Farmer: Key to global health is community-based care

Dr. Paul Farmer, a founding director of Partners In Health, delivers the season-opening Amphitheater lecture Monday morning. Photo by Megan Tan.

Nick Glunt | Staff Writer

podcastThe screen behind Dr. Paul Farmer depicted a Rwandan man with a short gray beard on his chin, his lips curved into a vague smile. He wore blue cloth pants held up with a loose belt that dangled from his fragile hips. He had no shirt, drawing immediate attention to his frail body. His ribs protruded from underneath his skin, his arms nothing but bone covered with a thin layer of skin. In his right hand, he gripped a wooden walking stick.

“I said upon meeting this man, whose name is John, ‘We have all the medications that we need to get you better,’” Farmer said.

The man didn’t entirely believe him, and neither did the Rwandan doctors — Farmer’s colleagues. This man was suffering from both AIDS and tuberculosis; surely there was no way to keep him healthy. But Farmer’s Haitian colleagues believed it. With Farmer, they had seen something like this so many times.

“This is the same fellow afterwards,” he said, revealing a second photo to gasps and applause from the Amphitheater audience Monday.

This photo depicted a much weightier and visibly happier man. A wide smile spread across his face, and a round belly lobbed over the strap of his gray cloth shorts. Only the man’s beard was similar between the two photos.

Farmer, the first lecturer of the season, is a founder of Partners In Health, an international organization focused on providing medical care to less fortunate patients in the world.

His speech, titled “Partnering with the Poor: One Physician’s Perspective on Global Health,” was the first in Week One’s theme “Global Health and Development as Foreign Policy.”

Partners In Health has centers in Haiti, Peru, the United States, Rwanda, Lesotho, Malawi and Russia, with supported projects in Mexico, Guatemala and Burundi.

Most of Farmer’s lecture, though, focused on the problems facing Haiti today. These problems — like the 2010 earthquake and recent outbreak of cholera — can be fixed, Farmer said, by strengthening world health systems. These issues, as well as his personal narrative, are dissected in his book, Haiti After the Earthquake.

Farmer arrived in Haiti within three days of the earthquake, which he calls an “unnatural disaster.” Haiti was not prepared, he said, for such a disaster, and is still facing the aftermath, almost a year and a half later.

“This is an acute-on-chronic disaster,” Farmer said. “Anybody in this room with a chronic ailment — asthma, diabetes, hypertension — knows that, and you don’t have to be a doctor or a nurse to know that, when you have an acute event like pneumonia, if you already have a chronic illness, it’s more complicated.”

The earthquake, he said, is an acute event worsened by Haiti’s chronic problems. The Haitian government released an estimation of 316,000 deaths as a result of the quake. Approximately 1.3 million people were left homeless. What hospitals that were left standing were filled with people suffering from spinal and brain injuries, crush injuries and multiple fracture wounds. Others faced mental trauma from the events.

In the U.S., there are many “nerve centers” in New York City, San Francisco, Chicago and others. In Haiti, Farmer said, there’s only one — in Port-au-Prince — and it, too, was struck by the quake. Partners HealthCare, a Harvard medical group that employs Farmer, sent more than 100 caregivers into the earthquake zone within one month.

However, many people were displaced because of the earthquake. Haitians left the earthquake zone to find refuge in rural areas, where family lived. The burdens of food and water shortages, which these families were already facing, were exacerbated, Farmer said. Within Port-au-Prince, people moved into open areas like parks and runway strips, living under tarps for shelter.

Furthermore, collapsing buildings killed medical workers as well as the general population. For example, the main nursing school in Port-au-Prince collapsed, crushing those in ongoing classes as well as faculty members.

Partners In Health opened up about 10 clinics in these various areas. And just as the refugees are still there, these clinics are still open today.

“A lot of the emergency response and relief workers have already left Haiti,” Farmer said. “I’m not exactly sure how.”

And then, on Oct. 22, cholera was confirmed in Haiti. There have been more than 331,000 cases, and it’s killed more than 5,000 people as of June 4. Farmer compared the outbreak to a bomb because of how quickly it spread.

In Haiti and the rest of the world, it is imperative to prepare for problems facing global health, he said.

