer reparations? And some of them have to involve transfer of resources to do those tasks that have not yet been done. And in doing that, obviously, we further the goals of public health and medicine in Haiti, but also education, building businesses, etc. You can’t, you know, really hope to have investment, local investment from local—I’m just going to say business, but as you know, I mean micro-enterprise, etc., if people are sick and if people are always living in fear of the next epidemic and want. And so, I think we’re all responsible. Anyway, I hope to be involved in this long term.

AARON MATÉ: Well, on this issue, the parties of the U.N. in Haiti spending hundreds of millions of dollars a year on a foreign military occupation, is it time for that foreign occupation, and given that there’s no war there, there hasn’t been for a century?

DR. PAUL FARMER: I’ll say again, as I did on the show last time, that that’s not the approach to human security that I would adopt, were I the architect. I would not have a militarized approach, but rather investments in basic social and economic rights for poor people, including the right to healthcare, the right to education. Those investments have not yet occurred in Haiti. Haiti will need rule of law and, you know, a police force, just like any other nation, but we need to shift the focus towards building up capacity in these arenas. And that is—that’s what we believed when there was a Haitian army, as well, that had no non—was founded during the U.S. occupation and never had a non-Haitian enemy.

AMY GOODMAN: Five seconds.

DR. PAUL FARMER: So, it’s still truth.

AMY GOODMAN: We’re going to leave it there. Paul Farmer, the author of To Repair the World: Paul Farmer Speaks to the Next Generation.

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Dr. Paul Farmer, UN Deputy Special Envoy for Haiti, on Haiti’s Challenges Following Catastrophic Earthquake and Years of Western Domination

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