“We’ll never be ready for these problems without thinking about strengthening health systems,” Farmer said. “The same systems that one would build to respond to one health care problem should be, of course, robust enough to respond to others.”

Q: I wonder if you would comment on, not just in the context of the disaster in Haiti and the concentration that has occurred since then, but in the long history you have of working in that country which including some time, frankly, when you were expelled and went back in anyway, so as you think about that and think about the sense of global health in its potential to inform foreign policy, throughout that history, have you had a positive interaction with the State Department or other policymakers and, if so, what is their focus of interest in hearing from you?

A: I’ll just be very personal about this and say that in the first 15 years or so, I actually rarely went to Port-au-Prince and rarely went to Washington. The first time that I gave testimony, some time in the ‘90s, in Congress, at the behest of a radical nun friend of mine, I got convinced by a social justice group to do this; I didn’t really know the scene back then. There weren’t a lot of people interested in what I had to say, which turned out to be right, actually. As the years went by, I learned more and, again, not to embarrass Mark Dybul, but when we started talking about a grand plan around AIDS, it was really to influence the White House, the State Department, to take up these goals. This current administration, in my opinion, is focusing a lot on what some in the State Department, including the secretary, are calling ‘human security,’ and it’s not a novel idea. It’s the idea that if we want to have security, we have to think about things like poverty, inequality; and one of the leading causes of poverty in the world, if not the leading cause of destitution, turns out to be catastrophic illness. So, in my experience, if people I meet take the time to engage the leadership, then you will be rewarded, if you’re patient, diplomatic, courtly, honest, persistent — that has, in my view, yielded a great deal for those of us working in the field on delivering these services I’m calling basic. So, yes, it’s a golden era, in my view, for global health, but also, it’s an era when people are really listening to these old arguments but true about human security as a key to security in general. That’s also one of the reasons why Rwanda is making such strides. They seem to embrace that notion of security as well.

Q: You mentioned working closely with the public-sector institutions. What techniques have you used to minimize the impact of corruption?

A: Well, the public sector does not have the corner market on corruption. Not to be just polemic, if you look at the problem of corruption, and I don’t want to take potshots at the financial sector. Clearly the transnational financial sector was rife with corruption, yet had the bookkeeping seal of approval from the leading houses in the world. So, corruption is a very slippery term, and one thing that I’ve learned over the years is to try to at least struggle to avoid conflating corruption with institutional poverty. So, for example, so that this doesn’t sound arcane, to be transparent requires an infrastructure of transparency — bookkeepers, computers, electricity, water, salaries for the public sector. Rwanda, which has been lifted up, I think, rightly as an example for real struggle for transparency, really pushed this zealously in the public sector. So, in other words, it’s kind of inconvenient when someone you’re working with in the public sector gets thrown into jail. That really was meant to be a joke, so thank you for laughing. But I really think it’s part of our job to struggle, to help deal with lack of transparency, help our partners to become transparent and not be corrupt. So that’s a sort of philosophical answer, but I wanted to say that we had actually tried to do these things inside the public sector — electricity, bookkeepers, the kind of technical assistance that we’ve taken to calling ‘accompaniment’ in our work. Accompaniment means you’re actually going to walk with your partners. That could be a patient or a city government, or a national government, a ministry of health. That’s what Mark (Dybul) and Helene (Gayle) have done with a lot of their careers is accompany at that level. You can also do it at the district or local level, and it requires resources and commitment and patience, and that’s a very difficulty project, but one that’s well worth pursuing over the years.

Q: Does your partnership also include engineers, landscape architects, architects to rebuild, plan and design the community and infrastructure to support your long-term goals?

A: The answer is yes, but I’m smiling because I’m kind of a tree hugger. Looking around and seeing all these trees, I love trees. It’s kind of my hobby, landscaping. Some of my coworkers, who are doctors, thought, Well, Paul’s not going to want to have landscaper volunteers, and I said, ‘Well, that’s not true.’ Actually, in northern Rwanda, we built this beautiful hospital. I wish I put a picture of it in here, but one of the reasons it’s so beautiful is because of engineers, architects and a landscaper — the woman who helped designed The High Line in New York — she lives in Rwanda and she was a volunteer, and I can tell you as proud as I am of things like the hospital I just showed you, it’s much better to have professionals. So, the answer is yes, we have volunteers from management. The day after tomorrow, on my way back to Rwanda; I’m going to be meeting with volunteers in advertising who are trying to help us convey what a really complex message is in a much more concise matter. Let’s just say concision is not my strong suit. So, we have volunteers from every walk of life, not just doctors and nurses.

Q: There are a number of questions that go to your personal experience with all this. This questioner participated in relief efforts in the field hospital set up by Harvard Medical Initiative on the ground of the Love A Child orphanage and continues medical work in poor Haitian neighborhoods. The question is: How do you do the work you do without internalizing the grief you see every day and the suffering?

A: I think doctors do internalize the grief and the suffering, and nurses, looking at my colleague. That is not a bad thing to do. Being cognizant of someone’s pain is obviously what empathy is all about. The question is how to be effective and focus on good outcomes for patients, for families, for areas, for systems, when you’re exposed to a lot of grief. I think one of the best ways to do that, and I’ll say this in an avuncular manner to any young people, or not young people, is with partnership. None of this work is done effectively with small groups. It’s really about bringing lots of people together. I don’t know what we would do in Haiti without our Haitian partners, who I regard as some of the toughest people I know in terms of helping all of us who are ‘transnational bilaterals.’ So, my coworkers who are American or European who are working in very difficult circumstances, all of us need to be spelled, including our Haitian colleagues. We’re really trying to think more about this in the future. Should we have a sabbatical system? Should we have shorter stints of engagement in the field? And the answer to all those questions is almost surely yes. So the main advice I’m giving you is you’re always going to work with a team; remember that it’s all about partnership, and everybody needs to be spelled.

Q: One of the things that is talked about in terms of responses to disasters are unintended consequences. You send in a lot of foodstuffs and you end up destroying a local marketplace; the farmers are driven right out of business. This questioner asks if there is a similar affect on the indigenous medical care — hospitals, clinics, doctors — that are trying to make it with a huge influx.

A: Well, that was the claim of the private sector providers in Haiti. They were being ruined by all of this free care. I think that they Haitian poor would be quick to point out that those people were not providing services for the poor before the earthquake. Very sharp critics, the Haitians. So, the claim was made many times, and very publically, and picked up by the international press, including the American press, was that the unintended consequence of all this free medical assistance and free water was damaging the local economy. I don’t find that a very compelling argument. What I would say is that sector, the private sector, was not providing adequate water, shelter, primary care or primary education before the quake, so we need a third answer. The unintended consequences, however, are after years, decade after decade, and I think we’re starting to learn more about predicting the consequences of engagement. It’s just that we need a big-picture analysis. You’re not going to understand food and security in Haiti by looking in Haiti. You have to look at the transnational economy. You have to look at U.S. agricultural arrangements to understand agriculture in Haiti, and that’s important to do.

Q: Do you think that the model, which Partners in Health has developed for developing under-resourced countries, has any relevance or value for the health care debate in the United States?

A: I do. I do think it does. I think you could even call this a technical part of this and, again, I hope that Helene (Gayle) will talk about this and others who are thinking about lessons learned in global health that could be applied here. One of the main ones, the technical ones, is community-based care for chronic disease. As someone who spends most of his clinical time outside the United States, listening to the debate about medical homes in the United States, they’re really still not talking about homes. It’s almost like we can’t get quite get to the point in the United States where we talk about home-based care, community health workers, really community-based care for chronic disease. That’s going to be absolutely critical to improving quality, and, I believe, lowering relative costs, although there’s a kind of fetishization of dropping cost. If we focus on quality, we’ll end up doing what we did in Haiti, which is to provide community-based care for chronic disease. That’s what our Boston project is all about. The patients who we’re serving there have fallen through the cracks of the most fantastic teaching hospitals you can imagine, and they’re still doing poorly with the people we started with in the Boston area had HIV disease, but we’ve extended that to major mental illness and diabetes, and most of the people we’re caring for in Boston with community-based care, with community health workers, have more than one diagnosis. I know this is adding a little bit onto the answer, but I was in a (neurologic disorder) conference in Uganda, and I was making a plea for community-based care, and I said, ‘We really need to have community health workers to train and involve them.’ I gave an example, unwisely, from Kenya because we had a neurologist visiting us at Harvard, in the ‘90s, and he did a study of the blood levels of seizure medicine somewhere in Nairobi. This isn’t even rural Kenya; it’s the capital city, and zero percent of the patients with seizure disorder who were being followed in a seizure clinic, had the correct blood level. They all had under treatment. Those are the people who actually made it in there. So, I was saying, ‘Look, we need community health workers,’ and a colleague who didn’t say where he was from in Africa, but I guarantee it was a capital city, got up and said, ‘Well, you wouldn’t say this, in the United States, that we should have community health workers.’ I was very happy to say, ‘That’s not true at all.’ I say this everywhere I go. I’m not changing the message from Boston to Kampala. It’s because I believe this is the best way to respond to these chronic illnesses: community-based care.

Q: This is from a group of students from the University of Pittsburgh, Student Leaders in International Medicine. We’ve met with Dr. Joseph in Malawi. Can you comment on your involvement in Malawi and its success? Also, do you need another personal assistant?

A: That’s very nice of you. Thank you guys. As long as it can be indentured labor, but they’re against that at Chautauqua. Dr. Joseph, who’s from Upstate New York, was a student of mine. He’s been working for Partners in Health for 15 years in Peru, in Haiti, in Boston, and then he went to direct PIH’s program in rural Malawi. It’s very much like all of our efforts in rural and urban areas, too. We’re doing three things at once: rebuilding infrastructure (in this case, there was no hospital in this district, as you may know), training local people to do this work and also putting resources into the system. So, that’s what happening in Malawi. The impact of those interventions, which have been fairly modest, again in partnership with the Clinton Foundation and the Ministry of Health, have been just enormous in terms of maternal mortality. In other words, the health system strengthening approach has led to massive reduction in infant mortality, maternal mortality, juvenile mortality and great outcomes among the patients we’ve been taking care of. So, to me, Malawi is just another conformation that many parts of this model are perhaps distinct from place to place, but most of them are actually general and applicable from the urban United States to the mountains of Lesotho. That’s what I believe the Malawi experience teaches us, too. Thank you for asking.

Q: In my view, you have all the characteristics of a modern-day visionary. Do you credit your commitment to the world of public health to a particular person in your life? Who inspired your great work — a parent, a grandparent, a religious leader? If none of the above, what about you drives your incredible mission to help others answering the question: How to make things better?

A: I’ve got to say that I think that is very common in public health, and I’m not trying to embarrass my friends who are here, including Helene (Gayle), who’s the reason I’m here today, but the people I know in public health really share that vision. I don’t know who asked the question, but I don’t think it’s rare in public health or public education. I believe it’s very common. Another thing that struck me, and it’s not just the Pittsburgh students who are making me say this, is that it’s also very common on the university campuses in the United States. I don’t have much experience in Europe or Asia; my experience is United States, Latin America and Africa. It’s just not rare, so people should not exceptionalize and, above all, I hope they won’t pathologize commitment to social justice. It’s common, and we need it. I will say that my oldest daughter, who read me, out loud, an essay, ‘Who’s her hero?’ and she said, ‘Martin Luther King.’ There are people in the world who we all know who are embodiments of real commitment to struggle to make things better. Of course, there are the Dorothy Days and the Martin Luther Kings, figures from Upstate New York in the 19th century. I gave the graduation speech at Wesleyan, and I said, ‘This is the coolest institution ever founded by white people in the 19th century.’ That was my opening line. But what I really want to say is there are these heroes, but there are everyday heroes — people who are struggling, women in rural Haiti who are struggling to keep their families safe and their kids in school — and I think it’s better for all of us to understand to not exceptionalize commitment, not just to one’s own family but to making things better. I think it’s a very under-recognized value in our species, and it’s much more common than avarice that we hear so much about, including in 2008 with the financial whatever it was, I’ve met a lot of people in that sector who are big supporters of Partners in Health who are upstanding, good people, too, so I don’t want to say that this commitment to make things better is just in public health, although I think it’s very common in public health. I think Helene (Gayle) and Mark (Dybul) would agree with me.

Transcribed by Patrick Hosken